Every finding on record at Shepherd of the Valley Rehabilitation and Wellness

Based on resident representative and staff interview, medical record review, facility incident review, and policy review, the facility failed to ensure residents were free from abuse from other residents for 1 of 8 sample residents (#37) reviewed for abuse. This failure resulted in actual harm to resident #37. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 7/17/26. 1. Review of the annual MDS assessment dated [DATE] showed resident #37 had a BIMS score of 3 out of 15, which indicated severe cognitive impairment, and had diagnoses which included non-Alzheimer's dementia, depression, and psychotic disorder. Further review showed the resident had behaviors of wandering daily. Review of the admission MDS assessment dated [DATE] showed resident #13 had a BIMS score of 10 out of 15, which indicated moderate cognitive impairment, and a patient health questionnaire-9 (PHQ-9) score of 24, which indicated severe depression. Further review showed the resident had diagnoses which included schizophrenia and a personal history of traumatic brain injury. The following concerns were identified: a. Review of an incident report dated 7/15/26 and timed 2 PM showed a CNA observed resident #13 hit resident #37 on the left side of his/her face. Both residents were assessed and sent to the emergency department (ED). Resident #27 returned from the ED on 7/15/26, and resident #13 returned from the ED on 7/24/26. Upon return from the ED, resident #13 received one-to-one supervision from staff. b. Review of a progress note dated 7/15/26 and timed 6:05 PM showed .[name] had a reddened area 1 x 1 inches in diameter on the left side of [his/her] face, next to [his/her] left eye, that was abraded. [S/he] also has reddened areas on [his/her] left cheekbone. Ice pack applied to left side of face . c. Interview with the resident's representative on 7/28/26 at 9:39 AM revealed she visited the resident on 7/19/26 and the resident told her s/he did not feel safe and felt afraid. d. Interview with CNA #3 on 7/30/26 at 9:05 AM revealed she had been assisting another resident in the bathroom when she heard an aggressive voice through the wall. She reported she found the shower aide to assist the resident in the bathroom, and when she went to the room next door, she saw resident #13 hit resident #37 2 to 3 times with a closed fist. She separated the residents, and took resident #37 to the nurses' station where the resident was assessed by the nurse. Further interview revealed resident #37 had a small abrasion on the left side of his/her face, and was scared and skittish following the incident. e. Interview with LPN #1 on 7/30/26 at 12:26 PM revealed she had been called to the secure unit after the incident. She stated resident #37's cheek was a little red and she was not sure if it was from the ice pack or being hit. She stated resident #37's demeanor was typically apprehensive and the resident was shaken after the incident. f. Interview with the DON on 7/30/26 at 12:45 PM revealed resident #37 had an ice pack applied to his/her cheek but there was no open skin. g. Interview with RN #2 on 7/30/26 at 1:06 PM revealed she had been told resident #13 punched resident #37. When she assessed the resident it was reddened. Further interview revealed the resident was quiet and stoic and afraid for [his/her] safety. 3. Review of the facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation last updated March 2025 showed .Each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse .The Center implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members, and others who may have unsupervised access to residents . 4. The facility implemented the following corrective action by 7/17/26: a. Resident #37 was assessed and provided with an ice pack and sent to the ED on 7/15/26. The resident returned to the facility on 7/15/26. b. Resident #13 was assessed and sent to the ED on 7/15/26. The resident returned to the facility on 7/24/26, and received one-to-one supervision upon his/her return from the hospital. c. The facility reported the incident to the State Survey Agency and the Police Department on 7/15/26. d. All facility staff involved were interviewed.e. The DON completed an audit in the secure unit, to validate there were no skin concerns, and interviewed staff and residents to validate anyone that may not have reported previous abuse. f. The DON/designee educated staff immediately. g. The Executive Director/designee began a daily audit in the morning meeting and reviewed progress notes to ensure no abuse occurred. Audits to be done daily and reported monthly in the Quality Assurance (QAPI) Meeting for 90 days or until substantial compliance was achieved.

Based on observation, staff interview, professional standard review, and policy review, the facility failed to ensure insulin medications were dated with an open date in 1 of 7 medication storage units (rehabilitation unit cart A). The findings were: 1. Observation on [DATE] at 11:04 AM of the rehabilitation cart A, with RN #1 showed the following concerns: a. Insulin Glargin-yfgn 100 unit per (ml) milliliter pen with an open date of [DATE], 30 days prior to the observation. b. Insulin Glargin-yfgn 100 units per ml pen with no open date. c. Insulin Lispro KwikPen 100 units per ml with an open date of [DATE], 48 days prior to the observation. d. Insulin Lispro KwikPen 100 units per ml with no open date. 2. Interview with RN #1 on [DATE] at 11:04 AM revealed the insulin pens were good for 28 days, and confirmed the medications were available for resident use. 3. Interview with the DON on [DATE] at 2:13 PM revealed she expected staff to date the insulin when it was removed from the fridge and made available for use, and to discard the insulin when they expired. 4. Review of policy Medication Storage provided by the DON on [DATE] at 3 PM showed .12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used .14. Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal . 5. Review of web page drxservices.com/did-you-know-insulin-glp-1-expiration-guide/ showed insulin lispro days good at room temperature was 28 days, and insulin glargine was good at room temperature for 28 days.

Based on observation, resident representative, and staff interviews, medical record review, and policy and procedure review, the facility failed to ensure individual activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident were provided for 3 of 4 sample residents (#34, #123, #178) reviewed for activity participation. The findings were:1. Review of the annual MDS assessment dated [DATE] showed resident #34's cognition was not assessed and they had diagnoses which included non-Alzheimer's dementia and depression. Further review showed the resident felt it was very important to go outside to get fresh air when the weather was good and somewhat important to have books, newspapers, and magazines to read, be around animals such as pets, keep up with the news, and perform his/her favorite activities. Review of the Activities care plan last revised on 3/31/26 showed interventions which included I would like staff to continue to invite me to activities of that [sic] may be of interest to me and Some of my activity interests include animals and pets, board games, volunteering, dining out, movies, spending time outdoors, listening to the radio, watching sports, and TV. The following concerns were identified: a. Interview with the resident's representative on 7/27/26 at 5:52 PM revealed she wished the facility would encourage the resident to participate in activities. She revealed the staff offered, but if the resident refused then staff did not attempt to reapproach him/her. b. Continuous observation on 7/29/26 beginning at 9:27 AM through 11:02 AM showed the resident was in his/her room seated in the recliner with his/her legs elevated, and no activities were offered during that time. Continuous observation on 7/29/26 from 2:26 PM through 4:15 PM showed the resident was in his/her room seated in the recliner with his/her legs elevated, and no activities were offered during that time. Review of the activity calendar for July 2026 showed the scheduled activities on 7/29/26 included daily chronicle, fun with fitness, reading time, treats, music, and reading/trivia. c. Review of the activity participation record from 4/28/26 through 7/29/26 showed the resident was documented as being offered activities 115 times which included 107 independent activities, 7 one to one activities, and 1 group activity. Further review showed the resident refused activities 52 out 107 activities offered which included refusing one to one activities once and independent activities 51 times. 2. Review of the admission MDS assessment dated [DATE] showed resident #123 had a BIMS score of 8 out 15, which indicated moderate cognitive impairment, and diagnoses which included progressive neurological conditions, non-Alzheimer's dementia, and seizure disorder or epilepsy. Further review showed the resident felt it was Very important to have books, newspapers, and magazines to read, to keep up with the news, and to go outside to get fresh air when the weather was good. Review of the Activities care plan last revised on 6/8/26 showed interventions which included The resident's preferred activities are: arts and crafts, ceramics, visiting with others, shuffleboard, watching sports, tv and movies, listening to 'oldies,' being outdoors, etc. Review of the I refuse to eat often r/t [related to] dementia and chemo treatments care plan last revised on 12/23/25 showed interventions which included Invite the resident to food-related activities and offer food, beverages of choice to encourage intake. The following concerns were identified: a. Review of the activity participation record from 5/27/26 through 7/29/26 showed the resident was documented as being offered activities 75 times which included 69 independent activities, 5 one to one activities, and 1 group activity. Further review showed the resident refused activities 10 times out of 75 activities offered, which included refusing group activities once and independent activities 9 times. 3. Review of the admission MDS assessment dated [DATE] showed resident #178 had a BIMS score of 3 out of 15, which indicated severe cognitive impairment, and diagnoses which included nontraumatic intracerebral hemorrhage, and macular degeneration. Further review of the MDS assessment showed it was very important to the resident to be around animals such as pets and somewhat important to listen to music he/she liked, do his/her favorite activities, and get outside for fresh air when the weather was good. Review of resident #178's initial activity evaluation dated 7/27/26 at 9:33 AM showed listed activity preferences of games, bingo, board games, cards, television, movies, animals, and pets. Review of resident #178's care plan dated 7/27/26 showed the resident had the ability to attend activities. Documented preferences included directed/independent activities in room including: watching TV, reading, iPad games, etc. and has supplies needed for independent activities . preferred activities are: games, movies, animals, and going outdoors. The following concerns were identified: a. Observation of resident #178 throughout the survey showed the resident visited with his/her daughter, sat alone in his/her wheelchair in his/her room, and slept in bed. The resident did not participate in any group or individual activities. Further observation on 7/30/26 at 9:20 AM showed there were four copies of the Daily Chronicle in the resident's room, but no activity calendar. b. Interview with the resident's representative on 7/28/26 at 10:09 AM revealed staff had not invited the resident to any activities and the resident had not attended any activities since admission. Further interview revealed she had not seen an activity calendar in the resident's room. c. Review of the medical record showed no evidence of activity participation. 3. Interview with COTA #1 on 7/30/26 at 8:41 AM revealed she was consulting for the activity program because the facility did not have an activity director. She revealed she did not perform activities daily, she only checked in with the team. She revealed one to one activities should be attempted 2 to 3 times per week and all residents should be invited to every group activity. She confirmed the facility did not facilitate independent activities for resident #34 or resident #123. She revealed newly admitted residents received an initial activity evaluation within 3 to 14 days of admission and activities staff were expected to invite every resident to every activity, distribute the Daily Chronicle daily, and invite residents to activities during distribution. Further interview confirmed staff had not offered resident #178 the opportunity to participate in any activities. 4. Review of the policy titled Activity Program last revised 2015 showed .5. Activities include individual, small or large group, one-to-one, and independent activities to meet the resident's needs, abilities, and interests. For residents confined to, or who choose to, remain in their room, the Activity Department provides and assists with in-room activities/projects/leisure pursuits in keeping with needs, abilities, and interests .

Based on observation, staff interview, medical record review, and professional standard review, the facility failed to ensure necessary services were provided timely for 1 of 4 sample residents (#57) reviewed for activities of daily living. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #57 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment, and had diagnoses which included cerebrovascular accident, depression, and benign prostatic hyperplasia. The MDS review showed the resident had bilateral impairment of the upper and lower extremities, required total assistance for toileting, upper and lower body dress, putting on footwear, and substantial/maximal assistance for personal hygiene. Further review showed the resident was always incontinent of bowel and bladder. Review of the ADL self-care performance deficit care plan showed Impaired balance. BED MOBILITY: I am Substantial/Maximum assistance on staff to routinely turn and reposition in bed and as necessary. DRESSING: I am Dependent assistance on staff of 1-2 to dress my upper body and lower body dressing. PERSONAL HYGIENE: I am Substantial/Maximum on staff of one with personal hygiene. The following concerns were identified: a. Observation on 7/27/26 at 3 PM showed the resident was lying on his/her bed with the resident's pants pulled down around his/her ankles and the bed sheet at the foot of the bed. The resident had a used brief rolled up under his/her upper legs, brown substance on his/her left upper thigh, and his/her perineal area was exposed. The mechanical lift sling was positioned under the resident, the mechanical lift was positioned beside the bed, the bed was elevated, and the privacy curtain was open. Continuous observation of the resident's room showed at 4:11 PM RN #3 entered the resident's room, and stated she was going to check on the roommate. Upon entering the room, the RN stated it looked looks like someone was changing resident #57, got called away, and did not finish the job. The RN covered the resident with the sheet and left the room to find help. At 4:20 PM the RN returned to the room, with CNA #4, donned gloves, provided perineal care, changed the brief, changed the resident's pants, and removed the dirty sling. At that time, CNA #4 stated CNA #1 told her he had put the resident to bed at 1 PM, and she had planned to check the resident before the RN came and got her. b. Interview with CNA #1 on 7/27/26 at 4:28 PM revealed he got the resident in his/her bed around 12:45 PM and had his/her brief tucked under him/her. He revealed the resident was incontinent of bowel and bladder, and he had left the resident exposed for the nurse to do a skin check, because his/her peri area was bleeding and hurting. He revealed the nurse was going to give a medication and then go check resident #57's skin. c. Interview with the DON on 7/27/26 at 5:22 PM revealed she expected the staff to check residents every 2-3 hours, and to finish providing care. Interview with the DON on 7/28/26 at 10 AM revealed the facility did not have a policy related to providing turning, repositioning, or checking the residents. Further interview revealed staff should follow professional standards. 2. Review of the professional standard titled Tertiary Prevention provided by the DON on 7/29/26 at 3 PM showed Tertiary prevention addresses the treatment of established disease to avoid complications and death. The major areas of focus for the older adult and the adult with a disability are preventing the complications of immobility and rehabilitation .Positions. 2. The recommendation is to change body position every 2 hours and, preferably, more frequently for patients who have no spontaneous movement.

Based on observation, medical record review, resident and staff interview, and policy review the facility failed to ensure they had developed and implemented a comprehensive person-centered care plan for for 1 of 31 sample residents (#7). The findings were: 1. Review of the 5/19/25 significant change MDS assessment showed resident #7 had a BIMS score of 14 out of 15, which indicated intact cognition, and diagnoses which included hemiplegia, stroke, history of venous thrombosis and embolism. The resident received medications which included the anticoagulant apixaban. Review of the physician orders showed the resident received apixaban oral tablet (anticoagulant) 5 mg (milligrams) by mouth two times a day and ANTICOAGULANT MEDICATION SIDE EFFECT MONITORING: New Onset - Bleeding, bruising, black tarry stools, red urine, sudden severe headache, N/V. every shift Nurse Initials = Side effects monitored. If noted, document in Progress Notes and notify the Medical Provider. The following concerns were identified: a. Observation on 7/28/26 at 11:13 AM showed resident #7 had bruises on both lower arms. Interview with the resident at that time revealed the bruising happened at the hospital, and s/he was on an anticoagulant. b. Review of a progress note dated on 7/24/26 and timed 3:51 PM showed the resident had been readmitted from a hospital. His/her skin condition included scattered bruising to bilateral arms from IV starts and blood draws. c. Review of the care plan failed to show anticoagulant use or interventions as part of the plan of care. 2 Interview with the DON on 7/30/26 at 10 AM confirmed the facility did not have an anticoagulant care plan for the resident, and the facility had formatted an anticoagulant care plan that day.

Based on observation, medical record review, staff interview, and CMS RAI manual review, the facility failed to complete a significant change MDS assessment for 1 of 5 sample residents (#123) reviewed for a significant change. The findings were:1. Review of the admission MDS assessment dated [DATE] showed resident #123 had a BIMS score of 8 out of 15, which indicated moderate cognitive impairment, and diagnoses which included progressive neurological conditions, non-Alzheimer's dementia, and seizure disorder or epilepsy. Further review showed the resident had no upper or lower range of motion impairment, did not use mobility devices, and was independent or set-up/clean up help only for all activities of daily living (ADL). The following concerns were identified:a. Observation on 7/29/26 at 2:30 PM showed the resident and a staff member exited the resident's room with the resident using a walker for ambulation and a gait belt in place around the resident's torso.b. Review of the quarterly MDS assessment dated [DATE] showed the resident did not use a walker. Further review showed the resident required partial/moderate assistance with oral hygiene, personal hygiene and shower/bathe self. The resident was independent or required set-up/clean up help for all other ADLs.c. Review of the quarterly MDS assessment dated [DATE] showed the resident did not use a walker. Further review showed the resident required partial/moderate assistance with oral hygiene, toileting hygiene, and personal hygiene and required supervision or touching assistance with shower/bathe self and putting on/taking off footwear.d. Review of the resident's completed MDS assessments showed no evidence a comprehensive MDS assessment, including a significant change assessment, had been completed since the admission assessment. 2. Interview with MDS coordinator #1, MDS coordinator #2, and MDS coordinator #3 on 7/30/26 at 9:55 AM revealed they were not aware the resident was using a walker and the resident probably should not have been coded as independent for ADLs at the time of the admission MDS assessment. They revealed at times, the CNAs do not document accurately regarding resident needs. They confirmed a significant change MDS should have been completed and had not been. 3. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.30.1 dated October 2025 showed .Significant Change in Status Assessment (SCSA) (A0310A = 04) The SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change. A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'selflimiting'; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan .

Based on medical record review, resident representative and staff interview, and policy and procedure review, the facility failed to provide a written notice of transfer and bed-hold for 1 of 5 sample residents (#34) reviewed for transfer and discharge. The findings were:1. Review of a progress note dated 11/20/25 and timed 12:48 PM showed resident #34 was transferred non-emergent to the hospital for evaluation. Review of a transfer notice dated 11/20/25 showed the resident's representative was verbally notified of the transfer; however, there was no evidence the transfer notice was provided in writing to the resident's representative. Review of a Bed Hold Agreement dated 11/20/25 showed the resident was notified verbally of the bed hold; however, there was no evidence the resident's representative was notified of the bed hold in writing. 2. Interview with the resident representative for resident #34 on 7/27/26 at 5:52 PM revealed the facility did not notify her of changes to the resident such as transfers to the hospital, new medication orders, or health status changes. Further she revealed when a resident was sick, the facility should notify the representative. 3. Interview with the DON on 7/30/26 at 12:54 PM confirmed the facility did not have evidence resident #34's representative was provided a written notice for transfer or bed-hold. 4. Review of the policy titled Transfer and Discharge last revised May 2025 showed .5. When a transfer or discharge is initiated, the resident receives written notice using the Resident Notice of Transfer or Discharge . 10. In case of emergency transfer, written notice including bed-hold policy is sent to the resident/responsible party .

Based on observation, medical record review, and staff interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 sample residents (#57). The findings were:1.Review of the significant change MDS assessment dated [DATE] showed resident #57 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment, and had diagnoses which included cerebrovascular accident, depression, and benign prostatic hyperplasia. The MDS review showed the resident had bilateral impairment of the upper and lower extremities, required total assistance for toileting, upper and lower body dress, putting on footwear, and substantial/maximal assistance for personal hygiene. Further review showed the resident was always incontinent of bowel and bladder. Review of the ADL self-care performance deficit care plan showed Impaired balance. BED MOBILITY: I am Substantial/Maximum assistance on staff to routinely turn and reposition in bed and as necessary. DRESSING: I am Dependent assistance on staff of 1-2 to dress my upper body and lower body dressing. PERSONAL HYGIENE: I am Substantial/Maximum on staff of one with personal hygiene. The following concerns were identified: a. Observation on 7/27/26 at 3 PM showed the resident was lying on his/her bed with the resident's pants pulled down around his/her ankles and the bed sheet at the foot of the bed. The resident had a used brief rolled up under his/her upper legs, brown substance his/her left upper thigh, and his/her perineal area was exposed. The lift sling was positioned under the resident, the mechanical lift was positioned beside the bed, the bed was elevated up in the air, and the privacy curtain was open. The residents roommate was in the room. Continuous observation of the resident's room showed at 4:11 PM RN #3 entered the resident's room, and stated she was going to check on the roommate. Upon entering the room, the RN stated it looked like someone was changing resident #57, got called away, and did not finish the job. The RN covered the resident with the sheet and left the room to find help. At 4:20 PM the RN returned returned to the room, with CNA #4, donned gloves, provided perineal care, changed the brief, changed the resident's pants, and removed the dirty sling. At that time, CNA #4 stated CNA #1 had told her he had put the resident to bed at 1 PM, and she had planned to check the resident before the RN came and got her. b. Interview with CNA #1 on 7/27/26 at 4:28 PM revealed he got the resident in his/her bed around 12:45 PM and had his/her brief tucked under him/her. He revealed the resident was incontinent of bowel and bladder, and he had left the resident exposed for the nurse to do a skin check, because his/her peri area was bleeding and hurting. He revealed the nurse was going to give a medication and then go check resident #57's skin. c. Interview with the DON on 7/27/26 at 5:22 PM revealed she expected the staff to check residents every 2-3 hours, and to finish providing care. Interview with the DON on 7/28/26 at 10 AM revealed the facility did not have a policy related to providing turning, repositioning, or checking the residents. Further interview revealed staff should follow professional standards.2. Review of the policy titled Resident Rights hand delivered by the DON during the survey showed .Policy Statement: Residents are informed about their rights at admission and at least annually during their stay .

Based on medical record review, and staff interview, the facility failed to ensure behavioral health services were provided to 1 of 3 sample residents (#13) with a psychiatric diagnosis. The following concerns were identified: 1. Review of the admission MDS assessment dated [DATE] showed resident #13 had been admitted to the facility on [DATE], had a diagnosis of schizophrenia, and a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. Review of the medication administration record (MAR) showed the resident received the antipsychotic medications haloperidol 2.5 mg, clozapine 12.5 mg, aripiprazole 15 mg. Review of the care plan initiated on 7/24/26 showed the resident had impaired psychosocial well-being as evidenced by behaviors requiring intervention and psychotropic drug utilization, and behaviors that included agitation, anger, cursing, grabbing, hitting and kicking. Interventions included redirection, remove from the situation, meaningful activity, reapproach, and one-to-one supervision. The following concerns were identified: a. Review of a facility incident report showed on 7/15/26 at 2 PM a CNA observed resident #13 hit resident #37 on the left side of his/her face. Both residents were assessed and sent to the emergency department (ED). b. Review of the medical record showed a preadmission screening and resident review (PASRR) Level II review had been completed on 4/23/26 and showed mental health rehabilitation services recommended were case management and a neurocognitive evaluation. c. Review of the medical record showed no evidence the resident received a neurocognitive evaluation or mental health services. d. Interview with the social services assistant #1 on 7/30/26 at 2:30 PM revealed she and the social services assistant #2 checked on the resident a couple of times a day, especially if [s/he] has behaviors. Further interview confirmed the resident had not received a neurocognitive evaluation upon admission and the resident did not receive case management services.

Based on medical record review, and staff interview, the facility failed to ensure a pharmaceutical services procedure related to accurate acquiring, receiving, dispensing and administration of medications for 1 of 6 sample residents (#65) reviewed for medication availability. The findings were: 1. Review of a quarterly MDS assessment dated [DATE] showed resident #65 had a BIMS score of 5 out of 15 which indicated severe cognitive impairment, and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, and seasonal allergic rhinitis. Review of the physician orders showed the resident was to receive Sudafed Sinus Congestion Oral Tablet 1 time a day for sinus congestion. The following concerns were identified: a. Review of the medication administration record (MAR) showed the resident did not receive the medication on 6/28/26 and 6/29/26, and the medication was on order from the pharmacy. b. Review of a progress note dated 6/28/26 and timed 11:46 PM showed .Cough present. Productive cough .c. Review of a progress note dated 6/29/26 and timed 7:12 AM showed Sudafed Sinus Congestion Oral Tablet Give 1 tablet by mouth one time a day for sinus congestion. May dc [discharge] when sx [symptoms] resolve. d. Interview with the DON on 7/30/26 at 1:50 PM revealed her expectation was for nursing staff to check and verify medication was not in backup. Further interview confirmed the medication had been in the medication cart, the MA-Cs did not see it, and the resident did not receive the sudafed on the days identified.

Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure an infection prevention and control program was designed to help prevent the development and transmission of communicable diseases and infections for 1 of 9 sample residents (#178). The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #178 had a BIMS score of 3 out of 15, which indicated severe cognitive impairment, and diagnoses which included non-traumatic brain dysfunction, cerebrovascular accident, and non-traumatic intracerebral hemorrhage. Further review showed the resident had an indwelling catheter and required supervision for personal hygiene. Review of the care plan EBP r/t a foley catheter last revised on 7/27/26 showed the resident had a foley catheter and interventions which included CDC guidelines for enhanced barrier precautions will be followed by personnel. Enhanced barrier precautions involve gown and glove use during high-contact care activities. The following concerns were identified: a. Observation on 7/29/26 at 11:21 AM showed CNA #2 applied hand sanitizer, donned gloves, drained the urine from the catheter bag, and wiped the end of the drainage tubing with an alcohol wipe. Further observation showed an Enhanced Barrier Precautions sign and a Personal Protective Equipment (PPE) cart was stationed outside the resident's room; however, no additional PPE was used during the catheter care. b. Interview with MA-C #1 on 7/30/26 at 12:50 PM revealed she did not wear a gown when she provided urinary catheter care; however, she was aware gowns and other PPE were available for use outside the resident's room.c. Interview with the infection preventionist on 7/30/26 at 2:02 PM revealed all residents with a urinary catheter were on enhanced barrier precautions and a gown, gloves, faceshield/goggles should be worn when providing catheter care. 2. Review of the policy and procedure titled Transmission Based Precautions dated May 2015 and updated March 2026, showed Enhanced Barrier Precautions (EBP), involve the use of gowns and gloves by care providers, during high contact resident care activities.EBP are used when caring for residents with colonization or infection with a targeted and epidemiologically important MDRO, chronic wounds, or indwelling medical device/s. Indwelling devices include.indwelling urinary catheter.High-contact care activities (gown and gloves required) Examples: .emptying drainage bags.

Based on resident and staff interview, medical record review, and policy and procedure review, the facility failed to ensure that 1 of 3 sample residents (#14) was provided with respiratory care, including tracheostomy care. The findings were: 1. Review of the comprehensive MDS assessment dated [DATE] showed resident #14 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included pneumonia, anxiety disorder, chronic lung disease, and respiratory failure. Further review showed the resident received tracheostomy care. Review of the medical record and hospital discharge instructions dated 7/14/26 showed the resident had a hospital admission from 7/3/26 to 7/14/26 for sepsis due to pneumonia. Review of the physician orders showed an order with a start date of 6/23/26 to change disposable inner cannula (6 internal diameter) every day and PRN [as needed] every day shift for Trach Care. The following concerns were identified:a. Interview with the resident on 7/27/26 at 1:57 PM revealed staff had not changed his/her inner tracheostomy cannula daily, and stated, They are supposed to change the inner cannula everyday, but they aren't doing it daily. They have been out of inner cannulas. Interview with the resident on 7/29/26 at 3:41 PM revealed the last inner cannula change s/he remembered occurred the previous Tuesday or Wednesday. S/he stated when no inner cannula was available, sometimes they pull it out and inspect it to make sure it's not dirty and reinstall it. They have talked about cleaning the inner cannula, but I haven't seen them clean it.b. Review of the treatment administration record (TAR) for June 2026 showed no evidence the inner cannula change was performed on 6/23/26, 6/25/26, 6/27/26, 6/28/26, and 6/29/26. Review of the TAR for July 2026 showed no evidence the inner cannula change was performed on 7/1/26, 7/2/26, 7/20/26, 7/21/26, 7/22/26, 7/23/26, 7/27/26, 7/28/26 and 7/29/26.c. Review of progress notes showed the disposable inner cannula was not changed and was documented not available on 6/23/26, 6/25/26, 6/27/26, 6/28/26, 6/29/26, 7/1/26, 7/2/26, 7/20/26, and 7/28/26.d. Interview with RN #1 on 7/29/26 at 3:04 PM revealed staff had not changed the inner cannula that day because the facility had only one inner cannula available, which was reserved for emergencies. He revealed the facility had difficulty obtaining inner cannulas from their supplier. Further interview revealed his expectation for tracheostomy care when no inner cannulas were available was to remove the inner cannula and assess for patency, cleanliness, and excessive secretions, or clean or sanitize the inner cannula and reuse it.e. Interview with the DON on 7/29/26 at 3:17 PM revealed her expectation was for the disposable tracheostomy inner cannula to be changed daily per physician orders. She stated when inner cannulas were unavailable, staff contacted the doctor and were given permission to clean the inner cannula with a tracheostomy cleaning kit. Further interview confirmed no physician order existed to clean the tracheostomy inner cannula if none were available. She stated the facility had ordered 45 inner cannulas two weeks prior and had not received the shipment.2. Review of the facility's policy and procedure titled Tracheostomy Care, dated December 2017, showed: .Unlock inner cannula by turning counterclockwise. Remove inner cannula. Place inner cannula in basin with hydrogen peroxide.Clean lumen and sides of inner cannula using pipe cleaners or sterile brush. Rinse inner cannula thoroughly by agitating in normal saline for several seconds.replace inner cannula into outer cannula.

Based on observation, staff interview, incident report review, medical record review, manufacturer's recommendation review, and mechanical lift reference guide review, the facility failed to ensure safe staff practices and safe working condition of assistive devices for 1 of 4 sample residents (#1) reviewed for accident hazards. This failure resulted in a cervical fracture to resident #1 who fell during a mechanical lift transfer which resulted in the determination of immediate jeopardy due to a failure to follow manufacturer's instructions for safe mechanical lift transfers. Corrective measures were implemented prior to the survey and compliance was determined to be met on 2/16/26. The findings were: 1. Review of the 11/13/25 quarterly MDS assessment showed resident #1 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact and had diagnoses which included morbid obesity, heart failure and renal insufficiency. Further record review showed the resident was dependent with transfers and required the use of a full body mechanical lift. The following concerns were identified:a. Review of the incident report dated 2/13/26 showed resident #1 fell out of a full body mechanical lift sling on 2/12/26 at approximately 1 PM while being transferred from his/her bed to a recliner by CNA #1 and nursing aide #1 using a full body mechanical lift. Further review of the incident description showed .The left shoulder strap on the hoyer sling came loose from the hoyer causing the resident to fall to the floor. Review of the Conclusion section showed The resident had a tendency to shift weight and reposition while in the sling, it is a reasonable conclusion that the sling strap came up on one side, and the weight of the resident caused it to come off the lift . Further review of the incident report showed the resident was transferred to the emergency room.b. Review of the emergency room Report dated 2/12/26 and timed 5:10 PM showed the resident sustained a fall from a full body mechanical lift while s/he was being transferred and complained of a headache, neck pain, shoulder pain, and left distal femur and knee pain. Imaging results showed Mildly displaced fracture of the left C2 transverse process with extension into the left aspect of the C2 vertebral body. Review of the Critical Care/Intensivist Consultation note dated 2/12/26 and timed 11:14 PM, showed the resident went into cardiac arrest and death was pronounced at 9:19 PM. c. Review of the Witness Statement for RN #1 dated 2/12/26 showed .Observed resident on the floor, laying face down with legs over one leg of the hoyer lift. Further review showed all but one sling strap remained attached to the full body mechanical lift. d. Interview with CNA #1 on 3/11/26 at 11:20 AM revealed the full body mechanical lift did not have safety clips at the time of the incident and one of the sling shoulder straps had detached from the full body mechanical lift.e. Interview with nursing aide #1 on 3/11/26 at 12:01 PM revealed . the strap loop came off of the hook and I heard a loud pop. Further interview revealed the full body mechanical lift did not have safety clips at the time of the incident.f. Interview with RN #1 on 3/11/26 at 12:41 PM confirmed there were no safety clips on the full body mechanical lift at the time of the fall on 2/12/26. The interview further revealed the safety clips were installed on all of the lifts following the fall on 2/12/26. At that time, RN #1 pointed to the Tollos Titan mechanical lift and indicated it was the device used at the time of the fall.g. Observation on 3/11/26 at 10:56 AM showed safety clips were present on the lift. Further observation showed a laminated Quick Reference Guide, for the Ultralift & Titan Tollos was attached to the Tollos Titan X full body mechanical lift. h. Review of the full body mechanical lift Quick Reference Guide last revised 2/2014 provided by the DON on 3/12/26 at 3:18 PM showed .Ensure safety clips on spreader bar is in position after sling has been applied. and .Check spreader bar safety clips are present and used properly.i. Interview with the DON on 3/10/26 at 11:46 AM revealed the safety clips were removed at some point because they would come off and were ineffective. Further interview confirmed the safety clips had been replaced.2. Based on the facility's failure to follow manufacture instructions, it was determined there was an immediate jeopardy situation on 2/12/26 at 1 PM when resident #1 fell from the full body mechanical lift after the shoulder strap detached from the spreader bar. There was a need for immediate action after the incident because other residents continued to be transferred using a mechanical lift and were at risk for serious injury, serious harm, serious impairment, or death. 3. Review of the facility's Performance Improvement Plan dated 2/12/26 showed the following interventions were implemented as a result of the incident:a. Hoyer lift inspections to ensure good working orderb. Sling inspections and removal of any in need of replacementc. ADHOC (A meeting to instantly address incident) QAPI (Quality Assurance and Performance Improvement) review with IDT (Interdisciplinary Team) d. Medical record reviewe. Random weekly audits of mechanical lift transfers X 4 weeks, then monthly X 2 monthsf. All nursing staff education and competency evaluations on mechanical lifts. 4. The implementation of the Performance Improvement Plan was verified during the survey and immediate jeopardy was determined to have been removed on 2/16/26.

Based on observation and staff interview, the facility failed to ensure infection prevention practices were implemented for 3 of 3 sampled residents (#7, #8, #9) reviewed for infection control. The findings were:1.Review of the 2/20/26 quarterly MDS assessment for resident #7 showed a BIMS score of 2 out of 15, which indicated severe cognitive impairment and had diagnoses which included cancer, depression, and non alzheimer's dementia. In addition the resident had lower extremity impairment, was wheelchair bound, and required substantial to maximal assistance with toileting hygiene. a. Observation on 3/10/26 at 11:58 AM showed approximately 100 milliliters of amber colored urine in a urinal hanging from a trash can next to resident #7's recliner. Further observation showed a dark blue and black discoloration inside the urinal and a dried yellow substance around the opening of the urinal. The urinal was not labeled with a date.b. Interview with CNA # 3 on 3/10/26 at 1:18 PM revealed residents' urinals were emptied every 2 hours and replaced with a new one monthly. c. Interview with CNA #3 on 3/10/26 at 1:54 PM confirmed the urinal was not dated, and appeared to have blue and black discoloration inside with a dried yellow substance around the opening of the urinal. She further stated that urinals were discarded and replaced once monthly (around the beginning, or end of the month) and weekly as needed.2. Observation on 3/10/26 at 2 PM showed two empty urinals dated 1/28/26 hanging from a trash can next to resident #8's bed. Interview with CNA #3 on 3/10/26 at 2:02 PM confirmed the urinals were not replaced after 1 month of use.3. Observation on 3/12/26 at 11:06 AM showed a urinal hanging from the nightstand of resident #9. The urinal was empty; however, there was yellow, amber, and dark blue colored staining on the inside. The urinal was not labeled with a date. Interview with CNA # 2 on 3/12/26 at 11:18 AM revealed urinals were changed monthly and as needed. She confirmed the urinal appeared soiled and was not dated.4. Interview with LPN #1 on 3/12/26 at 11:17 AM revealed staff were expected to throw out soiled urinals and replace them with new ones when they appeared soiled.5. Interview with the infection preventionist on 3/10/26 at 2:10 PM revealed staff were expected to label urinals and replace them at least monthly, or when visibly soiled.6. Interview with the DON on 3/10/26 at 2:18 PM confirmed urinals should have been replaced when they were visibly soiled. She further stated there were no facility policies regarding urinals.

