Every finding on record at Saint John Paul II Center

Based on clinical record review, review of facility documentation, facility policies, and interviews for one (1) sampled resident (Resident #1) who was reviewed for an allegation of inappropriate conduct by a staff member, the facility failed to ensure Resident #1 was free from sexual abuse by a housekeeper. The findings include:Resident #1's diagnoses included dementia, anxiety, bipolar disorder, delusional disorder, major depressive disorder, and schizoaffective disorder. The annual Minimum Data Set assessment dated [DATE], identified Resident #1 had some memory recall deficits. The Resident Care Plan dated 6/20/26, identified Resident #1 had impaired or decline in cognitive function or thought processes related to bipolar disorder and schizoaffective disorder. Interventions directed to observe and evaluate types of changes in cognitive status, to monitor for decline in activities of daily living function, need for Psych or Behavioral Health consult if indicated, and allow resident to make daily decisions. The nurse's note dated 7/17/26 at 3:00 PM identified at approximately 2:00 PM the housekeeping director notified the 7AM-3PM charge nurse that a housekeeping staff member, housekeeper #2, had reported a conversation she had with Resident #1. The note indicated housekeeper #2 explained that on 7/16/26 at approximately 1:30 PM while cleaning Resident #1's room, Resident #1 stated that he/she did not want a certain housekeeper, housekeeper #1, to clean his/her room as he/she felt housekeeper #1 was in love with him/her and asked Resident #1 how he/she was doing, whether he/she had eaten and told Resident #1 that he/she missed Resident #1. The note identified Resident #1 reported he/she told housekeeper #2 that he/she did not like the comments as he/she was married. The note indicated when the police arrived and interviewed Resident #1, Resident #1 alleged housekeeper #1 had touched his/her private area last week but could not recall the specific date or time of the alleged incident. The note identified Resident #1 was immediately transferred to the Emergency Department for a medical and psychiatric evaluation. The nurse's note dated 7/18/26 at 4:04 PM identified Resident #1 had returned from the hospital on 7/17/26 at approximately 8:20 PM. Review of the message section in the state Reportable Event portal dated 7/29/26 at 1:26 PM identified on 7/28/26, the Director of Nursing (DON) had a follow-up call with the police officer who handled the investigation. The officer stated the perpetrator was questioned at the police station, and the perpetrator vehemently denied the accusations during the interrogation. The note identified after much pressure, the perpetrator confessed and admitted to the crime and the officer stated they would be issuing a warrant of arrest. The note indicated Resident #1's Conservator was notified of the perpetrator's admission and wanted to press charges. Interview with the housekeeping director on 8/24/26 at 1:53 PM identified on 7/17/26 a housekeeper, housekeeper #2, reported Resident #1 had stated to housekeeper #2 that housekeeper #1 had made some inappropriate comments Resident #1 did not like. The housekeeping director identified she then notified her boss as well as the facility DON and administrator on 7/17/26, the day housekeeper #2 reported the incident to her. Interview with the DON on 8/24/26 at 2:05 PM identified on 7/16/26, Resident #1 reported to housekeeper #2 that housekeeper #1 had made some comments and gestures Resident #1 was not comfortable with. The DON explained at the time of the report, the police were notified, an assessment of Resident #1 was performed by the Advanced Practice Registered Nurse and Social Worker, housekeeper #1 was removed from the schedule, Resident #1 was then transferred to the emergency department for evaluation, and an investigation was initiated. The DON identified the outcome of the facility investigation and found that the allegation was substantiated based on the police officer's report that housekeeper #1 admitted to the allegation. The DON identified the facility policy directs that abuse of any type is prohibited and all staff were responsible for ensuring the policy is followed. Although attempted, an interview with housekeeper #2 was unable to be obtained. Review of the facility policy titled Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/Exploitation and Mistreatment, effective date 4/2026, directed, in part, the facility shall not use or permit verbal, mental, sexual or physical abuse or other mistreatment or neglect. This prohibition extends to abuse by anyone including, but not limited to, other residents, staff, consultants, volunteers, and staff of other agencies serving the residents, family members, legal guardians, friends, or other individuals. The facility developed and implemented a corrective action plan on 7/28/26:Staff will receive education of center abuse policy to include reporting and investigation of abuse, neglect, misappropriation, exploitation, and mistreatment policy.Audits will be completed for staff background checks.Resident interviews were conducted regarding abuse and mistreatment to ensure any form of abuse has not occurred.Livewell housekeeping and dietary staff education audits were conducted.Allegations of abuse received will be audited to ensure allegations have been reported timely weekly for four (4) weeks, then monthly for three (3) months. QAPI initiated and reviewed with the Medical Director on 7/28/26. The facility documentation identified that the estimated completion date was 7/29/26, with the exception for the ongoing audits. Based on the review of the facility's documentation, past non-compliance was identified as corrected on 7/29/26.

Based on clinical record review, review of facility documentation, facility policies, and interviews for one (1) sample resident (Resident #1) who was reviewed for an allegation of inappropriate conduct by a staff member, the facility failed to ensure a staff member reported to their supervisor or any facility staff an allegation of potential sexual abuse that Resident #1 made on 7/16/26 at 1:30 PM until 7/17/26 at approximately 2:00 PM (24-hours later). The findings include:Resident #1's diagnoses included dementia, anxiety, bipolar disorder, delusional disorder, major depressive disorder, and schizoaffective disorder. The annual Minimum Data Set assessment dated [DATE], identified Resident #1 had some memory recall deficits. The nurse's note dated 7/17/26 at 3:00 PM identified at approximately 2:00 PM the housekeeping director notified the 7AM-3PM charge nurse that a housekeeping staff member, housekeeper #2, had reported a conversation she had with Resident #1. The note indicated housekeeper #2 explained that on 7/16/26 at approximately 1:30 PM while cleaning Resident #1's room, Resident #1 stated that he/she did not want a certain housekeeper, housekeeper #1, to clean his/her room as he/she felt housekeeper #1 was in love with him/her and asked Resident #1 how he/she was doing, whether he/she had eaten and told Resident #1 that he/she missed Resident #1. The note identified Resident #1 reported he/she told housekeeper #2 that he/she did not like the comments as he/she was married. The note indicated when the police arrived and interviewed Resident #1, Resident #1 alleged housekeeper #1 had touched his/her private area last week but could not recall the specific date or time of the alleged incident. The note identified Resident #1 was immediately transferred to the Emergency Department for a medical and psychiatric evaluation. The nurse's note dated 7/18/26 at 4:04 PM identified Resident #1 had returned from the hospital on 7/17/26 at approximately 8:20 PM. Review of the message section in the state Reportable Event portal dated 7/29/26 at 1:26 PM identified on 7/28/26, the Director of Nursing (DON) had a follow-up call with the police officer who handled the investigation. The officer stated the perpetrator was questioned at the police station, and the perpetrator vehemently denied the accusations during the interrogation. The note identified after much pressure, the perpetrator confessed and admitted to the crime and the officer stated they would be issuing a warrant of arrest. The note indicated Resident #1's Conservator was notified of the perpetrator's admission and wanted to press charges. Interview with the housekeeping director on 8/24/26 at 1:53 PM identified on 7/17/26 a housekeeper, housekeeper #2, reported Resident #1 had stated to housekeeper #2 that housekeeper #1 had made some inappropriate comments Resident #1 did not like. The housekeeping director identified Resident #1 reported this to housekeeper #2 on 7/16/26 but that housekeeper #2 did not report this to her until the following day (7/17/26). The housekeeping director identified she then notified her boss as well as the facility DON and administrator on 7/17/26, the day housekeeper #2 reported the incident to her. Interview with the administrator on 8/24/26 at 1:58 PM identified the expectation was that an allegation of abuse should be reported immediately when the allegation was made with no waiting period. The administrator identified she would have expected housekeeper #2 to report the allegation she received immediately. The administrator identified the facility policy directed that any allegation of abuse should be reported within two (2) hours of receiving the allegation and all staff are responsible for ensuring the policy is followed. Although attempted, an interview with housekeeper #2 was unable to be obtained. Review of the facility policy titled Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/Exploitation and Mistreatment, effective date 4/2026, directed, in part, all alleged violations and results shall be reported immediately to the administrator and/or the DNS. The policy further directed, in part, section 1150B establishes two-hour limits for the reporting of reasonable suspicion of a crime, depending on the seriousness of the event that leads to the reasonable suspicion with serious bodily injury within a 2-hour limit: if the events that cause reasonable suspicion result in bodily injury to a resident, the covered individual shall report the suspicion immediately. The policy defined serious bodily injury as an 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 requiring medication intervention such as surgery, hospitalization or physical rehabilitee; or an injury resulting from criminal sexual abuse. The facility developed and implemented a corrective action plan on 7/28/26:Staff will receive education of center abuse policy to include reporting and investigation of abuse, neglect, misappropriation, exploitation, and mistreatment policy.Audits will be completed for staff background checks.Resident interviews were conducted regarding abuse and mistreatment to ensure any form of abuse has not occurred.Livewell housekeeping and dietary staff education audits were conducted.Allegations of abuse received will be audited to ensure allegations have been reported timely weekly for four (4) weeks, then monthly for three (3) months. QAPI initiated and reviewed with the Medical Director on 7/28/26. The facility documentation identified that the estimated completion date was 7/29/26, with the exception for the ongoing audits. Based on the review of the facility's documentation, past non-compliance was identified as corrected on 7/29/26.

Based on clinical record review, facility documentation, facility policy and interviews for one sampled resident (Resident #1) who was reviewed for Resident Rights, the facility failed to ensure Resident #1's verbalization of his/her wish to have the specific family member who had been appointed as his/her health care representative prior to admission was acknowledged by the facility. The findings include:Resident #1's diagnoses included dementia, anxiety, unspecified convulsions, depression and end stage renal disease. The Durable Power of Attorney document dated 1/17/21 identified a specific family member was appointed Resident #1's Agent, the document was notarized and witnessed. The quarterly Minimum Data Set assessment dated [DATE], identified Resident #1 had some memory recall deficits. The Resident Care Plan dated 1/13/26, identified Resident #1 had impaired cognition related to dementia. Interventions directed to administer medications as ordered, communicate with the resident/family/caregivers regarding the resident's capabilities and needs, monitor, document, and report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status. Review of the complaint filed by a family member, Person #1, identified Resident #1 and Person #1 had attempted to provide the facility with a signed Appointment of Health Care Representative form, signed in 2021, appointing Person #1 as Resident #1's healthcare representative, however the facility failed to acknowledge the form and informed Resident #1 and Person #1 that the form was outdated and Resident #1 would have to get a new form through the court before they would acknowledge Person #1 as Resident #1's health care representative. The social service note dated 3/18/26 identified Social Services (SW) #1 and the Director of Nursing meet with the ombudsman who had indicated to the facility the durable power of attorney form supplied by Resident #1's family member was a valid document and Resident #1 could choose who he/she would like to be the primary contact and receiver of updates, medically. The note indicated another family member, Person #2, was contacted via phone during the meeting and shared he/she did not have an issue with Person #1 appointed as the health care representative, receiving updates. Interview with Person #1 on 3/27/26 at 8:58 AM identified the facility continued to acknowledge another family member as Resident #1's health care representative, even after Resident #1 verbalized his/her wishes to have Person #1 as the health care representative. Interview with Resident #1 on 3/27/26 at 10:54 AM identified Resident #1 had told facility staff, including the Director of Nursing and Social services his/her wish was to have Person #1 as his/her health care representative and he/she had expressed that he/she did not want Person #2 listed as the health care representative, but the facility failed to follow through on his/her wishes. Interview with SW #1 on 3/27/26 at 11:13 AM identified Resident #1 had expressed to him that he/she would like to have Person #1 as his/her health care representative. SW #1 identified he acknowledged to Resident #1 that he would speak with his supervisor and Person #2 and move forward from that point. SW #1 identified Resident #1 did have a signed appointment of health care representative dated 2021, but this had the potential to expire. SW #1 explained the facility did not have any documentation signed by Resident #1 indicating Person #2 was his/her health care representative. SW #1 identified he and the Director of Nursing met with the ombudsman on 3/18/26 and at that time it was concluded Person #1 could and should be considered as Resident #1's health care representative as part of his/her resident rights. SW #1 indicated at that time Resident #1's clinical record was changed to reflect the change. Review of Resident #1's clinical record on 3/2726 failed to reflect documentation Person #1 was Resident #1's health care representative and continued to identify Person #2 as the emergency contact. Interview with the Director of Nursing (DON) on 3/27/26 at 1:10 PM identified in February 2026 Resident #1 did indicate he/she would like Person #1 designated as his/her health care representative. The DON explained the facility did not acknowledge Resident #1's choice at the time of admission. The DON indicated the facility did not have anything in writing and signed that noted Person #2 was Resident #1's health care representative, and although the facility had asked Person #2 to bring in documentation, Person #2 did not submit documentation to the facility. The DON identified she informed Person #1 that Person #1 would need to speak with Person #2 prior to the facility changing the clinical record to reflect Person #1 as Resident #1's health care representative. The DON identified when the facility contacted Person #2, he/she agreed it was appropriate to have Person #1 listed as the health care representative. The DON identified at the time of this interview, Resident #1's electronic clinical record did not reflect the change from Person #2 to Person #1 as the health care representative/emergency contact. Review of the facility policy titled Resident Rights under Federal Law, last revised date 5/1/24, directed, in part, the resident has the right to dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. The policy further directed, in part, the resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Additionally, the policy directed, in part, in the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with state law and any surrogate so designated may exercise the resident's rights to the extent provided by state law, the resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative, the resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by state law, and the facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable laws.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1), reviewed for accidents, facility failed to ensure staff failed to notify the Registered Nurse (RN) supervisor after Resident #1 sustained a fall. The findings include:Resident #1 had a diagnosis of schizophrenia, falls, dementia, and difficulty in walking. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) indicating severely impaired cognition, required maximum assistance for bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 8/28/2025 identified the resident needs assistance with activities of daily living and was a risk for falls. Interventions directed to ensure the bed was in the lowest position, call light within reach, and required assist of two (2) staff with a mechanical lift for transfers. Nursing note dated 10/3/2025 at 11 AM identified Resident #1 reported an unwitnessed fall during the night. Resident #1 had facial grimacing upon movement to the left arm and shoulder with bulging to left shoulder joint. No visible bruising or bleeding was noted. Resident #1 had no range motion of the shoulder and complained of pain to the left shoulder. The physician was notified, pain medication was given, and Resident #1 was transferred to the hospital for evaluation. Facility reportable event dated 10/3/2025 at 2:45 AM identified Resident #1 had dementia (BIMS 3), was non-ambulatory and required two (2) staff for transfers via mechanical lift. The report indicated Resident #1 fell while trying to get up from bed to get his/her shoes. Resident #1 complained of left arm and shoulder pain. Resident #1 was transferred to the hospital, and x-ray identified an acute mildly displaced fracture of the surgical neck of the left humerus (upper arm bone). Physician indicated Resident #1 was not a surgical candidate and was returned to the facility. The reportable event summary dated 10/8/2025 identified after the fall, the Nurse Aide (NA) picked his/her arm from the floor and placed back in bed. The resident was transferred to the hospital and diagnosed with a mildly displaced left humerus fracture. The NA was called via phone and admitted the resident had a fall and she picked the resident up and placed him/her in bed. The NA also admitted she did not report the incident to the charge nurse. The NA indicated she know to not move a resident from the floor without an RN evaluation and to report a fall. Interview with RN #1 on 10/16/2025 at 11:02 AM identified she was the supervisor during the night shift on 10/3/2025 and she did not know Resident #1 fell during the shift; she informed afterwards by management that NA #1 picked the resident up off the floor following a fall. RN #1 stated that NA #1 should have informed her the resident fell and she would have completed an RN assessment. Interview with NA #1 on 10/16/2025 at 11:16 AM identified at around 2:45 AM she went to answer a residents call light and when she walked by Resident #1's room she noticed Resident #1was on the floor next to his/her bed. Resident #1 asked NA #1 to put her/him back into bed. NA #1 stated she placed her left hand on the resident's back and her other arm under the resident's legs, and picked him/her up and into bed. NA #1 stated she did not notify the change nurse, the Nurse Aide assigned (NA #2) or the supervisor. NA #1 stated she should have notified the nurse when she observed Resident #1 on the floor. Interview failed to identify why NA #1 did not notify the charge nurse or supervisor that Resident #1 was on the floor. Review of Facility Falls Management Policy dated 5/1/24 directed a fall was considered to have occurred when a patient was found on the floor. Patients experiencing a fall will receive appropriate care. Interview and record review with the Administrator, Director of Nursing (DNS), and RN #2 on 10/16/2025 at 2:17 PM identified Resident #1 required use of a mechanical lift with two (2) staff for transfers. The DNS stated on 10/3/2025 during the 7 AM to 3 PM shift Resident #1 reported he/she had fallen about 2:45 AM and someone picked him/her up and placed him/her back in bed. The DNS stated the facility investigation identified NA #1 observed Resident #1 on the floor on 10/3/2025 about 2:45 AM and NA #1 picked Resident #1 up off the floor herself and did not notify the nurse or supervisor prior to moving the resident. The DNS stated she did not know why NA #1 did not notify the charge nurse or supervisor, and stated NA #1 should have notified the nurse and an RN assessment should have been completed prior moving Resident #1. Facility documentation review identified staff education was initiated on 10/3/2025 and included directing staff to report any fall incident immediately to the charge nurse or supervisor, and an RN assessment must be completed before the resident can be moved from the location of the fall. A QAPI meeting was held on 10/3/2025, and audits were initiated on 10/5/2025. Based on review of facility documentation, past non-compliance was identified.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1), reviewed for accidents, facility failed to ensure the resident was transferred in accordance with the plan of care. The findings include:Resident #1 had a diagnosis of schizophrenia, falls, dementia, and difficulty in walking. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) indicating severely impaired cognition, required maximum assistance for bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 8/28/2025 identified the resident needs assistance with activities of daily living and was a risk for falls. Interventions directed to ensure the bed was in the lowest position, call light within reach, and required assist of two (2) staff with a mechanical lift for transfers. Nursing note dated 10/3/2025 at 11 AM identified Resident #1 reported an unwitnessed fall during the night. Resident #1 had facial grimacing upon movement to the left arm and shoulder with bulging to left shoulder joint. No visible bruising or bleeding was noted. Resident #1 had no range motion of the shoulder and complained of pain to the left shoulder. The physician was notified, pain medication was given, and Resident #1 was transferred to the hospital for evaluation. Facility reportable event dated 10/3/2025 at 2:45 AM identified Resident #1 had dementia (BIMS 3), was non-ambulatory and required two (2) staff for transfers via mechanical lift. The report indicated Resident #1 fell while trying to get up from bed to get his/her shoes. Resident #1 complained of left arm and shoulder pain. Resident #1 was transferred to the hospital, and x-ray identified an acute mildly displaced fracture of the surgical neck of the left humerus (upper arm bone). Physician indicated Resident #1 was not a surgical candidate and was returned to the facility. Emergency department physician note dated 10/3/2025 at 2:33 PM identified x-ray results indicated a proximal (close to the shoulder) humerus (upper arm bone) fracture, with a sling placed and plan for outpatient orthopedic follow-up. The reportable event summary dated 10/8/2025 identified after the fall, the Nurse Aide (NA) picked his/her arm from the floor and placed back in bed. The resident was transferred to the hospital and diagnosed with a mildly displaced left humerus fracture. The NA was called via phone and admitted the resident had a fall and she picked the resident up and placed him/her in bed. The NA also admitted she did not report the incident to the charge nurse. The NA indicated she know to not move a resident from the floor without an RN evaluation and to report a fall. Interview with NA #1 on 10/16/2025 at 11:16 AM identified at around 2:45 AM she went to answer a residents call light and when she walked by Resident #1's room she noticed Resident #1was on the floor next to his/her bed. Resident #1 asked NA #1 to put her/him back into bed. NA #1 stated she placed her left hand on the resident's back and her other arm under the resident's legs, and picked him/her up and into bed. NA #1 stated she did not know Resident #1's transfer status, and stated she did not know why she transferred the resident without knowing the residents transfer status. NA #1 stated she should have checked the residents transfer status prior to transferring resident. Interview and record review with the Director of Rehabilitation on 10/16/2025 at 1:35 PM identified Resident #1's transfer status required the use of a mechanical lift with an assistance of two (2) staff. The Director of Rehabilitation stated if Resident #1 was on the floor, one (1) staff member should not lift the resident off the floor and instead should use a mechanical lift with the assistance of two (2) staff. Interview and record review with the Administrator, Director of Nursing (DNS), and RN #2 on 10/16/2025 at 2:17 PM identified Resident #1 required use of a mechanical lift with two (2) staff for transfers. The DNS stated on 10/3/2025 during the 7 AM to 3 PM shift Resident #1 reported he/she had fallen about 2:45 AM and someone picked him/her up and placed him/her back in bed. The DNS stated the facility investigation identified NA #1 observed Resident #1 on the floor on 10/3/2025 about 2:45 AM and NA #1 picked Resident #1 up off the floor herself; NA #1 did not call for assistance or use a mechanical lift for the transfer. Interview identified NA #1 1 transferred Resident #1 back into bed alone, by placing one hand on the resident's back and the other under the resident's legs and scooped him/her up and placed Resident #1 back into bed. The DNS stated she did not know why NA #1 did not transfer Resident #1 per the care plan and indicated a mechanical lift should have been used to transfer the resident back into bed after an RN assessment was completed. Review of Facility Falls Management Policy dated 5/1/24 directed a fall was considered to have occurred when a patient was found on the floor. Patients experiencing a fall will receive appropriate care and be evaluated for injury and a total lift will be used to lift patients off the floor. Facility documentation review identified staff education was initiated on 10/3/2025 and included directing ensure residents were transferred in accordance wth the plan of care. A QAPI meeting was held on 10/3/2025, and audits were initiated on 10/5/2025. Based on review of facility documentation, past non-compliance was identified.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff for transfers, the facility failed to ensure the appropriate number of staff, two (2), transferred the resident via a mechanical lift to prevent a minor injury. The findings include:Resident #1's diagnoses included morbid obesity, osteoarthritis to the right knee, gait abnormalities, and generalized muscle weakness. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits and was alert and oriented to time and situation, and was dependent on staff for turning and repositioning when in bed and transfers getting in and out of the bed and chair. The Resident Care Plan dated 6/27/25 identified Resident #1 had a self-care deficit and was at risk for falls due to gait abnormalities and muscle weakness. Interventions directed assistance of one (1) with bed mobility and assistance of two (2) with mechanical lift transfers. The resident care card identified Resident #1 was out of bed daily with the assist of two (2) for transfers via a mechanical lift. The nurse's note dated 8/16/25 at 11:35 AM identified when Resident #1 was transferred via the mechanical (Hoyer) lift by staff, the bar on the lift brushed up against Resident #1's nose and caused a light nosebleed. A body audit was conducted, no other injuries were identified, and vital signs were stable. The note identified the nursing supervisor and Advanced Practice Registered Nurse (APRN) were notified and the APRN directed a facial x-ray be done and every fifteen (15) minute neuro checks were initiated. The nurse's note dated 8/16/25 at 6:55 PM identified the 7AM-3PM nursing supervisor, Registered Nurse (RN) #1, assessed Resident #1 and did not identify any bruising to the face. The note indicated Resident #1 had referred to the Hoyer transfer as quite a ride and clarified the statement meant the sling of the Hoyer was swinging while he/she was in it. Resident #1 had explained he/she did not hit any metal part of the Hoyer but after feeling the Hoyer pad straps, Resident #1 felt based on the texture of the straps, he/she had hit the end of the loops of the straps. The note identified Resident #1 declined going to the hospital for x-rays and wanted to wait until the x-rays could be done at the facility and continuously stated he/she was fine. A written statement dated 8/16/25 by the 7AM-3PM nurse aide, Nurse Aide (NA) #1, who had been assigned to Resident #1 on 8/16/25, identified after he provided care, he decided to Hoyer lift Resident #1 on his own because all other nurse aides were providing care to other residents. NA #1 wrote doing the transfer, the sling slid over and snagged Resident #1's nose. The nurse's note dated 8/17/25 at 10:35 PM identified the x-ray results of the face and nose were normal. A physician's progress note dated 8/22/25 identified Resident #1 was accidentally hit by a strap from the Hoyer lift while being transferred. The note indicated Resident #1 denied fear; however, he/she had refused to get out of bed and this behavior may have been exacerbated due to the incident, and there was also a potential for increase in anxiety. The note indicated to continue to encourage Resident #1 to get out of bed and monitor. The facility's summary report dated 8/25/25 indicated Resident #1 was being transferred out of bed to the wheelchair. According to staff and Resident #1's interviews NA #1 transferred Resident #1 alone with the Hoyer lift and although there was another nurse aide in the room, NA #1 failed to ask the nurse aide for assistance. The report identified the transfer resulted in Resident #1 hitting his/her nose on the sling pad causing a bloody nose. The conclusion indicated NA #1 was terminated for not following the facility policy on safe resident handling and the use of the mechanical lift. Interview with the 7AM-3PM charge nurse, LPN #1, on 9/2/25 at 12:30 PM identified NA#1 was wheeling Resident #1 to the dining room when she noticed Resident #1's nose was bleeding and NA #1 was not aware of the nosebleed. LPN #1 explained Resident #1 had stated he/she had a rough ride and that he/she hit his/her nose on the Hoyer sling. LPN #1 identified NA#1 admitted , although another nurse aide was in the same room providing care to another resident with the curtains drawn, NA #1did not ask that nurse aide for help with the transfer of Resident #1 because he did not want to bother the other nurse aide. LPN #1 indicated the facility policy was that two (2) people were to transfer a resident with a Hoyer lift. Interview with Resident #1 on 9/2/25 at 12:50 PM identified he/she recalled the event when he/she got a bloody nose during a transfer. Resident #1 was able to express that a male transferred him/her on that day, and he was by himself. Resident #1 explained that two (2) people usually transferred him/her out of bed. Resident #1 denied any pain after and stated nothing was broken or bruised. Interview with the nurse educator, (RN) #2, on 9/2/25 at 1:30 PM identified she trained staff on the safe transfer policies and NA #1 had training in February 2025 with the annual staff training and then again on 7/7/25 and passed both trainings. RN #2 indicated the requirement of two (2) staff to conduct all Hoyer lit transfers was reviewed with staff along with the facility transfer policy during training and NA #1 was aware of that requirement. RN #2 identified the proper transfer technique was to be done by two (2) staff working together as a team. A staff member stands on either side of the bed and assists the resident onto the lift pad and then the staff attach the top and bottom straps to the lift and ensure they are secure. Next, one (1) person assumes the role of the machine operator and the other person assumes the role of the guide or spotter of the resident's body. The guide would place their hands on the resident or sling during the transfer to ensure the resident remains in the proper position while the lift is being moved. The operator controls the machine by manipulating the machine up and off one surface and then moves to the proper position to the next surface and then lowers the resident. Interview with the 7AM-3PM nursing supervisor, RN #1, on 9/2/25 at 1:40 PM identified on 8/16/25 she was called to evaluate Resident #1 due to the nosebleed. RN #1 indicated after ensuring Resident #1 was okay she spoke with NA #1 and determined he did not follow the facility transfer policy and transferred Resident #1 alone and NA #1 admitted he should have asked for help. Interview with the Director of Nursing (DON) on 9/3/25 at 1:50 PM identified NA #1 failed to follow the facility policy on transfers of residents using a mechanical lift and NA #1 was terminated. Review of the Safe Resident Handling/Transfer facility policy identified in part that two (2) trained people were required to operate a total lift or sit to stand lift, regardless of if manufacturer instructions state only one person is needed. Attempts to interview NA #1 were unsuccessful.

