Every finding on record at Solano Post Acute

Based on interview and record review the facility failed to provide professional standards of care, services and interventions for one out of three sampled residents (Resident 1), when:1. Resident 1's bilateral protective hand mitts (soft protective hand coverings designed to prevent repeated attempts to manipulate and pull at his G-tube which placed the resident at risk for accidental tube dislodgement and interruption of medically necessary treatment) were not applied as ordered, and as indicated on his Care Plan (CP, a structured, individualized document that outlines medical and supportive services a resident will need to address specific health conditions and goals); and,2. Resident 1's Complete Blood Count (CBC, a blood test that measures the cells in your blood to evaluate your overall health and detect conditions like infections) and Comprehensive Metabolic Panel (CMP, a routine blood test that measures 14 different substances to check your overall health, organ function, and metabolism) were not completed as ordered.These failures had resulted in the dislodgement of Resident 1's G-tube, and had the potential for delayed diagnosis of sepsis and organ failure.Findings:1. A review of Resident 1's admission Record (AR) indicated Resident 1 was admitted to the facility in July 2026 with diagnoses which included gastrostomy placement (PEG tube, a medical procedure to put a small, flexible feeding tube through the abdomen directly into the stomach) and severe sepsis with septic shock (a life-threatening medical emergency caused by an extreme response to an infection that leads to organ damage). A further review of the AR indicated Resident 1 was developmentally and intellectually delayed and nonverbal.During a review of Resident 1's Order Recap Report (ORR, physician's orders), dated 7/2/26, the ORR indicated, Bilateral protective hand mitts to reduce the risk of accident G-tube dislodgement due to resident's attempts to manipulate medical devices.During a review of Resident 1's Care Plan (CP, a structured, individualized document that outlines medical and supportive services a resident will need to address specific health conditions and goals), initiated 7/2/26, the CP indicated, Risk for accidental G-tube dislodgement due to attempts to manipulate medical devices: provide frequent observation, redirection and other individualized interventions; utilize bilateral protective hand mitts (soft protective hand coverings) to reduce the risk of accidental G-tube removal.During a review of Resident 1's Interdisciplinary Care Conference (IDT, a coordinated group of clinical and support professionals who work together to plan, deliver, and evaluate patient care) progress note, dated 7/2/26 at 11:47 a.m., the IDT progress note indicated Resident 1 was admitted to the facility with bilateral protective hand mitts. The IDT progress notes also indicated the IDT reviewed Resident 1's clinical status, behaviors and determined the need to continue the physician's order for the use of protective mitts due to Resident 1's ongoing risk of accidental G-tube removal.During a review of Resident 1's Nurses Progress Notes (NPN), dated 7/3/26 at 2:26 p.m. by Licensed Nurse (LN) 1, the NPN indicated LN 1 documented Resident 1 made multiple attempts at pulling out his G-tube. During a review of Resident 1's NPN dated 7/5/26 at 1:57 p.m. by LN 1, the NPN indicated LN 1 documented Resident 1's protective mittens had been removed and continued to have episodes of grabbing and pulling on the G-tube.During a review of Resident 1's Change in Condition (CIC) progress note, dated 7/11/26 at 4 a.m., the CIC indicated LN 2 notified the physician that Resident 1 was found chewing on the G-tube which had dislodged from the gastrostomy site.During a review of Resident 1's NPN, dated 7/11/26 at 5:29 a.m., the NPN indicated LN 2 entered Resident 1's room at 3:55 a.m. and observed Resident 1 chewing on his G-tube which had dislodged from his gastrostomy site, and Resident 1 was transferred to the emergency department for G-tube replacement.2. During a review of Resident 1's ORR, dated 7/2/26, the ORR indicated, CBC, CMP for screening related to severe sepsis with septic shock.During a review of Resident 1's CP, initiated 7/6/26, the CP indicated, Administer medications, treatments, and other services in accordance with physician orders.Lab [laboratory] work as ordered and report results to physician.Labs as ordered by the physician related to increased incidence of agranulocytosis (a severe drop in white blood cells which leaves the body unable to fight off dangerous infections).During a review of Resident 1's Progress Note - Follow Up, dated 7/7/26 at 6:04 p.m. by the Physician's Assistant (PA), the PA indicated Resident 1's CBC and CMP were N/A (not applicable/not available).During a review of Resident 1's Medication Administration Record (MAR) for July 2026, there was no documentation that indicated Resident 1's CBC and CMP had been collected.During a review of Resident 1's History and Physical Note, dated 7/12/26 at 9:06 a.m. by the Physician (MD), the MD diagnosed Resident 1 with septic shock, pneumoperitoneum (an abnormal presence of air or gas within the peritoneal cavity), a possible abscess and small bowel obstruction and admitted Resident 1 for inpatient comfort care measures with death imminent.During a review of Resident 1's Death Note (DN), dated 7/12/26 at 3:45 p.m., the DN indicated Resident 1's immediate cause of death was septic shock from an intraabdominal abscess caused by a misplaced G-tube.During a concurrent interview and record review on 8/14/26 at 3:55 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), Resident 1's ORP, CP, and progress notes were reviewed. The DON acknowledged Resident 1's protective hand mitts should not have been removed without a physician's order and without alternative methods identified, ordered and initiated for the securement and protection of Resident 1's G-tube from dislodgement. The DON acknowledged the dislodgment of Resident 1's G-tube resulted in additional harm and unnecessary stress for Resident 1. The DON additionally acknowledged Resident 1 had an order for a CBC and CMP and was unable to confirm if the tests had been collected or completed. The DON acknowledged physician's orders should be followed as written and acknowledged without baseline CBC and CMP results the clinical team missed the opportunity to evaluate and monitor Resident 1's overall health, organ function and detection of an infection. The DON further stated she expected information documented in each resident's medical record to be accurate, comprehensive and provide detailed information on the resident's condition and response to care.During a review of a written request for Resident 1's CBC and CMP results was submitted to the facility on 8/20/26 at 3:23 p.m. by the MD, Resident 1's CBC and CMP results were not provided.A review of the facility's policy and procedure (P&P) titled Charting and Documentation revised July 2017, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives.7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following: (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement treatment, disease prevention, or rehabilitative regiment . ordered by and within the scope of licensure of a physician .as defined by Section 1316.5 of the Health and Safety Code. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing 1997 State of California Department of Consumer Affairs. pp. 5)

Based on interview and record review, the facility failed to ensure informed consent was obtained prior to the administration of a psychotropic medication (drugs that affect the mind, emotions, and behavior by changing chemical messages in the brain) for one of three sampled residents (Resident 1), when Resident 1 was administered a psychotropic medication without a consent.This failure resulted in the violation of Resident 1's rights and had the potential for Resident 1 to experience unnecessary adverse reactions to a new medication.Findings:A review of Resident 1's admission Record (AR) indicated Resident 1 was admitted to the facility in July 2026 with diagnoses which included gastrostomy placement (PEG tube, a medical procedure to put a small, flexible feeding tube through the abdomen directly into the stomach), and severe sepsis with septic shock (a life-threatening medical emergency caused by an extreme response to an infection that leads to organ damage). A further review of the AR indicated Resident 1 was developmentally and intellectually delayed and nonverbal.During a review of Resident 1's Order Recap Report (ORR), the ORR indicated an order for quetiapine fumarate (an atypical antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) 50 milligrams (mg, a unit of measurement) give one half tablet at bedtime related to bipolar disorder.A review of Resident 1's medical record (MR) on 8/19/26 at 1 p.m., the MR did not include documentation that Resident 1's RP (Responsible Party) had been provided with the risks, benefits, or alternative treatment options for the use of quetiapine fumarate or that the RP gave consent for the facility to administer the medication.During a concurrent interview and record review on 8/19/26 at 1:55 p.m. with the Admissions Nurse (AN), Resident 1's MR was reviewed. The AN confirmed there was no informed consent for the use of quetiapine fumarate in Resident 1's treatment plan. The AN acknowledged the facility should not have administered the medication to Resident 1 and had the potential for Resident 1 to experience adverse effects from the medication. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use revised January 2026, the P&P indicated, The Facility should comply with the State Operations Manual, and all other Applicable Law relating to the use of psychoactive medications. 11. It is the responsibility of the attending health care practitioner to inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulation. The informed consent will be obtained by the Prescriber prior to initiation of the psychotropic medication and will be renewed every 6 months. 12. The Facility shall verify informed consent prior to the administration of a psychotropic medication for a resident.