Based on staff interview, medical record review and review of the bathing schedule, the facility failed to ensure activities of daily living were maintained based on the needs and choices of 1 of 3 sample residents (#11) reviewed for bathing. The findings were: 1.Review of the 1/23/26 quarterly MDS assessment for resident #11 showed a BIMS of 3 out of 15, which indicated severe cognitive impairment and diagnoses which included a history of hip fracture, stroke, anxiety and depression. Review of the care plan dated 10/24/25 showed the resident preferred bathing twice a week. Further review showed s/he required maximum assist with bathing and showering.a. Review of the resident's bathing record from 12/10/25 through 1/6/25 showed showers were completed twice weekly until 1/14/26, at which time they were decreased to once a week.b. Interview with the administrator on 3/12/26 at 10:50 AM revealed the resident had moved from another unit on 12/30/25 and his/her shower preferences should have been reassessed and had changed; however, no evidence of reassessment was provided. c. Interview with bath aide #1 on 3/12/26 at 11:40 AM revealed the facility encouraged maintaining bathing schedules when residents moved to other units.d. Interview with bath aide #2 revealed she would have asked the resident what their bathing preference was when she had received a new resident on her unit.e. Review of the current facility bathing schedule confirmed the resident was scheduled for weekly showers.f. Review of the resident's medical record showed no evidence of a reevaluation of preferences or change to the resident's bathing schedule.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 of 3 sample residents (#1). The following concerns were identified: Review of the admission MDS assessment dated [DATE] showed resident #1 had a BIMS score of 12 out of 15 which indicated s/he had moderately impaired cognition, and diagnoses which included non-Alzheimer's dementia, depression, and cancer. Review of the care plan last revised on 11/19/25 showed the resident was a moderate risk for falls related to confusion, gait and balance problems, and psychoactive drug use. Further review showed a care plan intervention initiated on 11/25/24 was to be sure the resident's call light was within reach. Review of the Braden Scale for Predicting Pressure Sore Risk dated 1/2/26 showed the resident scored 16 out of 23, which indicated the resident was at risk for skin breakdown. The following concerns were identified:a. Observation on 1/28/26 at 9:55 AM showed the resident was in his/her recliner that was situated at the foot of the bed, the call light was located at the head of the bed, and was not within reach. The resident had a blanket covering his/her lower body. Observation on 1/28/26 at 10:35 AM showed the resident's call light was located at the head of the bed and was not within reach. b. Interview with the resident on 1/28/26 at 11:28 AM revealed the resident did not know where his/her call light was located, and stated It should be around here somewhere. Interview with the resident on 1/28/26 at 11:33 confirmed his/her brief was wet and s/he could not request assistance because s/he did not know where the call light was.c. Interview with the resident's representative on 1/28/26 at 11:33 AM revealed the resident's brief was wet and s/he was covered in a blanket and did not have any pants on under the blanket. Further, the call light had not been in reach to request assistance.d. Observation on 1/28/26 at 11:48 showed the resident's call light was activated by his/her guest. Observation on 1/28/26 at 11:53 showed a CNA answered the resident's call light, closed the door, exited the room and returned with a clean blanket, and exited the room at 12:04 PM with 2 bags of soiled linens.e. Interview with the DON on 1/29/26 at 6:55 PM confirmed the expectation for staff when they left a resident alone in their room was to set up the resident with the call light and and any other needs, and wash their hands. f. Interview with the NHA on 1/29/26 at 7:15 PM revealed the facility did not have a policy on call light use.

Based on medical record review, resident representative and staff interview, facility incident review, and performance improvement plan review, the facility failed to protect the residents' right to be free from physical abuse by another resident for 1 of 8 sample residents (#12). This failure resulted in actual harm to resident #12. Corrective measures were implemented prior to the survey and compliance was determined to be met on 5/16/25. The findings were: 1. Review of the discharge MDS assessment dated [DATE] for resident #12 showed the resident admitted to the facility on [DATE] and a brief interview for mental status score of 2 out of 15, which indicated severe cognitive impairment. Further review showed the resident had wandering behaviors which occurred daily and diagnoses which included encephalopathy and restlessness and agitation. The following concerns were identified: a. Review of a facility incident report dated 4/28/25 and timed 3:50 PM showed resident #12 wandered into the room of resident #11, which was located on the memory care unit. Resident #11 asked resident #12 to leave and when s/he didn't, resident #11 hit resident #12 in the nose, which resulted in a bloody nose. Further review showed resident #11 admitted to hitting resident #12 in the nose. b. Review of a progress note dated 4/28/25 and timed 3:30 PM showed Resident wandered into another residents room and that resident punched [him/her] in the nose. Resident did have a nose bleed but was able to stop the bleeding. c. Interview with the resident representative for resident #12 on 5/21/25 at 2:32 PM revealed she was notified the resident was punched by another resident the day s/he admitted to the facility. d. Interview with RN #1 on 5/22/25 at 8:09 AM revealed following the altercation between the residents, she performed an assessment. She confirmed resident #12 had a bloody nose, which continued to bleed for 2 minutes, and she thinks his/her feelings were hurt after the incident. She confirmed resident #11 admitted to punching resident #12 because s/he was in his/her room. She revealed a stop sign and 1 to 1 staffing was implemented immediately as a result. 2. Interview with the DON on 5/21/25 at 4:37 PM confirmed resident #11 punching resident #12 resulted in a bloody nose for resident #12. She confirmed immediate correction included implementing 1 to 1 staffing for resident #11 and placement of a stop sign to resident #11's door. Additionally, she revealed resident #11's care plan was updated and verbal training was provided to staff. She revealed resident #12 was discharged on 5/3/25, as s/he was at the facility for respite care, and resident #11 remained on 1 to 1 staffing until s/he was hospitalized on [DATE]. 3. Interview with the DON on 5/22/25 at 8:58 AM revealed the IDT reevaluated the 1 to 1 staffing and determined on 5/5/25 that it was not necessary for resident #11. Further she revealed the facility's plan of correction was fully implemented on 5/16/25. 4. The following plan of correction was implemented by the facility by 5/16/25 and verified during the survey: a. Resident #12 discharged from the facility on 5/3/25. Resident #11 had 1 to 1 staffing implemented and a stop sign was placed on the resident's door immediately following the incident. b. Medication reviews and care plan review and updates were performed for resident #11. c. Staff education was performed for the use of stop signs, redirecting residents, and caring for residents with dementia. d. Audits were performed to evaluate the stop sign placement and effectiveness. e. Review and removal of 1 to 1 staffing for resident #11 following return from the hospital.

Based on observation, resident representative and staff interview, and medical record review, the facility failed to ensure residents received necessary treatment and services to promote healing, prevent infection, and prevent new ulcer development for 1 of 5 sample residents (#9) review for pressure ulcers. This failure resulted in actual harm to resident #9 who required additional surgical intervention. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #9 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and diagnoses which included wound infection, displaced simple supracondylar fracture without intercondylar fracture of the right humerus, unspecified open wound of the right elbow, and methicillin resistant staphylococcus aureus. Further review showed the resident had a surgical wound. Review of the care plan, initiated on 10/22/24 showed .I admitted with a right elbow surgical wound that has an infection and interventions included dressing changes as ordered. The following concerns were identified: a. Review of the medication administration record (MAR) for October 2024 showed the resident was to receive a wound vac change on Monday, Wednesday, and Friday which was ordered on 10/2/24. Further review showed the order was discontinued on 10/7/24. b. Review of a physician notification to the facility physician dated 10/7/24 showed the wound nurse requested to discontinue the wound vac and the reason showed Per wound nurse not applied. The order was signed by the PA-C on 10/7/24. There was no evidence the orthopedic surgeon was notified. c. Review of the Operative Note Final Report dated 10/11/24 showed .postop approximately 6 weeks status post Open Reduction and Internal Fixation (ORIF) right distal humerus extra-articular fracture and 2 weeks status post right elbow wound dehiscence Incision and Drainage (I & D) with placement of A stem cell therapy (A cell) and wound vac. Patient presented to clinic yesterday and has been staying at a skilled nursing facility. [S/he] is present with [his/her] wound Vac not in place and states that the facility decided to discontinue the wound vac. In clinic, the triceps tendon was obviously exposed and began developing eschar overlying it. Given the concern for possible contamination and the need to have a wound vac in place to provide a healthy soft tissue bed for potential plastic surgery coverage, we recommend returning to the OR for irrigation debridement of wound and placement of wound vac. d. Review of a progress note dated 10/13/24 and timed 10:54 PM showed Daily Skilled Evaluation for Fracture/Orthopedic Surgery/Spinal Surgery: Pt with hx [history] of falls, fracture of right elbow with post-surgical infection of deep tissue. NWB [non weight bearing] RUE [right upper extremity]. Pt had debridement of wound yesterday at [hospital] per [clinic] with a wound vac placed . e. Review of progress note dated 10/14/2024 and timed 3:36 PM showed .Pt had surgical debridement 10-11-24 on [his/her] right elbow wound making this the 4th surgical intervention. Pt returned with a wound vac in place and no new orders for a F/U or future wound care. This nurse did add wound vac orders on 10-12-24 to change every MWF [Monday, Wednesday, Friday] as that is standard for a wound vac. On this date this nurse went in to change wound vac per [clinic name], [clinic staff member name]. Wound vac canister was found with minimal clear drainage (75% of dry pack still dry). Wound vac dressing removed in which black foam was used and directly on Tendon that was thought to be fascia in prior assessment. Wound is completely dry at this time and foam stuck to parts of wound. Tendon is dry and frayed in areas. Facility PA-C in room during the entire assessment. PA-C agrees to not put wound vac back on as it is causing more damage. PA-C called [clinic name] whom stated both the surgeon and PA, [name] are out of the office this date, but they will have their nurse call back. This nurse placed hydrogel impregnated gauze over entire wound to help add moisture then secured it in place. Approximately 1 hour later [clinic name] nurse called PA-C with this nurse present. This nurse explained what wound looked like and that this nurse will not be able to replace the wound vac as it is contraindicated. [Clinic name] nurse states one of her providers will call back. A phone call was received from [clinic name's] PA, [name]. Both our facility PA-C and this nurse informed [PA] of what the wound looked like and that the black foam was placed directly on the tendon the PA, [name] stated at that time that she did not place the wound vac and that this nurse should place adaptic over tendon before placing the black foam, this nurse informed [name], PA that she will not be able to place the wound vac as it is not appropriate [name], PA became very mad and stated she did not want to talk to this nurse, so this nurse left the room. Per transportation [name], PA called to have appt set up for 10-15-24 with [clinic name] for wound vac placement. Transportation also states [clinic name] has now requested a consult with [alternate clinic name] on this date 10-14-24 for a skin graft. That appt is 10-17-24. f. Interview with the Orthopedic Surgeon on 3/20/25 at 1:15 PM revealed the resident required additional surgeries due to the facility's failure to apply the wound vac per the surgeon's orders. g. Interview with the DON on 3/20/25 at 11:46 AM revealed the wound care nurse contacted the facility's provider related to the wound vac and it was decided the vac was causing damage to the wound. The DON revealed the order was changed by the facility provider with the wound care nurse; however, she revealed the wound care nurse should have notified the surgeon and confirmed the surgeon was not notified.

Based on observation, resident representative and staff interview, medical record review, and policy review, the facility failed to provide quality of care for 3 of 10 sample residents (#2, #4, #10). This failure resulted in actual harm to resident #4 who was hospitalized for sepsis infection. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included diabetes mellitus, neuropathy, and renal insufficiency, renal failure, or end-stage renal disease. Further review showed the resident was at-risk for developing pressure ulcers/ injuries, had no venous or arterial ulcers, and no other ulcers, wounds, or skin problems present. Review of the care plan initiated on 1/27/25 showed I have potential for pressure ulcer development and skin breakdown . and interventions which included an air mattress for skin integrity. The following concerns were identified: a. Review of a progress note dated 2/13/25 and timed 4:46 AM showed .Skin Issue (New/Worsened/Change) Acute signs and symptoms (s/s): tachycardia, fever, chills, n/v, wound drainage, pain, mentation, interventions, outcomes, Vitals: Right (Rt) buttock wound noted with increased depth from last week. Upper aspect noted yellow/green sluff [sic] and blackened area. Noted foul odor, cleansed with NS and gauze. Applied zinc cream as ordered. Please advise, thank you. Further review showed no additional notes related to wound condition or possible infection until 2/21/25. b. Review of a progress note dated 2/21/25 and timed 8:12 PM showed .MD evaluated resident due to swollen left side of face. Orders received to culture drainage. Drainage cultured by day shift and sent to lab. Orders received for Rocephin 1 gram IM/IV every 24 hours times 6 days. Orders received for Metronidazole 500 milligram (mg) oral (po) every 8 hours times 7 days. Orders entered and faxed to pharmacy. c. Review of a progress note dated 2/22/25 and timed 5:10 AM showed .Infection Signs/symptoms tachycardia, fever/chills, n/v, pain, mental status. List clinical findings.: Resident continues on oral antibiotics for UTI. Resident remains A&O at baseline. Starting IM abx [antibiotic] injections this afternoon for possible facial infection. Resident resting in bed with eyes closed. vital signs (VS) stable. No adverse reactions noted. WCTM [will continue to monitor]. Vitals: 113/76, 97.3, 93, 15, 92%. d. Review of a progress note dated 2/22/2025 and timed 7:35 AM showed Family came in to visit resident. Family concerned about residents [sic] condition. Family requesting resident to be sent to WMC ER for evaluation due to not being [him/herself] per granddaughter. MOD [manager on duty] notified and came to unit to assist. VS obtained and resident was tachypneic and hypoxic at 82% on 2L. Oxygen adjusted up to 5L and sats [saturation] rose to 88%. 911 called and left with resident at 738 AM. MD called by MOD and notified of situation. e. Interview with the resident's representative on 3/19/25 at 1:38 PM revealed they were not notified of the skin breakdown or tunneling of the wound until 2/22/25. The representative revealed upon hospitalization it was learned the resident was septic and s/he should have gone to the hospital sooner. 2. Review of an admission MDS assessment dated [DATE] showed resident #10 had a BIMS score of 11 out 15, which indicated moderate cognitive impairment, and diagnoses which included displaced bicondylar fracture of right tibia, subsequent encounter for closed fracture with routine healing and history of falling. Further review showed the resident had a surgical wound. The following concerns were identified: a. Review of physician communication dated 2/10/25 showed Orders paint surgical incisions [with] betadine 2 x [times] daily begin keflex 500 mg QIb [sic] until follow up. FU [follow up] 1 wk [week]. The PA-C signed the note on 2/10/25 and it was marked noted MAR [medication administration record] updated 2/10/25. b. Review of the MAR and Treatment Administration Record (TAR) showed start dates for both orders were 2/15/25. c. Interview with the DON on 3/20/25 at 11:46 AM revealed the nurse failed to update the physician orders for wound care and antibiotic therapy and the delayed orders were identified on 2/15/25. d. Interview with the Orthopedic Surgeon on 3/20/25 at 1:15 PM revealed the facility failed to notify them of a delay to start wound care and Keflex orders. 3. Review of the admission MDS dated [DATE] showed resident #5 had severely impaired cognitive skills for daily decision making, and diagnoses which included depression. Further medical record review showed a diagnosis of altered mental status, and a Morse Fall Scale of 80, which indicated s/he was at a high risk for falls. The following concerns were identified: a. Review of a progress note dated 1/22/25 at 5:34 PM showed the resident fell in his/her room. Further review showed no observed bruising, skin tears or abrasions, range of motion to all extremities with no difficulties, and neurological checks were started at 5:15 PM. b. Review of a progress note dated 1/23/25 at 5:19 AM showed Resident noted walking down the hall without walker/wheelchair/oxygen. Staff responded to assist [him/her] back to [him/her] room and in w/c. Upon assessment noted bruising under left eye, on bridge of nose, and an abrasion area on forehead. When asked resident if [s/he] had fallen [s/he] stated 'you know I did you helped me up and then took me to eat dinner. I was walking up that incline and then was on the floor on my face' [sic] Resident did have an unwitnessed fall last evening at 15:04 [3:04 PM] in his/her room. Neuros have been WNL. Resident pleasantly confused . c. Review of the neurological evaluation showed one neuro assessment documented on 1/22/25 at 5 PM, and no further assessments documented, with a note on the form stating refused. d. Review of the emergency room report dated 1/23/25 at 11:16 PM showed a maxillofacial CT had been completed with the result of a nondisplaced acute nasal bone fracture. e. Interview with the DON on 3/19/25 at 4:15 PM revealed the resident had an unwitnessed fall in his/her room on 1/22/25, and there was a red mark on his/her forehead but no bruising at that time. Further interview revealed the facility protocol for neuro checks after a fall was every hour for the first 4 hours, and every 4 hours for the next 24 hours, with fall charting for 72 hours to monitor for any symptoms. f. Interview with the DON on 3/20/25 at 11:55 AM revealed she was the nurse on duty on 1/23/25 at 5:19 AM when the resident came out of his/her room and said s/he had fallen again, though the DON was unaware of any other falls. Further interview revealed neuro assessments had been completed but she did not know where the records were, or why the facility only had the first set of vitals taken. 4. Review of the Fall Management and Neurological Check policy last updated January 2025 showed .Head Injury/Unwitnessed Fall .1. In the event of a head injury or fall that is unwitnessed and the occurrence leads the nurse to conclude a head injury is likely, neurological checks are initiated .a. Example of when neurological checks may not be required: i. Resident is cognitively intact and able to state what occurred and there is no evidence of head injury .b. Neurological checks are completed per evidenced based guidance (See reference below): i. Hourly for four (4) hours then. ii. Every four (4) hours for 24 hours. c. Neurological checks include: i. Vital signs ii. Pupillary Response using light accommodation. iii. Motor function including 1. Hand grasp 2. Extremity Review iv. Monitoring for seizure, new onset vomiting, new onset headache, and new onset amnesia .