Based on clinical record reviews, facility policy, facility documentation and interviews for one (1) of three (3) sampled residents (Resident #2) who had a change in condition, the facility failed to ensure care and services provided were in accordance with professional standards. The findings include:Resident #2's diagnoses included hypertension, hypothyroidism, hyperlipidemia, morbid obesity, malignant neoplasm of thyroid gland and endometrium, and weakness. The physician's order dated [DATE] directed a full code and administer Cardiopulmonary Resuscitation (CPR). The resident care plan dated [DATE] identified Resident #2 had an established advanced directive, full code. Interventions directed to activate resident's advanced directives as indicated, allow opportunities for expression of feelings and ask questions, and inform the resident and/or the healthcare decision maker of any changes in status or care needs. The 5-day [NAME] data set dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #2 was alert and oriented to person, place, and time. The nurse's note dated [DATE] at 7:05 A.M. written by the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #2, identified upon assessment Resident #2 had no pulse or cardiac activity, pupils were fixed and dilated, Resident #2 had significant mottling of the feet and hands. The note indicated CPR was initiated and continued for twenty (20) minutes with no return of circulation and RN #2 pronounced Resident #2's death at 4:00 A.M. A physician's order dated [DATE] directed to release Resident #2's body to the funeral home. A review of the clinical record from [DATE] through [DATE] failed to reflect a physician's order for RN Pronouncement. Interview with NA #2 on [DATE] at 11:59 A.M. identified on [DATE] at approximately 3:30 A.M. she went to Resident #2's room to check on Resident #2 at which time she noted Resident #2 was unresponsive and appeared not to be breathing. NA #2 indicated she tried to wake up Resident #2, by calling out his/her name, tapping him/her on the shoulders, but Resident #2 did not respond. NA #2 identified she immediately notified RN #2 that Resident #2 was unresponsive and would not wake up. NA #2 indicated RN #2 grabbed the crash cart, went to check on Resident #2, and alerted LPN #1 who was on the unit down the hall. NA #2 identified RN #2 and LPN #1 were in Resident #2's room initiating CPR and she went to provide care to another resident. NA #2 indicated on [DATE] at approximately 2:00 A.M. she had observed Resident #2 lying in bed, alive, and breathing. Interview with RN #2 on [DATE] at 12:25 P.M. identified on [DATE] at approximately 3:30 A.M. NA #2 told her Resident #2 was unresponsive, not breathing, and that she thinks Resident #2 expired. RN #2 indicated she immediately grabbed the crash cart, went down to assess Resident #2. RN #2 explained Resident #2 appeared deceased , he/she was not breathing, had no cardiac activity, no pulse, the hands and feet were mottled, blue and cold, and the pupils were fixed and dilated. RN #2 indicated she alerted LPN #1, who came down to the room, and they started CPR on Resident #2. RN #2 identified she and LPN #1 continued to administer CPR for approximately 20-30 minutes, but it was not effective, and Resident #2 was still deceased . RN #2 identified she left the room to make phone calls to the on-call provider and Resident #2's family while LPN #1 continued to administer CPR. RN #2 indicated Resident #2's responsible party declined transferring Resident #2 to the hospital and stated the family would come right down to the facility to see Resident #2. RN #2 identified she did not call Emergency Medical Services (EMS) because it appeared Resident #2 had some type of cardiac arrest, CPR was not successful in resuscitating Resident #2, and Resident #2's responsible party declined transfer to the hospital. RN #2 identified she pronounced Resident #2's death on [DATE] at 4:00 A.M. without a physician's order directing an RN pronouncement. RN #2 identified that she should have called EMS so the emergency room doctor could have pronounced Resident #2's death. Interview with the Medical Director, MD #1, on [DATE] at 12:55 P.M. identified his expectations when a resident who is a full code was found unresponsive, not breathing, without a pulse, that 911 was called, and CPR is initiated. MD #1 identified that on [DATE] when Resident #2 was found unresponsive, not breathing, without a pulse, and CPR was initiated, 911 should have been called so EMS personnel could have pronounced Resident #2's death. MD #1 identified on [DATE] that Resident #2 did not have a physician's order that directed an RN pronouncement of death and RN #2 should not have pronounced Resident #2's death. Interview with the Director of Nursing (DON) on [DATE] at 1:25 P.M. identified on [DATE] when Resident #2 was found unresponsive and CPR was initiated, RN #2 should have called 911, so EMS could have pronounced Resident #2's death. The DON identified RN #2 should not have pronounced Resident #2's death and RN #2 should have known that an RN pronouncement requires a physician's order. Interview with LPN #1 on [DATE] at 3:35 P.M. identified on [DATE] RN #2 notified her Resident #2 was unresponsive and thought Resident #2 had expired. LPN #1 identified that Resident #2 was a full code, so she immediately went down to Resident #2's room with RN #2. LPN #1 indicated when she entered the room, Resident #2 was unresponsive, not breathing with an arm dropped down to the side and Resident #2 was blue. LPN #1 identified she and RN #2 immediately started CPR, continued performing CPR together for approximately 20-30 minutes, then RN #2 left the room to make phone calls to the family and on-call provider, and she continued CPR until the family arrived. Review of facility cardiopulmonary resuscitation (CPR) policy; in part, identified if a patient does not have a do not resuscitate order (DNR), CPR certified staff will initiate CPR and emergency medical services (EMS) will be activated. CPR should also be discontinued when a provider, including a nurse (RN) or nurse practitioner (NP) pronounces death provided they have the authority to do so.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for accidents, the facility failed to ensure a resident's neurological assessments were conducted following an unwitnessed fall. The findings include:Resident #2's diagnoses included hypertension, hypothyroidism, hyperlipidemia, morbid obesity, malignant neoplasm of thyroid gland and endometrium, and weakness. The fall risk assessment dated [DATE] at 7:35 PM completed by Registered Nurse (RN) #3 identified Resident #2 at a high risk for falls. The care plan dated 7/9/25 identified Resident #2 at high risk for falls related to confusion, deconditioning, gait and balance problems, poor communication/comprehension, psychoactive drug use, and unaware of safety needs. Interventions directed to anticipate and meet the resident's needs, be sure the call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, encourage resident to ask for help prior to getting out of bed, ensure the resident is wearing appropriate footwear when ambulating, or mobilizing in wheelchair, and physical therapy to evaluate and treat as ordered and as needed. The 5-day [NAME] data set dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #2 was alert and oriented to person, place, and time, was occasional incontinent of bowel, always incontinent of bladder, dependent on staff dependent on staff for all activities of daily living, including bed mobility, and transfers, was non ambulatory and dependent on staff for mobility in the wheelchair. The Facility Reported Incident report dated 7/20/25 identified at 2:50 AM the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #2, heard Resident #2 calling out for help, LPN #2 ran down to the room, observed Resident #2 lying on the floor next to the bed with his/her head at the bottom of the bed, and notified the nursing supervisor, Registered Nurse (RN) #1. RN #1 identified Resident #2 was conscious, laying on his/her back on the floor next to the right side of the bed. RN #1 indicated Resident #2 had no injuries and denied any pain. RN #1 indicated he conducted a skin check and Resident #2 had no skin impairments. The nurse's note dated 7/20/2025 at 4:30 AM written by RN #1 identified he was notified by LPN #2 that Resident #2 was lying on the floor on the right side of the bed and Resident #2 was conscious and verbal. RN #1 indicated he assessed Resident #2, no injuries noted, and Resident #2 denied any pain. RN #1 identified Resident #2 denied hitting his/her head, and neuro checks were initiated. RN #1 indicated the Advanced Practice Registered Nurse (APRN) and Resident #2's responsible party were notified. The APRN note dated 7/21/25 at 1:20 PM written by APRN #1 identified she was asked to see Resident #2 following a fall incident in his/her room. The note indicated Resident #2 was stable and had no signs of acute distress, Resident #2's vital signs were within normal limits, Resident #2 denied any pain and denied hitting his/her head. The note identified neurological checks were initiated for seventy-two (72) hours and an order directed an X-ray of the pelvis and hip to further evaluate Resident #2. A physician's order dated 7/20/25 directed to obtain X-rays of pelvis and bilateral hips for general assessment. The radiology results report dated 7/20/25 at 9:37 PM identified the findings showed no fractures of the right hip, left hip, and pelvis. Review of the neurological evaluation flow sheet dated 7/20/25 directed to conduct neurological evaluations at the initial time of the incident, then every fifteen (15) minutes for the first two (2) hours, then every thirty (30) minutes for two (2) hours, then every hour for four (4) hours, and then every eight (8) hours for at least sixty-four (64) additional hours. The neurological evaluation flow sheet identified on 7/20/25 neurological evaluations were initiated at 2:50 AM, conducted every fifteen (15) minutes until 4:35 AM. On 7/20/25 at 4:50 AM, 5:20 AM, 5:50 AM, 6:20 AM and 6:50 AM, LPN #2 documented Resident #2 was asleep, and had stopped evaluating Resident #2's neurological status. The neurological evaluation flow sheet was completed again at 7:20 AM on 7/20/25 at 7:20 AM to 2:00 AM on 7/21/25 indicating Resident #2's neurological status was assessed. Interview with RN #1 on 8/21/2025 at 11:12 AM identified on 7/22/25 at approximately 2:50 AM, LPN #1 notified him Resident #2 had a fall and was lying on the floor in his/her room. RN #1 indicated when he entered the room Resident #2 was lying on his/her back on the floor next to the bed and Resident #2 was alert and responsive, denied hitting his/her head, denied any pain, and no injuries were noted. RN #1 identified he assessed Resident #2's neurological status, Resident #2's neuros were within normal limits, and initiated neuro checks. Interview with the 11PM-7AM nurse aide, Nurse Aide (NA) #4, on 8/21/25 at 11:19 AM identified on 7/22/25 at approximately 2:50 AM, LPN #2 yelled to her to come down to Resident #2's room. NA #4 identified when she entered the room Resident #2 was on his/her back lying on the floor next to the bed with his/her head next to the bottom of the bed. NA #4 indicated Resident #2 was alert, awake, and talking and after RN #1 assessed Resident #2, they assisted Resident #2 back into bed using a mechanical lift. Interview with LPN #2 on 8/21/25 at 11:30 AM on 7/22/25 at approximately 2:50 A.M. Resident #2 was yelling out for help, so she ran down to the room and observed Resident on his/her back on the floor next to his/her bed with his/her head at the bottom of the bed. LPN #2 indicated she notified RN #1 who came to assess Resident #2 and no injuries were noted. LPN #2 identified Resident #2 was assisted back into bed by RN #1 and the nurse aides via a mechanical lift. LPN #2 identified she evaluated Resident #2's neurological status every fifteen (15) minutes from 2:50 AM until 4:50 AM but at approximately 5:20 AM Resident #2 fell asleep, so she did not wake Resident #2 up the remainder of her shift to evaluate Resident #2's neurological status and left at 7:00 AM. Interview and clinical record review with the Director of Nursing (DON) on 8/21/25 at 1:25 PM identified her expectations are anytime a resident has an unwitnessed fall neurological evaluations are initiated and conducted per the frequency on the neurological flow sheet until complete. The DON identified on 7/20/25 when Resident #2 was sleeping, LPN #2 should have woken up Resident #2 and assessed Resident #2's neurological status. Although requested, a facility neurological assessment policy was not provided.

Based on clinical record reviews, facility documentation, facility policy and interviews for one sampled resident (Resident #1) who was reviewed for an allegation of abuse, the facility failed to ensure Resident #1 was free from physical contact with a staff member. The findings include:Resident #1's diagnoses included surgical aftercare of the circulatory system, dysthymic disorder, pleurodynia, dissection of aorta, thrombocytopenia, hypertensive heart disease without heart failure, depression and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, and time. The Resident Care Plan dated 5/14/25 identified Resident #1 at risk for injury or complications related to the use of antiplatelet therapy medication. Interventions directed to give medication as ordered, monitor for cyanosis and pallor, observe for complaints of pain of bone, abdomen, or joint, and observe for active bleeding. The nurse's note dated 7/26/25 at 5:24 AM identified at 5:00 AM Resident #1 informed the charge nurse, Licensed Practical Nurse (LPN) #1, he/she wanted to make a complaint that a nurse aide, Nurse Aide (NA) #1, grabbed his/her wrist too hard. The note indicated there was no injury, Resident #1 was upset and wanted to make a report to the police. The note identified NA #1 was sent home, the police were notified as well as the provider. The Facility Reported Incident form identified on 7/26/25 Resident #1 reported to the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #1, that the agency nurse aide, NA #1, grabbed his/her right wrist too hard, he/she was not hurt, but wanted to report the incident to the police., who were called and came to the facility to get the report. Review of the written statement signed by Resident #1 identified on 7/26/25 during the early morning hours, NA #1 was arguing and yelling with LPN #1 in the hallway when Resident #1 went out to the hallway and asked NA #1 why are you so loud at which time NA #1 walked towards Resident #1 and put his hand over Resident #1's right wrist. Resident #1 identified he/she pulled away from NA #1 and stated, don't touch me to which NA #1 allegedly stated you are not black. Review of LPN #1's written statement dated 7/26/25 identified during the shift, NA #1 reported to her that a resident had refused incontinent care. LPN #1 identified she informed NA #1 that Resident #1 had a history of initially refusing and she would go in and speak with Resident #1. LPN #1 indicated she spoke with Resident #1 and reported to NA #1 Resident #1 was willing to accept incontinent care, but at that point, NA #1 refused to provide the care without LPN #1 going into the room with him. LPN #1 identified she informed NA #1 Resident #1 did not require two (2) staff members for care, she was in the process of doing her medication pass and could not assist in the room at that time. LPN #1 identified NA #1 began to yell you're racist repetitively walking out of the room into the hallway and then touching his skin stating, my skin is black, not yours, you're racist. LPN #1 identified NA #1 continued yelling in the hallway while residents were in the hallway asking what was going on. LPN #1 identified Resident #1 stood outside of his/her room and stated to NA #1, why are you yelling, calm down, NA #1 proceeded to reach over and grab Resident #1's right arm/wrist at which time Resident #1 stated why are you grabbing me, don't touch me and NA #1 dropped Resident #1's arm/wrist. LPN #1 indicated she went to report this to the nursing supervisor, RN #1, and Resident #1 accompanied her to report the incident. Interview with NA #1 on 8/20/25 at 10:47 AM identified he did get into a verbal altercation with LPN #1, but NA #1 identified he did not abuse anyone. Interview with the nursing supervisor, RN #1, on 8/20/25 at 11:52 AM identified on 7/26/25, LPN #1 and Resident #1 reported that NA #1 had grabbed Resident #1's right arm/wrist. RN #1 identified it was reported after NA #1 got into a verbal argument with LPN #1, Resident #1 came out of his/her room and that was when NA #1 grabbed Resident #1. RN #1 identified NA #1 was immediately sent home, the police were notified, and the provider was notified. RN #1 identified Resident #1 had no injury. Interview and clinical record review with the Director of Nursing (DON) on 8/20/25 at 12:56 PM identified it was reported that on 7/26/25, NA #1 grabbed Resident #1's right arm/wrist after he/she came out to find out why NA #1 had been arguing and yelling at LPN #1 in the hallway. The DON identified the administrator initiated an investigation and NA #1 was placed on the do not return list. The DON identified interviews were done with staff members as well as other residents on the unit. The DON identified the facility policy was zero-tolerance for abuse, and it was the responsibility of all staff to ensure the policy is followed. The DON identified NA #1 did not follow the facility policy as he had been upset. Although attempted, an interview with LPN #1 was unable to be obtained. Review of the facility policy titled Abuse and Neglect, undated, directed, in part, it is the policy of the facility to prevent any form of abuse or neglect towards a resident or residents whenever possible and to promptly and completely investigate and act upon the incident.