Based on interview and record review, the facility failed to provide quality care and treatment for one out of three sampled residents (Resident 1), when staff did not complete a comprehensive physical assessments for Resident 1's gastrostomy tube (G-tube, a small flexible tube used to deliver liquid nutrients, fluids, and medications directly into the stomach or small intestine when a person cannot chew or swallow safely).This failure had the potential to result in Resident 1's rapid, severe clinical and systemic decline when he was diagnosed with severe sepsis with septic shock (a life-threatening medical emergency caused by an extreme response to an infection that leads to organ damage) and subsequent death related to the continued use of an incorrectly placed G-tube.Findings:A review of Resident 1's admission Record (AR) indicated Resident 1 was admitted to the facility in July 2026 with diagnoses which included gastrostomy placement (PEG tube, a medical procedure to put a small, flexible feeding tube through the abdomen directly into the stomach) and severe sepsis with septic shock (a life-threatening medical emergency caused by an extreme response to an infection that leads to organ damage). A further review of the AR indicated Resident 1 was developmentally and intellectually delayed and nonverbal.During review of Resident 1's Order Recap Report (ORR, physician's orders), dated 7/1/26, the ORR indicated the following orders:1. Check tube placement prior to each feeding, flush, or medication administration every shift; and2. Monitor abnormal signs/symptoms every shift for.diarrhea, systolic blood pressure (SBP, measures the force of blood against your artery walls when your heart beats) below 100. when one result is abnormal increase monitoring to every four hours and report changes to the physician immediately.During a review of Resident 1's Care Plan (CP, a structured, individualized document that outlines medical and supportive services a resident will need to address specific health conditions and goals), dated 7/1/26, the CP indicated the following interventions:1. Monitor bowel movement pattern for changes, monitor for abdominal pain and distention; and2. Check patency, placement of G-tube and gastric contents/residual volume as ordered.During a review of Resident 1's CP, dated 7/6/26, the CP indicated, Assess for and report signs and symptoms of abdominal distention and pain, decrease in bowel movements and bowel sounds.During a review of Resident 1's Change in Condition (CIC), dated 7/7/26 at 10:43 p.m., by Licensed Nurse 4 (LN 4), the CIC indicated LN 4 reported to the physician that Resident 1 had a significant weight loss of seven (7) pounds (lbs., a measurement of weight) from an admission weight of 104.2 lbs. The CIC did not include a comprehensive assessment of Resident 1's G-tube and overall health status.During a review of Resident 1's Interdisciplinary Care Conference (IDT, a coordinated group of clinical and support professionals who work together to plan, deliver, and evaluate patient care) progress note, dated 7/8/26 at 10:40 a.m. the IDT progress note indicated nursing staff were to continue monitoring Resident 1's tube feed tolerance (how well a person's digestive system accepts and processes liquid formula delivered through a feeding tube), G-tube status, hydration, bowel function and signs and symptoms of aspiration (when food, liquid, vomit, or saliva enters the airway and lungs instead of the stomach).During a review of Resident 1's CIC, dated 7/11/26 at 4 a.m., by LN 2, the CIC indicated LN 2 notified the physician that Resident 1 was found chewing on the G-tube which had dislodged from the gastrostomy site. The CIC was not completed.During a review of Resident 1's Nursing Progress Notes (NPN), dated 7/11/26 at 11:35 a.m. by LN 3, the NPN indicated Resident 1 had returned to the facility. The NPN did not include a comprehensive assessment of Resident 1's G-tube upon return to the facility.During a review of Resident 1's CIC, dated 7/12/26 at 8:52 a.m., by LN 1, the CIC indicated LN 1 reported a CIC for Resident 1 to the physician for abnormal vital signs (low/high BP [blood pressure, the force of your blood pushing against the walls of your arteries as your heart pumps it through your body], heart rate, respiratory rate, weight change). The CIC was not completed. During a review of Resident 1's NPN from 7/1/26 to 7/12/26, the NPNs did not indicate facility staff had conducted a baseline and subsequent routine comprehensive assessments of Resident 1's G-tube.During a review of Resident 1's Death Note (DN), dated 7/12/26 at 3:45 p.m., the DN indicated Resident 1's immediate cause of death was septic shock due to an intraabdominal abscess due to a malpositioned G-tube.During an interview on 8/14/26 at 11:54 a.m. with LN 4, LN 4 was unable to define the core nursing guidelines for completing a comprehensive nursing assessment on a resident with a G-tube.During an interview on 8/14/26 at 2:34 p.m. with LN 5, LN 5 was unable to define the core nursing guidelines for completing a comprehensive nursing assessment on a resident with a G-tube.During a concurrent interview and record review on 8/14/26 at 3:44 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), Resident 1's medical record was reviewed. The DON acknowledged Resident 1's physician order to check for G-tube placement was incomplete and should have included specific directions for evaluating Resident 1's G-tube and when to notify the physician. The DON confirmed Resident 1's NPNs did not include comprehensive nursing assessments of Resident 1's G-tube. The DON acknowledged that without initial and routine comprehensive assessments nursing staff were unable to accurately monitor or assess a resident's condition to effectively evaluate a resident's treatment plan.During a concurrent interview and record review on 8/19/26 at 1:55 p.m. with the Admissions Nurse (AN), Resident 1's medical record (MR) was reviewed. The AN confirmed nursing staff failed to notify the physician when Resident 1 had abnormal results, when:1. Resident 1's SBP was below 100 on 7/6/26, 7/7/26 and 7/10/26; and,2. Resident 1's bowel patterns fluctuated between episodes of diarrhea and no bowel movement.The AN stated nursing staff were expected to monitor Resident 1's vital signs (basic measurements of the body's core life-sustaining functions) more frequently. The AN confirmed the information documented by nursing staff did not provide accurate and comprehensive information regarding Resident 1's overall health condition and status of his G-tube. The AN indicated without an accurate assessment of Resident 1's health condition nursing staff were not able to accurately monitor and identify underlying complications that developed from Resident 1's G-tube. The AN further indicated nursing staff should have monitored and assessed Resident 1 more frequently for complications related to tube feedings with the frequent changes in tube feeding formulas, administration rates (continuous or bolus feedings [feedings administered via a syringe over 10 to 15 minutes] and Resident 1's inability to self-report symptoms of pain, nausea, constipation, headache or chills. The AN further stated nursing staff should have been provided with resources and guidance for the systemic approach to completing a comprehensive assessment for residents with G-tubes.A request for policy and procedure of G-tube assessment, monitoring and maintenance was requested but not provided.

Based on interview and record review, the facility failed to ensure accurate accountability of controlled medications (medications with high potential for abuse or addiction) medications for one of four sampled residents (Resident 1) when Resident 1's Medication Administration Record (MAR - a record that tracks medications given, including dosage, time, route, and who administer it) and Controlled Drug Record (CDR - a log used to track the receipt, storage, dispensing, administration, and disposal of high-risk medications) did not reconcile to indicate doses of pain medications were administered to Resident 1.These failures resulted in the facility not having accurate accountability of controlled medications and had the potential for abuse or misuse of these medications.During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in November 2023 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and opioid (a controlled medication used to treat pain) dependence. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/29/26, indicated Resident 1 had intact cognition.During a review of Resident 1's physician order, dated 11/30/25, the order indicated an order for hydromorphone (an opioid used to treat moderate to severe pain) 2 mg (milligrams, a unit of measurement) one tablet by mouth every four hours as needed for moderate to severe pain.During a review of Resident 1's care plan, initiated on 9/18/25, the care plan indicated, .Black Box Warning [a warning for medications that may cause serious harm or death] for Use of [Hydromorphone].indication: Pain.Ensure accuracy when prescribing, dispensing, and administering.During a review of Resident 1's CDR, the CDR indicated Resident 1's Hydromorphone was signed on the following dates and times but was not signed as administered on Resident 1's MARs for June and July 2026:- 6/3/26 at 5 p.m.- 6/4/26 at 9:17 a.m.- 6/4/26 at 2:35 p.m.- 6/12/26 at 2 p.m.- 6/12/26 at 11:07 p.m.- 6/16/26 at 2:25 p.m.- 6/19/26 at 10:07 p.m.- 6/22/26 at 12 p.m.- 6/24/26 at 2 p.m.- 7/7/26 at 1 p.m.- 7/9/26 at 2:30 p.m.During a concurrent interview and record review on 8/4/26 at 3:38 p.m. with the Director of Nursing (DON), the DON confirmed Resident 1 was receiving Hydromorphone 2 mg one tablet every four hours as needed for moderate to severe pain. The DON reviewed Resident 1's CDR and MAR and acknowledged the discrepancies with the count on Resident 1's MAR and CDR. The DON stated staff should sign both the CDR and the MAR during administration to prevent diversion of controlled medication. The DON confirmed that staff was removing Resident 1's medication from stock but not signing the MAR and stated, .we don't know if the medication was given to [Resident 1].During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised 4/2019, the P&P indicated, .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication.23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:.a. The date and time the medication was administered.g. The signature and title of the person administering the drug.During a review of the facility's P&P titled Controlled Substances, revised 11/2022, the P&P indicated, .Dispensing and Reconciling Controlled Substances.1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following:.a. Records of personal access and usage.b. Medication administration records.