Based on resident representative and staff interview, medical record review, and policy review, the facility failed to notify residents' physicians with changes of condition or treatment for 2 of 10 sample residents reviewed (#9, #10). This failure resulted in actual harm to resident #9 who required additional surgical intervention. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #9 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and had diagnoses which included wound infection, displaced simple supracondylar fracture without intercondylar fracture of the right humerus, unspecified open wound of the right elbow, and methicillin resistant staphylococcus aureus. Further review showed the resident had a surgical wound. Review of the care plan, initiated on 10/22/24 showed .I admitted with a right elbow surgical wound that has an infection and interventions included dressing changes as ordered. The following concerns were identified: a. Review of the medication administration record (MAR) for October 2024 showed the resident was to receive a wound vac change on Monday, Wednesday, and Friday which was ordered on 10/2/24. Further review showed the order was discontinued on 10/7/24. b. Review of a physician notification to the facility physician dated 10/7/24 showed the wound nurse requested to discontinue the wound vac and the reason showed Per wound nurse not applied. The order was signed by the PA-C on 10/7/24. There was no evidence the orthopedic surgeon was notified. c. Review of the Operative Note Final Report dated 10/11/24 showed .postop approximately 6 weeks status post Open Reduction and Internal Fixation (ORIF) right distal humerus extra-articular fracture and 2 weeks status post right elbow wound dehiscence Incision and Drainage (I & D) with placement of A stem cell therapy (A cell) and wound vac. Patient presented to clinic yesterday and has been staying at a skilled nursing facility. [S/he] is present with [his/her] wound Vac not in place and states that the facility decided to discontinue the wound vac. In clinic, the triceps tendon was obviously exposed and began developing eschar overlying it. Given the concern for possible contamination and the need to have a wound vac in place to provide a healthy soft tissue bed for potential plastic surgery coverage, we recommend returning to the OR [operating room] for irrigation debridement of wound and placement of wound vac. d. Review of a progress note dated 10/13/24 and timed 10:54 PM showed Daily Skilled Evaluation for Fracture/Orthopedic Surgery/Spinal Surgery: Pt with hx [history] of falls, fracture of right elbow with post-surgical infection of deep tissue. NWB [non weight bearing] RUE [right upper extremity]. Pt had debridement of wound yesterday at [hospital] per [clinic] with a wound vac placed . e. Review of progress note dated 10/14/2024 and timed 3:36 PM showed .Pt had surgical debridement 10-11-24 on [his/her] right elbow wound making this the 4th surgical intervention. Pt returned with a wound vac in place and no new orders for a F/U or future wound care. This nurse did add wound vac orders on 10-12-24 to change every MWF [Monday, Wednesday, Friday] as that is standard for a wound vac. On this date this nurse went in to change wound vac per [clinic name], [clinic staff member name]. Wound vac canister was found with minimal clear drainage (75% of dry pack still dry). Wound vac dressing removed in which black foam was used and directly on Tendon that was thought to be fascia in prior assessment. Wound is completely dry at this time and foam stuck to parts of wound. Tendon is dry and frayed in areas. Facility PA-C in room during the entire assessment. PA-C agrees to not put wound vac back on as it is causing more damage. PA-C called [clinic name] whom stated both the surgeon and PA, [name] are out of the office this date, but they will have their nurse call back. This nurse placed hydrogel impregnated gauze over entire wound to help add moisture then secured it in place. Approximately 1 hour later [clinic name] nurse called PA-C with this nurse present. This nurse explained what wound looked like and that this nurse will not be able to replace the wound vac as it is contraindicated. [Clinic name] nurse states one of her providers will call back. A phone call was received from [clinic name's] PA, [name]. Both our facility PA-C and this nurse informed [PA] of what the wound looked like and that the black foam was placed directly on the tendon the PA, [name] stated at that time that she did not place the wound vac and that this nurse should place adaptic over tendon before placing the black foam, this nurse informed [name], PA that she will not be able to place the wound vac as it is not appropriate [name], PA became very mad and stated she did not want to talk to this nurse, so this nurse left the room. Per transportation [name], PA called to have appt set up for 10-15-24 with [clinic name] for wound vac placement. Transportation also states [clinic name] has now requested a consult with [alternate clinic name] on this date 10-14-24 for a skin graft. That appt is 10-17-24. f. Interview with the Orthopedic Surgeon on 3/20/25 at 1:15 PM revealed the resident required additional surgeries due to the facility's failure to apply the wound vac per the surgeon's orders. g. Interview with the DON on 3/20/25 at 11:46 AM revealed the wound care nurse should have called the surgeon, and she did not. 2. Review of an admission MDS assessment dated [DATE] showed resident #10 had a BIMS score of 11 out 15, which indicated moderate cognitive impairment, and diagnoses which included displaced bicondylar fracture of right tibia, subsequent encounter for closed fracture with routine healing and history of falling. Further review showed the resident had a surgical wound. The following concerns were identified: a. Review of physician communication dated 2/10/25 showed Orders paint surgical incisions [with] betadine 2 x [times] daily begin keflex 500 mg QIb [sic] until follow up. FU [follow up] 1 wk [week]. The PA-C signed the note on 2/10/25 and it was marked noted MAR [medication administration record] updated 2/10/25. b. Review of the MAR and Treatment Administration Record (TAR) showed start dates for both orders were 2/15/25. c. Interview with the DON on 3/20/25 at 11:46 AM revealed the nurse failed to update the physician orders for wound care and antibiotic therapy and the delayed orders were identified on 2/15/25. d. Interview with the Orthopedic Surgeon on 3/20/25 at 1:15 PM revealed the facility failed to notify them of a delay to start wound care and Keflex orders. 3. Review of the policy titled Skin Integrity last revised January 2025 showed .6. If skin impairment is noted after admission (in addition to the above steps), the LN [licensed nurse]: b. Completes (and documents) notifications to the physician and Resident or Resident Representative .8. Wounds are evaluated weekly by center clinicians. arterial, pressure, stasis, and venous ulcers, significant surgical wounds, and burns are evaluated, measured, and findings documented in the medical record. This evaluation includes pain associated with the wound during care. If a wound condition fails to improve after 2 weeks of treatment or the condition of the wound deteriorates, the Physician and Resident's Representative are notified. If a new treatment order is obtained the LN: a. Re-evaluates POC [plan of care] and resident's condition (e.g. off-loading pressure from skin impairment area, nutritional intake, blood sugars, and lab values) .

Based on medical record review, staff interview, review of incident and facility documentation, and policy and procedure review, the facility failed to ensure residents were free from physical abuse by other residents for 1 of 4 allegations reviewed, which resulted in actual harm to resident #1. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 9/6/24. 1. Review of the 8/18/24 quarterly MDS assessment showed resident #1 (victim) had severely impaired cognitive skills, had a diagnosis of non-Alzheimer's dementia, wandered daily, and exhibited physical behaviors 1-3 days a week. 2. Review of the 7/17/24 quarterly MDS assessment showed resident #2 (perpetrator) had a BIMS score of 10, indicating moderate impairment. In addition, the resident had diagnoses including traumatic brain injury and non-Alzheimer's dementia, and did not exhibit behaviors. Review of the the care plan, initiated 11/13/23, showed the resident had a behavior problem of making comments about being violent to women in the past, and stating how s/he was still capable of these actions. The resident would say that and then laugh, and say s/he would never do that. 3. Review of an incident report showed on 8/14/24 at 6:45 PM resident #1 approached resident #2 and was waving his/her fingers near the other resident's face and was saying something. Resident #2 said something back, and then resident #1 grabbed the arms of resident #2. The two residents then were shoving back and forth. The residents were separated and neither had injuries. 4. Review of an incident report showed on 8/18/24 at 12:45 PM resident #1 approached resident #2 in the hallway and was getting in [his/her] face. Resident #2 then punched resident #1 in the face, causing the resident to fall on his/her bottom. The incident report showed the resident stated s/he hit the other resident because the other resident flipped me off and threatened to hit me, so I hit [him/her] first. The resident was taken to the hospital and found to have a nasal bone fracture. 5. Review of the history and physical from the hospital dated 8/18/24 showed resident #1 was punched in the face by another resident. The resident had a small skin tear and bruise noted to the bridge of the nose. The documentation showed .[s/he] has a nasal bone fracture with what looks like chronic sinusitis on CT scan. 6. During an interview on 9/9/24 at 5:09 PM LPN #1 stated she was outside on the phone with a doctor on 8/18/24 when CNA students came out and got her and stated resident #2 punched resident #1 in the face. When she went inside she saw that resident #1 was on the ground, his/her nose looked broken, and his/her face was swelling. 7. During an interview on 9/9/24 at 5:11 PM CNA student #1 stated she witnessed resident #2 hit resident #1 in the face. She stated she saw his/her fist connect with the other resident's face, and then the resident fell down. 8. Review of the facility's policy Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated October 2022, showed .Each resident has the right to be free from abuse . The definition of abuse was The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .willful, as used in this definition of abuse, means the individual acted deliberately, not that the individual must have intended to inflict injury or harm. The definition of physical abuse included punching. 9. The facility implemented the following correction action by 9/6/24: a. Resident #2 was moved out of the secure unit with a wanderguard and increased supervision. b. Resident #1 had increased supervision when s/he returned from the hospital. c. A facility-wide audit was done to ensure no other physical altercations had taken place. d. Education was provided to staff to ensure escalating behaviors were being redirected before physical aggression took place. e. Weekly audits were started to ensure escalating behaviors were being redirected. Audits to be done weekly then monthly for 12 weeks and discussed in the QAPI meetings.

Based on medical record review, family and staff interview, and the resident's family's written timeline, the facility failed to ensure timely assessment and treatment for 1 of 5 sample residents (#1) with a change of condition. This failure resulted in actual harm for resident #1 who was transferred to the hospital and passed away while in the emergency room waiting area. The findings were: 1. Review of the admission MDS assessment dated [DATE], showed resident #1 had a brief interview for mental status score of 9 out of 15, which indicated moderate cognitive impairment, and required moderate assistance with toileting, dressing, and personal hygiene. Further review showed the resident received antiplatelet therapy (to prevent blood clots). 2. Review of the physician orders for February 2024 showed resident #1 received Reglan (anti-emetic) 10 mg by mouth 4 times a day for 7 days for treatment of enteritis and ondansetron (anti-emetic) 4 mg by mouth every 6 hours as needed for nausea/vomiting. Further review showed the Reglan order had a start date of [DATE] and end date of [DATE]. 3. Review of the Nutrition/Hydration care plan initiated on [DATE] showed resident #1 was at increased nutritional risk impacted by diagnoses, fluctuating oral intake, and a history of slightly elevated body mass index. Interventions included .Observe for s/s [signs and symptoms] dehydration: i.e. [id est or that is] dry mouth, cracked lips, dry skin, concentrated urine/decrease urine output, rapid weight loss, dry or sunken eyes, changes in mental status, fever, vomiting, dizziness, increased combativeness or confusion . 4. Review of the [DATE] at 4:55 PM Situation, Background, Assessment, and Recommendation showed the resident's change in condition, at that time, was decreased food and/or fluid intake, functional decline, and nausea and vomiting which began on [DATE]. Review of a progress note dated [DATE] and timed 8:21 PM showed Note Text: 6:02 PM non-emergent [transport] called per MD [orders]. 6:20 PM EMTs arrived and assisted the Pt to the ER. 6:37 PM report called to ER. Review of a progress note dated [DATE] and timed 2:42 AM showed the resident was returning to the facility from the hospital with a prescription for Reglan 10mg by mouth 4 times per day and s/he should return to the hospital with any worsening abdominal pain, inability to tolerate oral intake, concern for dehydration or any other concerns. Review of a progress note dated [DATE] and timed 00:59 AM PM showed the resident returned to the facility with a diagnosis of enteritis (inflammation of the small intestine.) The following concerns were identified: a. Review of the medication administration record for February 2024 showed the resident received ondansetron on [DATE] at 4:09 PM, on [DATE] at 5:15 PM and 8:41 PM (3 hours and 26 minutes after the previous dose), and on [DATE] at 5:24 AM and 10 25 AM (5 hours and 1 minute after the previous dose). Further review showed all administration times were indicated as effective except the 10:25 AM dose on [DATE]. b. Review of a progress noted dated [DATE] and timed 6:38 PM showed the resident had refused all meals and his/her only intake was a small orange in the morning and Pepsi. In addition, the resident had vomited around 5 PM and Zofran (ondansetron) was administered. Further review showed no evidence the physician was notified at that time. c. Review of a Medical Change of condition note dated [DATE] and timed 1:56 AM showed the resident had small amounts of emesis about every 2 hours and Zofran was administered. At that time the resident was asked if s/he wanted to go to the hospital and s/he declined stating s/he would wait until the physician came to the facility. Further review showed no evidence the physician was notified at that time. d. Review of a progress note dated [DATE] and timed 8:09 AM showed the resident had emesis and nausea; however, the order for Reglan had been discontinued after 7 days per the hospital discharge orders. Further review showed .MD to consider restarting the same medication or please advise on other course of action; however, further review showed no evidence the physician was contacted or notified of the resident's condition, at that time. e. Interview with the DON on [DATE] at 12:15 PM revealed the facility did not consider the resident's condition critical and his/her vital signs were stable. Further interview revealed the resident was transported via facility van because the van was at the facility and emergency medical services would have taken between 30 and 40 minutes to get to the facility. f. Review of a progress note dated [DATE] and timed 3:14 PM showed the resident had three to four episodes of emesis which were dark in color, all liquid. The resident's spouse was in contact with the facility and requested the resident be taken to the emergency room for evaluation. Further review showed the physician was contacted at 1:57 PM, 19 hours and 19 minutes after the first episode of vomiting, and the physician ordered non-emergent transport to the hospital related to multiple emesis episodes. Further review showed the resident left the facility at approx. [approximately] 2:45 PM, 48 minutes after the physician notification. There was no evidence the resident's vital signs were assessed prior to the transfer. g. Interview with the resident's son on [DATE] at 11:10 AM revealed the resident's family kept a written timeline of events during the resident's stay, including the day the resident passed away. Further interview revealed no facility health care staff members accompanied the resident during the transfer to the hospital and the resident was transferred via the facility van. h. Review of the written timeline provided by the resident's family showed on [DATE] at 8:57 AM the resident called family to express s/he had a horrible night, had not stopped throwing up, and s/he was being taken back to the emergency room . Review of the timeline showed on [DATE] at approximately 1:35 PM the resident's spouse contacted the facility and they had decided to wait until the doctor came in on Tuesday [[DATE]]; however, the timeline confirmed the spouse wanted the resident transported due to the resident still throwing up after days and couldn't even keep water down and s/he would take the resident to the hospital or meet the resident at the hospital if necessary. The timeline showed on [DATE] at approximately 2:15 PM the resident was transported to the hospital via facility van, no facility healthcare staff was present, and s/he was left in the emergency department waiting area with his/her spouse and facility staff. The timeline showed on [DATE] at 3:50 PM the son called the spouse while in the waiting area. At that time the resident was bent over and throwing up. Further review of the timeline showed on [DATE] at approximately 4:15 PM the resident had collapsed in the waiting room and there was blood all over. i. Review of a SNF/NF to Hospital Transfer Form dated [DATE] and timed 1:59 PM showed the reason(s) for transfer was indicated as Nausea/vomiting. j. Interview with the facility transportation administrator on [DATE] at 11:40 AM revealed on [DATE] the facility transportation staff member took the resident to the emergency room , checked him/her in, and left the resident at the hospital with his/her spouse. The transportation administrator revealed facility staff normally go with the resident or stay in the waiting room with the resident when there was no family, the resident had dementia, or the resident was really sick. Further interview revealed normally when a resident was really sick they were transported via ambulance and not the facility van. k. Interview with the facility transportation administrator and transportation staff member on [DATE] at 11:50 AM confirmed the transportation staff member took the resident to the emergency room and revealed a nurse said the resident had to go related to complaints of nausea and the resident was going to throw up. The transportation staff obtained a vomit bag for the resident and described him/her as doubled over with his/her chest to his/her thighs. Further interview revealed the normal procedure was to transport stable residents by facility transportation and transport unstable resident by ambulance. l. Interview with the DON on [DATE] at 1:30 PM revealed the facility sends a CNA with residents when they were transferred to the emergency room at times; however, it was up to the nurse's judgement to determine when a CNA should accompany a resident. Further interview revealed the facility did not feel the resident needed a staff member to accompany him/her even when s/he was doubled over. m. Interview with the DON on [DATE] at 11:47 AM confirmed the resident was doubled over and nauseated at the time of transfer to the emergency room . n. Review of a progress note dated [DATE] and timed 7:30 PM showed the resident's family .came by the facility to notify [the facility the] pt [patient] deceased at hospital.