Based on clinical record reviews and interviews for 4 of 5 residents reviewed for Unnecessary medication review (Residents #22, # 32, 58 and #86), the facility failed to ensure monthly pharmacy reviews were consistently completed. The findings included: 1. Resident #22's diagnosis included end stage renal failure, anxiety, major depression, thrombosis and gastrointestinal bleed. The care plan dated 2/10/2025 indicated Resident #22 was at risk for complications related to the use of psychotropic drugs. Intervention included having a gradual dose reduction as ordered, to monitor for side effects and consult physician and/or pharmacist as needed, and to monitor medications, especially new/changed/discontinued, for side effects and resident's/patient's response contributing to verbal behaviors The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 322 was cognitively intact, taking antipsychotic, antianxiety, antidepressant, opioid, antiplatelet and anticonvulsant medications. On 5/12/25 at 10:30 AM an interview, review of the clinical record and facility documentation with the DNS identified monthly pharmacist regimen reviews had been completed for 5/2024 and 6/2024 and 1/2025. The Director of Nursing Services (DNS) indicated May 2024, and June 2024 was prior to his/her start of employment at the facility in 8/2024. The DNS indicated the change in ownership consisted of a change in pharmacy companies and the person in charge at the time did not know the new pharmacy did not provide pharmacy consultants monthly for medication regimen reviews for each resident. The DNS indicated she/he would look for the 1/2025 monthly pharmacy review, but none were found. 2. Resident #32's diagnoses included unspecified dementia, schizophrenia and major depressive disorder. The care plan dated 3/5/25 identified Resident #32 is at risk for complications related to the use of psychotropic drugs. Interventions included: obtaining Abnormal Involuntary movement (AIMS) testing per protocol, gradual dose reduction as ordered, monitor for changes in mental status, functional level, effectiveness and for any adverse effects and report to the Medical Doctor (MD) as indicated. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was cognitively impaired and noted dependent for personal hygiene and oral hygiene care. The MDS also indicated Resident #32 was receiving antipsychotic medication on a routine basis. Review of clinical records identified no monthly medication regimen review was completed on 5/20/2024 for Resident # 32. Interview with the DNS on 5/12/25 at 10:30 AM indicated the facility switched pharmacy providers and the replacement pharmacy company did not have pharmacy services causing no pharmacy reviews for May 2024. She also could not explain why the other months did not have any pharmacy consultations. 3. Resident #58's diagnoses included Type 2 diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD) and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 58 as cognitively impaired and required substantial assistance with personal and oral hygiene. MDS also indicated the residents were receiving antipsychotic medications, anti-diabetic, anticoagulant, diuretic, opioids and other forms of medications. The care plan dated 3/26/25 identified Resident #58 is at risk or complication related to the use of anticoagulation therapy medication. Interventions included laboratory blood work as ordered, anticoagulant to be given as ordered etc. Review of clinical records identified no monthly medication regimen review was completed on for January 2024 and May 2024 for Resident # 58. Interview with the DNS on 5/12/25 at 10:30 AM indicated the facility switched pharmacy providers and the replacement pharmacy company did not have pharmacy services causing no pharmacy reviews for May 2024. She also could not explain why the other months did not have any pharmacy consultations. Facilities Consultant Pharmacy Provider requirement policy indicates in part Reviewing medication administration records, treatment administration records and physician orders (at least monthly). This monthly review is documented in the patients' medical record. 4. Resident #86's diagnosis included cerebral infarction, seizures, kidney failure and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident was severely cognitively impaired, noted no behaviors, utilization of antipsychotic, antidepressant hypoglycemic and antiplatelet medications. The care plan dated 3/21/2025 indicated Resident # 86 Resident is at risk for complications related to the use of psychotropic drugs. Interventions included in part to monitor for side effects and consult physician and/or pharmacist as needed. An interview and record review with the DNS on 5/8/2025 at 1:05 PM indicated the pharmacy regimen reviews were found in a binder all were present except 5/2024 and 6/2024. On 5/12/2025 at 10:30 AM the Director of Nursing Services (DNS) indicated May 2024 and June 2024 she/he was unable to provide the missing reports.

Based on observations of the facility Medication Storage and labeling, facility policy and interviews reviewed for 2 of 3 (1 North and 2 South Units) medication rooms, the facility failed to ensure that an expired medication was discarded. The facility failed to ensure the fridge temperatures were consistently checked and documented and failed to ensure that refrigerators were locked, utilizing locks. The findings included: 1. Observation on 5/13/25 at 10:15 AM of the medication room on 1 north identified the medication refrigerator containing medication was not securely locked with a padlock. Interview with RN#2 indicated she was just in the medication room and must have forgotten to lock it. After inquiry, the lock on the medication refrigerator was secured. 2.Observation on 5/13/25 at 10:37 AM of medication room on 2 South identified an Ear wax Removal Drop had expired on 11/13/24, stored in the medication room. Interview with RN#5 on 5/13/25 at 10:37 AM indicated the medication should have been discarded once the residents was no longer at the facility. RN#5 identified the nursing staff is responsible for going through and checking the medication rooms weekly for expired medications. She also indicated the ear wax removal must have been missed in error. 3. Observation on 5/13/25 at 10:52 AM of 2 South medication room identified missing temperatures/signatures for the refrigerator temperature logs. Missing dates were as follows: For the month of May 2025 (5 days), For the month of April 2025 (20 days) for the month of March 2025 (25 days), February 2025 (23 days) and January2025 (10 days) where refrigerator temperatures were not checked and signed off on. Interview with RN#5 and LPN #3 on 5/13/25 at 10:52 AM identified the temperature logs should completed daily on the 11-7 AM shift. They could not explain why this is not being done. 4.Observation on 5/13/25 at 10:57 AM of the refrigerator on 2 South medication room unlocked. Interview with LPN#3 on 5/13/25 at 10:57 AM indicated the lock was broken, therefore they were unable to use the padlock to close the refrigerator (which was storing medications). LPN #3 was unsure how long the lock had been broken. After the inquiry, the maintenance department was informed of the broken lock. Facilities Medication Storage policy indicated in part, Temperatures will be checked daily to ensure, it is the specified. Policy further indicates expired medications will be removed from the medication storage areas and disposed of in accordance with facility policy.

Based on observations of the dining, facility policy and interviews, the facility failed to ensure meals were served at the appropriate temperature. The findings include: Observation on 5/08/25 at 8:20 AM of food trucks leaving the kitchen. Observation on 5/08/25 at 8:20 AM of the food truck arriving at 2 North unit. Further observations identified dietary trays being passed out by all staff members. Observation on 5/08/25 at 9:06AM of the last resident on Unit 2 North being served (resident dining in the room). Food items leaving the kitchen were noted at the following temperatures: pureed eggs 200 degrees, pureed hash brown 198 degrees and pureed bread 182 degrees). However, during a test tray on 5/8/25 of the breakfast meal identified the following temperatures pureed hashbrowns were 110.1 degrees, pureed bread 106-degrees, pureed eggs were 106.3 degrees, (these food items left the kitchen at the following temperatures: pureed eggs 200 degrees, pureed hash brown 198 degrees and pureed bread 182 degrees). Interview with the Food Service Director on 5/08/25 at 9:06 AM identified the expectation is that meals are served warm. He further indicated the temperatures obtained were not considered warm enough for consumption. He also identified 135 degrees is acceptable for hot food temperatures and anything below that would need to be reheated Interview with DNS on 5/12/25 at 11:47 AM identified residents in the dining room and on the floors should be served warm food. The DNS also indicated that once the food trucks arrive on the unit, the food trays should be immediately distributed to the residents. She also indicated she believes the organization of the trays and delivery of the food trucks should be taken into consideration prior to leaving the kitchen to assist with efficient passing of the trays. The DNS expressed her suggestions to the kitchen staff after inquiry. The Facilities Food and Nutrition Dietary Services and Procedure policy indicates in part, Each resident shall receive, and facility should provide food and drink that is palatable and at a safe and appetizing temperature.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents ( Resident # 71), reviewed for Preadmission Screening and Resident Review ( PASARR), the facility failed to ensure a newly identified mental health diagnosis was referred to appropriate state- designated mental health authority for a level 2 evaluation. The findings include: Resident #71's diagnoses included schizoaffective disorder, mild cognitive impairment and delusional disorder. Review of Resident # 71 clinical records indicated identified a Level II was done on April 13, 2022, with a qualified diagnosis delusion. Further review of Resident #71 clinical records indicated a new diagnosis of schizoaffective was identified on 10/8/23. However, there was no evidence of a referral submitted to the appropriate state- designated mental health authority for a level 2 evaluation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was severely cognitively impaired. Resident #71 was noted independent with eating, bed mobility and personal hygiene. The resident's mood and behavior were unable to be assessed. The care plan dated 4/10/25 identified Resident #71 exhibits psychosocial distress with own well-being and/or social relationships related to: Illness/Disorder/Disease process: hallucinations delirium, mental retardation/developmental disability, use of antipsychotic medication. Interventions included to evaluate need for psychiatric/ behavioral health consult and document frequency and impact of the behaviors. Interview with Social Worker (SW #1) on 5/7/25 at 1:50 PM identiifed she would be informed by the psychiatry or the nursing team if there is a new diagnosis or change in condition (related to mental health). Social Worker #1 reported, given Resident #71 was long term care resident who has a history of a level II evaluation, she was not aware that a new referral had to be submitted for new mental health diagnosis. Facilities Social Services Policies and Procedure (Pre-admission Screening for mental Disorder and/or Intellectual Disability Patients) indicates in part, Notify the state mental health authority as applicable promptly after a significant change in mental or physical condition of a patient who has a mental disorderfor review.

Based on review of the clinical record, review of facility policy and staff interviews for 1 of the 3 residents reviewed for Activities of Daily Living (ADL) for (Resident #111), the facility failed to ensure the resident consistently received scheduled showers. The findings include: Resident #111's diagnoses included Guillain-Barre Syndrome (a neuromuscular disease) and muscle weakness. The care plan dated 4/29/2025 identified Resident #111 required assistance to perform activities of daily living, such as bathing and grooming, related to limited mobility. Interventions included helping with transfers with a rolling walker. The quarterly MDS assessment dated [DATE] identified Resident #111 was cognitively intact and required partial/moderate assistance for bathing/showering and partial/moderate assistance for transferring to and from the tub/shower. On 5/6/2025, an interview with Resident #111 indicated his/her shower day was Wednesday on the 3:00 PM to 11:00 PM shift. The resident indicated she/he had missed two showers on 4/23/2025 and 4/30/2023. Resident # 111 further indicated staff had told him/her the day staff were too busy to provide her/him with a shower. Additionally, Resident #111 recalled she/he had spoken to Nurse Aide (NA#3) regarding the missing showers. Resident #111 further indicated NA#3 recommended the resident notify the unit manager (RN#6). A review of Nursing Aide medical record documentation for bathing from 4/15/25 through 5/10/25 identified Resident #111 had one documented shower on 5/9/2025. Resident # 111 received bed baths on 4/15, 4/18, 4/22, 4/25, 4/29, 5/2, 5/6, and 5/9/2025. There was no documented bath or shower for 4/23 or 4/30/ 25 when the resident's shower day was scheduled. On 5/12/2025 at 11:11 AM, an interview with NA#1 indicated she recalled showering the resident on 5/9/2025 and indicated the week prior (4/30/2025), she had not showered the resident. NA#1 indicated she offered the resident a shower between 3:00 PM and 4 :00 PM, but the resident had requested a later shower. NA#1 further identified the resident requested the shower at 9:30 PM. NA#1 further indicated that at that time it was too late for a shower because the resident was an assist of two staff member to get up from the bed and shower. Na #1 also indicated all staff members were busy during that time of Resident # 111 request. NA#1 further indicated the resident complained to her (NA# 1) that she/he had missed a shower day when NA#1 was off but could not recall the date. NA#1 indicated when a resident receives showered, nurse aides document the shower in the medical record. On 5/12/2025 at 11:45 AM, an interview with the NA taking care of Resident #111 for the day (NA#2) identified Resident #111 complained to him that she/he had not received a shower the week of April 28 but could not recall the exact date. NA#2 indicated that he notified RN#6 about the resident's complaint. NA#2 indicated he was not aware of the outcome of the resident's complaint. On 5/12/2025 at 12:00 PM, an interview and record review with RN #6 identified she had been notified of the resident's complaint. RN#6 indicated she had not yet spoken to NA#1 (who had been caring for Resident #111) but had spoken to another nurse aide on the 3 :00 PM to 11 :00 PM shift that provided showers to Resident # 111. RN#6 indicated the resident has psychiatric diagnoses that may contribute to the resident thinking she/he did not get showered. RN #6 was not able to identify why the shower documentation in the medical record failed to identify that showers were given. RN # 6 also indicated that the expectation was that nurse aides document the resident shower in the electronic medical record. On 5/12/2025 at 12:39 PM, an interview with NA #3 indicated Resident #111 had complained to him that she/he had not received a shower. NA #3 indicated that he later spoke to NA #1 and NA #1 had assured him Resident # 111 had been getting showers. NA #3 was unable to recall when Resident #111 had complained of not getting a shower. NA #3 further indicated that showers are documented in the computer by the nurse aides. On 5/12/2025 at 12:45 PM, a review of nursing progress notes from 4/22/2025 through 5/9/2025 and the behavior monitoring from 4/1/2025 to 4/30/2025 failed to identify behaviors of care refusal or psychotic behaviors that would have contributed to the resident not receiving showers. The facility policy for Activities of Daily Living given onsite notes documentation of ADL care is recorded in the medical record and must be reflective of the care provided by nursing staff. The policy also indicated that ADL care must be documented in real time, as close to the time that care was provided.

Based on review clinical record reviews, observation, facility documents, review of policy and interviews for 1 of 4 residents reviewed for accidents (Resident #38), the facility failed to ensure a physician order was written for a diagnostic x-ray after a fall and for 1 of 1 resident reviewed for positioning (Resident #271), the facility failed to ensure the resident's cervical collar was positioned appropriately. The findings included: 1.Resident #38's diagnosis included dementia with behavioral disturbance and repeated falls. The annual MDS assessment dated [DATE] indicated Resident #38 was severely cognitively impaired, had 2 or more falls since prior assessment with no injury, no impairment of the upper and lower extremities and utilized a walker with supervision or touch assist to walk 10 feet once standing. The care plan in place on 7/30/2024 indicated Resident #38 was at risk for falls due to cognitive loss and lack of safety awareness. Interventions included: provide verbal cues for proper pacing and provide a clutter-free environment in the room, obtain psychiatric evaluation for increased agitation during the evening, when the resident attempts to stand unassisted, to provide cues to sit down and wait for assistance and noted the utilization of a wheelchair for safety due to not safe to ambulate independently with a walker. A nursing progress note dated 8/23/2024 at 05:47 PM indicated the Registered Nurse (RN) was called to the unit as Resident #38 fell after eating dinner when she/he attempted to stand. The RN indicated Resident #38 complained of pain in the right thigh, was assessed by the RN and placed in the wheelchair and transported to his/her room. The note further indicated that the Advanced Practiced Registered Nurse (APRN) was notified who then ordered an x-ray of the right hip and thigh and the Power of Attorney was notified. A nurse's note dated 8/23/2024 at 4:16 PM indicated in part, the responsible party was notified and informed an x-ray of the right thigh would be completed. The Radiology Report results for an x-ray of the femur 2 views was reported to the facility on 8/24/2024 at 9:11 AM (x-ray obtained on 8/23/2024 at 9:10 PM) indicated no acute fractures or dislocations, the femoral head and neck were intact if symptoms persist consider a follow up x-ray as clinically warranted. On 8/24/2024 at 7:02 PM a Nurse Practitioner telehealth notification note indicated the hip x-ray was negative for fracture. An interview and verbal review of the clinical record with APRN #1 on 5/13/2025 at 11:40 AM with the ADNS and DNS present indicated s/he no longer worked at the facility and had no access to clinical records. APRN #1 further indicated she/he could not recall what type of x-rays were ordered at the time of the fall and cannot recall the hip x-ray was completed only a femur x-ray. The DNS indicated the nursing notes dated 8/23/2024 identified a hip x-ray and a femur x-ray were ordered by the provider (APRN#1) and a note contacting the responsible party about Resident # 38's x-ray of the thigh would be completed. However, the two notes indicated different x-rays, but the physician order (never written) would have clarified what was ordered. The DNS further indicated the femur x-ray completed indicated the femoral head and neck were intact. The DNS also indicated a physician's order for the type of x-ray was not written. A facility policy labeled Physician/Advanced Practice Provider Orders reviewed and revised on 3/01/2022 indicated the facility policy is to ensure all physician orders were received from a credentialed practitioner before implementing. The policy further indicated that the licensed person taking the order must enter the physician's order into the electronic order management system. A Facility policy labeled Transcription of Orders reviewed and revised on 5/01 2023 indicated in part, transcribing is the recording of physician's orders obtained from a provider by an RN or Licensed Practical Nurse (LPN). 2. Resident #271 was admitted on [DATE] with diagnoses that included a cervical spine fracture and a brain bleed. The admission nursing assessment dated [DATE] identified Resident #217 was alert and oriented to self and place but not to time. The assessment also noted the resident as slightly limited in mobility. A physician's order dated 4/23/2025 directed to maintain cervical collar at all times and noted may be removed for care as needed until 7/23/2025. A care plan dated 4/23/2025 indicated Resident #271 had a self-care performance deficit related to a fracture of the cervical spine. Intervention included assisting to turn and reposition in bed. On 5/5/2025 at 1:20 PM, Resident #271's rigid cervical collar was observed to be inappropriately positioned, with the chin piece, which is usually positioned under the wearer's chin, on the resident's chin, right under the resident's lower lip. The front piece, which is usually positioned on top of the wearer's chest, was floating over the wearer's chest. On 5/5/2025 at 1:30 PM, an observation and interview with LPN #4 indicated that was how the resident's collar was supposed to fit since that is how it had always been placed. LPN #4 also indicated that the collar is removed for care and the last time she removed collar was on 5/5/2025 at 8:30 AM to inspect the skin. LPN#4 also indicated that physical therapy had provided staff with an in-service when the resident first arrived at the facility, but that she did not work that day. On 5/6/2025 at 2:44 PM an observation and interview with the Director of Physical Therapy (PT#1) identified Resident #271's collar was not appropriately positioned and PT #1 observed that the resident's chin piece was on the resident's chin close to the lower lip and the front piece was again floating over the resident's chest instead of directly on the resident's chest. PT #1 indicated that the collar was not positioned appropriately and proceeded to adjust Resident #271's collar to the correct position. A review with PT#1 of the resident's Physical Therapy Evaluation dated 4/24/2025 identified PT#1 had educated the resident and the staff on appropriate collar alignment. PT#1 further indicated that he had educated the staff who were on shift that day, including the unit manager. PT #1 also indicated Resident #271 receives physical therapy and occupational therapy, and the resident had received occupational therapy on 5/6/2025. On 5/7/2025 at 9:51 AM, an interview with Occupational Therapist (OT#1) indicated she had provided occupational therapy to the resident on 5/6/2025 after lunchtime around 1:30 PM or 2:00 PM. OT#1 indicated the resident moves the collar and she provided education to the resident. OT#1 indicated that when she left the resident on 5/6/2025, the collar was appropriately positioned. OT#1 did not recall if she had provided education to nursing staff regarding the resident's collar position. A review of the resident's care plan and nursing progress notes from 4/28/2025 through 5/7/2025 failed to identify instances where the resident was noted to be moving the cervical collar or behaviors that would contribute to inappropriate collar alignment. After surveyor's inquiry, a care plan dated 5/7/2025 identified that Resident #271 was resistant to care related to the cervical collar, with interventions including checking the collar placement and reiterating the importance of keeping the collar properly in place as directed per plan of care. The facility policy for Cervical Collar Application dated 5/1/2023 indicated that a wearer's chin must fit into the indentation on the front aspect of the collar.

Based on clinical record review, observation, facility policy and staff interviews for the only resident reviewed for Pressure Ulcer (Resident #99), the facility failed to ensure a physician order was obtained for mattress setting for a specialty mattress and failed to ensure licensed staff checked the settings per the facility policy. The findings include. Resident #99s diagnosis include dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #99 was severely cognitive impairment and a stage 3 pressure ulcer that was not present on admission. The care plan dated 4/15/2025 indicated in part Resident #99 was at risk for skin breakdown due to impaired cognition, incontinence, limited mobility, poor safety awareness and noted a Stage 3 pressure ulcer of the right trochanter. Interventions included: to provide a pressure redistribution surface to the chair and bed, to provide wound treatments as ordered and to reposition 4 times per shift. An observation on 5/5/25 at 12:23 PM noted Resident #99 in bed with an air mattress on the bed with the setting halfway up from soft. On 5/7/25 at 12:13 PM during an interview and record review with LPN #1 indicated the physician would write a physician's order then staff would set up the air mattress based on the resident's weight. However, LPN # 1 was unable to locate a physician order for the air mattress or any instructions for the settings and monitoring of the mattress. An interview and record review and facility policy review with the Director of Nursing Services (DNS) on 5/7/25 at 1:30 PM indicated s/he would have expected a physician order for the mattress along with settings and the nursing staff is responsible for monitoring the mattress. The facility policy labeled Specialty Mattress Replacement surfaces: Use of indicted in part a resident would be evaluated to determine the need for placement of, or the utilization of a specialty mattress and a physician's order will be obtained. The policy further indicated the settings would be adjusted to the manufactures settings by nursing, settings would be checked by a licensed nurse, and the bed kept in the low position when a resident was unsupervised.

Based on clinical record, facility policy review and staff interview for 1 of 4 residents (Resident #117) reviewed for nutrition, the facility failed to ensure weights were obtained per facility policy for a resident with weight loss. The findings include. Resident #117's diagnosis included obesity, dysphagia and aphasia. The electronic documentation section labeled vital signs/weights indicated on 3/4/2025 noted Resident #117 weighed 155.0 pounds. The electronic documentation section labeled vital signs/weights indicated on 4/13/2025 Resident #117 weighed 147.6 pounds (6.4 pounds weight loss in 39 days and no re weight obtained to verify the weight loss). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #117 had severe cognitive impairment, held food in mouth cheeks, weight was 148 pounds with no loss or gain of 5% in the last 30 days or 10% in the last 6 months, and noted the resident was on a mechanically altered diet. The care plan dated 5/6/2025 indicated in part Resident #117 was at risk for nutrition and hydration changes related to a mechanically altered diet, variable oral intake, dysphagia significant weight loss and obesity. Interventions included: to monitor for signs of malnutrition, holding food in the mouth, refusing to eat, difficulty swallowing, to monitor/report and record notification of the physician if Resident #117 had lost 3 pounds in a week, greater than 5% weight loss in one month, 7.5% in 3 months or 10% weight loss in 6 months and to obtain weight as ordered. A physician's order dated 4/24/2025 directed to obtain a weight on the 7-3 PM shift every Friday for 4 weeks. A physician's order dated 4/24/2025 directed to obtain weight on the 7-3 PM shift monthly during the first 5 days of the month. Resident #117 was readmitted to the facility from the hospital on 4/24/2025. A Nutritional assessment dated [DATE](4 days after readmission) indicated Resident #117 had been readmitted after a hospitalization with noted weight loss of 4.8% since 3/4/25 and triggered for a 5.5% weight loss from 3/4/25-4/11/25. A readmission weight was requested from nursing staff. Recommendations included 120mls of house supplement twice daily and to obtain a readmission weight. The electronic documentation section labeled vital signs/weights indicated on 4/30/2025 at 8:26 AM Resident #117 weighed 140.0 pounds (7.4 pounds within 29 days and readmission weight was obtained 6 days after readmission to the facility and 2 days after the dietician requested the readmission weight be obtained). No weight was documented as obtained to verify the weight loss. On 5/9/25 at 12:48 PM an interview and record review with the unit manager RN #6 indicated she/he did not know why a weight for the resident was not completed on readmission and reweights were not taken when weights were noted to be 5 pounds or greater less. RN #6 further indicated s/he had monitored the weights monthly after the monthly weights are obtained the first week of the month and did not look at the weights after when residents were readmitted from the hospital. RN # 6 further indicated she/he would look at results for residents with specific orders for daily or weekly weights. RN #6 further indicated not being able to find any documentation of the weight loss or that the physician was notified. After surveyor inquiry, RN # 6 indicated s/he would notify the physician and write a nursing note (26 days after the 6.4-pound weight loss noted on 4/13/2025 and 9 days after the 7.4-pound weight loss was noted on 04/30/2025). The facility policy labeled Monitoring Weights dated 4/09/2025, indicated in part resident weights are obtained within 48 hours of admission and readmission then weekly for 4 weeks. The policy further indicated that residents with an unplanned weight loss/gain of 5 pounds or more must be reweighed within 24 hours and a significant gain or loss of weight must be 1. Documented by nursing in the nursing progress notes 2. The care plan adjusted/revised accordingly. 3. Notification to the physician of the loss /gain 4. Refer to Dietician and the DNS for review.