Based on interview and record review, the facility failed to report an allegation of physical abuse to The Department within the regulatory time frame and to provide a 5-day investigative report to The Department when two of ten sampled residents (Resident 1 and Resident 2) were involved in an altercation. This failure resulted in The Department not being aware of the incident with the potential for further abuse to occur. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2026 with multiple diagnoses including cellulitis (bacterial skin infection) of left leg, sepsis (body's extreme response to infection causing tissue damage and organ failure) psychosis (mental state where person loses touch with reality), and schizophrenia (mental illness marked by hallucinations, delusions, and disorganized thinking). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/9/26, indicated Resident 1 was rarely or never understood and had long and short-term memory problems. A review of Resident 1's Progress Notes, dated 7/9/26 at 10:08 a.m., indicated .Around 1250AM, resident was interviewed regarding the report made by the resident roommate in B bed. Resident was unable to provide information regarding the reported event and did not appear to understand what was being discussed . A review of Resident 1's Interdisciplinary Care Conference, dated 7/9/26 at 12:32 p.m., indicated .The IDT [Interdisciplinary Team] completed a comprehensive review following the reported room safety event to evaluate contributing factors, assess the resident's clinical and behavioral status .The IDT recognized that the resident's documented history of schizophrenia, unspecified psychosis, impaired cognition, and impaired judgment may significantly affect his ability to accurately perceive, process, and respond to his surroundings .the reported behaviors appear consistent with the resident's underlying cognitive and psychiatric conditions . A review of Resident 1's Progress Notes, Admit Visit Note by provider, dated 7/9/26 at 7:37 p.m., indicated .Pt [patient] had an incident with another resident in his room this am with foul language, threatening behaviors, and physical aggression . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in July 2026 with multiple diagnoses including psoas muscle abscess (collection of pus in psoas muscle of the spine), sepsis, diabetes (too much sugar in the blood), and heart failure (heart does not pump blood as efficiently as it should). A review of Resident 2's MDS, Cognitive Patterns, dated 7/12/26, indicated Resident 2 had Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 that indicated Resident was cognitively intact. A review of Resident 2's Progress Notes, dated 7/9/26 at 9:54 a.m. indicated .Around 1250 am, resident in B bed reported that the resident in C bed attempted to take his phone. Resident in B bed stated that the phone belonged to him and that he retrieved it from the resident in C bed . A review of Resident 2's Progress Notes, dated 7/9/26 at 11:17 a.m., indicated .Addendum: At around 12:50AM During the initial interview, resident in B bed also reported that resident in C bed had been randomly throwing objects in the room. Resident stated that one of the objects, identified as a basin, made contact with him during this behavior .No visible injuries . A review of Resident 2's Progress Notes, dated 7/9/26 at 11:55 a.m., indicated .Resident -to- resident occurred. The incident was reported to local law enforcement . The attending physician (MD) was notified and made aware of the incident. The resident's responsible party was notified and informed of the incident in accordance with facility policy. Resident will continue to be monitored . A review of Resident 2's Interdisciplinary Care Conference, dated 7/9/26 at 12:55 p.m., indicated .The IDT completed a comprehensive review of the reported room safety event to evaluate contributing factors .The IDT [Interdisciplinary Team] identified multiple contributing factors, including the shared room environment and the roommates documented cognitive impairment and behavioral symptoms . A review of Resident 2's Progress Notes, dated 7/9/26 at 1:02 p.m., indicated .At approximately 12:20 PM today, officer from the [Law Enforcement Agency] spoke with residents . A review of a flowsheet titled Mandated Reporter provided by Director of Nursing (DON) indicated .Observes, has knowledge of, or reasonably suspects abuse in a Long-Term Care Facility .Physical Abuse .Caused by Resident Diagnosed with Dementia by Physician No Serious Bodily Injury . directed to contact LTC ombudsman (long term care ombudsman is person who protects residents in nursing homes) or Law Enforcement immediately and within 24 hours provide SOC 341 (Report of Suspected Dependent Adult/Elder Abuse- used by mandated reporters to report suspected abuse) written report to LTC ombudsman or Law Enforcement . During an interview on 7/23/26 at 11:46 a.m. with the DON, reviewed complaint intake involving resident to resident altercation between Resident 1 and Resident 2 on 7/9/26. The DON stated was not aware of the incident, but it should have been reported to the LTC ombudsman and law enforcement. The DON stated Resident 1 had schizophrenia and was discharged from the facility on 7/9/26 due to escalating aggressive behaviors. The DON stated the incident was documented in the electronic record. The DON stated they followed the guidelines for reporting as on the Mandated Reporter flowsheet provided by the Administrator. The DON stated the facility did not contact The Department because the flowsheet indicated if resident had dementia to contact ombudsman and/or law enforcement. The flowsheet did not indicate to notify The Department. The DON stated if the altercation caused no serious bodily injury and caused by resident with dementia there was no need to contact The Department. The DON stated this Mandated Reporter flowsheet was provided by the Administrator and was implemented for the first time for this incident. The DON stated prior to this incident and receiving this flowsheet, The Department would have been notified of this allegation of abuse. Requested the investigation report. The DON stated she does not have access to it but will try and obtain from Administrator. During an interview on 7/23/26 at 1:03 p.m. with the Social Services Director (SSD), the SSD stated she was notified to call the LTC ombudsman regarding altercation between Resident 1 and Resident 2. The SSD stated she was not aware of any notification sent to The Department. The SSD stated prior to this incident, if an allegation of abuse occurred, the process was to notify law enforcement, ombudsman, and The Department. The SSD stated that since the new flowsheet was implemented for this incident there was a different criteria for reporting to The Department. The SSD stated the process now was to call only law enforcement and the ombudsman if there was no injury and resident was confused. During an interview on 7/23/26 at 1:10 p.m. with the Director of Staff Development (DSD), the DSD stated if there is an allegation of abuse or a resident-to-resident altercation it should be reported to The Department, the ombudsman, and law enforcement within 2 hours. The DSD stated if resident has dementia, per Mandated Reporter flowsheet only needs to be reported to ombudsman and law enforcement. Reviewed with the DSD that reporting policy does not distinguish if resident has dementia. The DSD acknowledged that the Mandated Reporter guidelines does not correspond to the facility reporting policy. The DSD stated she does not know if an investigation report was completed for this incident. During an interview on 7/23/26 at 1:46 p.m. with the DON, the DON stated she had not located the investigation report yet. During an interview on 7/23/26 at 2:43 p.m. with CNA 1, CNA 1 stated it was reported to her by staff that Resident 1 had thrown a plastic water pitcher at Resident 2 and that Resident 1 was naked and trying to get up. CNA 1 stated if there is an allegation of abuse it is reported to The Department, ombudsman, and Administrator as soon as it happened. When asked if the reporting criteria was different if resident is confused, CNA 1 stated, No, have to report everything. During an interview on 7/23/26 at 2:49 p.m. with Resident 2, Resident 2 answered questions appropriately and was able to converse effectively. Resident 2 stated Resident 1 attacked him on 7/9/26 around 1 a.m. Resident 2 stated Resident 1 came to his bed and tried to steal his cell phone. Resident 2 stated Resident 1 picked up a small plastic basin, swung, and hit him on the lower lip and then went back to his own bed. Resident 2 stated he had a cut below his lower right lip. Observed small scab on face right below lower right lip. Resident 2 stated a few minutes later, Resident 1 came back and tried to grab his cell phone again and was throwing around stuff in the room. Resident 2 stated Resident 1 climbed on him, was naked, and smacked him on the left side of his face with an open hand. Resident 2 stated he yelled for help at that point and Resident 1 was moved to another room. Resident 2 stated the police came and he told them he wanted to file charges. During an interview on 7/23/26 at 3:05 p.m. with Licensed Nurse (LN) 2, LN 2 stated Resident 2 was asleep, and Resident 1 stood up and began throwing things out of the drawer. Resident 1 threw a plastic basin at Resident 2 and hit him with the basin. LN 2 stated incident was reported to police and ombudsman. LN 2 stated abuse should be reported to the DON, The Department, ombudsman, and police within 2 hours. During an interview on 7/23/26 at 3:42 p.m. with LN 3, LN 3 stated if there is an allegation of abuse they reported it to The Department, ombudsman and the police within 2 hours. When asked if reporting criteria was different if resident had dementia, LN 3 stated there is no difference in reporting allegations. During an interview on 7/23/26 at 5:15 p.m. with the DON, the DON acknowledged that The Department had not been notified of the abuse allegation between Resident 1 and Resident 2 because they were following the Mandated Reporter flowsheet implemented by the Administrator. The DON stated she was not able to provide an investigation report that included staff and resident interviews. The DON stated a 5-day investigation report was not sent to The Department. During a telephone interview on 7/28/26 at 8:46 a.m. with LN 4, LN 4 had received report at beginning of shift that Resident 1 had some behavior problems. LN 4 stated at approximately 1 a.m. Resident 2 called and reported Resident 1 had grabbed his phone but he was able to get it back. A review of Resident 2's progress note dated 7/9/26 at 11:17 a.m. indicated Resident 2 reported Resident 1 hit him with a small basin. LN 4 stated she observed the basin on the bed. LN 4 stated she assessed Resident 2 for injuries but did not see any. LN 4 stated she reported the incident to the DON in the morning on 7/9/26. LN 4 stated she did not report incident as abuse as she thought it sounded like a misunderstanding and did not think it was abuse. LN 4 stated if she had recognized it as abuse, she would have called ombudsman, The Department, police and filled out the SOC 341 within 2 hours. LN 4 stated if residents are confused, they still reported as usual and do all the steps. A review of the facility's Policy and Procedure (P&P) titled Abuse Prohibition, revised 10/25/24, indicated .Physical abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment .If the suspected abuse is resident-to-resident, the resident .an investigation will be completed .Upon receiving information concerning a report of suspected or alleged abuse, mistreatment .will perform the following .Report allegations involving abuse not later than two (2) hours after the allegation is made .Notify local law enforcement, Ombudsman, Licensing District Office, Licensing Boards, Registries and other agencies as required .Provide subsequent reports to the Department as often as necessary to inform the Department of significant changes in the status of affected individuals or changes in material facts originally reported .Initiate an investigation within 2 hours of an allegation of abuse that focuses on .whether abuse or neglect occurred and to what extent .The investigation will be thoroughly documented. Ensure that documentation of witnessed interviews is included .Conduct interviews using the Interview Record and Witness Interview Record .Report findings of all completed investigations within five (5) working days to the Licensing District Office .A review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 9/22, indicated .All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management .If resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other official according to state law .The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies .The state licensing/certification agency responsible for surveying/licensing the facility .Immediately is defined as .within two hours of an allegation involving abuse or results in serious bodily injury; or .Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury .All allegations are to be thoroughly investigated .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report .