Based on observation, medical record review and resident and staff interview, the facility failed to ensure staff were trained in the appropriate use of a mechanical lift for 1 of 5 sample residents (#4) reviewed for falls. This failure resulted in actual harm to resident #4 who suffered back pain, and head impact causing a hematoma as a result of the fall. The facility implemented corrective actions prior to the survey. These actions were verified by the survey team and the facility was determined to be in compliance on 3/8/23. The findings were: 1. Review of the 4/23/23 quarterly minimum data set (MDS) assessment showed resident #4 had a brief interview for mental status (BIMS) score of 11 out of 15 indicating moderate impairment. The resident had diagnoses which included multiple sclerosis and weakness, and was dependent on staff for transfers. Additionally, the resident had a history of falls and a fall risk score of 40 indicating the resident was at moderate risk of failling. a. Review of the 2/17/23 care plan showed staff used a mechanical lift with 2 staff members for transferring the resident, and that the resident had experienced a fall on 2/17/23. b. Review of the 2/17/23 nurse progress note time stamped 9:28 AM showed The resident was in the hoyer sling when the hoyer hook lifted and unhooked the sling and the resident fell to the ground. The resident did hit [his/her] head and has a goose egg on the back of [his/her] head. Review of the 2/17/23 at 10:56 AM nurse progress note showed the resident wanted to go to the hospital due to the fall and was experiencing back pain. c. Interview on 5/16/23 at 12:45 PM with resident #4 confirmed a fall from the mechanical lift causing a hematoma to his/her head, and back pain. d. Interview on 5/18/23 at 8:30 AM with CNA #4 and LPN #2, who were transferring the resident with the mechanical lift on 2/17/23, confirmed after getting the resident into the sling on the mechanical lift the sling became unhooked and the resident fell to the floor hitting his/her head causing a bump. Both staff members revealed they had not been trained on how to use that specific type of lift until after the resident fall. Interview on 5/18/23 at 10:56 AM with CNA #3 revealed she had not been trained how to use that specific lift until after resident #4 fell during transfer with the lift, and that other staff didn't like to use that lift because it was crappy. Interview on 5/17/23 at 4:35 PM with LPN #3 revealed she did not like to use that specific lift because it felt sketchy and not safe. e. The facility implemented a performance improvement plan which included maintenance checks all mechanical lifts on 2/20/23 to include the type of lift that was used when resident #4 fell , training of all staff who use lifts on 3/8/23, and ongoing audits of lift safety. These interventions were reviewed, and the facility was determined to be in substantial compliance as of 3/8/23.

Based on observation, review of facility infection control documentation, staff interview, review of policy and procedures, and CDC guidelines, the facility failed to ensure transmission-based precautions were followed consistently and correctly to prevent the spread of communicable disease. This failure resulted in an unacceptable risk to resident health and a determination of immediate jeopardy. In addition the facility failed to ensure acceptable infection control practices were followed related to hand hygiene during 1 observation of meal service. The census was 140. The findings were: 1. Observation on 2/9/22 at 11:53 AM showed an isolation cart located between rooms [ROOM NUMBERS] and one droplet precaution sign on the wall between the 2 resident name plates for room [ROOM NUMBER] and the 2 resident nameplates for room [ROOM NUMBER]. It was not clear which room was on precautions. The drawers of the isolation cart contained yellow gowns, gloves and goggles. The doors to both rooms were open and resident #1 was seated in a wheelchair in the hallway outside room [ROOM NUMBER]. The resident was not wearing a mask. The following concerns were identified: a. Review of the facility infection control documentation provided by the facility on 2/9/22 showed the facility was in outbreak status with 10 residents positive for COVID-19. Resident #1 was listed as positive for COVID-19. b. Observation of the meal service on 2/9/22 from 12 PM to 12:10 PM showed nutrition services aide (NSA) #1 was wearing a KN95 mask and goggles while assisting with setting up meal trays. He entered the room for resident #1 without performing hand hygiene, or donning a gown and gloves, or changing his mask to a N95 mask, and delivered the lunch tray. He exited the resident's room without changing his mask, performing hand hygiene or disinfecting his goggles. He walked into the communal dining room, retrieved some juice and brought the juice back to resident #1. When he entered the resident's room he again failed to don a gown, gloves, and N95 mask, and failed to perform hand hygiene. When he exited the resident's room he failed to change the KN95 mask, disinfect the goggles, or perform hand hygiene. He then returned to the communal dining room and assisted with the meal trays. NSA #1 returned to the resident's room for a third time to provide additional assistance, and donned an isolation gown that was hanging in the room. When he finished assisting the resident, he removed the isolation gown, hung it back up on the door, and failed to perform hand hygiene, change the mask or disinfect the goggles. c. Interview on 2/9/22 at 12:10 PM with NSA #1 confirmed resident #1 (room [ROOM NUMBER]) was on droplet precautions and the door should be kept closed. He also confirmed he donned an isolation gown that was hanging in the room because it was there. He revealed there were 2 gowns hanging in the room, which were for the CNAs. 2. Observation on 2/9/22 at 12:10 PM of the Rapid Recovery Unit showed CNA #1 was in room [ROOM NUMBER] providing resident care. A sign indicating the room required droplet precautions was posted, however the door was open. The CNA wore a KN95 mask and goggles. The following concerns were identified: a. Observation showed the CNA was not wearing gloves or an isolation gown. b. The CNA provided resident care by adjusting a cooling pad on the resident's leg that had an external fixator (orthopedic device). The CNA noticed the medical device that delivered ice water to the cooling pad needed to be refilled. She brought the medical device out of the room, did not disinfect the device, and did not perform hand hygiene, don a clean mask, or disinfect her goggles upon exit. c. The CNA poured the contents of the medical device into a sink at the nurse's station. The CNA then took the medical device, that had not been disinfected despite being taken from a room that was on droplet precaution, to the ice machine located in the communal dining room. She placed the medical device on the edge of the ice machine, used an ice scoop to dispense ice into the medical device multiple times and touched the inside of the medical device with the scoop. When she finished she placed the scoop back in the holder on the side of the ice machine. d. The CNA obtained the resident's lunch tray and returned to the resident's room with the tray and the medical device. She donned a yellow isolation gown and glove and assisted the resident with the meal tray, and the medical device. She doffed the isolation gown and gloves upon exit. However, she failed to dispose of her mask and don a clean mask, perform hand hygiene or disinfect her goggles. e. Meal service observation on 2/9/22 from 11 AM to 12:30PM showed staff utilized the ice machines in the dining rooms to fill meal tray cups and bedside cups. 3. Observation on 2/9/22 at 12:21 PM of the East Unit and Rapid Recovery Unit showed 4 out of 6 rooms with posted transmission-based precaution signage had open doors. 4. Interview on 2/9/22 at 6:05 PM with the DON and ADON confirmed when staff exit an isolation room they were to doff the gown and gloves and dispose of them in the garbage. They further stated hand hygiene should be performed and goggles/face shields should be disinfected. They also stated they had never thought about changing masks when they entered and exited the isolation rooms. The DON confirmed there was a policy and she needed to review it. 5. Review of the facility policy Limiting the Spread of COVID-19 in Skilled Nursing Facilities, with a revision date of 2/22 showed COVID-19 Isolation and Outbreak Status: .10. PPE use upon entry to isolation rooms: a. Appropriate PPE upon entry to isolated rooms include: eye protection (preferable a face shield), respirator, gown and gloves. b. N95 or higher level respirators are required upon entry to positive COVID-19 rooms and enhanced droplet precaution rooms c. PPE should be removed and discarded as appropriate upon leaving an isolation room .12. Used dedicated or disposable noncritical equipment when available 13. All residents should remain in their rooms with door closed whenever possible until the outbreak is resolved. If unable to keep door closed, position resident 6 feet from the door 6. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 2/2/2022, found at https://www.cdc.gov/coronavirus/2019-ncov/infection-control-recommendations.html and retrieved 2/10/22 showed .2. Recommended infection prevention and control (IDC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-COV-2 infection . HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-COV-2 infection should adhere to standard precautions and use a NIOSH- approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection . On 2/9/22 at 3:46 PM the administrator was informed of an immediate jeopardy situation in the area of infection control related to a failure to implement safe infection control practices regarding hand hygiene, donning and doffing PPE and handling medical equipment for residents in designated isolation precaution rooms. The facility submitted an action plan which included the following immediate changes: a. Resident #1 who had Covid-19 was educated on the importance of the quarantine period, due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Both staff members who were identified received written counsel and education regarding PPE, hand hygiene, infection control practices, and isolation room guidelines. c. PPE storage checked and the facility was noted to have appropriate supplies, and isolation carts were stocked. d. The ice machine was shut down, with a sign that read Do Not Use, and maintenance was notified to empty, drain, and sanitize the ice machine. e. Shared medical equipment will be thoroughly cleaned between use. f. Isolation rooms were clearly labeled and identifiable as such on the door. g. Education to current staff regarding PPE, hand hygiene, infection control practices and isolation room guidelines started 2/9/22 at 5 PM. Any staff not working will be educated prior to the start of their next shift. h. Education will be provided by the staff development coordinator or designee annually, and upon hire for staff regarding PPE, hand hygiene, infection control practices, and isolation room guidelines. i. DON to ensure new admissions that are in isolation and/or new COVID-19 diagnosed residents have appropriated PPE protocols in place. j. Random audits will be conducted daily on isolation rooms, isolation carts, hand hygiene for 4 weeks, then reassessed during the quality assurance meeting. Random audits of staff will be conducted daily with questioning of appropriate PPE use for 45 weeks, then reassessed in the quality assurance meeting. The action plan was accepted on 2/10/22 at 10:30 AM. The implementation of the action plan was verified and immediacy was removed on 2/10/22 at 11:08 AM; however, deficient practice remained at a scope and severity level of E. Concerns related to hand hygiene during meal service: 1. Observation on 2/9/22 from 11:53 AM to 12:10 PM of the meal service on the East nursing unit showed the following concerns: a. CNA #2 entered rooms [ROOM NUMBER] without performing hand hygiene, delivered lunch trays, assisted the residents and exited the rooms without performing hand hygiene. Further observation showed the CNA walked into the communal dining room, removed a resident's mask and no hand hygiene was performed prior to the CNA offering fluids to the resident. b. Interview on 2/9/22 at 12:10 AM with the CNA confirmed she was to perform hand hygiene upon entrance and exit of resident rooms and after providing resident care. She further stated the hand gel dispensers were not easily accessible and they were under pressure to get the meal trays to the residents. c. According to the CDC guidelines for Hand Hygiene in Healthcare Settings: hand hygiene should be performed immediately before touching a resident, and after touching a resident or the resident's immediate environment: retrieved 2/16/22 from https://www.cdc.gov/handhygiene/providers/index.html.

Based on medical record review, and staff and physician interview, the facility failed to ensure timely assessments and physician notification in accordance with professional standards for 1 of 2 sample residents (#1) who had a significant change in condition. This failure resulted in harm to resident #1, who experienced a significant delay in receiving medical intervention after a change in condition. The findings were: Review of the [DATE] significant change MDS assessment showed resident #1 was admitted to the facility on [DATE]. The resident had a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact. S/he required supervision of 1 staff member for transfers and walking. Review of oxygen saturation data for [DATE] through [DATE] showed the resident consistently maintained oxygen saturation levels of 88% or greater. Review of the [DATE] progress note timed at 6:33 AM showed .Note Text: 0300 [3 AM] Medaide informed this nurse about resident O2 [oxygen saturation] being 55% on 2 liters [supplemental oxygen], R [respirations] 22, P [pulse] 146, BP [blood pressure] ,d+[DATE], resident was put in a high fowlers position, oxygen tubing and nasal cannula changed, resident O2 came up to 87% on 2L [2 liters of oxygen]. At 0530 AM [5:30 AM] resident was found laying at the foot end of [his/her] bed, with no oxygen on, [s/he] was cold and clammy to touch, sweating, foaming in [his/her] mouth and [his/her] under pants and pants were below [his/her] knees. Resident was quickly put in a high fowlers position, oxygen placed back on with a venturi mask, [s/he] was slightly awake but oriented times 4. Resident's O2 started increasing and got to 86% on 4L, R 22, P106, BP ,d+[DATE]. Review of the [DATE] progress note timed at 7:45 AM showed .Note Text: Resident O2 keeps dropping, put resident on 10L [10 liters of oxygen] rebreather mask brought up to 92%. 8:20 [8:20 AM] covid test done neg [negative]. Resident took to the BR [bathroom] by the nurse on 5L [5 liters of oxygen] NC [nasal cannula] assist back to bed O2 drops to 46 [46%]. Son [son's name] notified and wants [resident] sent to [local emergency department (ED)]. [Physician] agrees to have resident sent to [local ED]. Resident alert and left for [local ED] 9:10 [9:10 AM] per ambulance. Review of the [DATE] progress note times at 8:30 AM showed .Note Text: Resident was placed on 10mL [10 liters per minute] rebreather mask O2 92%. Resident assisted to BR, O2 drops to 46 [46%] on 5L NC. Resident in high fowlers with O2 rebreather mask on at 10L comes back up to 92%. This is a new onset of shortness of breath. Resident lungs are coarse and wet throughout cough wet. Covid test at 8:20 [8:20 AM] negative. VS [vital signs] 97.2 [temperature] 104 [pulse] 32 [respirations]. Resident is alert. [Child of resident, and POA] called and wants [him/her] seen and [physician] gives order for [resident] to be seen. The following concerns were identified: 1. Review of the [DATE] progress notes showed no evidence the physician was notified of the resident's change in condition until [DATE] at 8:20 AM (5 hours and 20 minutes after the resident's oxygen saturation was first noted to be low). 2. Further review of the [DATE] timed at 6:33 AM progress note showed no evidence the resident's breath sounds were assessed by the nurse when the resident's oxygen saturation was noted to be 55 % on 2 liters of oxygen. 3. Interview on [DATE] at 11:30 AM with LPN [licensed practical nurse] #1, who cared for the nurse on [DATE] during the night shift, confirmed he wrote the night shift progress notes which documented the resident's significant change in condition. He stated he felt the resident had stabilized, and he was going to pass the information on to the day shift nurses. He left the resident in order to pass medications and perform other tasks for residents in the 2 hallways he was assigned to. The LPN stated he documented everything he did, and confirmed he failed to notify the physician. 4. Interview on [DATE] at 11:50 AM with RN #3, who cared for the resident on [DATE] during the day shift revealed she felt the resident was 'okay' until the note showing she took the resident to the bathroom. At that time, she realized the resident had a significant change, and she notified the physician and family member. 5. Interview with the primary physician on [DATE] at 1:45 PM showed her expectation was for the night nurse on [DATE] to have notified her when it became obvious the resident had a significant change in condition. She stated the on-call physician service was ,d+[DATE] for the purpose of timely intervention in the case of a significant change in condition, as was the case with the resident. She stated that the facility failed to notify her in a timely manner, which was important, and the resident was diagnosed at the ED on [DATE] with pseudomonas pneumonia. She stated the POA agreed to hospice services when the resident was at the local hospital, where the resident was placed and died shortly thereafter.