Based on review of employee files, facility documentation for skills competency and interview for 1 licensed staff (LPN # 8), the facility failed to ensure licensed staff completed clinical competency validations to provide nursing and related services to meet the residents' needs safely for the year 2024. The findings include:. A review of LPN #8's personnel file identified the date of hire as 5/23/23. However, the employee file failed to identify that Clinical Competency Validations were completed for the year 2024 for LPN # 8 and other licensed staff members. The Facility assessment dated [DATE] identified in part, employee competency assessment and education are an integral part of maintaining proper care of Residents. Staff should possess a clear understanding of their scope of practice and the duties they are responsible for daily. Interview with the Director of Nursing Services (DNS) on 5/13/25 at 11:30 AM identified no licensed staff received clinical competency validations for the year 2024. The DNS further indicated the former Staff Development employee, who was responsible for conducting the competency validations, did not complete them prior to leaving the organization. The DNS also identified that moving forward, the Assistant Director of Nursing Services (ADNS) will assume responsibility for conducting clinical competency validations. A policy for clinical competency validations for licensed staff was requested but not provided.

Based on clinical record reviews and staff interviews for 2 of 5 residents reviewed for (Residents # 26 and # 58) reviewed for vaccinations, the facility failed to obtain an influenza vaccine consent or refusal from the resident's responsible party. The findings include: 1 Resident #26 was admitted to the facility with diagnoses that included [NAME] encephalopathy (a severe neurological condition caused by a Vitamin B1 deficiency). An annual MDS assessment dated [DATE] indicated Resident #26 had severe cognitive impairment A care plan reviewed on 4/14/2025 indicated Resident #26 had a court-appointed conservator with interventions that included involving the conservator in care planning. On 5/7/2025 at 11:50 AM during record review and interview with the facility Infection Preventionist (LPN#5) identified Resident #26's Conservator of Person (COP) had consented to yearly influenza vaccination on 9/25/2023. The resident's immunization record identified that on 10/3/2023, the resident refused the influenza vaccine. The immunization record failed to indicate if the resident had received or been offered the influenza vaccine for the 2024-2025 season. An interview with LPN#5 identified Resident #26's COP had changed in November of 2024 and that neither consent nor refusal had been obtained from the new conservator. 2. Resident #58'S diagnoses included bipolar disorder and dementia. An MDS assessment dated [DATE] indicated Resident #58 had severe cognitive impairment. A care plan reviewed 4/29/2025 indicated Resident #58 had a court-appointed conservator with interventions that included involving the conservator in care planning. On 5/7/2025 at 11:50 AM during record review and interview with the facility Infection Preventionist (LPN#5) identified Resident #58 had given consent for influenza immunization on 9/29/2023. The resident's immunization record identified that on 10/4/2023, the resident received the influenza vaccine. The immunization record failed to indicate if the resident had received or been offered the influenza vaccine for the 2024-2025 season. An interview with LPN#5 identified Resident #58 was self-responsible in October 2023 and then was assigned a Conservator of Person (COP) in November 2023, and that neither consent nor refusal had been obtained from the conservator for the 2024-2025 influenza season. LPN#5 indicated that emails were sent in October 2024 for COP and Power of Attorneys to contact the facility to provide consent for the influenza vaccine. The facility then sent another email in December 2024 with education and consent forms to designated contacted people. LPN #5 further indicated that she received an email from Resident #58's conservatory requesting a list of all the residents conserved by them who reside at the facility to provide consents. LPN#5 indicated that she had not sent a list back to the conservator since the list dated 2/17/2025 had not been updated.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for discharge, the facility failed to provide discharge education for a diabetic resident newly prescribed insulin and failed to ensure medication reconciliation prior to discharge resulting in a resident being discharged home without prescribed medications and supplies. The findings include: a. Resident #1 had diagnoses that included type 2 diabetes mellitus, zoster, lack of coordination, and pneumonia. Review of a hospital note dated 2/16/2025 at 5:23 P.M. by MD #2 identified Resident #1 would start taking a steroid, h/her blood sugars may increase, and to continue with insulin sliding scale. The nursing admission assessment dated [DATE] at 1:49 P.M. by the Assistant Director of Nurses (ADNS) identified care management teaching and training education was not provided. APRN #1's note dated 2/24/2205 at 9:18 P.M. identified Resident #1's blood sugar levels were elevated in the setting of steroid use and were managed with insulin sliding scale. The Resident Care Plan dated 2/24/2025 identified Resident #1 had diabetes mellitus with nephropathy and interventions including diabetes medication as ordered by the provider, monitor and document for side effects and effectiveness, educate regarding medications and importance of compliance, have the resident verbally state an understanding, educate resident on diabetes as a chronic disease and that compliance is essential to prevent complications, review complications and prevention with the resident, elicit a verbal understanding from the resident, monitor/document/report any signs or symptoms of hyperglycemia or hypoglycemia. A physician's order dated 2/24/2025 directed to administer Insulin Lispro (a medication for diabetes mellitus) per sliding scale: if blood sugar is 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 399 = 10 units above 400 call MD, intramuscularly three times daily for diabetes mellitus. A social service note dated 3/12/2025 at 3:56 P.M. by Social Worker (SW) #1 identified she met with Resident #1 for discharge planning and Resident #1 stated h/she was not ready for discharge and had stairs at home. The note indicated Resident #1's plan was to discharge home when h/she was able to and started working on stairs with therapy. The Notice of Medicare Non-Coverage (NOMNC) dated 3/12/2025 identified Resident #1's Medicare coverage would end on 3/14/2025. The Quality Improvement Organization (QIO) dated 3/13/2025 identified Resident #1 requested an appeal and based on review of the medical record it was determined that termination of skilled services was appropriate. A social service note dated 3/14/2025 at 10:23 A.M. by SW #1 identified Resident #1's discharge plan documentation, discharge summary, and transition plan were completed. The discharge plan documentation dated 3/14/2025 at 10:23 A.M. by SW #1 and RN #1 (unit manager) identified Resident #1's estimated/scheduled discharge date was 3/15/2025 at 11:00 A.M. to h/her home alone with home health services and that Resident #1 had no changes or discontinuation of h/her medications. RN #1 indicated that Resident #1's current reconciled medication list was provided to the subsequent provider. APRN #1's note dated 3/14/2025 at 12:57 P.M. identified Resident #1 was seen for a physical assessment for a possible discharge to home/community on 3/15/2025. APRN #1 identified SW #1 notified her Resident #1 was no longer covered by insurance and Resident #1 agreed to discharge home. The note identified Resident #1 had h/her own medications that were brought to the facility on admission to the facility. The note identified Resident #1 was to continue current medication orders and that Resident #1 was educated to continue taking medications as ordered. The discharge summary medication list dated 3/14/2025 directed to inject Insulin Lispro as per sliding scale: if blood sugar is 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 399 = 10 units above 400 call MD, intramuscularly three times a daily. A physician's order dated 3/15/2025 directed to discharge Resident #1 to home/community on 3/15/2025. Nurse's progress notes from 2/24/2025 to 3/15/2025 failed to identify documentation to reflect education on management of diabetes mellitus, how to obtain a blood sugar with the use of a glucometer, use and action of Insulin Lispro, insulin sliding scale, or how to self-inject insulin. A nurse's note dated 3/15/2025 at 10:47 A.M. by RN #1 indicated she reviewed all medications with Resident #1, h/she stated understanding of use and classification, and h/she was discharged home with services. Interview with RN #1 on 4/4/2025 at 9:45 A.M. indicated that identified educational needs for residents should be addressed before residents discharge and any medical equipment should be ordered. RN #1 identified that Lispro Insulin was a new medication for Resident #1 since the most recent hospitalization. RN #1 identified that Resident #1 required education on diabetes management which included the use of Lispro Insulin, sliding scale, how to inject insulin, and how to obtain blood sugars using a glucometer. RN #1 identified Resident #1 was not provided with education during h/her admission to the facility and could not explain why. RN #1 identified on 3/18/2025 (3 days after discharge) she went to Resident #1's home with a glucometer, the required supplies to obtain blood sugars, and provided verbal education to Resident #1. RN #1 identified that she did not communicate to APRN #1 that Resident #1 needed a glucometer, and supplies ordered. RN #1 identified that Resident #1 should have been provided with education prior to h/her discharge on [DATE]. Interview with RN #2 on 4/4/2025 at 11:52 A.M. identified on 3/15/2025 when Resident #1 was discharged she was not aware that Resident #1 required education on how use a glucometer to check blood sugars, how to administer Lispro Insulin, how to self- inject insulin, or when to notify a provider. RN #2 indicated residents are supposed to be provided with education throughout their stay at the facility not just on the day of discharge. Interview with APRN #1 on 4/4/2025 at 11:25 A.M. identified upon admission resident's educational needs were identified and addressed. APRN #1 identified the nurses should provide residents with education and ensure residents verbalize understanding prior to discharge. APRN #1 identified that Resident #1's educational needs should have been addressed prior to h/her discharge home on 3/15/2025. APRN #1 identified that RN #1 did not notify her that Resident #1 needed a prescription for a glucometer and glucometer supplies. Interview with the DNS on 4/4/2025 at 1:00 P.M. identified that education on disease management, medication, and post-discharge is initiated based on residents identified needs upon admission to the facility. The DNS indicated nurses initially provide verbal education and when required, nurses demonstrate how to use different medical equipment. The DNS indicated nurses should have residents verbalize understanding and redemonstrate skills to assess understanding of the education. The DNS identified that Resident #1 was not provided with diabetes education or demonstrations on how to use a glucometer to obtain a blood sugar level or Lispro Insulin administration during admission to the facility. The DNS identified that RN #1 should have ensured that Resident #1 was educated and verbalized understanding of the education prior to discharge, and a glucometer should have been provided at the time of discharge. b. Resident #1 had diagnoses that included type 2 diabetes mellitus, zoster, lack of coordination, and pneumonia. A physician's order dated 2/24/2025 directed to administer Insulin Lispro (a medication for diabetes mellitus) per sliding scale: if blood sugar is 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 399 = 10 units above 400 call MD, intramuscularly three times a daily for diabetes mellitus. A physician's order dated 2/28/2025 directed to administer gabapentin (a medication used to treat nerve pain) 100 milligrams three times a day for pain. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of thirteen indicative of intact cognition, was occasionally incontinent of bowel and bladder, required partial assistance with ADLs, bed mobility, and transfers. The Resident Care Plan dated 3/3/2025 identified Resident #1 had the potential for discharge or was expected to be discharged related to the resident's desire to discharge to the community and admission for skilled short-term stay. Interventions directed to identify, discuss, and document resident desires and concerns/barriers regarding discharge, evaluate discharge planning needs taking into consideration care plans, resident/patient goals, cognitive skills, functional mobility and need for assistive devices, identify educational needs with the resident and initiate an education care plan, provide ongoing communication to the interdisciplinary team (IDT) members, physician/mid-level provider, and resident about the discharge planning process, and make referrals to community-based agencies, providers, and services communicating the residents needs and barriers to care. A social service note dated 3/12/2025 at 3:56 P.M. by Social Worker (SW) #1 identified she met with Resident #1 for discharge planning and Resident #1 stated h/she was not ready for discharge and had stairs at home. The note indicated Resident #1's plan was to discharge home when h/she was able to and started working on stairs with therapy. The Notice of Medicare Non-Coverage (NOMNC) dated 3/12/2025 identified Resident #1's Medicare coverage would end on 3/14/2025. The Quality Improvement Organization (QIO) dated 3/13/2025 identified Resident #1 requested an appeal and based on review of the medical record it was determined that termination of skilled services was appropriate. A social service note dated 3/14/2025 at 10:23 A.M. by SW #1 identified Resident #1's discharge plan documentation, discharge summary, and transition plan were completed. Review of the discharge plan documentation dated 3/14/2025 at 10:23 A.M. by SW #1 and RN #1 (unit manager) identified Resident #1's estimated/scheduled discharge date was 3/15/2025 at 11:00 A.M. to h/her home alone with home health services and that Resident #1 had no changes or discontinuation of h/her medications. RN #1 indicated that Resident #1's current reconciled medication list was provided to the subsequent provider. APRN #1's note dated 3/14/2025 at 12:57 P.M. identified Resident #1 was seen for a physical assessment for a possible discharge to home/community on 3/15/2025. APRN #1 identified SW #1 notified her Resident #1 was no longer covered by insurance and Resident #1 agreed to discharge home. The note identified Resident #1 had h/her own medications that were brought to the facility on admission. The note identified Resident #1 was to continue current medication orders and Resident #1 was educated to continue taking medications as ordered. Review of Resident #1's discharge summary medication list dated 3/14/2025 directed to take gabapentin 100 milligram (a medication used to treat nerve pain) capsule three times per day and inject Insulin Lispro per sliding scale: if blood sugar is 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 399 = 10 units above 400 call MD, intramuscularly three times a daily. Review of the nurse's note dated 3/15/2025 at 10:47 A.M. by Registered Nurse (RN) #1 indicated she reviewed medications with Resident #1 and h/she stated understanding of use and classification. The note identified that Resident #1 was discharged home with services. Review of the Facility's Accident and Incident Form dated 3/18/2025 at 3:00 P.M. identified the home care nurse assigned to Resident #1 called the facility with a concern that Resident #1's medications, discharge teaching, and instructions were not provided upon discharge. Review of APRN #1's note dated 3/18/2025 at 5:04 P.M. identified she was notified by SW #1 that Resident #1 was discharged on 3/15/2025 without h/her Insulin Lispro and gabapentin and further indicated she was told not to call prescriptions in to the pharmacy on the day of discharge. The note indicated she was informed Resident #1 brought all home medications into the facility and h/she would be discharging with all home medications. The note identified Resident #1 was currently prescribed Insulin Lispro but based on review of blood sugar levels, she would be discontinuing Insulin Lispro and would order Insulin Glargine 3 units at bedtime instead. The note identified she ordered gabapentin 100 milligram capsule three times per day for pain, Glargine insulin 3 units at bedtime, Insta-Glucose Gel, a glucometer, test strips, lancets, a lancing device, alcohol pads, cotton balls/gauze, and a blood sugar logbook, from the pharmacy. Review of a statement dated 3/20/2025 at 7:33 P.M. by RN #1 identified she discussed Resident #1's discharge medications with APRN #1 and informed APRN #1 that Resident #1 already had h/her medications. RN #1 identified she overlooked two medications that were part of Resident #1's active discharge orders, and she did not complete discharge teaching with Resident #1 for insulin administration and blood sugar monitoring. Review of the Facility Accident and Incident and Summary dated 3/21/2025 identified that on 3/18/2025 the home care nurse assigned to Resident #1 called the facility with a concern that medications and teaching/instructions were not provided upon discharge. An investigation was initiated that identified RN #1 did not clearly communicate to APRN #1 what medications needed to be ordered and RN #1 told APRN #1 that Resident #1 did not need any medications ordered since Resident #1 was taking h/her home medications back home upon discharge. The summary identified discharge medications should have included gabapentin and Lispro Insulin per sliding scale and, on 3/18/2024, RN #1 went to Resident #1's home to provide Resident #1 with discharge teaching and instructions and to reconcile medications. Interview with RN #1 on 4/4/2025 at 9:45 A.M. identified she was responsible for Resident #1's discharge on [DATE]. RN #1 identified on 3/14/2025 while preparing Resident #1's discharge packet she did not conduct a pre and post medication reconciliation. RN #1 identified she should have reconciled the medications to ensure Resident #1 had all medications upon discharge. Interview with APRN #1 on 4/4/2025 at 11:25 A.M. identified that on 3/14/2025 RN #1 informed her that Resident #1 had all medications for discharge home on 3/15/2025. APRN #1 identified on 3/18/2025 SW #1 notified her that Resident #1's home care nurse notified the facility Resident #1 did not have gabapentin or Lispro Insulin at home. APRN #1 identified she then called prescriptions and all necessary supplies into the pharmacy. APRN #1 identified a reconciliation of all pre-discharge and post-discharge medications should be conducted for discharge and RN #1 should have reconciled Resident #1's medications. Interview with the DNS on 4/4/2025 at 1:00 P.M. identified on 3/18/2025 when she was notified by a home care nurse that Resident #1 was missing medications, she initiated an investigation. The DNS identified, based on her investigation, that RN #1 did not reconcile Resident #1's medications resulting in Resident #1 not having a supply of gabapentin and Lispro Insulin. The DNS identified that when a resident is being discharged , medications should be reconciled and RN #1 should have reconciled Resident #1's pre-discharge medications with post-discharge medications. Review of facility discharge planning process policy dated May 2024; in part, identified the discharge transition plan must include but is not limited to: a reconciliation of all pre-discharge medications with the patient's post-discharge medications (both prescription and over-the counter), identify discharge needs and develop a plan to meet those needs, and provide ongoing support, encouragement, and education to patients and patient representatives.

Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 5 residents (Resident #91, 22 and 124) reviewed for accidents, for Resident #91, the facility failed to provide the physician ordered 1:1 supervision which resulted in a fall with injury, for Resident #22, the facility failed to provide adequate supervision to prevent a fall, and for Resident #124, the facility failed to ensure the bed was locked to prevent a fall, and for 1 of 5 residents (Resident #93) reviewed for unnecessary medications, the facility failed to ensure that pharmacy recommendations were reviewed and implemented for a resident with a history of multiple falls. The findings include: 1. Resident #91 was admitted to the facility in August 2022 with diagnoses that included dementia, difficulty in walking and repeated falls. The care plan dated 12/1/22 identified Resident #91 required assistance related to confusion. Interventions included providing contact guard for transfers, toileting, and ambulating although the resident was noncompliant with asking for and waiting for assistance due to cognitive deficits. Further, Resident #91 was at risk for falls due to cognitive loss, lack of safety awareness, and dementia. Interventions included to encourage to accept cues for safety reminders, encourage to sit in common area after morning care for breakfast as he/she allows, encourage to accept cues for safety reminders and to offer toileting four times per shift as resident allows. A physician's order dated 12/15/22 directed the resident to receive 1:1 supervision at all times. The quarterly MDS dated [DATE] identified Resident #91 had severely impaired cognition, required extensive assistance with transfer, walking in room/corridor, locomotion on unit, and toilet use. Additionally, Resident #91 had unsteady balance when moving from a seated to a standing position, while walking, turning around, moving on and off toilet, and was only able to stabilize with staff assistance. The physical therapy discharge summary dated 1/12/23 identified Resident #91 was using an assistive device up to 100 feet with contact guard. The physician's order dated 3/1/23 directed the resident to receive 1:1 supervision at all times. Although requested a fall risk assessment prior to the fall on 3/5/23 was not provided. The reportable event form dated 3/5/23 at 1:30 AM identified Resident #91 fell in the bathroom and sustained a laceration to the top of the head that measured 3.5 cm and was bleeding. Resident #91 was transferred to the hospital at 2:00 AM for treatment. Neurological and skin assessment performed. The reportable event form identified there was no witness to the fall. Review of the neurological assessment flow sheet dated 3/5/23 at 2:00 AM identified neurological checks was within normal range and Resident #91 had a fall with a head laceration and Resident #91 was transferred to the hospital. The nurse's note dated 3/5/23 at 2:11 AM identified RN #6 Resident #91 fell in the bathroom and sustained a laceration to the top of the head that measured 3.5 cm with bleeding noted. Resident #91 fell at 1:30 AM and left the facility at 2:00 AM. Resident was on 1:1 at all times. Review of the nurse aide flow record identified that NA #3 provided care to Resident #91 on 3/5/23 during the 11:00 PM - 7:00 AM shift (at the time the resident fell on [DATE] at 1:30 AM). Review of a statement written by NA #3 dated 3/5/23 identified NA #3 found Resident #91 on the floor by the bathroom after he had left the room and gone to get report from the nurse. NA #3 identified the last time he saw Resident #91 was at 1:00 AM and the resident was sleeping in bed. Review of a statement written by NA #5 dated 3/5/23 identified NA #5 went to assist with Resident #91. NA #5 indicated when she arrived in the room Resident #91 was up on his/her feet and walking. NA #5 indicated Resident #91 looked alright and his/her head was bleeding. NA #5 indicated they called for the nurse LPN #3 and the RN #6. The nurse's note dated 3/5/23 at 5:48 AM identified Resident #91 returned from the hospital with 4 staples to the top of the head and staff resumed 1:1 supervision. Review of the hospital W-10 form dated 3/5/23 identified Resident #91 was admitted on [DATE] at 2:25 AM. Resident #91 was discharged with a diagnosis of laceration of scalp and sutures to be removed within one week. Review of 1:1 supervision in-service sign in sheet dated 3/6/23 identified when a resident is placed on a 1:1 the staff are to complete the 1:1 form and staff need to be either inside or outside of the resident room as directed by the supervisor. Review of the 1:1 binder on 2 North (the dementia unit) on 5/9/23 at 11:00 AM failed to reflect documentation that Resident #91 had been monitored on 1:1 on 3/4/23 and 3/5/23. Interview with the DNS on 5/17/23 at 2:39 PM identified she was not employed by the facility at the time of the incident. The DNS indicated NA #3 should not have left Resident #91 alone because Resident #91 had an order for 1:1 monitoring. Although attempted, an interview with NA #3 was not obtained. Although attempted, an interview with LPN #3 was not obtained. Although attempted, an interview with NA #5 was not obtained. Although attempted, an interview with RN #6 (supervisor) was not obtained. Review of the facility enhanced patient supervision: continuous 1:1 policy directed to when using continuous 1:1 supervision, designated staff will be assigned to manage the 1:1 supervision of the patient. The designated staff will only be involved with the delivery of care to this patient and no other patient. The designated staff must be with the patient at all times; must obtain coverage for breaks; and will provide positive interaction in conjunction with therapeutic interventions. Continuous 1:1 supervision will be provided per nursing judgement or when recommended by a physician/advanced practice nurse. Designated staff will document patient activities every 30 minutes on the continuous 1:1 supervision flowsheet. Review of the falls management policy directed to patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Patients experiencing a fall will receive appropriate care and post-fall interventions will be implemented. In the event a fall occurs, an assessment will be completed to determine injury. Any patient who sustains an injury to the head from a fall and/or has an unwitnessed fall will be observed for neurological abnormalities by performing neurological check, per policy. The physician/APRN will be notified of any abnormal findings. 2. Resident #22 was admitted to the facility in February 2022 with diagnoses that included Alzheimer's disease, dementia, absence of left toes and non-pressure chronic ulcer of left/right foot. The care plan dated 2/5/23 identified Resident #22 was at risk for falls due to Alzheimer's disease, osteoarthritis of knee, and partial amputation of left foot. Interventions included that when the resident is tired, to encourage him/her to remain in view of staff until ready to go to sleep in bed. The nurse aide care card dated 2/5/23 identified for safety, when the resident is tired, to encourage him/her to remain in view of staff until ready to go to sleep in bed. Resident #22 is independent with ambulation using rolling walker. The physical therapy discharge evaluation dated 3/2/23 identified Resident #22 was to ambulate 200 - 300 feet with rolling walker with supervision and stand by assist (SBA) (cueing, coaxing, and stand by for safety), with supervision/touching assist. The annual MDS dated [DATE] identified Resident #22 had severely impaired cognition and required limited assistance with transfers, walking in room, walking in corridor, and required supervision with locomotion on unit. Additionally, Resident #22 was not steady, only able to stabilize with staff assistance with moving from seated to standing position, walking, and turning around. Further, Resident #22 had an impairment of range of motion on one side of lower extremity and used a walker with ambulation. A reportable event form dated 4/24/23 at 9:00 PM identified Resident #22 resides on the memory care unit and had a witnessed fall. NA #6 indicated she observed Resident #22 walking with the rolling walker in the hallway. NA #6 indicated Resident #22 then lifted the walker up, loss his/her balance and fell to the floor on his/her right side. Resident #22 complained of bilateral hip pain which was more prominent to the right hip. The physician was notified, and Resident #22 was transferred to the hospital for further evaluation. Review of the fall form dated 4/24/23 identified Resident #22 was observed in a right lateral position on the floor. A physician telehealth consult was done, and bilateral hip x-rays were ordered, however, Resident #22 was transferred to the hospital due to the length of wait time for x-rays and symptoms of fracture. The APRN progress note dated 4/27/23 identified Resident #22 returned from the hospital with a diagnosis of inferior pubis ramus fracture after a fall while ambulating with walker at facility. Resident #22 takes Dilaudid routinely for chronic pain due to severe peripheral vascular disease with history of toe amputation of left foot. Chronic osteomyelitis managed with Bactrim. Dementia due to Alzheimer's is managed with memory care and safety precautions. Diagnosis of pelvic fracture. Plan: acute pelvic fracture pain change Dilaudid to every 4 hours routinely with Robaxin and Tylenol. Follow up with physical therapy. The revised care plan dated 4/28/23 identified Resident #22 was at risk for falls: Alzheimer's disease, osteoarthritis of knee, and partial amputation of left foot. Interventions include to offer bed when observed walking around the hallway in the late evening as resident allows. Review of the summary report dated 4/29/23 at 5:31 PM identified Resident #22 was independent with transfer and ambulation with use of rolling walker. On 4/25/23 Resident #22 was readmitted to the facility with no surgical interventions for the fracture. Resident #22 remains comfortable with pain management use of as needed Dilaudid and scheduled Methocarbamol every 8 hours for 14 days. Resident #22 was in no distress. The care plan was reviewed and revised to have rehab evaluate activity level. Administered pain medication as ordered. Update APRN/MD as needed. Interview and review of the clinical record with the Physical Therapy Director on 5/16/23 at 8:30 AM identified Resident #22 was discharged from physical therapy on 3/2/23 with the following: Resident #22 was to ambulate 200 - 300 feet with rolling walker with supervision to stand by assist (SBA) (cueing, coaxing, and stand by for safety), with supervision/touching assist. The Physical Therapy Director indicated Resident #22 was not independent with ambulation. The Physical Therapy Director indicated nursing staff were made aware of the recommendations on 3/2/23. Interview and review of the clinical record with the DNS on 5/17/23 at 2:40 PM indicated she was not aware of the physical therapy discharge notes dated 3/2/23 indicating Resident #22 needed supervision to stand by assist (SBA) with ambulation with rolling walker with supervision/touching assist. The DNS indicated she was not employed with the facility at that time. The DNS indicated she thought Resident #22 was independent with ambulation with rolling walker. The DNS indicated NA #6 witness Resident #22's fall. Although attempted, an interview with RN #8 was not obtained. Although attempted, an interview with NA #6 was not obtained. Review of the facility falls management policy identified patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Patients experiencing a fall will receive appropriate care and post-fall interventions will be implemented. In the event a fall occurs, an assessment will be completed to determine possible injury. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. 3. Resident # 93 was admitted to the facility on [DATE] with diagnoses that included dementia, psychosis, and anxiety disorder. The physician's orders dated 2/1/23 directed to administer Seroquel (an antipsychotic medication used for psychosis) Clonazepam (a benzodiazepine used for anxiety), Lorazepam (a benzodiazepine used for anxiety), and Morphine oral solution (an opioid used for pain relief). The quarterly MDS dated [DATE] identified Resident #93 had severely impaired cognition, was always incontinent of bowel and bladder, and required the assistance of 2 or more staff members with transfers, dressing, and toileting. The MDS also identified Resident #93 was receiving hospice care and had a history of falls. The care plan dated 2/2/23 identified Resident #93 was at risk for falls. Interventions included completing medication evaluations as needed. The monthly pharmacist medication reviews completed on 2/20/23 and 4/21/23 identified that the use of 2 concurrent benzodiazepines (Lorazepam and Clonazepam) increased the risk for falls, especially in combination with Seroquel and Morphine. Recommendations included considering reducing or eliminating Lorazepam and Clonazepam. The recommendation further identified that if the medications were continued, the facility should ensure that ongoing monitoring is in place for efficacy and potential side effects including new onset falls. The clinical record failed to identify that the pharmacy recommendations of 2/20/23 and 4/21/23 were reviewed or implemented by clinical staff at the facility. Review of the clinical record identified that Resident #93 had multiple falls without major injury on the following dates: 2/23/23, 2/28/23, 3/6/23, 3/23/23, 4/19/23, and 4/28/23. Interview with the Medical Director, (MD #1) on 5/17/23 at 12:05 PM identified that he or the facility APRN would usually review and sign the monthly pharmacy recommendations. MD #1 further identified that he and the APRN signed off all the reviews that were provided each month to them by the DNS, and the signed report is placed in the resident's paper chart. MD #1 identified that if a change was made based on the recommendation, the resident's orders would be updated. Interview with the DNS on 5/17/23 at 12:18 PM identified she was unsure why the pharmacy recommendations had not been reviewed by the facility staff or given to the physician or APRN for review. The DNS identified that she provided the provider (MD/APRN) with the pharmacy recommendations for review and signature, and the signed paperwork was placed in the resident's medical record. The DNS further identified that because Resident #93 was on hospice, she was unsure that the recommendations would have prevented the multiple falls Resident #93 had but was unable to provide any documentation to identify the recommendations had ever been provided to the MD or APRN for review. The facility policy on falls management directed that the purpose was to identify risks for falls and minimize the risk for recurrence of falls. The policy further directed that interventions would be implemented and documented according to the resident's risk factors. 4. Resident #124 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, dementia, and epilepsy. The care plan dated 3/13/23 identified Resident #124 was at risk for falls due to tardive dyskinesia. Interventions included assisting the resident to organize belongings for a clutter-free environment in resident's room and consistent furniture arrangement. The quarterly MDS dated [DATE] identified Resident #124 had severely impaired cognition, required supervision for walking in the room and hall without the use of an assistive device, was occasionally incontinent of bowel and bladder and had 2 or more falls since admission or prior assessment. A reportable event form dated 3/26/23 identified that at 5:00 AM Resident #124 was found in the prone (face down) position on the floor by RN #5, the bed was unlocked, and the resident was barefoot. A neurological evaluation flow sheet dated 3/26/23 identified neurological assessments began as per protocol at 5:00 AM and continued at 15-minute intervals and were normal. A statement by RN #5, dated 3/29/23 identified the bed was in the lowest position when the resident was found on the floor and that is what caused the bed to move. Interview with Administrator on 5/16/23 at approximately 10:40 AM identified although staff locks the beds, if lowered too low, the beds become unlocked, and although Resident #124 was cognitively impaired, he/she was known to raise and lower the bed independently. Review of the policy for accidents/incidents identified the interventions to eliminate (accidents) if possible, and if not possible, reducing the risk of the accident/incident after having been identified and implemented. 46040

Based on clinical record reviews, observation, review of facility documentation, review of policy and interviews for one of two sampled residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from sexual abuse and the facility failed to ensure the safety of others following the alleged incident of sexual abuse resulting in a finding of Immediate Jeopardy. The findings include: Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated April 2022 identified Resident #2 had impaired cognitive function, impaired thought processes and impaired communication related to dementia. Interventions included: to evaluate behavioral symptoms for underlying causes, and to use verbal cues, gestures, and demonstration to assist in decision making if needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. The quarterly assessment also noted Resident #2 was severely cognitively impaired and had memory problems. Resident #2 was independent with transfer, walking in corridor and noted no behaviors. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the referring hospital discharge summary dated 2/1/22 identified Resident #1 was alert and orient time three (to person place and time) The resident's family reports Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the summary noted Resident #1 has an extensive history of physical abuse toward his/her family, non-compliance with medication regimen, wandered, verbal aggression toward staff. Resident # 1's Admission Record identified the resident was admitted to the facility on [DATE] on a shared secure dementia unit. The nursing admission note dated 2/07/22 identified Resident #1 was an admission from a behavioral health institution with history of behavioral disturbance. For mental health/ behavior the nursing admission assessment note failed to identify the resident's history of physical and verbal abuse directed towards others and a history of wandering. The admission MDS assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) 0-15 a score of 0 which indicated the resident is rarely /never understood. The admission assessment also noted Resident #1 exhibited the following behaviors: verbal behaviors that was threatening to others, screaming at others, cursing at others, and noted no sexually abusive behaviors. The MDS assessment 3/1/22 further indicated that Resident #1 was independent with walking in room, corridor, required limited assistance with transfers and noted the utilization of antipsychotic medications. The RCP dated 3/8/22 for resident exhibits or has the potential to demonstrate verbal behaviors related to cognitive loss/dementia, history of physical outburst directed toward others. Intervention included to evaluate the need and provide Psychiatric/Behavioral Health Consultation and to allow time for expression of feelings, provide empathy, encourage, and provide reassurance. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated 4/26/22 at 2:27 PM identified Resident #1 exhibited verbal outburst directed at staff and begin yelling profanities down the hallway. Resident #1 was able to deescalate by not engaging with residents. As staff would come into Resident # 1's sight s/he would start screaming profanities while raising both hands high in the air and making inappropriate gestures. Resident # 1 also started to yell at staff and other residents. Another resident attempted to intervene to protect staff and go after Resident #1. At which time a call was placed to the Advanced Practice Registered Nurse (APRN) regarding Resident # 1's behavior. A new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's notes dated 5/16/22 at 4:18 AM identified Resident # 1 was noted screaming /cursing and disrobing in the hallway demanding to take a shower while calling staff in appropriate names and refusing to be re-directed by staff. The supervisor was notified. A nurse's note dated 5/16/22 at 4:10 PM identified that the charged nurse was summoned to the unit and observed Resident #1 yelling and cursing at staff in the hallway while clenching his/her fist. The charge nurse attempted to talk to Resident #1 at which time the resident became physically aggressive and pushed the charge nurse shoulder. The Medical Doctor (MD) was notified and ordered Resident # 1 to be evaluated at a crisis center. A nurse's note dated 5/22/22 at 7:02 AM identified Resident #1 was sitting in hallway yelling and swearing. Resident #1 was redirected, and the nursing supervisor notified. A nurse's note dated 5/22/22 at 6:40 PM identified Resident #1 was seen exposing him/herself to other residents on the unit and was told several times to keep his/her shirt down and his/her hand to him/herself and noted the resident continued to be non- compliant. No other interventions were identified in the clinical record on 5/22/22 to address the resident's exposing him/herself to other residents. A nurse note dated 5/23/22 at 6:50 PM identified Resident #1 was seen coming out of a female resident (Resident # 3) room and was redirected by staff. A nursing note dated 5/26/22 at 2:31 PM identified Resident #1 was noted to be undressing in the common area in front of other residents. Staff intervened and redirected Resident #1. Resident #1 was reminded to keep his/her clothes on. Resident #1 was very difficult to redirect. Resident #1 was noted staring at RN #2's breast while attempting to touch RN #2's breast. RN #2 reminded Resident # 1 to keep his/her hands to self. No other interventions were identified in the clinical record on 5/26/22 to address Resident # 1's undressing in the common area, resident's non-compliance with redirection and the touching of RN # 2's breast in the clinical record. A nurse's note dated 5/31/22 at 3:30 PM identified the charge nurse was hit on the arm by Resident # 1 while passing by the resident. Resident # 1 continued to call staff inappropriate names. A nurse's note dated 5/31/22 at 3:53 PM identified Resident #1 was sent to emergency room via Physician's Emergency Certificate (PEC) for behaviors and a call was placed to the crisis center to transport the resident to the hospital for an evaluation. The Resident Care Plan dated 5/31/22 identified Resident #1 exhibited verbal behaviors related to Cognitive loss/Dementia and noted a history of verbal and physical outbursts directed toward others such as use of abusive language, patterns of challenging/confrontational verbal behavior related to Psychiatric Disorders. Interventions included evaluating the need for Psychiatric Behavioral Health consultation and directed to allow time for expression of feeling, provide empathy, encouragement, and reassurance. A nurse's note dated 6/6/22 at 2:25 PM identified that Resident #1 was seeking out a female resident. RN # 2 intervened and prevented Resident #1 from encouraging a female resident into his/her room. RN #2 redirected the female resident with good effect. A Reportable Event report dated 6/07/22 at 2:00 PM identified staff entered room of Resident #2 and observed Resident # 2 having oral sex with Resident #1. Additionally, the report alleges that Resident #2 (severely cognitively impaired resident) was observed willingly having oral sex with Resident #1 (alert and confused). The residents were immediately separated, placed on 1:1, seen by psychiatry for medication review, body audits conducted which identified no injury. The Administrator, physician, responsible party, and police were notified. The nurse's note dated 6/07/22 at 2:00 PM identified Nurse Aide (NA) #1 notified (RN #1) that when she (NA#1) was picking up Resident # 2's lunch tray, she observed Resident #1's pants down with his/her private part near Resident #2's mouth. Staff was able to redirect Resident #1 back to his/ her room. An assessment of Resident #2 after the incident identified no injury, Resident #2 verbalized to a staff interpreter that he/ she could not recall the incident and stated the incident never happened. Observations on 7/1/22 at 12:00 PM identified Resident #1 was angry at surveyor, begin using curse words and slamming the room door 3 times. Resident # 1 then proceeded to pace the hallway and common area before returning to the room and slamming the door. An interview on 7/01/22 at 12:15 PM with Nurse Aide (NA #1) identified that she witnessed the 6/7/22 incident between Resident #1 and Resident 2. She identified that she was picking up the lunch tray from Resident #2 's room on 6/7/22. When she knocked on the door and entered the room, she observed Resident #1 standing over Resident #2 with his/ her pants down and Resident #2 sitting down on a chair performing oral sex on Resident #1. NA #1 separated the residents and updated (RN #1) charge nurse. NA #1 further identified that she had been assigned to Resident #1 for 1:1 several times since the incident. NA #1 further indicated she was afraid of Resident # 1 because Resident #1 had blocked his/her door preventing her (NA#1) from exiting the room and indicated at times she (NA # 1) felt threatened by Resident #1's aggressive behaviors. An interview on 7/01/22 at 12:30 PM with Licensed Practical Nurse (LPN #1) identified that she had observed Resident # 1 exposing him/herself to other residents on the unit and reported the behavior to the nursing supervisor. She identified that she was directed by the nursing supervisor to document each occurrence of unacceptable behaviors. She further identified that prior to the incident between Resident #1 and Resident 2, Resident #1 had to be redirected several times from the door of Resident #2 that day by her and the nursing supervisor. She further identified that she felt threatened by Resident #1 being on the unit because Resident #1 was alert and understood what he/she was doing. An interview on 7/05/22 at 11:27 AM with Assistant Director of Nursing Services (ADNS) identified that Resident #1 was redirected and educated by staff and evaluated by psychiatry for his/her behavioral incidents. She further identified that she was not aware of Resident #1 sexual inappropriate behavior prior to incident on 6/07/22. An interview on 7/1/22 at 1:05 PM with Registered Nurse (RN #1) nursing supervisor for the unit identified that Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . When Resident #1 grabbed her breast on (5/26/22) she did not consider his/her behaviors as threatening or inappropriate to others due to his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to implement interventions to protect Resident #2(who was severely cognitively impaired and not capable of consenting to a sexual act) with Resident #1 when Resident #2 was observed performing oral sex on Resident #1 and the failed to protect other residents from potential sexual abuse when Resident #1 exhibited an increase in sexually inappropriate behaviors such as encouraging female residents to leave their room with him/her resulting in a finding of Immediate Jeopardy. Attempts to interview the Director of Nursing Services (DNS) on 7/1/22 and 7/5/22 were unsuccessful The facility submitted a removal plan on 7/5/22 which included the following: Resident #1 is currently on a one to one to ensure that the behavior does not re-occur, staff will be educated on how to identify inappropriate sexual behaviors and notifying the supervisor immediately. Residents displaying inappropriate sexual behaviors will be placed on one-to-one monitoring until evaluated by the healthcare provider, nursing supervisor will interview staff members on each unit each shift to identify if any residents are exhibiting new sexual behaviors. Daily audits of behavior monitoring system for new sexual behaviors will be completed for 7 days, weekly for 4 weeks, monthly for 3 months with remedial actions per center practices and results will be reviewed at QAPI and the Administrator or designee are responsible for oversight of this plan of correction. A review of the facility's Abuse policy notes in part that the center prohibits abuse, mistreatment, and exploitation of all residents. The policy defined sexual abuse as non-consensual sexual contact of any type with a resident. Additionally, the policy includes sexual harassment, sexual coercion, or sexual assault. Physical abuse hitting, slapping, pinching, kicking, as well as controlling behavior through corporal punishment. Exploitation is the act of taking advantage of patient for personal gain by manipulation, intimidation, threats, or coercion. The policy further directs that the facility's staff is responsible for preventing occurrence of abuse, mistreatment and exploitation of residents and directed staff to apply appropriate interventions to address aggressive or catastrophic reactions of residents.