Based on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 2) was free from physical abuse when Resident 1 hit Resident 2 in the face with a plastic basin. This failure had the potential for Resident 2 to feel unsafe in the facility resulting in a decreased quality of life. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2026 with multiple diagnoses including cellulitis (bacterial skin infection) of left leg, sepsis (body's extreme response to infection causing tissue damage and organ failure) psychosis (mental state where person loses touch with reality), and schizophrenia (mental illness marked by hallucinations, delusions, and disorganized thinking). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/9/26, indicated Resident 1 was rarely or never understood and had long and short-term memory problems. A review of Resident 1's Progress Notes, dated 7/8/26 at 4:54 p.m., indicated .Resident was admitted to C bed this shift. Shortly after admission, the resident in B bed and the resident's spouse notified nursing that the newly admitted resident was repeatedly opening and closing the bedside privacy curtains . A review of Resident 1's Progress Notes, dated 7/9/26 at 10:08 a.m., indicated .Around 1250AM [12:50 a.m.], resident was interviewed regarding the report made by the resident roommate in B bed. Resident was unable to provide information regarding the reported event and did not appear to understand what was being discussed . A review of Resident 1's Interdisciplinary Care Conference, dated 7/9/26 at 12:32 p.m., indicated .The IDT [Interdisciplinary Team] completed a comprehensive review following the reported room safety event to evaluate contributing factors, assess the resident's clinical and behavioral status .The IDT recognized that the resident's documented history of schizophrenia, unspecified psychosis, impaired cognition, and impaired judgment may significantly affect his ability to accurately perceive, process, and respond to his surroundings .the reported behaviors appear consistent with the resident's underlying cognitive and psychiatric conditions . A review of Resident 1's Progress Notes, Admit Visit Note by provider, dated 7/9/26 at 7:37 p.m., indicated .Pt [patient] had an incident with another resident in his room this am with foul language, threatening behaviors, and physical aggression . A review of Resident 1's Progress Notes, dated 7/9/26 at 12:57 p.m., indicated .Monitor for episodes of throwing objects, intrusive behavior . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in July 2026 with multiple diagnoses including psoas muscle abscess (collection of pus in psoas muscle of the spine), sepsis, diabetes (too much sugar in the blood), and heart failure (heart does not pump blood as efficiently as it should). A review of Resident 2's MDS, Cognitive Patterns, dated 7/12/26, indicated Resident 2 had Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 that indicated Resident was cognitively intact. A review of Resident 2's Progress Notes, dated 7/8/26 at 4:57 p.m., indicated . Resident and spouse reported concern that the newly admitted resident in C bed was repeatedly opening and closing the bedside privacy curtain .Staff were instructed to conduct frequent safety rounds and ongoing monitoring of both residents, with CNA [Certified Nursing Assistant] and licensed nurse providing routine observation and reporting any changes . A review of Resident 2's Progress Notes, dated 7/9/26 at 9:54 a.m. indicated .Around 1250 am, resident in B bed reported that the resident in C bed attempted to take his phone. Resident in B bed stated that the phone belonged to him and that he retrieved it from the resident in C bed . A review of Resident 2's Progress Notes, dated 7/9/26 at 11:17 a.m., indicated .Addendum: At around 12:50AM During the initial interview, resident in B bed also reported that resident in C bed had been randomly throwing objects in the room. Resident stated that one of the objects, identified as a basin, made contact with him during this behavior .No visible injuries . A review of Resident 2's Progress Notes, dated 7/9/26 at 11:55 a.m., indicated .Resident -to- resident occurred. The incident was reported to local law enforcement . Resident will continue to be monitored . A review of Resident 2's Interdisciplinary Care Conference, dated 7/9/26 at 12:55 p.m., indicated .The IDT completed a comprehensive review of the reported room safety event to evaluate contributing factors .The IDT [Interdisciplinary Team] identified multiple contributing factors, including the shared room environment and the roommates documented cognitive impairment and behavioral symptoms . A review of Resident 2's Progress Notes, dated 7/9/26 at 1:02 p.m., indicated .At approximately 12:20 PM today, officer from the [Law Enforcement Agency] spoke with residents . During an interview on 7/23/26 at 11:46 a.m. with the Director of Nursing (DON), reviewed resident-to-resident altercation between Resident 1 and Resident 2 on 7/9/26. The DON stated Resident 1 had schizophrenia and was discharged from the facility on 7/9/26 due to escalating aggressive behaviors. The DON stated the incident was documented in the electronic record. The DON stated when a resident-to-resident altercation occurs residents are separated and assessed for injuries. During an interview on 7/23/26 at 1:46 p.m. with the DON, the DON stated Resident 1 had a prior diagnosis of psychosis but had not been taking his medications. The DON stated Resident 2 reported the incident to staff and talked to the police. The DON stated Resident 1 was placed on 1:1 (one to one) supervision. During an interview on 7/23/26 at 2:43 p.m. with CNA 1, CNA 1 stated it was reported to her that Resident 1 had thrown a plastic water pitcher at Resident 2 and that Resident 1 was naked and trying to get up. During an interview on 7/23/26 at 2:49 p.m. with Resident 2, Resident 2 answered questions appropriately and was able to converse effectively. Resident 2 stated Resident 1 attacked him on 7/9/26 around 1 a.m. Resident 2 stated Resident 1 came to his bed and tried to steal his cell phone. Resident 2 stated Resident 1 picked up a small plastic basin, swung, and hit him on the lower lip and then went back to his own bed. Resident 2 stated he had a cut below his lower right lip. Observed small scab on face right below lower right lip. Resident 2 stated a few minutes later, Resident 1 came back and tried to grab his cell phone again and was throwing around stuff in the room. Resident 2 stated Resident 1 climbed on him, was naked, and smacked him on the left side of his face with an open hand. Resident 2 stated he yelled for help at that point and Resident 1 was moved to another room. Resident 2 stated the police came and he told them he wanted to file charges. During an interview on 7/23/26 at 3:05 p.m. with Licensed Nurse (LN) 2, LN 2 stated Resident 2 was asleep, and Resident 1 stood up and began throwing things out of the drawer. Resident 1 threw a plastic basin at Resident 2 and hit him with the basin. LN 2 stated residents were separated, and Resident 1 was moved to another room. Resident 2 was assessed for injury, and incident was reported to police and the ombudsman.During an interview on 7/23/26 at 3:57 p.m. with the DON, the DON acknowledged that Resident 2 had been hit with basin by Resident 1. The DON stated that no bleeding or injury was identified on Resident 2 at the time. When asked what could have been done to prevent altercation, the DON stated when behaviors were identified 1:1 supervision was implemented. The DON stated Resident 1's behaviors escalated and he was transferred to the hospital on 7/9/26.During a telephone interview on 7/28/26 at 8:46 a.m. with LN 4, LN 4 had received report at beginning of shift that Resident 1 had some behavior problems including pulling the privacy curtains and getting up. LN 4 stated while she was doing her rounds, Resident 1 kept trying to get up and was taking his brief off and throwing it. LN 4 stated Resident 1 was only wearing a brief and was naked without the brief. LN 4 stated at approximately 1 a.m. Resident 2 called and reported Resident 1 had grabbed his phone but he was able to get it back. A concurrent review of Resident 2's progress note dated 7/9/26 and timed at 11:17 a.m. indicated Resident 2 reported Resident 1 hit him with a small basin. LN 4 stated she had observed the basin on the bed. LN 4 stated she assessed Resident 2 for injuries but did not see any. LN 4 stated she reported the incident to the DON in the morning on 7/9/26.A review of the facility's Policy & Procedure (P&P) titled Abuse Prohibition, revised 10/25/24, indicated .Health Care Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents.Physical abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment.Purpose: To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse.If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed.The Center will provide adequate supervision when the risk of resident-to-resident altercation is suspected.The Center is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit behaviors that make them more likely to be involved in an altercation.