Based on observation, resident and staff interview, medical record review, review of the facility infection line listing, policy and procedure review, and review of the Centers for Disease Control (CDC) guidelines, the facility failed to ensure staff who were symptomatic for COVID-19 infection did not work, and further did not ensure appropriate use of PPE and social distancing to protect residents and staff from COVID-19. This pattern of infection control breaches contributed to the continuation of the COVID-19 outbreak at the facility, resulting in harm to residents as COVID-19 infections continued to rise. The census was 128. The findings were: Regarding staff working while symptomatic for COVID-19: 1. Review of the facility's COVID-19 surveillance form dated 10/21/20 showed CNA #1 reported symptoms which included a new headache, sudden loss of taste or smell, and nausea or vomiting. Review of the facility's COVID-19 surveillance form dated 10/22/20 showed the same CNA reported symptoms which included a cough, sore throat, muscle pain, a new headache, sudden loss of taste or smell, nausea or vomiting, diarrhea, and contact with a COVID positive individual in the last 14 days. The following concerns were identified: a. Interview with the employee on 10/29/20 at 3:49 PM revealed she reported her symptoms to the facility screening staff member and the manager on duty. The CNA revealed she was told since she was not running a fever, she should work. Further interview revealed the CNA had been tested for COVID-19 on 10/20/20 as part of the facility's routine screening and the result was still pending on 10/22/20. The CNA was also tested for COVID-19 on 10/22/20 with a rapid screen, which resulted in a positive result. The sample collected on 10/20/20 also resulted in a positive result on 10/24/20. b. Review of time card data provided by the facility showed the CNA worked for 6 hours and 37 minutes on 10/21/20, and 2 hours and 25 minutes on 10/22/20, despite reporting symptoms of COVID-19. 2. Review of the facility's COVID-19 surveillance form dated 10/19/20 showed LPN #1 reported symptoms which included cough, fever, shortness of breath, sore throat, chills or repeated shaking with chills, and new muscle pain. Further review showed a comment which said okay by management unit coverage found. Review of the facility's COVID-19 surveillance form dated 10/20/20 showed the same LPN reported symptoms which included cough, sore throat, chill or repeated shaking with chills, new muscle pain, and recent diarrhea. Further review showed a comment which said ok to work and was signed by an RN (name illegible).The following concerns were identified: a. Review of the line list of infections provided by the facility on 11/2/20 showed the LPN's last date of work was 10/20/20 and the LPN left with signs and symptoms of COVID. Further review showed the LPN was tested for COVID-19 on 10/20/20 and the facility received the positive results on 10/23/20. b. Review of time card data provided by the facility showed the LPN worked for 12 hourse and 23 minutes on 10/19/20, and 11 hurs and 19 minutes on 10/20/20, despite reporting symptoms of COVID-19. 3. Review of the facility's COVID-19 surveillance form dated 10/18/20 showed LPN #2 reported symptoms which included a cough, new headache, and nausea or vomiting. Further review showed a comment which said Ok to work per nurse manager. The following concerns were identified: a. Interview with the LPN on 10/29/20 at 4:01 PM revealed symptoms started on 10/15/20 and she notified the facility's screening staff of symptoms which included nausea, headaches, and cough on 10/18/20. Further interview revealed the screening staff member notified the on-call nurse who told the LPN she could work since she didn't have a fever. The LPN revealed she monitored her temperature throughout the shift and when she detected an elevated temperature, the nurse manager obtained the 10/18/20 specimen and sent the LPN home. The following concerns were identified: b. Review of the line list of infections provided by the facility on 11/2/20 showed the LPN was tested for COVID-19 on 10/18/20 and the facility received the positive result on 10/22/20. c. Review of time card data provided by the facility showed the LPN worked for 11 hours and 27 minutes on 10/18/20, despite reporting symptoms of COVID-19. 4. Review of the facility's COVID-19 surveillance form dated 10/10/20 showed CNA #2 reported symptoms which included cough, sore throat, new headache, and contact with a COVID-19 positive individual. The following concerns were identified: a. Interview with the CNA on 10/29/20 at 11:13 AM revealed he worked with COVID-19 symptoms for 2 1/2 days and he reported the symptoms to the nurses as well as the facility screening staff member. Further interview revealed on his second day with symptoms, the facility did not have anyone at the entrance to screen employees and employees screened themselves. b. Review of the facility's line list of infections provided by the facility on 11/2/20 showed the employee was tested for COVID-19 on 10/11/20 and the facility received the positive result on 10/18/20. c. Review of the time card data provided by the facility showed the CNA worked 12 hours and 2 minutes on 10/10/20, and 5 hours and 27 minutes on 10/11/20, despite reporting symptoms of COVID-19. 5. Interview with the facility screening staff member on 10/29/20 at 4:10 PM revealed when staff report symptoms they have to step out of the building and are screened by a nurse manager to determine if they can work. Further interview revealed some staff members who report symptoms were allowed to work. 6. Interview with the infection preventionist on 10/29/20 at 4:17 PM revealed anyone reporting symptoms which are not related to a chronic illness should be sent home and should not be allowed to work. 7. Interview with unit manager #1 on 11/2/20 at 5:40 PM revealed staff who reported symptoms were sent home for mandatory quarantine if the symptoms were new onset and not chronic. The only staff who worked with COVID-19 symptoms had symptoms which were identified as chronic. 8. Interview with the wound nurse on 11/5/20 at 12:54 PM revealed when staff members report symptoms a visual assessment was performed and if the employee did not have visible symptoms and was not running a fever, they were allowed to work. 9. Interview with the assistant administrator on 10/29/20 at 6:20 PM revealed if staff had symptoms, they were not allowed to work. The facility implemented rapid screening last week in an attempt to prevent staff from working with symptoms. 10. Review of the line list of infections provided by the facility on 11/2/20 showed the facility had 70 residents and 49 staff members who had tested positive for COVID-19. Further review showed the facility had 10 COVID-19 positive resident deaths. Regarding PPE use and social distancing: 11. Observation on 10/28/20 at 1:35 PM showed 14 residents were seated in the east dining room. Three round tables in the dining room had 2 residents seated at each table, within arm's reach, and none of the residents were wearing face masks or face coverings. 12. Observation on 10/28/20 at 1:57 PM showed 3 residents were seated at a long table in the east activity area near the pool table. All 3 residents were seated at the same end of the table, within arm's reach, and none of the residents were wearing face masks or face coverings. 13. Observation on 11/3/20 at 11:46 PM showed 15 residents were seated in the dining room. Four tables had 2 residents seated at the tables, within arm's reach, and the residents were not wearing face masks or face covering. At that time, there were 4 tables with no residents seated at them. Observation at 12:01 PM showed 5 tables had 2 residents seated at the tables, within arm's reach, and no face masks or face coverings were worn. At that time, there were 4 tables with no residents seated at them. 14. Observation on 11/4/20 at 9 AM showed RN #2 was seated at the Rapid Recovery nurse's station and was not wearing a face mask. 15. Interview with the DON on 10/28/20 revealed all staff should wear face masks and goggles at all times while at the facility and all residents on the Rapid Recovery unit were positive for COVID-19. 16. Interview with the infection preventionist on 10/29/20 at 4:17 PM revealed residents should be encouraged to wear masks when they were out of their rooms and they should be placed 6 feet away from each other during meals. If a table is not big enough to ensure 6 feet of distance between residents, there should only be 1 resident at each table. Further interview revealed staff should wear a mask prior to entering the facility. 17. Review of the policy titled COVID-19 Policy and Procedure last revised on 9/26/20 showed .D. Personal Protective Equipment .a. The PPE (personal protective equipment) recommended when caring for a patient with known or suspected COVID-19 includes an N95 respirator facemask .G. Interventions During an Active COVID-19 Outbreak in the Center .8. All care staff will wear an N95 . 18. Review of the CDC guidance titled Preparing for COVID-19 in Nursing Homes (found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, retrieved on 11/6/20) last updated 6/25/20 showed .Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. Cloth face coverings should not be placed on anyone who has trouble breathing, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance .Remind residents to practice social distancing, wear a cloth face covering (if tolerated), and perform hand hygiene .Considerations when restrictions are being relaxed include: Allowing communal dining and group activities for residents without COVID-19, including those who have fully recovered while maintaining social distancing, source control measures, and limiting the numbers of residents who participate .Implement Source Control Measures. HCP (Healthcare Personnel) should wear a facemask at all times while they are in the facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Guidance on extended use and reuse of facemasks is available. Cloth face coverings should NOT be worn by HCP instead of a respirator or facemask if PPE is required .

Based on medical record review, staff interview, review of facility incident reports, and policy and procedure review, the facility failed to ensure resident safety for 1 of 6 sample residents (#2) reviewed for falls. This failure resulted in actual harm for resident #2, who fell and sustained a fracture shortly after admission to the facility. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #2 had an admission date of [DATE] and [DIAGNOSES REDACTED]. The resident had a BIMS score of 9, indicating moderately impaired cognition. Further review showed the resident required the extensive assistance of 1 person for bed mobility, transfers, locomotion on the unit, and toilet use, extensive assistance of 2 or more people for dressing, and total assistance of 1 person for bathing. The following concerns were identified: a. Review of the facility policy titled Fall Evaluation (Morse Scale) and Management updated (MONTH) 2008 showed Policy Statement: The Center implements a fall management plan based on medical history review and resident evaluation .Admission: 1. The licensed nurse (LN) completes the[NAME]Scale on admission to the Center. a. All residents have the potential of falling. Certain factors that may require implementation of specific care plan measures are: i. if the total[NAME]Scale score is greater than 45, the resident is considered as having High Potential for falls. Implement appropriate care plan interventions for fall management . b. Review of an incident report dated 11/7/19 and timed 8:05 PM showed staff walked past the resident's room and saw him/her lying on the floor next to the bed. The resident's right wrist was swollen and painful. The resident told staff s/he went to the bathroom and fell twice, once after toileting him/herself and once while trying to clean the toilet. Review of the other info section showed Resident was educated on use of call light which was within reach clipped to (his/her) bed spread. Educated on no self transferring as well. Per sister resident had been self transferring and unsafe at the hospital. Review of the notes section showed soft touch call light, education to use call light before getting up. c. Review of a progress note dated 11/7/19 and timed 9:30 PM showed the resident was transported to the hospital after falling twice. Review of a progress note dated 11/8/19 and timed 1:47 AM showed the resident returned from the hospital with a [DIAGNOSES REDACTED]. The resident was to follow up with orthopedics in 2-3 days. d. Review of a physician progress notes [REDACTED]. e. Review of the care plan last revised on 11/18/19 showed the resident's care plan for falls was not initiated until 11/8/19, after the resident had already fallen in the facility. The plan showed the resident had an actual fall with (sic) r/t (related to) poor balance. Interventions initiated on 11/8/19 included I need reminders to use my call light before getting up until I am stronger, I prefer a soft touch call light, neuro-checks per protocol, provide me activities that promote exercise and strength building where possible, and PT (physical therapy) consult for strength and mobility. f. Interview with the DON on 12/12/19 at 3 PM revealed the resident admitted to the facility following a spinal fracture and the facility did not implement a fall care plan until after the resident's fall on 11/7/19 because staff were still getting to know (him/her).

Based on review of facility incident reports, emergency room (ER) admission report review, disciplinary action form review, Plan of Correction review, training record review, medical record review, staff interview, and policy and procedure review, the facility failed to ensure residents were free from neglect for 1 of 7 sample residents (#8) reviewed for incidents and accidents. This failure resulted in actual harm to resident #8, who required treatment at the hospital after falling during transport while not properly secured. The failure was determined to be past non-compliance. Corrective measures were implemented by the facility and compliance was determined to be met on 12/11/19. The findings were: 1. Review of a facility incident report dated 12/11/19 and timed 7:34 PM showed resident #8 was on the facility transportation van and tipped over. The resident was transported to the ER for evaluation. The following concerns were identified: a. Review of a statement dated 12/11/19 showed van driver #1 reported she picked up the resident at a doctor's office and loaded the resident in the van. The van driver attached the 2 rear straps to the resident's wheelchair; however she was in a hurry and did not secure the 2 front straps. During transportation, the resident tipped backward and the van driver pulled into a parking lot where she checked on the resident and contacted the facility. b. Review of an ER Admission Report dated 12/11/19 and timed 5:30 PM showed the resident was transferred to the hospital after leaving a doctor's appointment. Further review showed the resident reported .The Driver did not secure (his/her) wheelchair; and when they started to drive, (s/he) flew backwards out of (his/her) wheelchair hitting (his/her)head. (S/he) said (s/he) saw stars, did not pass out, and has neck pain . The hospital placed a collar for treatment of [REDACTED]. c. Review of a disciplinary action form dated 12/11/19 showed .Employees comments: I am so sorry for my negligence. I can assure you this will never happen again . d. Interview with van driver #1 on 12/12/19 at 4:21 PM revealed when the resident was picked up, the van driver was running far behind and the resident had been waiting for over an hour. The van driver revealed she secured the 2 rear straps, but failed to secure the 2 front straps, which resulted in the resident's wheelchair tipping backwards during transport. The van driver revealed there was disciplinary action for running late; however, the van was over-scheduled and she felt burnt out due to the heavy work load. e. Interview with the DON on 12/12/19 at 3 PM revealed all van drivers were trained to strap in wheelchairs, correctly use van lifts, van and lift weight limits, oxygen tank securement, and safety checks prior to driving the van. 2. Review of the Plan of Correction related to van incident on 12/11/19 showed the facility planned to provide immediate education to van drivers with return demonstration on securing residents, suspended the van driver, and instituted audits for return demonstration of van securement. Results of the audits were to be reviewed monthly at the quality assurance and performance improvement (QAPI) meeting for 3 months. 3. Review of the Coach Driver Training Record showed the facility performed training with 4 of 6 van drivers (including van driver #1) on 12/11/19, and 2 of 6 van drivers had a training date of 12-19. Return demonstrations and a written exam were performed by 6 of 6 van drivers on 12/11/19. 4. Review of the policy titled Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation updated (MONTH) (YEAR) showed .Neglect: Failure of the Center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .

Based on observation, medical record review, staff interview, and family interview, the facility failed to ensure an ongoing assessment was completed to implement adequate interventions to address weight concerns for 2 of 2 residents (#101, #126) identified with significant weight loss. This failure resulted in harm to both residents, whose loss of significant amounts of weight went unidentified by the facility. The findings were: 1. Medical record review showed resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The following concerns were identified: a. Review of the resident's recorded weights showed a weight of 158.8 pounds on 10/28/18, and a weight of 120.4 pounds on 1/17/19 (24.8% weight loss over approximately 3 months). b. Observation of the resident being placed in bed with a sit-to-stand lift on 2/13/19 at 1:23 PM showed the resident's pants were loose, and had to be adjusted to prevent them from falling off. At that time, the wound care nurse and a family member of the resident, who was also his/her power of attorney, stated the resident had been losing enough weight to need smaller pants. The resident's power of attorney also revealed the resident's pants were downsized in the last month already due to weight loss, though the resident ate well. The resident was observed during 2 meals during the survey, the 2/12/19 evening meal and the 2/13/19 noon meal, and no concerns with the resident's eating were identified. The resident required only set-up assistance during meals. c. Review of the 1/4/19 RD Nutrition Follow-up showed the area to notify the physician or nurse practitioner of a significant nutritional weight change was marked not applicable (N/A). Monthly weights, labs as available, and follow-up via MDS schedule were marked for interventions. No weight was documented, and the last weight documented in the medical record was 158.8 lbs on 10/28/19. d. Review of the care plan showed the RD revised the plan on 1/9/19 to include, Monitor weights monthly or as indicated. The plan failed to include interventions that were required of staff when the resident's weight was different than prior documented weights, or what weight difference would trigger an intervention. Review of the entire medical record showed the resident's significant weight loss was not addressed. d. Interview with the RD on 2/13/19 at 4:14 PM confirmed he was not made aware of the resident's weight loss and had not assessed the weight loss. He further stated his expectation of staff was that he and the charge nurse would be notified of a change in residents' weight. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #126 had [DIAGNOSES REDACTED]. The resident required supervision or cueing with setup help only for eating and had a weight loss of 5% in the last month or 10% in the last 6 months which was not physician prescribed. Review of the physician orders [REDACTED]. The following concerns were identified: a. Review of the admission MDS assessment dated [DATE] showed the resident had a weight of 196 pounds and no weight loss was identified. Further review showed no nutritional interventions were implemented at that time. b. Review of the weight summary dated 10/3/18 showed the resident weighed 181.2 pounds. Further review showed the resident's weight declined to 163.8 pounds on 11/9/18, 145.8 pounds on 12/3/18, 138.4 pounds on 1/18/19, and 130.4 pounds on 2/5/19. The weight loss from 10/3/18 to 2/5/19 was 50.8 pounds or 28% weight loss over approximately 4 months. c. Interview with the RD on 2/13/19 at 3:45 PM revealed the resident had some recent hospitalization s and [DIAGNOSES REDACTED]. The dietitian confirmed the resident was ordered a supplement in August, and revealed s/he did not receive any dietary interventions until a week or 2 ago when a mechanical soft diet and small portions were implemented. Further, the dietitian confirmed no interventions were implemented in (MONTH) or (MONTH) and he believed the resident received assistance with meals related to the resident not eating well.

Based on medical record review, facility investigation review, and staff interview the facility failed to implement measures to maintain 24-hour resident safety during an investigation to identify a potential perpetrator of an alleged sexual assault. This failure resulted in an immediate jeopardy situation related to lack of increased supervision to protect at-risk adults during the night shift. The census was 157. The findings were: 1. Review of the medical record showed resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a BIMS score of 1, which indicated severe cognitive impairment. Further review of the medical record showed the resident presented to the emergency roiagnom on [DATE] due to a significant change related to respiratory status, and an assessment at that time prompted the hospital to perform a sexual assault forensic exam, and notify local law enforcement. 2. Review of the facility's investigation showed on 12/5/18 the facility was notified by the local law enforcement agency the sexual assault forensic evidence kit indicated there was DNA other than the resident's present (P30 [MEDICATION NAME]; pre-seminal fluid). Further review showed the police planned to collect a DNA sample from the only male CNA on shift during the time period an assault was suspected to have occurred. 3. Interview with the administrator, the assistant administrator, and the DON on 12/7/18 at 2:30 PM confirmed DNA was collected from one CNA on 12/6/18, and the CNA was suspended pending the results of the DNA testing. They stated 40 interviews of cognitively intact residents were conducted about feeling safe, and all residents felt safe. They provided additional education to staff about residents being in areas of the facility they didn't usually frequent, and awareness of visitors. They stated the wound care nurse conducted skin checks starting with female residents and also planned to assess all male residents' skin. They also assigned management staff to round for increased presence and awareness on each unit during the day and in the evening. However, they confirmed no extra management staff had been scheduled to round on the night shift. The administrator stated the latest management staff was in the building was in the evening. 4. On 12/7/18 at 6:10 PM the administrator, assistant administrator, and DON were notified of the immediate jeopardy related to the lack of resident protection during the night shift while a potential perpetrator of an alleged sexual assault remained unidentified. 5. The facility's action plan included the following corrective actions: a. Education to all staff on duty beginning on 12/6/18 in the following areas: i. awareness of strangers/visitors in the building and their location, ii. awareness of residents from other units who are not on their home unit, iii. awareness of any resident to resident relationship, iv. awareness of residents wandering into other resident rooms, recognizing abnormal behavior and reporting these to managers, v. report anything that is suspicious or out of the ordinary to a manager immediately, observation and reporting of any resident injuries. b. Immediate implementation of specific management rounding of the facility 24/7. The rounding personnel will be comprised of staff from all departments and assigned exclusively to the rounding task. c. Education and training of managers to the rounding expectations which included filling out rounding logs. 6. The facility action plan was accepted on 12/8/18 at 12:10 PM and the immediate jeopardy was removed at 12:58 PM. Deficient practice, however, remained at a scope and severity of [NAME] (pattern of no actual harm with potential for more than minimal harm).