Based on clinical record review, review of facility documentation, review of facility's policy, and interviews for one of two sampled resident (Resident #1) reviewed abuse, the facility failed to develop and implement a comprehensive care plan to address Resident #1's sexually inappropriate behaviors. The findings include: Resident # 1's Admission Record identified the resident was admitted to the facility on [DATE] on a shared secure dementia unit. The nursing admission note dated 2/07/22 identified Resident #1 was an admission from a behavioral health institution with history of behavioral disturbance. For mental health/ behavior the nursing admission assessment note failed to identify the resident's physical abuse and history of wandering. The admission MDS assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) 0-15 a score of 0 which indicated the resident is rarely /never understood. The admission assessment also noted Resident #1 exhibited the following behaviors: verbal behaviors that was threatening to others, screaming at others, cursing at others, and noted no sexually abusive behaviors. The MDS assessment 3/1/22 further indicated that Resident #1 was independent with walking in room, corridor, required limited assistance with transfers and noted the utilization of antipsychotic medications. The RCP dated 3/8/22 for resident exhibits or has the potential to demonstrate verbal behaviors related to cognitive loss/dementia, history of physical outburst directed toward others. Intervention included to evaluate need and provide Psychiatric/Behavioral Health Consultation and to allow time for expression of feelings, provide empathy, encourage, and provide reassurance. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated 5/22/22 at 6:40 PM identified that Resident #1 was seen exposing him/herself to other residents on the unit and was told several times to keep his/her shirt down and his/her hand to him/herself and noted the resident continued to be non- compliant. A nurse note dated 5/23/22 at 6:50 PM identified Resident #1 was seen coming out of a female resident (Resident # 3) who was severely cognitively impaired room and was redirected by staff. A nursing note dated 5/26/22 at 2:31 PM identified Resident #1 was noted to be undressing in the common area in front of other residents. Staff intervened and redirected Resident #1. Resident #1 was reminded to keep his/her clothes on. Resident #1 was very difficult to redirect. Resident #1 was noted staring at RN #2's breast while attempting to touch RN #2's breast. RN #2 reminded Resident # 1 to keep his/her hands to self. The Resident Care Plan dated 5/31/22 identified Resident #1 exhibited verbal behaviors related to Cognitive loss/Dementia and noted a history of verbal and physical outbursts directed toward others such as use of abusive language, patterns of challenging/confrontational verbal behavior related to Psychiatric Disorders. Interventions included evaluating the need for Psychiatric Behavioral Health consultation and directed to allow time for expression of feeling, provide empathy, encouragement, and reassurance. A nurse's note dated 6/6/22 at 2:25 PM identified that Resident #1 was seeking out a female resident. RN # 2 intervened and prevented Resident #1 from encouraging a female resident into his/her room. RN #2 redirected the female resident with good effect. A Reportable Event report dated 6/07/22 at 2:00 PM identified staff entered room of Resident #2 and observed Resident # 2 having oral sex with Resident #1. Additionally, the report alleges that Resident #2 (severely cognitively impaired resident) was observed willingly having oral sex with Resident #1 (alert and confused). The residents were immediately separated, placed on 1:1, seen by psychiatry for medication review, body audits conducted which identified no injury. The Administrator, physician, responsible party, and police were notified. An interview on 7/1/22 at 1:05 PM with RN #1 (nursing supervisor) identified she was aware Resident #1 was seen coming out of Resident #3's room but did not think it was an issue because Resident # 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 further indicated she intervened and prevented Resident #1 from encouraging Resident # 3 to come into his/her room. An interview on 7/05/22 at 11:27 AM with ADNS identified that she was not aware of Resident #1's sexual inappropriate behavior until the 6/7/22 incident. Additionally, the ADNS was not able to provide documentation that a comprehensive care plan was developed with goals and interventions to address Resident # 1's sexually inappropriate behaviors before the 6/7/22. This lack of the facility to develop a comprehensive care to address Resident #1's increase in sexual behaviors and encouraging female residents to come with him/her resulted in the facility failure to prevent a subsequent resident to resident sexual abuse that occurred when Resident # 2 (who was severely cognitively impaired and not capable of consenting to participating in an oral sexual act) was observed performing oral sex on Resident #1 resulting in a finding of Immediate Jeopardy. Interview on 7/07/2022 at 9:03 AM with LPN #2 identified that during her medication pass on 5/23/22, Resident #1 was seen coming from Resident #3's room and shutting the door behind him/ her. She asked Resident #1 what he/she was doing Resident #1 responded s/he was in the wrong room. LPN # 1 warned Resident #1 that he/ she should not be going into rooms of opposite sex /gender. Attempts to interview the Director of Nursing Services (DNS) on 7/1/22 and 7/5/22 were unsuccessful. The facility submitted a removal plan on 7/6/22 that included: Resident #1 is on 1:1 and will continue until the psychiatric team deems no longer or 30 days without sexual or physical behaviors is achieved. The licensed staff will be educated to investigate the circumstances and evaluate if another resident with known physical or sexual behavior wanders into a resident's room that is unobserved to immediately notify the supervisor, investigate, nursing supervisor will interview staff members on each unit each shift to identify if any residents are exhibiting new sexual behaviors. Daily audits of behavior monitoring system for new sexual behaviors will be completed for 7 days, weekly for 4 weeks, monthly for 3 months with remedial actions per center practices and results will be reviewed at QAPI and the Administrator or designee are responsible for oversight of this plan of correction. A review of the facility's abuse policy identified that the center prohibits abuse, mistreatment, and exploitation of all residents. The policy identified that staff would, identify events such as suspicious occurrences, patterns, and trends that may constitute abuse and determine the direction of the investigation. The investigation will be thoroughly documented within the Risk Management Portal and staff will ensure that documentation of witnessed interviews is included. The facility staff is responsible for preventing occurrence of abuse, mistreatment and exploitation of residents and apply appropriate interventions.

Based on clinical record review, review of facility's policy and interviews for one resident (Resident #1) who was reviewed for sexual abuse, the facility failed to initiate and thoroughly investigate a potential sexual abuse incident to ensure the safety of other residents from abuse. The findings include: Resident # 1's Admission Record identified the resident was admitted to the facility on [DATE] on a shared secure dementia unit. The nursing admission note dated 2/07/22 identified Resident #1 was an admission from a behavioral health institution with history of behavioral disturbance. For mental health/ behavior the nursing admission assessment note failed to identify the resident's physical abuse and history of wandering. The admission MDS assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) 0-15 a score of 0 which indicated the resident is rarely /never understood. The admission assessment also noted Resident #1 exhibited the following behaviors: verbal behaviors that was threatening to others, screaming at others, cursing at others, and noted no sexually abusive behaviors. The MDS assessment 3/1/22 further indicated that Resident #1 was independent with walking in room, corridor, required limited assistance with transfers and noted the utilization of antipsychotic medications. The RCP dated 3/8/22 for resident exhibits or has the potential to demonstrate verbal behaviors related to cognitive loss/dementia, history of physical outburst directed toward others. Intervention included to evaluate need and provide Psychiatric/Behavioral Health Consultation and to allow time for expression of feelings, provide empathy, encourage, and provide reassurance. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's notes dated 5/16/22 at 4:18 AM identified Resident # 1 was noted screaming /cursing and disrobing in the hallway demanding to take a shower while calling staff in appropriate names and refusing to be re-directed by staff. The supervisor was notified. A nurse's note dated 5/22/22 at 6:40 PM identified that Resident #1 was seen exposing him/herself to other residents on the unit and was told several times to keep his/her shirt down and his/her hand to him/herself and noted the resident continued to be non- compliant. A nurse note dated 5/23/22 at 6:50 PM identified Resident #1 was seen coming out of a female resident (Resident # 3) room and was redirected by staff. A nursing note dated 5/26/22 at 2:31 PM identified Resident #1 was noted to be undressing in the common area in front of other residents. Staff intervened and redirected Resident #1. Resident #1 was reminded to keep his/her clothes on. Resident #1 was very difficult to redirect. Resident #1 was noted staring at RN #2's breast while attempting to touch RN #2's breast. RN #2 reminded Resident # 1 to keep his/her hands to self. The Resident Care Plan dated 5/31/22 identified Resident #1 exhibited verbal behaviors related to Cognitive loss/Dementia and noted a history of verbal and physical outbursts directed toward others such as use of abusive language, patterns of challenging/confrontational verbal behavior related to Psychiatric Disorders. Interventions included evaluating the need for Psychiatric Behavioral Health consultation and directed to allow time for expression of feeling, provide empathy, encouragement, and reassurance. A nurse's note dated 6/6/22 at 2:25 PM identified that Resident #1 was seeking out a female resident. RN # 2 intervened and prevented Resident #1 from encouraging a female resident into his/her room. RN #2 redirected the female resident with good effect. Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] identified that Resident #3 had severely impaired cognition and required limited assistance with bed mobility, transfers, and supervision with walking. The physician's note dated 5/11/22 identified that Resident #3 was alert and confused. A nurses note dated 5/23/22 at 6:50 PM identified Resident #1 was seen coming out of a female resident (Resident # 3) room and was redirected by staff. A review of the clinical record and review of facility documentation dated 5/23/22 through 7/5/22 failed to reflect that the facility had initiated an investigated why Resident #1 (history of sexual abuse) was noted coming out of Resident # 3's (severely cognitively impaired resident) room. An interview on 7/1/22 at 1:05 PM with RN #1 (nursing supervisor) identified she was aware Resident #1 was seen coming out of Resident #3's room but did not think it was an issue because Resident # 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 further indicated she intervened and prevented Resident #1 from encouraging Resident # 3 to come into his/her room. An interview on 7/05/22 at 11:27 AM with ADNS identified that she was not aware of Resident #1's sexual inappropriate behavior until the 6/7/22 incident. Interview on 7/07/2022 at 9:03 AM with LPN #2 identified that during her medication pass, Resident #1 was seen coming from Resident #3's room and shutting the door behind him/ her. She asked Resident #1 what he/she was doing Resident #1 responded s/he was in the wrong room. LPN # 1 warned Resident #1 that he/ she should not be going into rooms of opposite sex /gender. LPN#1 indicated she did not check on Resident # 3 after the incident and /or notify the supervisor of her observation of Resident # 1 coming out of Resident # 3's room for an undetermined amount of time. The facility failure to thoroughly investigate a potential sexual abuse incident when Resident #1 (with a history of sexual abuse) was noted coming out of Resident # 3's room for an undetermined amount of time. This resulted in the facility failure to prevent a subsequent resident to resident sexual abuse that occurred when Resident # 2 (who was severely cognitively impaired and not capable of consenting to participating in an oral sexual act) was observed performing oral sex on Resident #1 resulting in a finding of Immediate Jeopardy. Attempts to interview the Director of Nursing Services (DNS) on 7/1/22 and 7/5/22 were unsuccessful. The facility submitted a removal plan on 7/6/22 that included: Resident #1 is on 1:1 and will continue until the psychiatric team deems no longer or 30 days without sexual or physical behaviors is achieved. The licensed staff will be educated to investigate the circumstances and evaluate if another resident with known physical or sexual behavior wanders into a resident's room that is unobserved to immediately notify the supervisor, investigate, nursing supervisor will interview staff members on each unit each shift to identify if any residents are exhibiting new sexual behaviors. Daily audits of behavior monitoring system for new sexual behaviors will be completed for 7 days, weekly for 4 weeks, monthly for 3 months with remedial actions per center practices and results will be reviewed at QAPI and the Administrator or designee are responsible for oversight of this plan of correction. A review of the facility ' s abuse policy identified that the center prohibits abuse, mistreatment, and exploitation of all residents. The policy identified that staff would, identify events such as suspicious occurrences, patterns, and trends that may constitute abuse and determine the direction of the investigation. The investigation will be thoroughly documented within the Risk Management Portal and staff will ensure that documentation of witnessed interviews is included. The facility staff is responsible for preventing occurrence of abuse, mistreatment and exploitation of residents and apply appropriate interventions.

Based on clinical record reviews, review of facility documentation and policies and interviews for one of three sampled residents (Resident #1) who had food allergies, the facility failed to ensure the resident did not receive a food item that resulted in an allergic reaction that resulted in a finding of Immediate Jeopardy. During the on-site visit Immediate Jeopardy was verified as corrected when the facility implemented an immediate action plan to mitigate further risk to all residents. The findings include: Resident #1's diagnoses included diabetes mellitus, asthma and cerebral infarction. The admission nurse's note dated 5/21/21 identified Resident #1 was alert and oriented to person, place and time. A physician's order dated 5/21/21 directed for a consistent carbohydrate diet, regular texture and identified Resident #1 had an allergy to peanut butter. The nurse's note dated 5/23/21 at 5:45 PM identified at 12:30 PM Resident #1 began to consume a bit of a custard looking pie and immediately notified the staff of a peanut butter like taste and Resident #1 spit the pie out. The note indicated the physician was notified and [MEDICATION(S)] 50 milligrams (mg) by mouth was administered at 12:40 PM. The note identified at 1:00 PM Resident #1's blood pressure was 140/89 (normal 120/80), heart rate 258 (normal between 60 to 100 beats per minute) and the oxygen saturation level was 78% (normal saturation levels 97% to 100%) [MEDICATION(S)] 1 milligram per milliliter subcutaneously was administered with immediate improvement, Resident #1 was also placed on two (2) liters of oxygen via nasal cannula and 911 was called. The note identified that prior to the transfer to the hospital for an evaluation Resident #1's heart rate was 70-80 beats and the oxygen saturation level was 100%. The nurse's note indicated Resident #1 returned from the hospital at 5:45 PM where Resident #1 was monitored status post allergic reaction with no signs or symptoms of ill effects. Resident #1 received [MEDICATION(S)] prophylactically while in the hospital, the EKG was normal and no new recommendations for care were received from the hospital. Review of the lunch menu dated 5/23/21 identified the dessert served was peanut butter pie. Review of Resident #1's lunch meal tray card dated 5/23/21 identified Resident #1 was allergic to peanuts and peanut butter and was to receive grapes for dessert. Interview with Dietary Aide #2 on 6/7/21 at 10:30 AM identified Resident #1's meal ticket listed the peanut and peanut butter allergies. Dietary Aide #2 indicated he checks the trays for the correct diet, and he did not check the dietary card for food allergies prior to placing the tray in the dietary cart. Interview with the 7AM-3PM charge nurse, Registered Nurse (RN) #1, on 6/7/21 at 11:00 AM identified a nurse aide served Resident #1's lunch tray. RN #1 indicated she looks at the list of textures, fluid consistency, food allergies before lunch trays are served to the residents and everything checked out. RN #1 identified a slice of pie that looked like a beige, tan custard, pudding was on Resident #1's lunch tray. RN #1 indicated Resident #1 took a bite of the pie and spit it out because it tasted like peanut butter. RN #1 identified the nurse aide called her to come into Resident #1's room and upon arrival Resident #1 was alert and oriented, calm and Resident #1's vital signs were stable. RN #1 identified Resident #1 received [MEDICATION(S)] by mouth after the first set of vital signs were taken. RN #1 indicated the second set of vital signs identified Resident #1's pulse was elevated, and the oxygen saturation level dropped at which time oxygen was applied and she administered [MEDICATION(S)] subcutaneously once. RN #1 identified that 911 was called and Resident #1 was sent to the hospital for an evaluation. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 6/7/21 at 11:55 AM identified she delivered Resident #1's lunch tray. NA #1 indicated along with RN #1 they verified Resident #1's diet consistency, liquid consistency and everything seemed fine. NA #1 identified she was aware Resident #1 had peanut allergy as it was printed on the meal ticket. NA #1 indicated the dessert on Resident #1's lunch tray looked like a tan, brown colored pudding. NA #1 identified about a minute after delivering Resident #1's tray, she went to answer Resident #1's call light and Resident #1 stated to her that he/she thought he/she tasted some peanut butter in the dessert. NA #1 indicated she called RN #1, who went in to assess Resident #1 and she called the kitchen to verify what kind of dessert was served and the kitchen staff told her the dessert was peanut butter pie. NA #1 identified she told the kitchen staff that the peanut butter pie was on the tray of a resident who had peanut butter allergy. NA #1 identified Resident #1's vital signs were being monitored every fifteen (15) minutes and the first set of vital signs were within normal limits for Resident #1. NA #1 indicated with the second set of vital signs, Resident #1's heart rate was a little high, so she alerted RN #1. Interview with Dietary Aide #1 on 6/7/21 at 12:15 PM identified Resident #1 was supposed to receive grapes for dessert, however grapes were no available, so he substituted the grapes with the peanut butter pie without checking Resident #1's food allergies or checking with the cook. Dietary Aide #1 indicated that checking for allergies just slipped by him. Interview with Resident #1 on 6/7/21 at 12:55 PM identified the nurse aide brought the lunch tray and there was a slice a pie for dessert. Resident #1 identified he/she swallowed a small piece, tasted the peanut butter and called for help. Resident #1 indicated he/she looked at the pie and did not realize it was a peanut butter pie until he/she tasted it. The Dining and Food Preferences Policy directed the individual tray assemble ticket will identify all food items appropriate for the resident based on diet order, allergies, intolerances and preferences. Subsequent to the incident the facility implemented an immediate plan of correction on 5/23/21 that included: For Resident #1 [MEDICATION(S)] protocol was followed and was sent to the hospital and to prevent an incident from occurring to other residents, dietary will have a list of food allergies at the tray line to identify resident allergies, the food allergies are now highlighted on the tray tickets, the cook will review allergies with the tray line staff before each meal, the tray line starting position dietary staff will place items on the tray that are indicated on the tray ticket, the second person on the tray line will read the resident's name, diet any allergies or other instructions indicated on the tray card and checks all items on the tray to make sure it matches what ins on the ticket, any items not indicated on the ticket or select menu are removed and corrections made, if a substitution needs to be made, an appropriate or equal item should be used and if the item is changed, the tray card needs to be marked with the substitution and the missing item marked off. The plan directed education was immediately initiated with the dietary and nursing and dietary staff on 5/23/21 regarding reviewing tray tickets for food allergies and audits were conducted and on 5/24/21 the rehab and recreation staff were educated to review food allergies before providing food to residents. Dietary and nursing will perform random audits to monitor compliance.

Based on clinical record reviews, interviews and observations for 1 of 3 sampled residents reviewed for accidents (Resident #224) the facility failed to communicate to nursing staff, a decline in resident's status to ensure that the resident was provided with appropriate transfer assistance (2 staff) to prevent a fall with injury and/or the facility failed to ensure the call light system was operating efficiently to allow the residents to call for assistance through the communication system should an emergency arise. The findings include: 1. Resident #224's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified the resident as moderately cognitively impaired, required extensive assistance of one with transfers, toileting and personal hygiene. The assessment further noted that the resident's balance during transition and walking were not steady and only able to stabilize with staff assistance. A RCP dated 7/27/17 identified the resident at risk for falls due to impaired mobility, poor cognition and psych medication use. Interventions included assist of 1 for transfers and for ambulation using a rolling walker. A physical therapy (PT) discharge summary dated 08/02/17 identified the resident had been treated for [REDACTED]. A review of a nurse's note/assessment and the facility accident and incident (A&I) report identified that on 08/15/17 at 4:30 PM, the resident was being toileted and lost her/his hold of the bathroom grab bar. The nurse aide (NA#10) grabbed the resident to prevent him/her from falling and in the process, the resident hit her/his forehead on the bathroom wall and her/his left hand slipped behind the grab bar. A change in condition evaluation dated 08/15/17 identified that NA#10 grabbed the resident by the pants in an attempts to stabilize the resident. The resident was subsequently transferred to the hospital emergency department (ED) and diagnosed with [REDACTED]. It also noted that the degree of osteopenia limited further evaluation but noted that there was a likely involvement of the articulating surface. The hospital discharge information further identified that the resident had a head injury and pleural effusion. The resident returned to the facility after being evaluated at the hospital. Interview with LPN #6 on 01/08/17 at 2:45 PM identified that he/she was called to the resident's room following the incident. LPN#6 indicated that NA#10 informed him/her that while the resident was holding onto the bathroom grab bar her/his legs became weak. Interview with NA#10 on 01/08/17 at 3:18 PM identified that he/she is employed on a per diem basis but had taken care of the resident on previous occasions. NA#10 further noted that at the time of the incident he/she toileted the resident, provided personal care and applied a brief while the resident stood and held onto the bathroom grab bar. He/she further noted that while pulling the resident's pants up, the resident started to fall backwards, at which time he/she grabbed the resident by the pants to keep the resident from falling and that's when the resident hit her/his forehead on the wall. NA#10 then transferred the resident to the wheelchair and then alerted the nurse. The nurse aide indicated the nurse then informed him/her that the resident had been sick for a week and was weak. The nurse aide also indicated that he/she had not used a gait belt with the resident because in the past he/she never had a problem and that the resident was strong so he/she did not need to use one. He/she further noted that his/her shift starts at 3:15 PM because he/she comes from another job and that he/she had not received report from the previous shift because they had already left for the day. He/she also noted that if he/she had known the resident had been sick and weak he/she would have used a gait belt and/or requested assistance with transferring and providing care to the resident. A second interview with LPN #6 on 01/10/18 at 1:03 PM identified that due to the resident's decline and weakness, they had been using two staff members to transfer the resident. LPN#6 identified that he/she had not given report to the nurse aide and indicated that nurse aides usually give report to each other. The facility failed to update the care plan and/or communicate the change in transfer status in R#224 to nursing staff to ensure the safety of the resident. Review of the facility's policy on gait belt use identified that gait belts are to be utilized for all assisted transfers with exceptions for certain situations and conditions. 2. Observation on 1/09/18 at 9:55 A.M. identified the receiver was off the hook of the call light system causing the system to de-activate the sound on the unit. Interview with LPN #1 on 1/9/18 at 9:55 A.M. identified that although he/she was seated next to the call light system, he/she did not know why the system was disabled and that it made sense to place the receiver to enable the system. Once enabled, two call lights sounded immediately. Interview with the Administrator on 1/9/18 at 10:55 A.M. identified that at another time when he/she had been monitoring call light response times and he/she had observed the receiver off the hook on one of the units. The Administrator reported that at the time of discovery, he/she informed staff that they must keep the receiver on the hook or they would be written up.