Based on interview and record review, the facility failed to investigate an allegation of abuse for two of ten sampled residents (Resident 1 and Resident 2), when Resident 1 hit Resident 2 in the face with a plastic basin. This failure had the potential for abuse to continue if causes are not identified and interventions not implemented. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in July 2026 with multiple diagnoses including cellulitis (bacterial skin infection) of left leg, sepsis (body's extreme response to infection causing tissue damage and organ failure) psychosis (mental state where person loses touch with reality), and schizophrenia (mental illness marked by hallucinations, delusions, and disorganized thinking). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/9/26, indicated Resident 1 was rarely or never understood and had long and short-term memory problems. A review of Resident 1's Progress Notes, dated 7/9/26 at 10:08 a.m., indicated .Around 1250AM, resident was interviewed regarding the report made by the resident roommate in B bed. Resident was unable to provide information regarding the reported event and did not appear to understand what was being discussed . A review of Resident 1's Interdisciplinary Care Conference, dated 7/9/26 at 12:32 p.m., indicated .The IDT [Interdisciplinary Team] completed a comprehensive review following the reported room safety event to evaluate contributing factors, assess the resident's clinical and behavioral status .The IDT recognized that the resident's documented history of schizophrenia, unspecified psychosis, impaired cognition, and impaired judgment may significantly affect his ability to accurately perceive, process, and respond to his surroundings .the reported behaviors appear consistent with the resident's underlying cognitive and psychiatric conditions . A review of Resident 1's Progress Notes, Admit Visit Note by provider, dated 7/9/26 at 7:37 p.m., indicated .Pt [patient] had an incident with another resident in his room this am with foul language, threatening behaviors, and physical aggression . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in July 2026 with multiple diagnoses including psoas muscle abscess (collection of pus in psoas muscle of the spine), sepsis, diabetes (too much sugar in the blood), and heart failure (heart does not pump blood as efficiently as it should). A review of Resident 2's MDS, Cognitive Patterns, dated 7/12/26, indicated Resident 2 had Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 that indicated Resident was cognitively intact. A review of Resident 2's Progress Notes, dated 7/9/26 at 9:54 a.m., indicated . Around 1250 am, resident in B bed reported that the resident in C bed attempted to take his phone. Resident in B bed stated that the phone belonged to him and that he retrieved it from the resident in C bed . A review of Resident 2's Progress Notes, dated 7/9/26 at 11:17 a.m., indicated .Addendum: At around 12:50AM During the initial interview, resident in B bed also reported that resident in C bed had been randomly throwing objects in the room. Resident stated that one of the objects, identified as a basin, made contact with him during this behavior .No visible injuries . A review of Resident 2's Progress Notes, dated 7/9/26 at 11:55 a.m., indicated .Resident -to- resident occurred. The incident was reported to local law enforcement . The attending physician (MD) was notified and made aware of the incident. The resident's responsible party was notified and informed of the incident in accordance with facility policy. Resident will continue to be monitored . A review of Resident 2's Interdisciplinary Care Conference, dated 7/9/26 at 12:55 p.m., indicated .The IDT completed a comprehensive review of the reported room safety event to evaluate contributing factors .The IDT [Interdisciplinary Team] identified multiple contributing factors, including the shared room environment and the roommates documented cognitive impairment and behavioral symptoms . A review of Resident 2's Progress Notes, dated 7/9/26 at 1:02 p.m., indicated .At approximately 12:20 PM today, officer from the [Law Enforcement Agency] spoke with residents . During an interview on 7/23/26 at 11:46 a.m. with the DON, reviewed complaint intake involving resident to resident altercation between Resident 1 and Resident 2 on 7/9/26. The DON stated was not aware of the incident, but it should have been reported to the LTC ombudsman and law enforcement. The DON stated Resident 1 had schizophrenia and was discharged from the facility on 7/9/26 due to escalating aggressive behaviors. The DON stated the incident was documented in the electronic record. The DON stated the investigation was documented in the IDT Care Conference notes. Requested the investigation report. The DON stated she does not have access to it but will try and obtain from Administrator. The DON stated she did not know if had been sent to The Department. During an interview on 7/23/26 at 1:10 p.m. with the Director of Staff Development (DSD), the DSD stated she did not know if an investigation report was completed for this incident. During an interview on 7/23/26 at 1:46 p.m. with the DON, the DON stated had not located the investigation report yet. During an interview on 7/23/26 at 2:49 p.m. with Resident 2, Resident 2 answered questions appropriately and was able to converse effectively. Resident 2 stated Resident 1 attacked him on 7/9/26 around 1 a.m. Resident 2 stated Resident 1 came to his bed and tried to steal his cell phone. Resident 2 stated Resident 1 picked up a small plastic basin, swung, and hit him on the lower lip and then went back to his own bed. Resident 2 stated he had a cut below his lower right lip. Observed small scab on face right below lower right lip. Resident 2 stated a few minutes later, Resident 1 came back and tried to grab the cell phone again and was throwing around stuff in the room. Resident 2 stated Resident 1 climbed on him, was naked, and smacked him on the left side of his face with an open hand. Resident 2 stated he yelled for help at that point and Resident 1 was moved to another room. Resident 2 stated the police came and he told them he wanted to file charges. During an interview on 7/23/26 at 5:15 p.m. with the DON, the DON acknowledged that The Department had not been notified of the abuse allegation between Resident 1 and Resident 2 because they were following the Mandated Reporter flowsheet implemented by the Administrator. The DON stated she was not able to provide an investigation report that included staff and resident interviews with the outcome of the investigation. The DON stated the police department made a report. The DON stated a 5-day investigation report was not sent to The Department. A review of the facility's Policy and Procedure (P&P) titled Abuse Prohibition, revised 10/25/24, indicated .Physical abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment .If the suspected abuse is resident-to-resident, the resident .an investigation will be completed .Upon receiving information concerning a report of suspected or alleged abuse, mistreatment .will perform the following .Provide subsequent reports to the Department as often as necessary to inform the Department of significant changes in the status of affected individuals or changes in material facts originally reported .Initiate an investigation within 2 hours of an allegation of abuse that focuses on .whether abuse or neglect occurred and to what extent .The investigation will be thoroughly documented. Ensure that documentation of witnessed interviews is included .Conduct interviews using the Interview Record and Witness Interview Record .Report findings of all completed investigations within five (5) working days to the Licensing District Office .A review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 9/22, indicated .All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management .All allegations are to be thoroughly investigated. The administrator initiates the investigations . The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation .The Individual conducting the investigation as a minimum .reviews the documentation and evidence .reviews the resident medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident .interviews the person(s) reporting the incident .interviews any witnesses to the incident .interviews the resident (as medically appropriate) or the resident's representative .interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .interviews the resident's roommate, family members, and visitors .reviews all events leading up to the alleged incident .documents the investigation completely and thoroughly . Witness statements are obtained in writing, signed, and dated .Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified .The follow-up investigation report will provide as much information as possible at the tme of submission of the report .

Based on interview and record review the facility failed to protect one of 2 residents sampled for abuse (Resident 1) when Resident 1 was punched in the face multiple times by Resident 2.This failure resulted in Resident 1 sustaining minor injuries to the left eye area.A review of the facility's SOC 341(Report of Suspected Dependent Adult/Elder Abuse) dated 6/21/26 report indicated, Resident 1 was allegedly hit by his roommate Resident 2 as reported by Resident 1 to his family member.A review of Resident 1's Facesheet indicated Resident 1 was admitted to the facility in 2026 with a stroke affecting his left side of his body.A review of Resident 2's Facesheet indicated Resident 2 was admitted to the facility in 2026.A review of Resident 1's progress note dated 6/21/26 indicated, at around 2:20 p.m., Resident 1's family member notified staff that Resident 1 reportedly stated he had been punched by his roommate (Resident 2). A skin discoloration was observed by facility nursing staff to Resident 1's left eye area. At approximately 4 p.m., Resident 1 was sent to the local Emergency Department for assessment as ordered by his Physician.A review of Resident 1's Emergency Department Provider Note dated 6/21/26 indicated, The patient presented to the ED [emergency department] after being punched in the left face . Initial exam noted left periorbital [around or near the eye] bruising . Final ED Diagnosis Assault, closed head injury.A review of Resident 1's After Visit Summary for the local ED dated 6/21/26 indicated, Reason for visit Eye Pain, Assault.A review of Resident 2's Change in Condition assessment dated [DATE] indicated, The resident [Resident 2] was interviewed by LN [licensed nurse] and RN [Registered Nurse] Supervisor regarding reported incident. During the interview, the resident stated that he had struck his roommate, explaining that the roommate had been yelling and using profane language.A review of Resident 2's Social Service Progress Note dated 6/22/26 indicated, Provided psychosocial support to resident regarding the alleged physical [sic] to another resident. Asked resident what happened yesterday, resident verbalized he punched his roommate I must have went to the bathroom and maybe did a quick detour to hit him before going back to sleep.During an interview on 7/7/26, at 10:59 a.m., in Resident 2's room, Resident 2 stated he had a concern with his former roommate in bed C (Resident 1) I punched him. Resident 2 stated he punched Resident 1 during the night recently because he kept yelling and screaming profanities. Resident 2 stated he was woken up in the night by Resident 1 yelling, so he went to the bathroom and after leaving the bathroom he walked over to Resident 1's bed and punched him twice in the side of the face and twice in the nose. Resident 2 stated he stopped yelling after that. Resident 2 stated after he punched Resident 1 he spoke with the Police and the facility's Administrator and told them the truth of what happened.A review of Resident 2's Brief Interview for Mental Status (BIMS: standardized cognitive screening test used by healthcare providers) score dated 6/17/26 indicated a score of 15, indicating Resident 2 was cognitively intact with no deficits.A review of Resident 1's progress note dated 6/22/26 indicated, a local police officer interviewed both Resident 1 and Resident 2. The note indicated Resident 2 admitted to the police officer he hit Resident 1 in the face and apologized.A review of Resident 1's progress note dated 6/7/26 indicated, Resident 1 was moved into a new room with Resident 2 because he had a behavior of Screaming, yelling cussing & Saying bad words.A review of Resident 1's progress note dated 6/8/26 at 12:14 a.m., indicated, Resident continue to scream and yell about getting out of the bed.A review of Resident 1's progress note dated 6/29/26 indicated, Resident 1 had a behavior of yelling and cursing.A review of Resident 1's progress note dated 7/5/26 indicated, Resident exhibited behavioral concerns, including cursing and yelling.During an interview on 7/7/26, at 1:33 p.m., with the Director of Nursing (DON) DON stated, Resident 1's progress notes indicate he does have a history of yelling and cursing.During an interview on 7/7/26, at 1:45 p.m., with Administrator (ADM) ADM stated, he interviewed Resident 2 after the incident, and Resident 2 told him he hit Resident 1.During an interview on 7/8/26, at 10:42 a.m., with Family Member (FM 1), FM 1 stated she visited Resident 1 on 6/21/26 and noticed a new bruise on his left eye area. FM 1 stated she asked Resident 1 what happened and he stated he was hit by his neighbor (Resident 2). FM 1 stated three days prior to her visit he did not have a bruise.A review of the facility's policy and procedure titled, Resident Rights dated 2025 indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse

Based on the interview, and record review, the facility failed to implement its abuse prevention policy for two out of ten sampled residents, when Resident 1 and Resident 2 were continued to be roomed together after Licensed Nurse (LN 1) witnessed Resident 2 touching Resident 1 in his bed and Resident 1 had a left eye injury with bleeding that was not previously observed. This failure had the potential safety risk for Resident 1 and increased the likelihood of resident-to-resident abuse. Findings: During a review of Resident 1's admission Record (AR), dated 4/15/26 (print date), the AR indicated Resident 1 was admitted to the facility in December of 2025 with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mild cognitive impairment (a condition causing noticeable memory or thinking problems greater than normal aging). During a review of Resident 1's Progress Note (PN) dated 4/11/26, the PN written by LN 1 indicated, During routine rounds at approximately 1830 [6:30 p.m.], [LN 1] observed [Resident 2] squatting beside [Resident 1] bed. [Resident 2] was noted holding both arms of [Resident 1]. Staff immediately intervened and separated both residents. [Resident 1] was assessed immediately after the incident. Assessment revealed redness to the left sclera [white area of the eye] with scant bleeding estimated at approximately 0.5mL [milliliters unit of volume]. An abrasion measuring approximately 0.5 cm [centimeter, unit of measurement] was noted on the left cheek, with no active bleeding at the time of assessment. No other visible signs of physical injury were observed. Left eye noted to have vision impairment per assessment.Resident complained of severe pain in the left eye, rated 10/10 on pain scale [highest pain] .new orders were received to transfer resident to the emergency department for further evaluation and management. During a review of Resident 1's Care Plan (CP) initiated on 4/13/26, the CP indicated, Risk for further injury related to exposure to other resident with behavioral dysregulation, as evidenced by incident on 4/11/2026 resulting in minor facial abrasion, corneal [eye surface] abrasion, and subconjunctival hemorrhage [bleeding in the white area of the eye]. During a review of Resident 2's AR, dated 4/15/26 (print date), the AR indicated, Resident 2 was admitted to the facility in April of 2026 with diagnoses which included dementia (a progressive state of decline in mental abilities), disorientation, and anxiety. During a review of Resident 2's PN dated 4/12/16, the PN indicated, Upon routine rounds, resident [Resident 2] noted to have increased confusion and restlessness. LN [licensed nurse] saw resident standing up from bed and aggressively tried to attack [Resident 1] of the same room, LN immediately intervened hold resident's arm and tried to re-orient him calmly. But resident refused to settle and tried to attack LN with his right hand. LN called for help but resident tried to hit staffs who responded. Resident throws water at CNA [Certified Nurse Assistant], and tried to swing.Called Physician, advised to call 911 and send patient to ED [Emergency Department] for further evaluation. Resident able to calm down but still confused and tried to stand, walk to rooms and hit residents. During a review of Resident 2's CP initiated on 4/9/26, the CP indicated, Resident is at risk for behavioral dysregulation with potential for unintended physical contact with others.resulting in impaired impulse control, poor safety awareness, and decreased ability to interpret environment.Risk for further injury related to exposure to other resident with behavioral dysregulation, as evidenced by incident on 4/11/2026 resulting in minor facial abrasion, corneal [eye surface] abrasion. During an interview on 4/15/26 at 2:44 p.m. with LN 1, LN 1 stated that on 4/11/26 at around 6:30 p.m., she walked into Resident 1's and Resident 2's [roommates] room and saw how Resident 2 was kneeling over Resident 1's bed and holding Resident 1's hands. Resident 1 had left eye redness and scant bleeding that was not seen earlier that day [new injury]. LN 1 stated that Resident 2 was taken out to the nurse's station and Resident 1 was sent out to the emergency department (ED) for evaluation and returned later on the same day. LN 1 confirmed that Resident 1 and Resident 2 were not separated in different rooms upon Resident 1's return from the ED. During an interview on 4/16/26 at 3:48 p.m. with the Director of Nursing (DON), the DON confirmed that Resident 1 and Resident 2 were not put into separate rooms after the reported injury incident on 4/11/26. The DON expected residents to be separated and housed in different rooms because keeping them together constituted continued exposure of the victim to the potential abuser. The DON stated that she was unable to provide documentation that two residents were continually monitored by staff in the room after the incident on 4/11/26. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition, revised 10/25/24, the P&P indicated, Health Care Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. The Center will implement an abuse prohibition program through the following: .Prevention of occurrences.Investigation of incidents and allegations; Protection of patients during investigations. If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed.

Based on interview and record review, the facility failed to timely report abuse-related incident for two out of ten sampled residents (Resident 1 and Resident 2), when Licensed Nurse (LN 1) witnessed Resident 2 touching Resident 1 in his bed, and Resident 1 had a left eye injury with bleeding that was not previously observed. This failure delayed the investigation by the Department and increased the likelihood of abuse for Resident 1.Findings: During a review of Resident 1's admission Record (AR), dated 4/15/26 (print date), the AR indicated, Resident 1 was admitted to the facility in December of 2025 with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mild cognitive impairment (a condition causing noticeable memory or thinking problems greater than normal aging). During a review of Resident 1's Progress Note (PN) dated 4/11/26, the PN written by LN 1 indicated, During routine rounds at approximately 1830 [6:30 p.m.], [LN 1] observed [Resident 2] squatting beside [Resident 1] bed. [Resident 2] was noted holding both arms of [Resident 1]. Staff immediately intervened and separated both residents. [Resident 1] was assessed immediately after the incident. Assessment revealed redness to the left sclera [white area of the eye] with scant bleeding estimated at approximately 0.5mL [milliliters unit of volume]. An abrasion measuring approximately 0.5 cm [centimeter, unit of measurement] was noted on the left cheek, with no active bleeding at the time of assessment. No other visible signs of physical injury were observed. Left eye noted to have vision impairment per assessment.Resident complained of severe pain in the left eye, rated 10/10 on pain scale [highest pain] .new orders were received to transfer resident to the emergency department for further evaluation and management. During a review of Resident 1's Care Plan (CP) initiated on 4/13/26, the CP indicated, Risk for further injury related to exposure to other resident with behavioral dysregulation, as evidenced by incident on 4/11/2026 resulting in minor facial abrasion, corneal [eye surface] abrasion, and subconjunctival hemorrhage [bleeding in the white area of the eye]. During a review of Resident 2's AR, dated 4/15/26 (print date), the AR indicated, Resident 2 was admitted to the facility in April of 2026 with diagnoses which included dementia (a progressive state of decline in mental abilities), disorientation, and anxiety. During a review of Resident 2's PN dated 4/12/16, the PN indicated, Upon routine rounds, resident [Resident 2] noted to have increased confusion and restlessness. LN [licensed nurse] saw resident standing up from bed and aggressively tried to attack [Resident 1] of the same room, LN immediately intervened hold resident's arm and tried to re-orient him calmly. But resident refused to settle and tried to attack LN with his right hand. LN called for help but resident tried to hit staffs who responded. Resident throws water at CNA [Certified Nurse Assistant], and tried to swing.Called Physician, advised to call 911 and send patient to ED [Emergency Department] for further evaluation. Resident able to calm down but still confused and tried to stand, walk to rooms and hit residents. During a review of Resident 2's CP initiated on 4/9/26, the CP indicated, Resident is at risk for behavioral dysregulation with potential for unintended physical contact with others.resulting in impaired impulse control, poor safety awareness, and decreased ability to interpret environment.Risk for further injury related to exposure to other resident with behavioral dysregulation, as evidenced by incident on 4/11/2026 resulting in minor facial abrasion, corneal [eye surface] abrasion. During an interview on 4/15/26 at 2:44 p.m. with LN 1, LN 1 stated that on 4/11/26 at around 6:30 p.m. she walked into Resident 1's and Resident 2's [roommates] room and saw how Resident 2 was kneeling over Resident 1's bed and holding Resident 1's hands. Resident 1 had left eye redness and scant bleeding that was not seen earlier that day [New injury]. LN 1 stated that Resident 2 was taken out to the nurse's station and Resident 1 was sent out to the emergency department (ED) for evaluation and returned later on the same day. LN 1 confirmed that Resident 1 and Resident 2 were not separated in different rooms upon Resident 1's return from the ED. During an interview on 4/16/26 with the Administrator (Admin), the Admin confirmed that the incident between Resident 1 and Resident 2 with an eye injury to Resident 1 was documented on 4/11/26 and was reported on 4/13/26. Admin confirmed that the incident should have been reported within 2 hours. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating, dated September 2022, the P&P indicated, .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. Immediately is defined as: a. Within two hours of an allegation involving abuse or result in serious bodily injury; or b. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observation, interview and record review the facility failed to ensure three of 7 sampled residents (Resident 2, Resident 7 and Resident 5) was offered and had access to sufficient fluids to maintain hydration when:Resident 2 was observed with dry lips and a dry tongue, with a dry cup present on the bedside table, and no fluids available. During the observation period, no staff were observed offering or providing fluids to the resident,Resident 7's water pitcher was not within reach, and;Resident 5's water pitcher was not refilled in a timely manner.These failures had the potential to result in inadequate fluid intake and negatively affect the residents' hydration status. 1.During a review of Resident 2's AR, the AR indicated, Resident 2 was initially admitted on [DATE] with diagnoses including Urinary Tract infection (UTI-an infection in the part of the body that makes and carries urine, usually caused by bacteria.), Need assistance with personal care, Unspecified Dementia ( Dementia- a condition where a person's memory, thinking, and ability to do everyday tasks slowly get worse over time.) During a review of MDS dated [DATE] indicated, Resident 2 has severe cognitive impairment. Resident 2's self-care assessment indicated Resident 2 was dependent (Helper does all the effort) for eating. During a review of Resident 2's care plan, revised 4/9/26, indicated, .Resident 2 is at nutritional risk and has risk for dehydration. interventions listed includes, .encourage po (oral) intake based on resident cues and desire.offer fluids of choice.monitor signs/symptoms of dehydration (dry mucous membranes, mental status changes. During an observation on 4/10/26, at 10:30 a.m., 11 a.m., 11 a.m., 12 noon, 1:30 p.m., and 1:50 p.m., respectively, Resident 2 was observed lying flat on her back, eyes closed, lips and tongue were very dry. There was an empty dry drinking cup on the table. Did not observe any staff assisting her with hydration during those observation times. During an interview on 4/10/26 at 2:53 p.m. with Licensed Nurse (LN) 2, LN 2 stated, his expectation is for the Certified Nurse Assistants (CNA) to offer fluids and supplements to their residents whenever they round every 2 hours. LN 2 further stated, depending on residents' fluid restriction, and dietary restrictions, fluids can still be offered, and the amount needs to be documented. 2. During a review of Resident 7's admission Record (AR), the AR indicated, Resident 7 was admitted on [DATE] with diagnoses which included End Stage Renal Disease (ESRD-irreversible kidney failure), muscle weakness and calculus of kidney (kidney stone). During a concurrent observation and interview on 4/10/26 at 10:23 a.m., in Resident 7's room, Resident 7's water pitcher was on the overbed table, which was pushed against the window behind him. Resident 7 stated he was unable to reach the water pitcher and was thirsty. 3. During a review of Resident 5's AR, the AR indicated, Resident 5 was re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), need for assistance with personal care, chronic kidney disease (kidneys are damaged gradually), and anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities). During an observation on 4/10/26 at 10:35 a.m., Resident 5 was heard from the hallway calling out loudly, Agua, Agua (water). At 10:47 a.m., upon entering Resident 5's room, Resident 5 stated Agua para [NAME] (water to drink), please. An empty water pitcher was observed on the overbed table. At 10:51 a.m., Resident 5 continued calling out, stating, Agua, I need water, his pitcher still empty. During an interview on 4/10/26 at 11:28 a.m., with Director of Staff Development (DSD), DSD stated that water pitchers should be accessible to residents and refilled as soon as possible when needed. The DSD stated it was important to provide water to maintain hydration and accommodate resident preferences, such as temperature. During a review of the facility's policy and procedure (P&P) titled, Encouraging and Restricting Fluids, revised 10/10, the P&P indicated, .be supportive of the resident's fluid intake.take the fluid container to the resident's room.encourage the resident to drink the fluid. During a review of the facility's P&P titled, Resident Hydration and Prevention of Dehydration, revised 3/25, the P&P indicated, .Nurses' Aide will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care .