Based on observation, medical record review, staff and resident interview, and review of policies and procedures and employee files, the facility failed to ensure 4 of 10 sample residents (#36, #41, #123, #148) identified in reported allegations of abuse and/or neglect, were free from abuse and/or neglect. This failure resulted in past non-compliance at actual harm to residents #34 and #41 who were physically injured by another resident (#137), and resident #123 who was spanked as a reminder to not go to the bathroom without assistance. In addition, this failure resulted in past non-compliance for neglect of resident #148 who was injured when staff failed to apply the required safety straps appropriately in the transport van. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 10/8/18. The findings were: 1. Review of the 8/30/18 nursing notes for resident #36 showed s/he told staff resident #137 hit him/her. Further review showed the nursing assessment of the resident's injuries included red areas on the right cheek, deltoid, and back areas. Review of the 8/30/18 nursing notes for resident #137 showed the resident reported s/he hit resident #36 because the resident came into his/her room. Interview on 10/8/18 at 2 PM with the staff development coordinator revealed both residents had dementia and resided in the closed care unit. She further stated resident #137 became angry when resident #36 entered resident #137's room on 8/30/18. Review of the facility's investigation of the incident and interview with the director of nursing (DON) on 10/9/18 at 9:30 AM revealed the facility reported the incident to the state survey agency on 8/30/18, and implemented corrective actions to prevent re-occurrence. The actions taken by the facility included: a. At the time of the incident, staff responded promptly and separated the residents. One-to-one monitoring and every fifteen minute checks were implemented for resident #137 until s/he was admitted to a behavior management facility on 8/31/18. The resident received inpatient care and returned to the facility on [DATE]. b. The physician who provided care for the resident at the behavior management facility continued to provide guidance for staff and follow-up care for the resident after 9/13/18. c. Staff reviewed this incident and past incidents to identify patterns, trends, and precipitating factors, including environment, medications and staffing. None were identified d. Concerns regarding resident behaviors and incidents of abuse were being addressed by the Quality Assurance and Performance Improvement Committee. e. Abuse education was provided for staff on 4/13/18 and 8/17/18. 2. Interview on 10/8/18 at 2 PM with the staff development coordinator revealed resident #137 and resident #41 had dementia and resided in the closed care unit. During the interview she stated resident #137 entered resident #41's empty room by mistake on 9/30/18. She further stated resident #41 found resident #137 in the room and asked resident #137 to leave. Interview on 10/9/18 at 3:10 PM with CNA #1 revealed she witnessed resident #137 punching resident #41 in the face multiple times on 9/30/18 when resident #41 asked resident #137 to leave resident #41's room. The CNA further stated staff responded promptly and intervened. Review of the 9/30/18 nursing notes for resident #41 showed resident #41 had redness on the left side of his/her face; and resident #137 did not have injuries. Observation of resident #41 on 10/9/18 at 10:05 AM showed s/he had a purple colored bruised area under his/her left eye and peri-orbital redness. Review of the facility's investigation of the incident and interview with the staff development coordinator on 10/8/18 at 2 PM, revealed the facility reported the incident to the state survey agency on 9/30/18 and implemented corrective actions to prevent re-occurrence. The actions taken by the facility included: a. At the time of the incident, staff responded promptly and separated the residents. One-to-one monitoring and every fifteen minute checks were implemented for resident #137 until s/he was admitted to a behavior management facility on 10/1/18. As of 10/9/18 the resident had not returned to the facility. b. Staff determined when the resident returned to the facility the physician at the behavior management facility would continue to monitor the resident's medications and assist the staff in developing effective interventions to prevent re-occurring aggressive incidents. c. Staff reviewed this incident and past incidents to identify patterns, trends, and precipitating factors, including environment, medications and staffing. None were identified d. Concerns regarding resident behaviors and incidents of abuse were being addressed by Quality Assurance and Performance Improvement Committee. e. Staff efforts to find alternate placement for resident #137 have been unsuccessful. f. Abuse education was provided for staff on 4/13/18 and 8/17/18. 3. Review of the 8/17/18 quarterly MDS assessment showed resident #123 had severe cognitive impairment and ambulated with assistance. Review of the 8/27/18 care plan showed the resident required limited assistance of 1 with bed mobility, transfers and ambulation. Interview with the staff development coordinator on 10/8/18 at 2 PM revealed care assistant #1 witnessed CNA #2 spank resident #123 on 9/16/18 because the resident went to the bathroom without staff assistance. The staff coordinator further stated CNA #2 described her actions as a love pat to remind the resident not to go to the bathroom without assistance. Review of the nursing post-incident assessment revealed the resident did not have any visible signs of injury. Review of the employee file for CNA #2 showed no evidence of past similar incidents or record of abuse/neglect findings. Further review showed the CNA had received abuse/neglect training every 6 to 12 months and her certification was current. Review of the facility investigative report showed the incident was reported to the state survey agency on 9/16/18 and the corrective action to prevent re-occurrence was to terminate the employment of CNA #2 on 9/19/18. 4. Review of the 8/27/18 annual MDS assessment showed resident #148 had a brief interview for mental status (BIMS) score of 15 and was dependent on a wheelchair for mobility. Review of the corresponding care plan showed the resident required extensive assistance with transfers, toilet use, dressing, and personal care due to limited functional abilities and left leg amputation. Review of the 9/20/18 nursing notes showed the resident was injured in the van during transport to an appointment. Review of the facility's investigation of the incident showed the van driver did not apply the security straps appropriately. Interview with the staff development coordinator on 10/8/18 at 2 PM, revealed the van driver stopped at the stop light, then went forward when the light turned green and the resident fell backwards in his/her wheelchair. Review of the emergency department report, dated 9/20/18, showed the resident had a hematoma on the back of his/her head,and no fractures. Interview on 10/9/18 at 1:10 PM with the resident revealed when s/he flipped over backwards, it scared the hell out of me. The resident also stated the hematoma was painful. Review of the van driver's employee file showed she received appropriate training prior to transporting residents and periodically thereafter. This review also showed she had not been involved in similar incidents during past years transporting residents in the van. Review of the investigative report showed the incident was reported to the state survey agency on 9/20/18; and staff implemented the following corrective actions to prevent re-occurrence. a. Staff education was provided for all the van drivers. b. A safety check of the van was completed to ensure the safety straps were functioning properly. c. The van driver's employment was terminated. 5. Review of the 10 sample selected facility investigations, and facility policies and procedures showed the investigations were implemented and completed as directed by their abuse/neglect policies and procedures. Further review showed the policies and procedures were developed according to regulatory requirements.

Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure a timely assessment concerning a change in condition for 1 of 3 sample residents (#157) with a urinary catheter. This failure resulted in increased and prolonged discomfort, and the need for emergency treatment for [REDACTED]. The findings were: Interview with resident #157 on 6/19/18 at 6:05 PM revealed s/he had been sent to the local emergency room recently due to his/her urinary catheter draining blood, and increased discomfort over two days. The resident stated staff first changed the catheter when s/he brought the issue to staff's attention, but the blood and discomfort continued and increased for two days until s/he was sent to the hospital. The following concerns were identified: a. Review of the nursing progress notes the following documentation dated 6/1/18 and timed 1900 (7 PM): Patient came to the nurses station after visiting (spouse) and notified me about the blood in (his/her) catheter tubing. When assessed there was a significant amount of blood present which was not there early that day. (S/he) denied pain at this time. Unit manager and infection control nurse also assessed the urine and blood. It was close to supper time so (s/he) went in and ate. I let (him/her) know that after (s/he) was finished we would lay (him/her) down and assess things further. When myself and the other nurse went in the patient's (genitalia) looked very swollen and red. Per nursing judgement and facility protocol we felt it was in the best interest to change (his/her) catheter and see if the problem would resolve. Both nurses assisted with placement of Silicone Catheter changed at 1830 (6:30 PM). Per sterile technique. Small amount of urine return present. Patient denied pain after the procedure was completed. Further review showed the physician was not notified of the resident's condition at that time. b. Further record review showed no nursing progress notes or further assessment concerning the resident's issue with his/her urinary catheter until 6/3/18 at 12:32 PM. Review of the nursing progress note dated 6/3/18 at 12:32 (12:32 PM) (41 hours and 28 minutes after the catheter drained blood and was changed) showed the following: Situation: Resident having serious bleeding from bladder since Friday (6/1/18). Background Data: Resident had a new Foley catheter placed on Friday, has had significant blood in the bag since. Today resident c/o (complained of) pain and burning sensation. Assessment: Assessment of insertion site showed a swollen (genitalia) with a yellowish green drainage coming out of opening of (urethral passageway). Response: Sent resident into the ER at (local hospital) to be evaluated via SOV transport. Response: Name of family member notified and time of notification: (The resident's family member), resident was on the phone with (family member) and handed me the phone. Response: Name of MD notified and time of notification: (Resident's physician) at 11:30 AM. Further review failed to show any evidence the physician was notified before 6/3/18 at 11:30 AM of the resident's change in condition. c. Review of the nursing progress note dated 6/3/18 and timed 17:15 (5:15 PM) showed the following, Resident returned from (local hospital) with a DX (diagnosis) of a UTI (urinary tract infection), new Foley inserted. Prescription for [MEDICATION NAME] 500 mg P.O. (by mouth) for 10 days sent with (him/her) . d. Review of the 6/3/18 emergency room Report showed, Chief Complaint: Catheter pain. History of Present Illness: .The patient had the catheter changed on Thursday. The patient says it was quite uncomfortable when (s/he) had it changed. There has been bleeding in there since then. There has been 'lots of blood.' (S/he) says, 'If there is a procedure, please put me under anesthesia. I cannot stand the pain anymore.' The patient complains of (genitalia) pain .Emergency Department Course: Foley catheter was changed. The urine is now clear. There is no more blood. White count is 12,000. Hemoglobin is 12. Urine shows quite a few white cells but few bacteria. The patient was improved following the change of the catheter .Assessment: 1. Possible urinary tract infection. 2. Mild dehydration. e. Interview with unit manager #1 on 6/20/18 at 6:10 PM revealed her expectation was for ongoing assessment of the resident's catheter issue after identification, and further, the physician should have been contacted at that time. f. According to the facility policy titled, Change of Condition or Status last revised (MONTH) (YEAR), under Procedures, I. Physician Notification: .In the event of a change in status, using the following criteria to discern immediate versus next day contact of the physician. A. The resident's condition is assessed and reported to the physician immediately if the resident experiences: .6. A need to alter the resident's medical treatment significantly .8. A need to transfer the resident to a hospital/treatment center .13. Uncontrolled bleeding .16. A significant change in the resident's physical, mental, or psychosocial status; deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications. 17. Any other significant change in condition as determined by a Licensed Nurse. B. The resident's condition is assessed and reported in a timely manner either verbally or written if the resident experiences: .3. Signs and symptoms of infection.

Based on family and staff interview, medical record review, and review of emergency medical services records, the facility failed to promptly assess 1 of 3 sample residents (#170) who had a change in condition. This failure resulted in a delay in assessment and transport for resident #170, who had an emergency medical condition. The findings were: 1. Review of the 3/1/18 quarterly MDS assessment showed resident #170 had a brief interview for mental status (BIMS) score of 15 (indicating s/he was cognitively intact), and required extensive assistance of 2 people for bed mobility, transfers, and toilet use. The following concerns were identified: a. Review of a Nurses notes entry dated 3/27/18 and timed 8:56 AM showed Resident reported to CNA that (s/he) was having chest pains. This nurse and other RN immediately responded to resident and found that (s/he) was on the phone with (his/her) son explaining to him that she was unable to get help. Resident expressed (s/he) was very scared and feeling extremely anxious, and expressed wanting to go to the hospital. 911 was called immediately and UM notified. Resident sent to (hospital) following c/o (complaints of) chest pain radiating down right arm and up right side of neck into (his/her) jaw. Resident left facility via gurney and ambulance at 0855. b. Interview with the resident's son on 3/30/18 at 10:32 AM revealed the resident contacted him at 7:20 AM on 3/27/18 and told him s/he was having chest pain and the call light had been on for 10 minutes. During the call, a staff member entered the resident's room, and the resident reported the chest pain. The staff member turned off the call light and left the room. The son reported that he told the resident to turn the call light on again. Further interview revealed that the staff member continued to come in and answer the call light until around 8 AM at which time the nurse entered the room. The resident's son stated he knew the time the phone call with the resident began because he had checked his cell phone history. c. Interview with CNA #1 on 3/30/18 at 1:54 PM revealed she answered the resident's call light the morning of 3/27/18. She stated the resident requested a nurse because of chest pain and she reported it to the nurse at that time. Further interview revealed the CNA answered the call light two more times and reported the chest pain to the nurse again after answering the call light the subsequent times. The nurse went in about 30 minutes after being notified of the chest pain. d. Interview with RN #1 on 3/30/18 at 3:16 PM revealed CNA #1 reported the resident was having chest pain during morning med pass. e. Interview with RN #2 on 3/30/18 at 4:27 PM revealed CNA #1 reported the resident was having pain. The nurse revealed she gathered pain medication, entered the resident's room, and learned s/he was having chest pain. She further revealed the facility always sends residents with chest pain to the hospital, and the resident reported being scared. f. Review of the 3/27/18 emergency medical services (EMS) patient care report showed the call to transport the resident to the emergency room was received at 8:35 AM. EMS arrived at the facility at 8:44 AM, and departed with the resident at 8:57 AM. g. Interview with the unit manager on 3/30/18 at 2:15 PM revealed the facility expectation was for a nurse to complete an assessment as soon as possible when chest pain is reported. The unit manager further revealed the resident was admitted to the hospital with [REDACTED].

Based on observation, medical record review, incident investigation review, resident and staff interview, review of employee education files, and review of quality assurance performance improvement (QAPI) meeting minutes, the facility failed to ensure safety for 1 of 1 residents (#1) who was injured during motor vehicle transport. Based on the failure of the facility to provide effective training to all drivers and ensure safety belt checks were completed, this deficient practice was cited as past noncompliance at actual harm as the resident sustained [REDACTED]. A complete van driver re-certification process was completed on 11/18/16. The findings were: Review of the 11/17/16 incident investigation summary showed on 11/12/16 while being transported on a facility van to an activity, resident #1 was not secured in his/her wheelchair and was injured when the van came to an abrupt stop. The resident's wheelchair had been secured; however, a check to ensure the resident was belted in was not completed. The resident sustained [REDACTED]. Interview with the resident on 11/29/16 at 12:37 PM regarding the 11/12/16 accident verified the seatbelt was not secured and s/he fell out of the wheelchair and fractured his/her leg. The resident stated s/he didn't realize the seatbelt was undone until the fall occurred. Observation at that time showed the resident had a brace on the left leg. The resident revealed s/he continued to be non-weight bearing and hoped the physician would clear him/her that week to begin therapy. The resident stated medication was administered for pain, the leg was stiff and had spasms. Review of the 9/21/16 Quarterly MDS assessment showed the resident was cognitively intact with a BIMS score of 15/15. Further review of the facility investigation showed it was thorough and the van driver was suspended pending the investigation. Review of the 11/15/16 QAPI meeting minutes showed the root cause of the accident was a knowledge deficit of the driver (#1). The driver was taken off driving duty permanently after the incident. Review of the education file related to driving/transportation for driver #1 showed there was a 26-question test completed. There was no date on the test and the driver had failed to answer correctly on 6 of the 26 questions. The other 4 drivers employed at the facility were provided re-education/certification on 11/18/16. Review of the employee files for these drivers showed completion of this certification. In addition, the safety committee was assigned to continue monitoring by completing audits to ensure system compliance. Observation on 11/29/16 at 2:58 PM of van #1 and at 4:20 PM of van #2 showed the 2 facility transportation vans were equipped with safety straps to secure the wheelchairs as well as shoulder/lap belts to secure the residents. Interview with driver #2 at 4:20 PM verified she was provided the re-certification and that safety monitoring and checks were being completed. Interview with the DON on 11/29/16 at 4:31 PM verified the education driver #1 received prior to being allowed to drive was not the best. She verified the safety plan was implemented on 11/18/16 when the re-certification of the drivers was completed and the problem was corrected as of that date with continuing QAPI audits.