Based on clinical record reviews, interviews, observations, review of facility policy and procedure, and reviews of facility documentation for six of six residents reviewed for pressure ulcers (Residents #7, 14, 112, 129, 147, and 163), the facility failed to initiate and/or document interventions to prevent pressure ulcer developement and/or aid in healing. The findings include: 1. Resident #7's [DIAGNOSES REDACTED]. An admission care plan dated 10/7/14 identified Resident #7 was at risk for skin breakdown. Interventions included conducting skin assessments per facility policy, apply barrier cream, off the load heels and conduct weekly skin assessments. The five day MDS admission assessment dated [DATE] identified Resident #7 was moderately cognitively impaired, required extensive assistance of one staff for bed mobility, two staff for transfers and toileting, was incontinent of bowel and bladder, was at risk for pressure ulcer development, and was not admitted with a pressure sore. The skin integrity report dated 10/20/14 identified a new in house acquired stage 2 sacral pressure ulcer, which measured 0.75 cm x 0.75 cm x 0.1 cm, with100% granulation and healthy surrounding tissue. Review of wound documentationon dated 10/23/14 identified the sacral pressure ulcer was identified as a 3 cm x 2 cm x <0.1 cm. stage 3 with 30% necrosis, 40% granulation and 30% skin. On 10/30/14, the pressure ulcer was a stage 3 with 20% necrotic tissue and 80% granulation and measured 0.5 cm x 0.5 cm <0.1 cm. Wound documentation dated 11/6/14 identified the pressure ulcer was a stage 4 that measured 4 cm x 3 cm x <0.1 cm with 100% necrotic tissue, minimal serous drainage, inflamed surrounding tissue, and wound edges that were macerated. The wound care specialist (physician) note dated 10/23/14 recommended to obtain a Group 2 low air loss mattress, limit the resident's sitting to 60 minutes, off load the wound, reposition the resident per facility policy, and continue the use of Santyl. The wound care specialist evaluation dated10/30/14 identified a stage 3 pressure wound of the sacrum with thick adherent necrotic tissue, 30% granulation, 70% necrotic and the wound was improved. Additionally, Resident #7 was noted to be on a Group 1 bed and a pressure reducing cushion. Interview and review of facility documentation on 3/24/15 at 1:50 PM with RN #7 and LPN #4 identified facility staff do not consistently document when turning and re-positioning is provided. LPN #7and LPN #4 indicated turning and re-positioning is randomly documented in the nursing notes. RN #7 and LPN #4 further identified that individuals with decreased mobility are turned and repositioned "per policy", however, were unable to identify where the information would be documented. Further review failed to reflect the wound specialist recommendations were initiated related to limited seating and off loading of the wound and the care plan lacked updates to prevent the wound from declining further after it developed and/or after it declined (i.e. repositioning and off loading the wound). Interview and review of facility documentation with RN #8 on 3/26/15 at 11:00 AM identified Resident #7 was assessed as a moderate risk to develop a pressure ulcer. RN #8 indicated the facility does not implement any different interventions for residents identified at pressure ulcer risk because the facility uses pressure reducing devices for the bed and chair and off-loading of the heels is provided for all residents. Additionally, RN #8 was unable to provide information related to Resident #7 prior to January 2015. RN #8 identified each individual Unit Manager is the person responsible for the wound program on their unit and Resident #7's former Unit Manager no longer works in the facility. Interview with the Clinical Operations Manager (COM) on 3/26/15 at 2:25 PM identified the facility does not document turning and positioning of a resident because it was extraneous that, after the Resident #7's wound developed, the physician wrote for staff to turn and reposition the resident every two hours. The COM identified that turning and repositioning should be documented on the care plan and in the physician orders. The COM was unable to provide documentation that turning and repositioning was carried out by staff prior to the physician writing the order. 2. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 30 day MDS assessment dated [DATE] identified the resident had impaired cognition, required extensive assistance with bed mobility, toilet use and personal hygiene, was always incontinent of bladder and bowel, was at risk for pressure ulcer development, and did not have a pressure ulcer. The care plan dated 1/26/15 identified a risk for skin breakdown. Interventions included to evaluate for any localized skin problems, conduct the Norton/Braden assessments per facility policy, float the heels in bed, and conduct weekly skin assessments by the licensed staff. The skin integrity report dated 2/23/15 identified a 0.2 cm by 0.2 cm by 0.1 cm open area on the coccyx with 20% slough and a healthy peri-wound. The treatment kardex indicated to apply Xeroform twice a day to the wound. Review of the treatment kardex identified the Xeroform treatment was "circled" indicating it was not done on 2/24/15 for the evening shift and on 2/26/15 for both the day and evening shift. The treatment kardex lacked licensed staff initials for 2/25/15 to identify the treatment was conducted by staff. The skin integrity report dated 2/24/15 noted that the wound had "partial skin loss" and had deep purple color surrounding the wound. The wound consultant physician assessment dated [DATE] identified a stage 2 wound of the sacrum measuring 0.2 cm by 0.2 cm. Recommendations included to provide off loading of the wound and the physician order [REDACTED]. The skin integrity report dated 3/5/15 identified the wound had increased to 1.0 cm by 1.0 cm and was now a stage 3 pressure sore. The wound consultant physician report dated 3/5/15 identified the wound had declined to an unstageable necrosis that required surgical debridement of the muscle. The treatment was changed to include [MEDICATION NAME] ointment. The wound consultant physician note dated 3/12/15 identified a 2.0 cm by 1.5 cm unstageable necrotic wound that was again surgically debrided. An xray report dated 3/13/15 indicated lucency and deformity in the segment of the sacrum/coccyx subjacent to the skin wound and osteo[DIAGNOSES REDACTED] cannot be excluded. On 3/16/15, the APRN assessed the resident and ordered 6 weeks of intravenous antibiotics for a stage 4 pressure ulcer with osteo[DIAGNOSES REDACTED]. On 3/17/15, the facility nurse documented on the skin integrity report that the wound was a stage 3 measuring 4.0 cm by 4.0 cm by 1.5 cm with necrosis and slough present and the resident was experiencing pain associated with the wound. On 3/19/15, the wound consultant debrided necrotic tissue and muscle from the stage 4 pressure sore. The facility nurse documented on the same day via the skin integrity report that the wound was a stage 3. Observation of the wound on 3/27/15 at 11:00 AM with LPN #6 identified an unstageable, 100% necrotic pressure ulcer on the sacrum measuring 2.5 cm x 2.7 cm x 2.0 cm with undermining noted at 7 and 8 o'clock. The peri-wound was noted to be macerated. LPN #6 indicated that Resident #14 was going to the wound clinic today for follow up. Interview and review of the clinical record with RN #6 on 3/27/15 at 11:00 AM identified when the resident was identified with a stage 2 pressure ulcer on 2/23/14, the treatment orders that were noted on the TAR should have been initiated and documented on the TAR. RN #6 was unable to explain why the clinical record failed to reflect a physician's orders [REDACTED]. Although the treatment kardex directed staff to "reposition the resident frequently", the documentation indicated that the resident was not being repositioned every 2 hours per standards of pressure sore prevention and treatment and only at 6 AM, 9 AM, 11 AM, 1 PM, 3 PM, 5 PM, 9 PM and 11 PM. Further review failed to provide documentation the care plan had been updated to reflect the presence of an actual pressure sore until 3/25/15 and/or develop and implement interventions to aid in healing the wound, including a Roho cushion in the wheelchair and air mattress for the bed which were not added until subsequent to surveyor inquiry on 3/25/15. 3. Resident #112 [DIAGNOSES REDACTED]. A significant change MDS assessment dated [DATE] identified that the resident was cognitively impaired, dependent on staff for all ADL ' s including eating, did not walk, was incontinent of bowel, and recently healed a stage 4 pressure ulcer. The nurse aide assignment dated 12/27/14 indicated to assist with turning and positioning frequently. On 2/23/15 the assignment directed to keep the resident off his/her back while in bed. A wound physician consult dated 1/21/15 indicated that the stage 4 pressure sore of the left ischium had healed. The skin integrity report dated 2/22/15 indicated the resident was found with a stage 2 pressure ulcer on the coccyx that measured 2.0 cm x 1.2 cm with 50% necrosis. Additionally, a stage 2 pressure ulcer was noted on the left buttock that measured 1.5 cm x 0.3 cm with 100% granulation, and a stage 1 pressure ulcer of the right buttock that measured 0.3 cm by 2.8 cm. The care plan dated 2/24/15 identified an actual skin breakdown. Interventions included to keep resident off back and turn side to side in bed, barrier cream with each cleansing, float heels in bed, and Roho cushion in the wheelchair. On 3/2/15 elbow pads were added. On 3/2/15 the skin integrity report identified a stage 2 pressure ulcer of the left elbow and on 3/5/15 the area was noted as unstageable with 100% necrosis. The next facility nursing assessment of the coccyx, right and left buttock pressure ulcers was on 3/5/15 (11 days later), when documentation noted that the 3 areas were now one area measuring 4.0 cm by 3.5 cm with 100% necrosis and moderate drainage. A wound physician consult report dated 3/5/15 indicated the sacrum pressure sore was unstageable due to necrosis and required surgical debridement of muscle and the necrosis. The physician indicated that the ulcer might be a Kennedy or end of life ulcer. The physician also surgically removed the necrosis from the resident ' s elbow. On 3/12/15, the wound physician note indicated that the sacral wound had declined and elbow had improved. The sacral wound was again debrided. The left elbow wound healed on 3/19/15. On 3/26/15, the wound physician note indicated the sacral wound had improved. A review of the clinical record and interview on 3/27/15 at 11:20 AM with the DNS and RN #7 indicated Resident #112 was identified with a pressure ulcer on 9/12/12 that healed on 1/2/15 and reopened on 2/22/15. RN #7 was unable to provide documentation that turning and positioning was provided as outlined in the resident care plan. RN #7 indicated turning and repositioning was a standard of practice and was not documented. The DNS and RN #7 further indicated if there were special instructions for the turning and positioning it would be included on the nurse aide kardex. DNS and RN #7 were unable to provide documentation of special instructions related to Resident #112's turning and positioning to prevent the re-opening of the pressure sore. 4. Resident #129's [DIAGNOSES REDACTED]. The care plan originally dated 3/27/14 identified an actual skin breakdown related to a stage 3 of the left buttock. Interventions included evaluate wound area daily, and wound treatment as ordered. A pressure redistribution wheelchair cushion was added to the care plan on 11/11/14. The MDS quarterly dated 12/18/14 identified that the resident was without cognitive and/or memory impairments, had no problem behaviors, required extensive assistance for bed mobility, required extensive assistance of two for transfers, could not ambulate, was incontinent of bowel and had one stage 3 pressure sore. Review of wound assessment records noted a new onset, facility acquired, stage 3 pressure sore of the left lower buttock on 9/25/14. On 2/12/15, the record noted that the wound had healed. On 3/5/15 the area was noted as having reopened and first note written identified the area was a stage 4 with 20% necrotic tissue. Observations on 3/26/15 at 2:25 PM with the wound physician noted a clean, red wound with slight maceration. The physician indicated that the resident's wound has reopened for the 2nd time because the resident likes to sit in the chair and is non compliant with going back to bed. The physician indicated that a Roho cushion was being used in the wheelchair. Observation of the resident's wheelchair at that time failed to refelct a Roho cushion in the wheelchair. The Wheelchair was noted with a hard, small plastic cushion. The resident at that time indicated that he/she had a pad at one time that did not stay inflated. Interview and review of the clinical record with RN #6 on 3/27/15 at 12 noon failed to provide documentation that care plan interventions to alleviate pressure to the buttocks were initiated and/or developed with repeated re-opening of the left buttock wound. Further review failed to provide documentation the resident was offered and/or refused alternative positioning plans to aide in healing the wound and preventing re-opening. Subsequent to surveyor inquiry, the resident was supplied with a Roho cushion to alleviate pressure while in the wheelchair. 5. Resident #147 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing note dated 10/21/14 identified a reddened, blanchable area located on the sacrum. An admission MDS assessment dated [DATE] identified the resident had impaired cognition, displayed no mood issues or behaviors, required extensive assistance of two for bed mobility, toilet use and personal hygiene, was always incontinent of bladder and bowel, and had one unstageable pressure ulcer. Nurse ' s notes dated 10/23/14 identified a new onset change in skin integrity as evidenced by a stage two pressure ulcer located on the coccyx measuring 2.0 cm x 1.7 cm. Admission Physician orders [REDACTED]. Physician orders [REDACTED]. The skin integrity report dated 10/23/14 identified an unstageable pressure ulcer located on the sacrum measuring 1.5 cm x 1.5 cm x <0.1 cm with 60% necrotic tissue and minimal serous drainage. The wound physician consult note dated 10/23/14 identified an unstageable necrotic pressure ulcer on the sacrum measuring 1.5 cm x 1.5 cm with light serous exudate and 60% thick adherent devitilized necrotic tissue. Recommendations included surgical debridement of the subcutaneous tissue, and to apply Santyl daily. The care plan dated 10/28/14 identified a risk for skin breakdown. Interventions included to apply barrier cream, and Norton/Braden Scale assessments per policy. Interview and review of the clinical record with RN #6 on 3/27/15 at 10:00 AM identified the resident was admitted with a red blanchable area located on the sacrum. The interventions at that time should have been to ensure turning and repositioning and to provide incontinent care as needed. The clinical record failed to reflect interventions were implemented until 10/23/14, 3 days later, when the area declined and was identified as an unstageable pressure ulcer. 6. Resident #163 was admitted in April 2014 with [DIAGNOSES REDACTED]. Nursing admission assessment dated [DATE] noted no pressure sores and that the resident utilized splints on the right arm and right lower leg. The resident care plan dated 4/5/14 identified the resident was at risk for skin breakdown. Interventions included floating the heels and applying barrier cream after incontinence care. Physician's progress notes dated 1/30/15 noted the presence of a new contracture of the right lower extremity. Physical therapy evaluation on 1/31/2015 identified the resident had significantly increased tone and decreased range of motion in the right lower extremity resulting in a risk for skin breakdown and contracture. A wound assessment and nursing readmission assessment on 2/17/15 identified a 2 cm x 1 cm open, non-pressure area behind the right knee. Physician orders [REDACTED]. An MDS assessment dated [DATE] noted that the resident was cognitively impaired, required the assist of 2, total dependence for bed mobility and transfers, incontinent of bowel and bladder and absence of pressure sores. A wound assessment that was undated but documented sometime between 2/17/15 and 3/5/15 indicated that the area behind the right knee had declined to a Stage 4 pressure sore with 30% necrotic tissue. Review of physician's orders [REDACTED]. Observation of the resident on the morning of 3/25/15 noted no splinting of the right knee and the presence of a dressing behind right knee. The wound was observed and noted to be a Stage 4 ulcer with approximately 20% necrosis. Interview and clinical record review with LPN #5 at 11:30 am on 3/25/15 failed to provide documentation that interventions were in place to prevent skin to skin pressure breakdown when the resident was noted in January 2015 to have increased contracture of right lower extremity. Further review failed to provide documentation the care plan was updated when the wound was first noted on 2/17/15 and/or when the wound declined to a Stage 4 pressure sore sometime between 2/17/15 and 3/5/15. Subsequent to surveyor inquiry, a nursing care plan dated 3/25/15 was noted that identified the resident had actual skin breakdown and included interventions to monitor the wound daily for signs of drainage and/or signs of infection. An interview with the wound care physician on 3/26/15 at 3:55 PM noted that interventions including a brace, range of motion and [MEDICATION NAME] treatments secondary to the leg/knee contracture could have been implemented to prevent the pressure sore.

Based on clinical record review and staff interview for one of three residents in the survey sample reviewed for mistreatment (R # 42), the facility neglected to treat a wound which subsequently decline, for three consecutive days. The findings include: Resident # 42 [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive deficits, required extensive assistance from staff for bed mobility, and did not walk. A resident care plan dated 1/16/15 identified skin breakdown on the right lower extremity. Interventions included evaluate the wound area daily and provide wound treatment as ordered. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A wound care specialist note dated 1/29/15 indicated R # 42 had a stage 4 pressure wound on the right calf that measured 2.3 cm x 0.2 cm with 100% granulation tissue. An unstageable pressure wound on the right ankle measured 0.6 cm x 0.6 cm with 50% necrosis and 50% granulation. A review of an investigation dated 2/3/15 indicated that on 2/3/14, R #42's right leg dressings were noted to be dated 1/30/15. The investigation indicated it was determined that the resident's wound dressings were not treated as per the Physician orders [REDACTED]. The wound dressings were changed on 2/3/15 when the error was discovered. The wounds were reassessed on 2/4/15 after it was discovered the wound treatments were not done for 3 days. A skin integrity report dated 2/4/15 indicated the right calf wound was a stage 4 that had increased in size to 5 cm x 0.5 cm with 20% slough and 80% granulation. The right ankle pressure sore had increased in size and necrosis to 1 cm x 1 cm with 75% slough. Review of the clinical record and interview on 3/25/15 at 3:30 PM with RN #6 indicated that although LPN #2 had signed that the treatments were done on R #42's wounds on 1/31/15, 2/1/15, and 2/2/15, the dressings were dated 1/30/15. Per facility policy dressings are to be dated when they are changed. He/she further indicated that although the right calf increased in size on the 2/4/15 measurement, the periwound redness was included in the measurement which was not included in the 1/29/15 measurement. An interview on 3/25/15 at 3:45 PM with LPN # 2 indicated although he/she was responsible to change R #42's leg dressings on 1/31/15, 2/1/15, and 2/2/15, he/she could not recall if he/she had changed the dressings and/or evaluated the wounds on those days. LPN #2 indicated he/she usually dated the wound dressings when they were changed per facility policy.

Based on clinical record review and staff interview for one of three residents in the survey sample reviewed for mistreatment (R # 42), the facility failed to treat a wound for three consecutive days. The findings include: Resident #42's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive deficits, required extensive assistance from staff for bed mobility, and did not walk. A resident care plan dated 1/16/15 identified skin breakdown on the right lower extremity. Interventions included evaluate the wound area daily and provide wound treatment as ordered. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A wound care specialist note dated 1/29/15 indicated R # 42 had a stage 4 pressure wound on the right calf that measured 2.3 cm x 0.2 cm with 100% granulation tissue. An unstageable pressure wound on the right ankle measured 0.6 cm x 0.6 cm with 50% necrosis and 50% granulation. A review of an investigation dated 2/3/15 indicated that on 2/3/14, R #42's right leg dressings were noted to be dated 1/30/15. The investigation indicated it was determined that the resident's wound dressings were not treated as per the Physician orders [REDACTED]. The wound dressings were changed on 2/3/15 when the error was discovered. The wounds were reassessed on 2/4/15 after it was discovered the wound treatments were not done for 3 days. A skin integrity report dated 2/4/15 indicated the right calf wound was a stage 4 that had increased in size to 5 cm x 0.5 cm with 20% slough and 80% granulation. The right ankle pressure sore had increased in size and necrosis to 1 cm x 1 cm with 75% slough. Review of the clinical record and interview on 3/25/15 at 3:30 PM with RN #6 indicated that although LPN #2 had signed that the treatments were done on R #42's wounds on 1/31/15, 2/1/15, and 2/2/15, the dressings were dated 1/30/15. Per facility policy dressings are to be dated when they are changed. He/she further indicated that although the right calf increased in size on the 2/4/15 measurement, the periwound redness was included in the measurement which was not included in the 1/29/15 measurement. An interview on 3/25/15 at 3:45 PM with LPN # 2 indicated although he/she was responsible to change R #42's leg dressings on 1/31/15, 2/1/15, and 2/2/15, he/she could not recall if he/she had changed the dressings and/or evaluated the wounds on those days. LPN #2 indicated he/she usually dated the wound dressings when they were changed per facility policy.

Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #404) who had required Intravenous (IV) fluids, the facility failed to notify the attending physician and/or Advanced Practice Registered Nurse (APRN) of abnormal blood work levels at the time the facility was notified by the laboratory center. The findings include: Resident #404's [DIAGNOSES REDACTED]. The laboratory report dated 5/12/14 identified that Resident #404's sodium level was 131 (normal range 133-145), potassium 4.0 (normal range 3.3-5.1), Blood Nitrogen Urea (BUN) was 6 (normal range 6-20) and the creatinine 0.5 (normal range 0.7-1.5). A physician's order dated 5/12/14 directed to obtain a Basic Metabolic Panel (BMP) in one week. The laboratory report dated 5/19/14 identified the sodium level was 117, potassium 3.7, creatinine 0.4 and BUN 6. Review of the nurse's notes from 5/19/14 through 5/20/14 failed to reflect documentation that the abnormal bloodwork results had been reported to the physician and/or APRN on 5/19/14. Review of facility documentation dated 5/21/14 in a written statement the 7-3 PM Registered Nurse (RN) #4, identified that she had called the laboratory center on 5/20/14 at about 4:00 PM to follow up on the critical low sodium level from 5/19/14. The statement identified that the laboratory center had called the facility on 5/19/14 at 10:56 AM and reported to the charge nurse, Licensed Practical Nurse (LPN) #4, the low sodium level. The nurse's note dated 5/20/14 identified that the charge nurse had received a call at 1:45 PM from the APRN regarding Resident #404's sodium level at 117 and new orders were obtained. The APRN order dated 5/20/14 directed to start intravenous fluids 0.9% Normal Saline at 75 cubic centimeters (cc) per hour times three liters. Review of the clinical record identified that on 5/21/14 at 3:52 AM Resident #404 arrived at the hospital. The hospital progress record dated 5/21/14 at 8:00 AM identified that Resident #404 had come in with a sodium level of 111 and four episodes of [MEDICAL CONDITION] activity that lasted 2-3 minutes each. In an interview on 3/9/15 at 11:30 AM, APRN #2 indicated that on 5/20/14 while she was reviewing the laboratory results for the facility, she discovered the abnormal bloodwork report for Resident #404 dated 5/19/14 timed at 10:47 AM with a sodium level of 117. Interview with Licensed Practical Nurse (LPN) #4 on 3/19/15 at 11:15 AM identified that she became aware of the critical laboratory result for Resident #404 on 5/20/14 and does not recall receiving the result on 5/19/14. Interview with the Regional Corporate Nurse on 3/19/15 at 2:30 PM indicated it was the expectation for the nursing staff to report a critical laboratory result to the APRN. Review of the facility's physician/mid-level provider notification policy identified, in part, that a licensed nurse will report abnormal lab values to the physician/mid-level provider. Subsequent to the 5/19/14 incident, the record of counseling dated 5/28/14 identified that LPN #4 was terminated for failure to follow up on a resident's critical low sodium level. LPN #4 failed to report the critical level to the physician and/or APRN for treatment. LPN #4 failed to follow facility policy.

Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #406) who required an assistive device to aid with breathing, the facility failed to ensure the physician was notified when the [MEDICAL CONDITION] (Bi-level Positive Airway Pressure) equipment was not going to be available. The findings include: Resident #406's [DIAGNOSES REDACTED]. The nurse's progress note dated 2/4/15 at 3:07 PM identified that Resident #406 was admitted to the facility. An admission physician's orders [REDACTED]. oximetry every shift to keep the oxygen saturation level equal to or greater than 92%. The nurse's progress note dated 2/5/15 at 7:55 AM identified that from 3:00 AM through 6:00 AM Resident #406 had a change in medical condition. The resident's vital signs documented at 7:56 AM were temperature 98.1 degrees Fahrenheit, pulse 110, respirations 22, blood pressure 141/74 and the oxygen saturation level was 88% with oxygen via mask. Resident #406's facial color was cyanotic, the level of consciousness confused and the resident was experiencing moderate chest pain. Subsequent to physician notification Resident #406 was transferred to the hospital for an evaluation. The Emergency Department (ED) provider note dated 2/5/15 at 6:26 AM identified that the resident presented to the ED for dyspnea. The resident had stated that he/she was supposed to receive a [MEDICAL CONDITION] machine to sleep but the facility did not have one. The ED physician had been informed by the Emergency Medical Service (EMS) that upon their arrival Resident #406's oxygen saturation level was 42%. The initial nursing assessment at 6:40 AM indicated that Resident #406 had diminished lung sounds and labored breathing, blood pressure was 166/79, pulse 101, respiration 26 and an oxygen saturation of 42%. The hospital chart report identified that Resident #406 was discharged back to the facility at 10:38 AM. In an interview on 3/18/15 at 1:45 PM RN #2 identified that she assisted with admitting process Resident #406 and called the Advanced Practice Registered Nurse (APRN) to verify the orders. RN #2 indicated that was expecting the [MEDICAL CONDITION] unit to be delivered on the evening of 2/4/15 and at the end of her shift the [MEDICAL CONDITION] unit had not been delivered. RN #2 indicated that deliveries have occurred at 11:00 PM or later and she informed the 11-7 Nursing Supervisor (RN #1) that the [MEDICAL CONDITION] unit had not arrived. Interview with APRN #2 on 3/19/15 at 11:30 AM identified that when Resident #406 arrived the afternoon of 2/4/15 she only reviewed the medication orders and then left the facility, (it was near the end of her shift (8:00 AM to 6:00 PM). APRN #2 indicated that on 2/5/15 at 8:00 AM was informed that Resident #406 had a change in condition overnight and was transferred to the hospital for evaluation. APRN #2 identified that the APRN on call had been notified by the facility of Resident #406's change in condition and had instructed the facility staff to notify the attending physician (MD #1). In an interview on 3/19/15 at 1:45 PM, MD #1 identified that the APRN should notify him of a resident's admission. MD #1 indicated that he was not notified of Resident #406's admission, of the change in condition and/or that the [MEDICAL CONDITION] unit was unavailable on 2/4/15. MD #1 identified that had he was aware a [MEDICAL CONDITION] unit was not available the resident would not have been admitted to the facility. In an interview on 3/19/15 at 2:30 PM, the Regional Corporate Nurse indicated that once the nursing staff notifies the APRN of any changes in a resident, the expectation is that the APRN will notify the attending physician. Interview with APRN #3 on 3/23/15 at 11:45 AM identified that on 2/4/15 about 6:00 PM she was notified by the facility staff that they needed to contact MD #1 about a piece of equipment not being available for the resident. APRN #3 directed the staff to call MD #1 of the situation and the facility did not call her again. APRN #3 indicated that it was her understanding if a resident has a change in condition and the decision was to send them to the hospital then it was the facility's responsibility to notify the attending physician. According to the facility's policy on physician/mid-level provider notification, upon identification of a patient who has a change in condition a nurse will report this to the physician/mid-level provider.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #406) who required a respiratory device to aid with breathing, the facility failed to ensure the breathing equipment was obtained on the day of the resident's admission and ready for use at the hour of sleep. The findings include: Resident #406's [DIAGNOSES REDACTED]. The nurse's progress note dated 2/4/15 at 3:07 PM identified that Resident #406 was admitted to the facility. An admission physician's orders [REDACTED]. oximetry every shift to keep the oxygen saturation level equal to or greater than 92%. The nurse's progress note dated 2/5/15 at 7:55 AM identified that from 3:00 AM through 6:00 AM Resident #406 had a change in medical condition. The resident's vital signs documented at 7:56 AM were temperature 98.1 degrees Fahrenheit, pulse 110, respirations 22, blood pressure 141/74 and the oxygen saturation level was 88% with oxygen via mask. Resident #406's facial color was cyanotic, the level of consciousness confused and the resident was experiencing moderate chest pain. Subsequent to physician notification Resident #406 was transferred to the hospital for an evaluation. The Emergency Department (ED) provider note dated 2/5/15 at 6:26 AM identified that the resident presented to the ED for dyspnea. The resident had stated that he/she was supposed to receive a [MEDICAL CONDITION] machine to sleep but the facility did not have one. The ED physician had been informed by the Emergency Medical Service (EMS) that upon their arrival Resident #406's oxygen saturation level was 42%. The initial nursing assessment at 6:40 AM indicated that Resident #406 had diminished lung sounds and labored breathing, blood pressure was 166/79, pulse 101, respiration 26 and an oxygen saturation of 42%. The hospital chart report identified that Resident #406 was discharged back to the facility at 10:38 AM. The nurse's note dated 2/5/15 at 8:32 PM identified the attending physician was notified that the [MEDICAL CONDITION] equipment was still not available tonight and the physician directed to transfer Resident #406 to the ED [MEDICATION NAME]. The ED progress note dated 2/5/15 at 9:47 PM identified that the facility notified the hospital that the [MEDICAL CONDITION] equipment not being available was a vender failure and the resident's family will bring in the resident's mask from home, therefore the facility will be able to accept the resident back. The hospital record identified that Resident #406 arrived at the ED on 2/5/15 at 9:03 PM and was discharged on [DATE] at 10:48 AM. The respiratory evaluation dated 2/6/15 at 1:09 PM, conducted after the resident had returned from the ED, identified that the initial evaluation was completed and the resident's [MEDICAL CONDITION] was set up. Interview with Resident #406 on 3/18/15 at 10:15 AM identified that he/she had been transferred to the hospital twice after the 2/4/15 admission to the facility because a [MEDICAL CONDITION] unit was not available. The resident indicated that he/she does not always use the treatment at home. In an interview and clinical record review on 3/18/15 at 11:00 AM, the Regional Corporate Nurse identified that the [MEDICAL CONDITION] unit was delivered on 2/5/15 and needed to be calibrated prior to use. The Regional Corporate Nurse was informed that the calibration needed to be conducted by a respiratory therapist. In an interview on 3/18/15 at 11:15 AM, the Admissions Director identified she was informed by the hospital liaison about an hour before Resident #406 was admitted that the resident had used a [MEDICAL CONDITION] unit while in the hospital and at home. The Admissions Director indicated she called the respiratory services on 2/4/15 as soon as she received the information from the hospital liaison, ordered the [MEDICAL CONDITION] unit for delivery that day and informed the 3-11 shift Nursing Supervisor, Registered Nurse (RN) #2, that the unit was ordered. The Admissions Director identified that it was her understanding once an order was placed the expected time of delivery was within four hours of the order. In an interview on 3/18/15 at 1:45 PM, RN #2 identified that she was expecting the [MEDICAL CONDITION] unit to be delivered on the evening of 2/4/15 and at the end of her shift the [MEDICAL CONDITION] unit had not been delivered. RN #2 indicated that deliveries have occurred at 11:00 PM or later and she informed the 11-7 Nursing Supervisor (RN #1) that the [MEDICAL CONDITION] unit had not arrived. Interview with RN #1 on 3/19/15 at 11:55 AM identified that he was aware the [MEDICAL CONDITION] unit had not delivered at the start of his shift on 2/4/15 at 11:00 PM and believed that Resident #406 could do without the [MEDICAL CONDITION] unit for this one night since the resident had been non-compliant at home and during the recent the hospitalization . RN #1 indicated that as the shift progressed Resident #406's oxygen saturation levels dropped when the resident was sleeping and subsequently the resident was transferred to the hospital for an evaluation on 2/5/15. Interview with the attending physician (MD #1) on 3/19/15 at 1:45 PM identified that Resident #406 was transferred to the hospital on [DATE] for a change in respiratory condition and there was no [MEDICAL CONDITION] unit available for 2/4/15 and 2/5/15. MD #1 indicated had he been aware that a [MEDICAL CONDITION] unit was not available Resident #406 would not have been admitted to the facility. Subsequent to the 2/4/15 and 2/5/15 events, the nursing staff was in-serviced by the respiratory therapist related to [MEDICAL CONDITION] and CiPAP set up of equipment and pressure settings.

Based on clinical record review, review of facility documentation and interview for one of three sampled residents (Resident #404) that required Intravenous (IV) fluids, the facility failed to administer the type of solution in accordance with the physician's order and/or for one sampled resident (Resident #400) reviewed for pain management, the facility failed to ensure that pain medication were administered in a timeframe after the resident's request. The findings include: 1. Resident #404's [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] identified that Resident #404 had no cognitive or memory impairments and was independent with eating. The laboratory report dated 5/12/14 identified that Resident #404's sodium level was 131 (normal range 133-145), potassium 4.0 (normal range 3.3-5.1), Blood Nitrogen Urea (BUN) was 6 (normal range 6-20) and the creatinine 0.5 (normal range 0.7-1.5). A physician's order dated 5/12/14 directed to obtain a Basic Metabolic Panel (BMP) in one week. The laboratory report dated 5/19/14 identified the sodium level was 117, potassium 3.7, creatinine 0.4 and BUN 6. Review of the nurse's notes from 5/19/14 through 5/20/14 failed to reflect documentation that the abnormal bloodwork results had been reported to the physician and/or APRN on 5/19/14. The nurse's note dated 5/20/14 identified that the charge nurse had received a call at 1:45 PM from the APRN regarding Resident #404's sodium level at 117 and new orders were obtained. The APRN order dated 5/20/14 directed to start intravenous fluids 0.9% Normal Saline at 75 cubic centimeters (cc) per hour times three liters. The nurse's note dated 5/20/14 at 2:20 PM identified that a peripheral intravenous catheter was inserted in Resident #404's left forearm, a subsequent note dated 5/20/14 at 7:00 PM identified that a peripheral intravenous catheter was inserted in Resident #404's left thumb because the previous intravenous line infiltrated. The nurse's note dated 5/20/14 at 11:00 PM identified the intravenous fluids of Normal Saline was in progress at 75 cc. The Reportable Event Form dated 5/21/14 at 3:30 AM identified that Resident #404 was receiving 0.45% Normal Saline at 75 cc per hour instead of the 0.9% Normal Saline at 75 cc per hour that was ordered. Resident #404 was noted to have [MEDICAL CONDITION] and subsequently transferred to the hospital for further evaluation. The facility's investigation identified that Registered Nurse (RN) #4 retrieved a liter bag of Normal Saline and gave the bag to Licensed Practice Nurse (LPN) #3. In a written statement RN #4 identified that she had not checked the solution bag therefore she was not aware that the solution was 0.45% and not 0.9% Normal Saline. The investigation identified that the Nursing Supervisor, RN #5, had started the intravenous fluids. The report indicated that Resident #404 had [MEDICAL CONDITION] activity in clusters, was unable to return to baseline at 3:10 AM and was transferred to the hospital at 3:30 AM. Review of facility documentation dated 5/21/15 in a written statement the 7-3 PM Registered Nurse (RN) #4, identified that she had called the laboratory center on 5/20/14 at about 4:00 PM to follow up on the critical low sodium level from 5/19/14. The statement identified that the laboratory center had called the facility on 5/19/14 at 10:56 AM and reported to the charge nurse, Licensed Practical Nurse (LPN) #4, the low sodium level. The hospital history and physical identified that Resident #404 was admitted with [DIAGNOSES REDACTED]. The resident's sodium level was 111 and the potassium 3.4. The plan of care included, in part, to monitor blood work, sodium and potassium levels every three hours, administer Potassium Chloride 20 milliequivalents intravenously per hospital protocol, nephrology consultation, fluid restriction of 800 cc per day. Resident was discharged from the hospital with a sodium level of 135 and potassium 3.7 and readmitted to the facility on [DATE]. Interview with the 3-11 Nursing Supervisor RN #5, on 3/18/15 at 2:45 PM identified that RN #4 informed her everything was ready for the intravenous infusion in Resident #404's room and the nurse would be in to start the line. RN #5 was unable to recall who had connected the tubing to the catheter, the IV Nurse or the charge nurse. Review of the facility's policy of Continuous Infusion of Medications and Solutions the nurse shall be competent in the safe delivery of infusion therapy and must verify the physician order. 2. Resident #400 was admitted to the facility on [DATE] for pain management secondary to multiple Emergency Department visits for intractable pain to the right hip. Review of the resident's clinical record and confirmed by the facility identified that the resident's Medication Administration Record [REDACTED]. The investigation was initiated following a request by Resident #400, who was alert and oriented, to speak to the Interim Director of Nursing (UM #1) on 1/21/15. Review of UM #1's written statement identified that the resident was "visibly upset and crying" as he/she told of having to wait one hour after requesting pain medication on the night shift (of 1/20/15). A second incident that day, on the day shift of 1/21/15, the resident waited two hours following the request before the medication was administered. The facility investigation, following staff interviews, found the allegation unsubstantiated. A physician's order dated 1/20/15 directed [MEDICATION NAME] HCL 2 milligram (mg) tablet every three hours for a pain level of 1-3 and 4 mg (2 tablets) every three hours for a pain level of 4-7 by mouth. Although the MAR indicated [REDACTED]. Review of the log reflected that the early AM hours of 1/21/15, at 4:00 AM, the resident was medicated with 4 mg of [MEDICATION NAME]. The resident again received the 4 mg of [MEDICATION NAME] at 2:28 PM on 1/21/15. During interviews on 3/17/15 at 1:05 PM and 3/18/15 at 8:05 AM, NA #1 and LPN #1, respectively, stated that both knew of Resident #400's request for pain medication and that the request was made "early in the shift" according to NA #1 and at approximately 2:30 AM by LPN #1. RN #1, who could not be reached for interview gave a written statement to the facility, identified that he did not learn of the request until 3:30 AM and that he gave the medication himself at 4:00 AM. Interview with LPN #2 on 3/17/15 at 12:45 PM stated that because Resident #400's medications had not yet been delivered from the pharmacy, when the resident requested pain medication at around 12:30-12:45 PM, LPN #2 contacted the Unit Managers on the unit that she required pain medication and that the Unit Managers stated that they did not have the key to the emergency box; that the other RN had the key and she was in a meeting. LPN #2 stated she did not contact the RN with the key and told Resident #400 that she would "deliver the pain medication when it was available." The medication was delivered at 2:28 PM. LPN #2 stated that she was re-educated and directed to stop medication pass to get pain medication when a resident requests it. During interview on 3/17/15 at 12:00 PM UM #1, acting DNS at the time, stated that the expectation was that the LPN on the unit would contact the supervisor themselves when requiring pain medication for residents from the emergency box and stop what they were doing and get the pain medication for the resident. Review of the facility policy for Pain Management failed to reflect the facility's approach to the expediency of response to the patient who is experiencing pain.

Based on clinical record review, observation and interview for 1 of 3 sampled residents reviewed for pressure ulcers (Resident #154), the facility failed to conduct skin assessments to prevent the development of a pressure ulcer. The findings include: Resident #154's [DIAGNOSES REDACTED]. The quarterly Minimum data Set assessment dated [DATE] identified severe cognitive impairment, extensive assistance of two for transfers, limitation in range of motion of one upper extremity, and a risk for the development of pressure ulcers. The physician's orders [REDACTED]. The physician's orders [REDACTED]. A wound care specialist initial evaluation dated 1/17/13 identified an unstagable 1.5 centimeter (cm) in length, 1.4cm in width and 0.1cm in depth area on the left lateral hand that was due to necrosis and a hand splint that caused the skin to open. The evaluation further identified the etiology of the wound was due to pressure. The area was debrided to a stage 4 with muscle exposed. The post debridement depth was noted as 0.3cm. Observation of the pressure ulcer on 1/28/13 at 10:00 AM identified the pressure ulcer was located on the area below the thumb and due to the inability to rotate the resident's hand the nurse was required to bend down and look under the resident's hand to visualize the area. Interview and review of the clinical record on 1/25/13 at 1:37 PM with the Infection Control Nurse (INC) identified that the wound was caused by the hand splint/brace. The ICN noted that the resident had a behavior of rubbing her/his hand on the side of the head. The ICN was unable to locate documentation that the resident's skin beneath the hand splint was assessed on a daily basis by a licensed nurse. It was further identified that although the resident was due for a weekly skin check on 1/15/13, and it was signed off in the treatment kardex as being conducted, the nurse's note lacked documentation of the assessment. The INC was unable to explain how the pressure ulcer could be identified as an unstageable without other indications of an alteration in skin integrity if the area was asssessed daily.

Based on clinical record review, observation and interviews for 1 of 4 sampled residents reviewed for accidents (Resident #154), the facility failed to ensure the resident received the necessary care per the plan of care and/or supervision to prevent accidents with injuries. The findings include: 1a. Resident #154's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified severe cognitive impairment, extensive assistance of two for transfers, did not ambulate, total assistance of one for toilet use and incontinence of bowel and bladder function. The assessment further identified a limitation in range of motion of one upper extremity, the resident was unsteady and was only able to stabilize with staff assistance, and a history of falls. The resident's plan of care dated 5/8/12 identified a risk for falls related to impaired balance and poor coordination with interventions that included transferring out of bed to the wheelchair with a seatbelt alarm, secondary to dementia and poor safety awareness. The care plan further identified a self-care deficit with interventions that included assistance of two with transfers, toileting and bed mobility. The Reportable Event dated 06/26/12 at 7:45 AM identified the resident was left unassisted on the commode while Nurse Aide #4 went to the bathroom to retrieve a toiletry item. When NA #4 was in the bathroom the resident fell to the floor and sustained a laceration to the left forehead, an abrasion to the left knee and a laceration to the left elbow. The resident was subsequently transferred to the emergency department for an evaluation. the resident was admitted to the hospital with [REDACTED]. Interview with the Director of Nurses (DNS) on 1/28/13 at 2:35 PM identified that NA #4 received education for leaving a resident that should not be left alone on the commode. The DNS identified it is the facility practice that only residents who are independent are to be left alone in the bathroom or on a commode/shower chair. The DNS indicated the shower chairs and/or the commodes in the facility at the time did not have seatbelts to secure a resident. Attempts to reach NA #4 were unsuccessful. b. The annual Minimum Data Set assessment dated [DATE] identified severe cognitive impairment, extensive assistance of two for transfers, did not ambulate, total assistance of one for toilet use and incontinence of bowel and bladder function. The assessment further identified a limitation in range of motion of one upper extremity, the resident was unsteady and was only able to stabilize with staff assistance, and a history of falls. The care plan dated 8/8/12 identified a risk for falls related to impaired balance and poor coordination with interventions that included transferring out of bed to wheelchair with a seatbelt alarm secondary to dementia with poor safety awareness. the care plan further identified a self-care deficit with interventions that included assistance of two with transfers and the use of a Sarita (stand up) lift with assistance of at least two people. The Reportable Event dated 09/11/12 identified that on 09/09/12 on the 3- 11:00 PM shift, the resident sustained [REDACTED].#5. The transfer was conducted by only one person, not the two people specified in the resident's plan of care. The resident sustained [REDACTED]. Interview with NA #5 on 1/25/13 at 3:00 PM identified that at the time the resident sustained [REDACTED].#6. Although NA #6 was in the room during the attempted transfer, NA #6 was not assisting NA #5 to transfer Resident #154 from the wheelchair to the bed, NA #5 indicated that during the transfer the resident lost balance and fell . NA #5 could not recall what the resident hit his/her head on during the fall. Interview with NA #6 on 1/28/13 at 3:00 PM identified that he was aware that the resident required the assistance of two people in order to be transferred, however, directed NA #5 to transfer the resident alone.

Based on clinical record reviews and interviews for two of six sampled residents reviewed for pressure sores (R#44, 154), the facility failed to conduct thorough assessments of the resident's pressure sores, and/or failed to provide appropriate wound care and/or failed to provide appropriate repositioning plans to prevent a pressure sore from declining. The findings include: 1. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary identified the presence of a stage II pressure sore on the sacrum measuring 0.5 cm round with 0.3 cm depth with the coccyx red, excoriated, and discolored and a 0.5 cm pressure sore of the buttock (no other location noted). The nursing admission assessment dated [DATE] identified the presence of a stage II pressure sore of the coccyx. No description, size, stage, color, odor or further assessment was noted in either the nursing notes or the admission assessment form. The initial MDS dated [DATE] identified that the resident was cognitively impaired, totally dependent on staff for all ADL's, incontinent of bowel, had a Foley catheter, and had two stage II pressure sores and one stage one pressure sore. Physician orders [REDACTED]. The pressure ulcer assessment form noted the first assessment had not been completed until 6/14/10 and described the area as 10 by 10 cm red and denuded with a 2 by 2 cm superficial "abrasion" on the right buttock. No stage or depth was present. The care plan initiated on 6/14/10 and reviewed on 6/28/10 noted the presence of a pressure ulcer. Interventions included to keep skin clean and dry, and to ensure special mattress is in place (type not specified). No further updates to the care plan were noted throughout the residents stay at the facility. An undated customized positioning plan directed staff to get the resident out of bed to his/her power wheelchair at 10:30 AM and to keep upright in the chair until 2:30 PM (4 hours with pressure on coccyx/sacral area). Review of the pressure ulcer documentation form noted that the stage of the wound had not been recorded for all 7 assessments present. The assessments lacked depth on 6 assessments, wound bed tissue type on 5 of the assessments and condition of surrounding skin on 4 of the assessments. The last assessment present was dated 7/15/10 and noted the wound as 1.5 cm by 0.5 cm depth. On 7/16/10, the resident was sent to the local Wound Care Center for consult and returned with orders to irrigate the wound well with spray cleanser, wick, do not pack, with 1/4 inch gauze strip, apply and abd pad to absorb and protect and to use zinc to the surrounding area. No wound description or assessment was noted on the consult report. Interview and review of the clinical record with the DNS on 11/4/10 at 7:15 AM failed to provide documentation that the wound was assessed on admission, that wound care orders had been obtained on admission, that a specialty mattress had been placed prior to 6/14/10, that a positioning plan had been implemented that assured every 2 hour repositioning, or that complete, accurate assessments had been done at least weekly after admission. 2. Resident #154 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of an admission nursing assessment dated [DATE] identified a stage two pressure ulcer on the right heel. An admission assessment (MDS) dated 6/9/10 identified the resident with impaired cognition, total dependence with bed mobility, transfers, limited range of motion with the legs and feet, frequently incontinent of bladder, and three stage two pressure ulcers. A care plan dated 6/24/10 identified a problem with impaired skin integrity related to the presence of pressure ulcer secondary to immobility. Interventions included treatments as ordered, monitor healing, turn and reposition with skin care as needed. No care plan was developed on admission identifying the presence of a pressure ulcer and/or identifying a risk for further skin breakdown. Review of pressure ulcer documentation dated 6/2/10 through 6/16/10 identified a stage two pressure ulcer on the right heel with a wound measurement of "not opened". No description, size, stage, color, odor or further assessment was noted in the documentation. Subsequent notes dated 6/23/10 and 6/30/10 identified a dry blister measuring 2.5cm x 2.5cm. On 7/6/10 an area described as " scabby " was noted. No further description, size, stage, color, or odor was noted in the documentation. On 7/26/10 (20 days later) a "stage two" blister was noted with redness/eschar measuring 3.0cm x 2.5cm. Review of admission physician orders [REDACTED]. A physician order [REDACTED]. No documentation was noted indicating the pressure ulcer was reevaluated and/or further treatment orders obtained. Observation of the wound on 11/9/10 at 10:30am identified a pressure area on the right heel measuring 1cm x 1cm x .2cm with approximately 95% slough. The periwound was noted to be macerated, with slight serosanguinous drainage, no odor was noted. Interview and review of the clinical record with the DNS on 11/8/10 at 2:00pm failed to provide documentation that a comprehensive care plan was developed when a stage two pressure ulcer was identified on admission and/or interventions implemented to prevent further skin break down, and/or documentation that the pressure ulcer was assessed and/or the treatment revised when the pressure ulcer declined. Facility policy for residents at risk for skin breakdown directs the staff to develop an individualized care plan to prevent and/or treat skin breakdown with interventions specific to risk factors.