Based on observation, interview and record review the facility failed to ensure the call light (a device that allows residents to communicate with nursing staff when they need assistance) was within reach for three of 7 sampled residents (Resident 7, Resident 5 and Resident 4).This deficient practice had the potential to result in Resident 7, Resident 5 and Resident 4 to not be able to call facility staff for help or assistance.Findings:During a review of Resident 7's admission Record (AR), the AR indicated, Resident 7 was admitted on [DATE] with diagnoses which included End Stage Renal Disease (ESRD-irreversible kidney failure), muscle weakness and abnormalities in gait and mobility.During a review of Resident 7's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 2/19/26, the MDS indicated Resident 7 had moderate cognitive impairment. The MDS also indicated Resident 7 needed assistance with eating, oral hygiene, toileting hygiene, personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear.During a review of Resident 7's Care Plan (CP), initiated on 10/2/24 and revised on 6/17/25, the CP indicated Resident 7 was at risk for falls and intervention included placing the call light within reach while in bed or at close proximity to the bed.During a review of Resident 5's AR, the AR indicated, Resident 5 was re-admitted on [DATE] with diagnoses which included abnormalities of gait and mobility, need for assistance with personal care, dementia (a progressive state of decline in mental abilities) and anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 5's MDS dated [DATE], MDS indicated Resident 5 had severe cognitive impairment. The MDS also indicated Resident 5 needed assistance with eating, oral hygiene, toileting hygiene, personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear.During a review of Resident 4's AR, the AR indicated, Resident 4 was re-admitted on [DATE] with diagnoses that included osteomyelitis of right ankle and foot, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscular weakness or partial paralysis) of left non-dominant side, need assistance with personal care and muscle weakness.During a review of Resident 4's MDS dated [DATE], MDS indicated Resident 4 had moderate cognitive impairment. The MDS also indicated Resident 4 needed assistance with eating and was dependent on a helper for oral hygiene, toileting hygiene, shower, upper and lower body dressing and putting on/taking off footwear.During a review of Resident 4's CP, initiated on 9/19/25 and revised on 9/30/25, the CP indicated Resident 4 was at risk for falls and intervention included placing the call light within reach while in bed or at close proximity to the bed.During a concurrent observation and interview on 4/10/26 at 10:23 a.m. in Resident 7's room, Resident 7 stated he did not call for assistance because he did not have a call light button. It was observed the call light button was tied to the side rail of the bed next to him.During an interview on 4/10/26 at 10:33 a.m. with Licensed Nurse (LN) 3, LN 3 confirmed the call light tied to the side rail of the bed next to Resident 7 belonged to Resident 7.During a concurrent observation and interview on 4/10/26 at 11:02 a.m. with Director of Staff Development (DSD) in Resident 5's room, DSD confirmed Resident 5's call light button was on the floor by the bedside table. The DSD stated call lights should be kept within reach of the resident.During an interview on 4/10/26 at 11:28 a.m. with DSD, DSD stated it was important for call light button to be within reach and accessible for resident safety and allow residents to call for assistance.During a concurrent observation and interview on 4/10/26 at 2:44 p.m. in Resident 4's room, Resident 4 was in bed with the head of the bed elevated in a sitting position. Resident 4 stated he had a call light button for when he needed assistance but could not find it at that time. The call light button was on top of the bedside table. At 3:10 p.m., the call light remained on the bedside table, and Resident 4 stated he still could not find it and that no one had checked on him to provide him with the call light button.During a review of the facility's policy and procedures (P&P) titled, Answering Call Light, revised 10/24, the P&P indicated, . 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on observation, interview, and record review, the facility failed to ensure that residents received necessary assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves), including turning and repositioning and timely incontinence care, for two out of seven sampled residents (Resident 1 and Resident 2) when:Resident 1 was not repositioned and provided incontinence care in accordance with the care plan, as evidence by a prolonged gap without repositioning and toileting care, andResident 2 did not receive any assistance with repositioning, comfort, or incontinence care during the observation period, as no such care was observed.These failures has the potential to cause pressure on skin and prolonged exposure to moisture, putting both residents at higher risk for skin breakdown and discomfort.Findings:During a review of Resident 1's admission Record (AR), AR indicated, Resident 1 was initially admitted on [DATE] with diagnoses which included Diabetes Mellitus Type 2 (DM 2- a disorder characterized by difficulty in blood sugar control and poor wound healing), Muscle weakness (Generalized), Morbid [Severe] Obesity (a chronic condition defined by a Body Mass Index, BMI - simple screening tool that uses the height and weight to estimate if a person is in a healthy weight range of 40 or higher with serious obesity-related health conditions).During a review of Minimum data Set (MDS- a federally mandated resident assessment tool), dated 3/18/26, indicated, Resident 1 has intact cognition. MDS indicated Resident 1 requires maximal assistance (Helper performing more than half of the effort) for turning and repositioning.During a review of Resident 1 Care Plan (CP), initiated, 11/2/21, the CP indicated, .Resident has high risk or at risk for pressure ulcer development.related to bladder and bowel impairment, impaired mobility.obesity with interventions which indicated, .resident needs to turn/reposition at least every 2-4 hours,.more often as needed.During a review of Resident 2's AR, the AR indicated, Resident 2 was initially admitted on [DATE] with diagnoses including Urinary Tract infection (UTI-an infection in the part of the body that makes and carries urine, usually caused by bacteria.), Need assistance with personal care, Unspecified Dementia ( Dementia- a condition where a person's memory, thinking, and ability to do everyday tasks slowly get worse over time.)During a review of MDS dated [DATE] indicated, Resident 2 has severe cognitive impairment. Resident 2's self-care assessment indicated, Resident 2 was dependent (Helper does all the effort, total dependence) on her care related to toilet hygiene, and repositioning.During a review of Resident 2's care plan revised 2/23/26 indicated, there was no evidence of a person-centered care plan related to Resident 2's toilet hygiene and repositioning.During an observation on 4/10/26, at 10:35 a.m., 11 a.m., 12 p.m., and 1:30 p.m. respectively, Resident 1 was observed head of bed up, positioned on her back with no staff observed offering assistance for repositioning and or incontinence care.During an observation on 4/10/26, at 10:30 a.m., 11 a.m., 12 noon, 1:30 p.m., respectively, Resident 2 was observed lying flat on her back, no incontinence care and repositioning assistance was observed and was provided during these times.During an observation on 4/10/26 at 1:40 p.m., a Certified Nurse Assistant (CNA 1) entered Resident 1's room and performed incontinence care. Following completion of care, at 1:51 p.m., Resident 1 remained in the same supine position (on her back) with her head up at 60 degrees, with no repositioning assistance observed.During an observation on 4/10/26 at 2 p.m., Resident 2 was observed lying flat on her back, no incontinence care and repositioning assistance was observed during this time.During an interview on 4/10/26 at 1:51 p.m. with Resident 1, Resident 1 stated that the last incontinence care and repositioning provided prior to 1:40 p.m. occurred approximately at 2 a.m. Resident 1 confirmed she has not been changed or repositioned since that time. Resident 1 further stated, .they never turn me, not even every 4 hours.If I don't call for assistance, they will not come to help me. Resident 1 stated, it was not her preference to be changed once a shift, but because she was a big and heavy-set person, she just sometimes had to wait. An attempt was made to interview CNA 1 to confirm the allegation, however, the CNA was no longer in the facility. The facility was asked to provide contact information, but no information was provided. During an interview on 4/10/26 at 2:15 p.m. with CNA 2, CNA 2 stated, residents must be changed and repositioned every 2 hours, to keep them clean, dry, comfortable.During an interview on 4/10/26 at 2:39 p.m. with LN 1 stated, the expectation is for the resident to be turned and repositioned every 2 hours, and incontinent care is provided whenever the resident needs to be changed.During an interview with Director of Nursing (DON), on 4/10/26 at 3:30 p.m., DON stated, turning, repositioning and incontinence care must be performed every 2-3 hours, and as directed by the care plan.During a review of the facility's policy and procedure titled, Care Plan Comprehensive dated, 8/25/21 indicated, .the facility's interdisciplinary team, in coordination with the resident and or her/his family or representative, must develop and implement a comprehensive person-centered care plan for each resident.that includes measurable objectives, and timeframes.that are identified in the comprehensive assessment.During a review of the facility's policy and procedure titled, Turning a Resident on His/her Side Away from You, revised,10/2010 indicated, .the purpose of this procedure is to provide comfort to the resident, to prevent skin irritation and breakdown.