Based on observation, medical record review, staff interview and policy review, the facility failed to provide oxygen to 3 of 6 sample residents (#1, #4, #5) that utilized oxygen. This failure resulted in actual harm for resident #1 who required cardiopulmonary resuscitation (CPR) and transport by emergency medical services (EMS) to the hospital. The findings were: 1. Review of the [DATE] quarterly MDS assessment for resident #1 showed the resident utilized oxygen and had [DIAGNOSES REDACTED]. The following concerns were identified: a. Review of a facility incident report for [DATE] showed at 6:35 AM there was a power surge that appeared to last momentarily. Continued review of the incident report showed a CNA entered resident #1's room and found the resident unresponsive and the oxygen concentrators were not operating. The nurse was notified, CPR was initiated, and the resident was transported to the hospital via EMS at 7:44 AM. b. Review of nurse's note for resident #1 dated [DATE] at 8:27 AM showed the resident was found cyanotic at 7:10 AM by a CNA who reported to the nurse. Continued review of the nurse's note showed the nurse had previously assisted the resident to switch from O2 (oxygen) to [MEDICAL CONDITION] (Bilevel positive airway pressure) at 6:30 AM. c. Review of physician orders [REDACTED]. Titrate O2 sats to 89% or greater PRN (as needed) related to acute and chronic [MEDICAL CONDITION]. d. Review of a Physician Record of Visit dated [DATE] showed the nurse communicated that o2 needs decrease when patient is compliant/uses [MEDICAL CONDITION] (15L/min (liters per minute) with [MEDICAL CONDITION]/20L/min without [MEDICAL CONDITION]). Further review of the Physicians Record of Visit showed the nurse requested specific parameters for titration in regard to the O2 saturation and the physician gave parameters of ,[DATE]%. e. Interview with resident #1's physician on [DATE] at 4:57 PM revealed the resident experienced [MEDICAL CONDITION] (a deficiency in the amount of oxygen reaching the tissue) and decreased oxygen saturation levels without continuous oxygen. Further interview at that time revealed the [MEDICAL CONDITION] and decreased oxygen saturation levels could result in death. Continued interview revealed the resident could be without oxygen maybe 30 minutes because the resident had returned to the facility on [DATE] after being hospitalized for [REDACTED]. f. Interview with the maintenance director on [DATE] at 9:30 AM revealed backup generators supply power to the facility in case of power interruption. All generators were running at the time of the incident. Further interview at that time revealed the generators only supply power to hall lights, heating and cooling systems, call systems, fire alarm systems, and red outlets that are throughout the facility. However, no red outlets are located in resident rooms. g. Interview with the NHA on [DATE] at 10:45 AM revealed the oxygen for resident #1 was a lifesaving piece of equipment and s/he required it continuously. 2. Review of the [DATE] quarterly MDS assessment for resident #5 showed the resident utilized oxygen and had [DIAGNOSES REDACTED]. The following concerns were identified: a. Observation on [DATE] at 4:50 PM showed the resident was in the dining room awaiting meal service. The resident did not have oxygen being used at the time and no oxygen tank or concentrator was available for use. The nurse attempted to obtain an oxygen saturation level and was unable to get the machine to register. The nurse instructed a CNA to locate the resident's oxygen. The CNA returned to the dining room at 4:58 PM and applied the oxygen to the resident. At 5:00 PM according to the oxygen saturation monitor the resident had an oxygen saturation of 85%. b. Review of physician order [REDACTED].#5 was to receive oxygen at 3 liters per minute by nasal cannula at all times. 3. Review of the [DATE] quarterly MDS assessment for resident #4 showed the resident utilized oxygen and had [DIAGNOSES REDACTED]. a. Observation on [DATE] at 4:30 PM until 4:37 PM showed the resident was sitting in his/her room in the wheelchair. The oxygen concentrator was running and the wrapped tubing was hanging on the concentrator. The resident did not have a portable oxygen unit on the wheelchair and was not receiving oxygen at that time. b. Review of physician orders [REDACTED]. Titrate O2 sats to 89% or greater PRN. Currently on 4L PER nasal cannula every shift for health maintenance. 4. Review of facility policy Oxygen Usage revised [DATE] showed Procedures. 3. It will be administered under a physician's orders [REDACTED]. 5. Interview with the NHA on [DATE] at 10:45 AM revealed staff should assist residents with oxygen utilization and O2 should be administered per the physician orders.

Based on staff interview and medical record review, the facility failed to ensure nursing assessment and monitoring was adequately provided to recognize the early signs and symptoms of a [MEDICAL CONDITION] for 1 of 1 sample residents (#167) who sustained a head injury (subarachnoid hemorrhage). In addition, 4 of the 8 medical records reviewed (#11, #101, #132, #167) revealed post fall assessments were incomplete and/or there were missed vital signs. The findings were: 1. Review of the nursing note dated 10/1/11 and interview with RN #1 on 10/18/11 at 5:30 PM revealed the following sequence of events: Resident #167 injured his/her head when s/he fell in the TV room on 10/1/11 at 7 AM. The initial post fall assessments at 7 AM and 7:15 AM revealed the resident's vital signs and neurological assessments were within normal parameters. At that time the nursing staff began to record the neurological assessment and vital signs on the neurological assessment form as directed by the facility's policy and protocol for falls resulting in a head injury. This protocol included assessments every fifteen minutes for the first hour, every thirty minutes for two hours, every hour for four hours, every four hours for eight hours, and every eight hours for forty-eight hours. The timed neurological assessments were to include vital signs and assessments of pupil responses, mental status, and extremity movements. However, from 7:15 AM until 10 PM that day (fourteen and a half hours), the resident's vital signs were only taken at 9 AM and 6 PM; the neurological assessments were not performed. In addition, there was no documentation regarding the description of the injured area on the resident's head. During the interview with RN #1, she stated the assessments and documentation were not done due to staff reassignments and "staff were busy that day." Review of the 10/2/11 nursing notes and interview with LPN #1 on 10/18/11 at 10:45 AM revealed the following sequence of events: the vital signs and neurological assessments were completed at 1 AM, 4 AM and 6:45 AM and documented as within normal limits. The resident requested and received pain medication for a headache at 12:30 AM. At 1 AM, the resident stated the pain medication had not provided relief. At 3:15 AM the resident complained that the headache had worsened. At that time the resident ignored his/her gluten free dietary restrictions and ate a sandwich. At 3:35 AM, the resident vomited the undigested sandwich and again requested medication to relieve his/her headache. At 3:45 AM, the nurse assessed the left side of the resident's head and documented,"...found a bruise measuring approximately 3 inches long and 1 1/2 to 2 inches wide. A bump also noted in this area that was raised about 1/2 inch high, area very tender to touch, res (resident) flinched and jerked head away when attempted to measure the bump." At 4:45 AM, the resident "appeared to be sleeping." LPN #1 assessed the resident at 6:45 AM, but the next nursing assessment was not completed until 11:45 AM (five hours later) by RN #1. During the interview on 10/18/11 at 5:30 PM, RN #1 stated the nurses did not assess the resident from 6:45 AM to 11:45 AM because the resident was sleeping. The RN also stated CNA #1 "checked on" the resident at least two or three times during that time period and did not report any changes in the resident's condition. At 11:45 AM the CNA reported the resident was unresponsive. The resident was immediately transported to the hospital and diagnosed as having a subarachnoid hemorrhage ([MEDICAL CONDITION]). This was almost twelve hours after the resident first complained of a headache. Review of the medication records for the July, August, and September 2011 showed no evidence that the resident had ever requested medication for or complained about a headache prior to 10/2/11. 2. Eight randomly selected sample records were reviewed for post fall assessments. Review of the August, September and October 2011 quality improvement "Falls Management" records showed the following information had been collected for the eight residents: staff did neurological checks for all unwitnessed falls and those falls involving the head, follow up monitoring and charting was done every shift for seventy-two hours and vital signs were documented. However, Review of the POS [REDACTED]. Review of the medical record for resident #11 showed the 10/4/11 post fall assessments were incomplete. Review of the medical record for resident #167 showed the tasks were not performed after s/he fell on [DATE]. Review of the medical record for resident #101 showed the 10/13/11 post fall assessments were incomplete. Review of the medical record for resident #132 showed the post fall neurological assessments and vital signs were not performed according to the facility's policy after s/he fell on [DATE]. 3. During the interview on 10/19/11 at 12:10 PM, the administrator stated the quality improvement "Falls Management" information was a checklist and had not been revised to identify whether or not tasks were completed or done correctly. 4. The facility was unable to provide evidence of a monitoring system for ensuring that neurological assessments and documentation were completed according to the facility policy. 5. According to White, Lois, RN, PhD, Duncan, Gena, RN, MSEd, MSN, and Baumle, Wendy, RN, MSN (2010). Foundations of Adult Health Nursing, third edition, Neuroglial System, page 319,"[MEDICAL CONDITION] is a common complication of any head injury. Subdural hematomas (bleeding in the brain, subarachnoid hemorrhage) cause immediate pressure on the brain. Subdural hematomas are acute, within forty-eight hours of injury. Common symptoms are headache, drowsiness, slow mentation and confusion." 6. According to the March 2008 Centers of Disease Control and Prevention publication entitled, "[MEDICAL CONDITION] in Seniors", the signs and symptoms of a [MEDICAL CONDITION] for an older adult who has a fall related injury include a headache that gets worse or does not go away; repeated vomiting or nausea; increased confusion, restlessness, or agitation; and inability to awaken.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure 6 of 21 sample residents (#69, #91, #105, #118, #145, #135) and 6 non-sample residents (#141, #26, #21, #9, #104, #71) were treated in a manner that maintained each resident's dignity. In addition, resident #105 experienced psychosocial harm based on the reasonable person concept in that s/he had become resigned to being incontinent of bowel and bladder due to lack of staff assistance and no longer bothered to ring the call light for assistance after every instance of incontinence. Findings were: 1. Interview on 3/27/11 at 3 PM with resident #105, who was totally dependent on staff to provide incontinence care, revealed s/he does not call staff for assistance each time s/he is incontinent of urine or bowel. The resident stated staff take such a long time to answer his/her call light, s/he has become resigned to letting incontinence episodes build-up 2-3 times before calling for assistance. Refer to F309 regarding the lack of bowel incontinence care for this resident. 2 Observation of the noon meal on 3/27/11 revealed at 12:21 PM seven residents: #69, #91, #135, #21, #104, #9, #26 were all seated at the assisted dining table in the central dining room. Observation showed all seven residents required extensive or total assistance with their meals. Observation also showed one CNA #1 was assisting all seven residents with occasional help from CNA #2. Observation revealed CNA #1 stood and walked around the table feeding each resident one spoonful of food at a time. The CNA continued this process until the meal was over. Observation of the noon meal on 3/28/11 revealed six of the same residents (#69, #91, #135, #21, #104 and #9,) were seated at the assisted table and CNA #1 again stood and walked around and around the table feeding each resident one spoonful at a time until the meal was finished. Interview with the administrator on 3/29/11 at 12:15 PM revealed she thought there was enough staff to assist dependent residents with their meals, but that the problem was because there was no "horseshoe" table where the CNA could sit and go from one resident to the other without standing. 3. During an observation of the midday meal on 3/28/11 the cook provided a peanut butter and jelly (PBJ) sandwich for resident #91. When the cook told the resident what kind of sandwich s/he was being given, the resident yelled out "I don't want it. I don't want it; I'm sick of peanut butter and jelly sandwiches." The cook left the sandwich and walked away. Despite the resident's statements s/he did not receive any other food to replace the PBJ sandwich. 4. Interview with resident #145 on 3/28/11 at 12:45 PM revealed when staff changed his/her oxygen tanks out, they would take away the empty tank and then go obtain a full tank. Meanwhile the resident was left without any oxygen. The resident said s/he had told staff s/he needs the oxygen immediately, but staff would say, "Just go to your room." According to the 2/28/11 physician's orders [REDACTED]. The resident stated s/he felt staff were not understanding of or considerate to his/her needs. 5. Random observations on 3/26, 3/27, and 3/28/11 revealed non-sample resident #71 wore black shoes and a black hat which were visibly soiled with spilled/splattered food debris. Interview with RN #1 unit on 3/28/11 at 1:48 PM revealed staff were to send soiled clothing to the laundry or clean the items. 6. Observation on 3/29/11 at 12:50 PM revealed resident #118 was wearing the same green shirt that s/he had worn on 3/27/11 and 3/28/11. Observation on 3/28/11 at 3 PM showed there was a small food stain on the shirt near the third button. Observation on 3/29/11 at 12:50 PM showed the shirt was still stained in that spot. Interview with the resident at that time revealed s/he would never wear dirty clothes, s/he stated s/he kept his/her clothes clean. 7. Review of the medical record for resident #141 showed s/he required assistance with personal hygiene care due to cognitive impairment and physical limitations. Periodic observation from 3/26/11 to 3/29/11 revealed an area of dried feces on the resident's left shoe. The resident was observed wearing the soiled shoe during meal times and as s/he wheeled himself/herself throughout the unit. On 3/29/11 at 10:35 AM, CNA #10 stated she had not noticed the fecal stains on the resident's shoe until the surveyor called her attention to it. The CNA further stated the resident frequently resisted care provided by staff, and the best time to clean the resident's shoe would be at bedtime.

Based on medical record review, observation and staff interview, the facility failed to provide appropriate incontinence care for 1 of 16 sample residents (#105) with bowel incontinence. This resident experienced psychosocial harm based on the reasonable person concept because the resident had become resigned to his/her incontinence due to a lack of care. In addition, the facility failed to ensure effective wound treatment was provided for 1 of 1 sample residents (#4) who were identified to have non-pressure wounds. The findings were: 1. Observation during incontinence care for resident #105 on 3/27/11 at 5:35 PM revealed the resident was lying on linens and pads saturated with both urine and loose stool. Stool was found on the anterior perineum and was also dried on the resident's skin. Interview with CNAs #3 and #4 revealed they were uncertain when the resident was last checked for incontinence. Interview with the resident earlier that day at 3 PM revealed she was last checked and changed at 11 AM (six hours and 35 minutes prior). Review of the MDS assessment dated [DATE] revealed the resident was totally dependent on staff for incontinence care. Refer to F241 related to details regarding how the resident felt about being incontinent and why. 2. Review of the 1/15/11 quarterly MDS assessment for resident #4 showed the resident was totally dependent on staff for all activities of daily living. Review of the 1/25/11 nursing assessment and 1/26/11 physician's orders [REDACTED]. Review of the care plan showed approaches that addressed the resident's skin integrity and included the following: apply protective skin barrier ointment, turn and reposition every two hours, lay down between meals and observe and report signs of skin breakdown. Observation on 3/27/11 at 2 PM revealed nurse aide (NA) #1 and CNA #11 provided urinary incontinence care for the resident. At that time bloody drainage from the previously healed bruised area on the resident's right inner thigh was observed. During the observation, the NA and CNA both stated the open area had not been present prior to this day. They completed the incontinence care and applied the protective skin barrier ointment. Interview on 3/28/11 at 8:30 AM with RN #5, who was responsible for the resident's care that day, revealed she had not received any reports and had no knowledge of this resident's previously healed area on the thigh reopening. At 1:15 PM, on 3/28/11 when CNAs #10 and #12 provided incontinence care for the resident, it was noted that the area on the resident's right thigh was open and moist. There was no evidence of any care or treatment of [REDACTED]. Interview with the wound care nurse on 3/28/11 at 1:15 PM and 3:15 PM revealed the area on the resident's right thigh that was initially identified on 1/25/11 had healed and no longer required monitoring or weekly assessments. The nurse stated the area was just scar tissue. She further stated that she had not received any reports from staff that the area had re-opened. On 3/29/11 at 10:10 AM, CNAs #13 and #11 were observed providing urinary incontinence care for the resident. The bloody drainage from the resident's right thigh wound was noted. After the observation, a review of the March 2011 treatment record, care plan, and medication administration records showed no evidence that nursing staff had assessed, monitored or implemented treatment for [REDACTED].

Based on observation, medical record review, and staff interview, the facility failed to provide appropriate care to promote dryness for 3 of 17 sample residents (#4, #69, #105) and 1 non-sample resident (#5) who had urinary incontinence. The findings were: 1. Review of the current care plan for resident #69 showed s/he was incontinent of urine all of the time. Further review revealed the resident was to be checked and changed every two to three hours. Observation on 3/28/11 at 10 AM revealed the resident's incontinence brief was saturated with urine. Observation of the incontinence brief that was soiled had a date of 3/28/11 at 5 AM marked on it. Interview with CNA #6 at that time confirmed 5 AM was the last time the resident was checked and changed, five hours earlier. 2. Observation on 3/27/11 at 5:35 PM showed resident #105 had been incontinent of urine and was being provided incontinence care. During the incontinence care, the resident was noted to be lying on saturated pads and linens. Interview at that time with CNAs #3 and #4 revealed they were uncertain when the resident was last checked for incontinence. The CNAs stated there was a flow sheet for incontinence care in the resident's bathroom. Review of the flow sheet showed the resident was last changed at 4 AM that morning. However, interview with the resident earlier that day at 3 PM revealed s/he was last checked/changed at 11 AM, which was six hours and 35 minutes before the observation. Refer to F241 regarding this resident's statement of being resigned to being incontinent due to staff being unable to respond to his/her call light. 3. Refer to F309 for information regarding the failure to provide incontinent care for resident #4 in a timely manner. 4. Review of the 2/14/11 quarterly MDS for resident #5 showed the resident required staff assistance with personal hygiene and toileting. Review of the resident's care plan showed staff were to check and change the resident every two to three hours. Observation on 3/27/11 at from 10:30 AM until 2:20 PM revealed the resident sat in his/her wheelchair without being checked or changed during that time. At 2:20 PM when nurse aide (NA) #1 transferred the resident to bed, she removed the resident's urine-soaked disposable brief. At that time the NA stated the resident's brief had not been checked by staff since 8:45 AM that morning. The NA further stated staff were unable to check the resident earlier due to other tasks.