Based on observations, interview and record review the facility failed to provide a safe, sanitary environment for five Residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) in a census of 159 when flies were found in the rooms of all five residents. These findings compromised the residents' right to receive care in a clean, safe, and dignified setting, and increased the risk for infection, cross contamination, and created an unsanitary environment. Findings:Resident 1 was admitted to the facility in mid-2024 with diagnosis which included major depressive disorder, anxiety disorder, muscle weakness, and inability to walk.Resident 2 was admitted to the facility in late 2025 with diagnosis which included major depressive disorder, urinary tract infections, and muscle weakness.Resident 3 was admitted to the facility in early 2022 with diagnosis which included dementia, failure to thrive, and muscle weakness.Resident 4 was admitted to the facility in early 2021 with diagnosis which included major depressive disorder, dementia, and need for assistance with personal care.Resident 5 was admitted to the facility in late 2020 with diagnosis which included difficulty communicating, muscle weakness, and lack of muscle coordination.During an observation and interview on 1/28/26 at 10:52 a.m. with Resident 1 in Resident 1's room, Resident 1 stated there were bugs in her room, They are everywhere. Resident 1 pointed to a small fly on the privacy curtain. Observed a small fly on her privacy curtain, several small flies hovering in the air, and several flies on the wall.During an observation on 1/27/26 at 11:11 a.m. of Resident 3's room, Resident 3's bed was unmade, there was a small black fly on his pillowcase, there were multiple flies on the privacy curtain and wall. On Resident 3's bedside table was a sandwich in plastic wrap, there were multiple small flies on and inside the wrapper, there were small flies on the speaker end of his phone, and on his drinking cup.During an observation on 1/27/26 at 11:13 a.m. of Resident 4's room, Resident 4 was lying in his bed, a thick yellow dried substance was on the sheets, the bed frame and pooled on the floor. There were numerous small black flies on his mattress, the bed frame, the wall and the privacy curtain. There were several small flies on Resident 4's gown and one on his pillowcase. Multiple flies were slowly flying around his head.During an observation on 1/27/26 at 11:15 a.m. of Resident 5's room, Resident 5 was lying in bed, he was unable to answer my questions. Observed multiple small black flies on the privacy curtain and flying around.During a concurrent observation and interview on 1/27/26 at 11:16 a.m. with Certified Nursing Assistant 1 (CNA) in the shared room of Resident 3, Resident 4 and Resident 5, CNA 1 confirmed the flies and stated, It's not supposed to be like that.During a concurrent observation and interview on 1/27/26 at 11:17 a.m. with the Housekeeping Manager (HM) in the shared room of Resident 3, Resident 4 and Resident 5, the HM confirmed the presence of flies on multiple surfaces including the sandwich and phone of Resident 3, on the mattress and pillow of Resident 4, and flying around.During an observation on 1/27/26 at 11:22 p.m. of Resident 2's room, several flies were flying in the room. One small black fly was observed on the lid of a cup.During a concurrent observation and interview on 1/27/27 at 11:25 a.m. with Resident 4 in his room, Resident 4 was waving away flies from in front of his face and stated the flies had been here awhile. Resident 4 stated he was unable to get out of bed on his own and stated the flies bothered him.During a concurrent observation and interview on 1/27/26 at 11:37 a.m. with the Administrator (ADM) of the shared room of Resident 3, Resident 4 and Resident 5, the ADM confirmed presence of multiple flies and stated, It should not be like this.During an interview on 1/27/26 at 12:53 p.m. with the Infection Preventionist (IP), the IP was shown a picture of the flies, and stated her expectation was for residents to have a safe and clean environment to prevent infections. The IP further stated the flies could cause GI (gastro-intestinal) and respiratory issues.During an interview on 1/27/26 at 3:04 p.m. with the Assistant Director of Nursing (ADON), the ADON was shown pictures of the flies on Resident 4's bed and clothing and the dried tan liquid on his sheets and bedframe, the ADON stated she would not expect to see that in the facility, That is not good for someone with depression or for anyone. During a review of the facility policy and procedures (P&P) titled, Infection Prevention and Control Program, dated 9/23, the P&P indicated, An infection prevention and control program (ICPC) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.During a review of the facility P&P titled, Pest Control, dated 5/08, the P&P indicated, Our facility shall maintain an effective pest control program.This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.Maintenance services assist, when appropriate and necessary, in providing pest control services.During a review of the facility P&P titled, Homelike Environment, dated 2/21, the P&P indicated, Residents are provided with a safe, clean, comfortable and home like environment and encouraged to use their personal belongings to the extent possible.clean, sanitary and orderly environment.clean bed and bath linens.During a review of the facility P&P titled, Resident Rights, dated 10/25, the P&P indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence.

Based on observation, interview, and record review the facility failed to ensure that food was stored in accordance with professional standards for food service for a census of 161 residents when food items in freezer #1 were expired or not properly sealed. These failures had the potential to cause food borne illness.Findings: During an observation and interview on 12/2/25 at 9:09 a.m. with the Dietary Manager (DM), the following was found in kitchen Freezer #1: 2 small plastic containers of ice cream with no open or use by date, a bag of unsealed donut holes with a preparation date (prep date) of 10/30/29 and use by date of 11/30/25, a lemon cake with a prep date of 10/30/25 and use by date of 11/30/25 and a bag of flour tortillas that were in an unsealed and undated bag. The DM confirmed the above findings and said her expectation would be for expired food to be thrown out and that food should be properly sealed. DM stated that not sealing freezer foods could cause freezer burns and affect the taste of the food.Review of policy and procedure (P&P), titled, Food Storage: Cold Foods, revised 2/2023, the P&P indicated, all foods will be stored in wrapped or in covered containers, labeled and dated .

Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately and correctly when:1. Loose pills, non-medication items, bisacodyl suppositories (a stimulant laxative), and a tube of triamcinolone cream (topical corticosteroid for itching, redness or swelling) were found in the 400 Even medication cart,2. Bisacodyl suppository and brownish residue were found in the 600 Hall medication cart,3. Expired over-the-counter (OTC) medications were found in medication room [ROOM NUMBER], and;4. Two medications found at Resident 1's bedside table. These failures had the potential for medication misuse, drug diversion, and diminish medication effectiveness.Findings: 1.During an inspection of medication cart 400 Even with Licensed Nurse (LN) 5 on 12/3/25 at 1:31 p.m., LN 5 verified that there had been five loose pills, a bisacodyl suppository stored with oral medications; a tube of triamcinolone cream; an oxygen nasal cannula; two dignity bags for a Foley catheter; and one Stat Lock (adhesive stabilizer) for Foley catheter in the medication cart. 2. During an inspection of medication cart 600 hall with LN 6 on 12/3/25 at 2:07 p.m., LN 6 verified that there was a box of Bisacodyl suppository stored with oral medications. It was also observed that there was a brownish residue on the first drawer of the medication cart. During an interview on 12/4/25 at 9:20 a.m. with Director of Nursing (DON), DON stated the expectation for the medication cart was that it should contain only medications. DON stated non-medication items were not to be stored in the cart, and the cart was to be kept clean and free of loose pills to prevent contamination and reduce the risk of infection. 3. During an inspection of Medication room [ROOM NUMBER] on 12/4/25 at 10:38 a.m. with Assistant Director of Nursing (ADON), ADON verified that the following medications were expired: one bottle of antacid (medication that neutralizes stomach acid) liquid (medication that neutralizes stomach acid), one bottle of diphenhydramine (antihistamine-treats allergy symptoms), one bottle of probiotic acidophilus (a dietary supplement that improves digestion), 1 bottle of antacid tablets, one bottle of guaifenesin (medication to relieve chest congestion), two bottles of senna (stimulant laxative), and two bottles of nasal saline spray. (moisturizes dry passages and loosens mucus). During a telephone interview with Pharmacy Consultant (PC), PC stated that bisacodyl suppositories should not be stored with oral medications to prevent accidental oral administration and cross contamination. The PC stated that medications carts should be kept clean at all times to prevent infection; that loose pills should not be left on the cart to avoid accidental administration; and that expired medications should be discarded to prevent them from being mistakenly given to residents. During a review of the facility's policy and procedure (P&P) titled Storage of Medications, revised 11/20; the P&P indicated, .nursing staff is responsible for maintaining storage and preparation areas in a clean, safe and sanitary manner. discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 4.A review of Resident 1's admission record (AR), indicated, she was admitted 11/24 with diagnosis of acute and chronic respiratory failure with hypoxia (hypoxia - a condition where the body or a part of it does not get enough oxygen). Resident 1's Minimum Data set (MDS- a federally mandated resident assessment tool), dated, 11/26/25 indicated, she had no memory impairment. During a review of Resident 1's medication administration record dated 12/1/25 to 12/3/25 (MAR- a daily documentation record used by licensed nurse to document medications and treatments given to a resident), the MAR indicated, [brand name for calcium carbonate] oral tablet. give 2 tablets by mouth every 8 hours as needed for heartburn. Fluticasone Propionate Nasal Suspension 1 spray in each nostril one time a day for nasal congestion. During a review of Resident 1's medical records, there was no documented evidence of care plan and of physician's order for self-administration of medication at bedside. During a concurrent observation and interview on 12/2/25 at 11:05 a.m. in Resident 1's room, there were 2 round tablet medications with color yellow and pink in a medication cup. Resident 1 confirmed and stated, That's my [brand name of calcium carbonate]. There was a bottle of fluticasone nasal spray seen at Resident 1's kidney basin on her table. Resident 1 stated, That's for my allergies. The two medications found at the bedside did not have Resident 1's name and did not have any labels and were not in their original packaging. During a concurrent interview and record review on 12/2/25 with Licensed Nurse (LN) 3, Resident 1's MAR was reviewed. LN 3 confirmed there were no orders for Resident 1 to self-administer medications at bedside. LN 3 confirmed there should be orders for residents to keep medications at the bedside. LN 3 stated and confirmed Resident 1's medication found at bedside was not labeled or in their original packaging and acknowledged he left the medications at Resident 1's bedside.

Based on observation, interview and record review, the facility failed to implement an effective pest control program for 20 out of 32 sampled residents (Resident 37, Resident 133, Resident 97, Resident 98, Resident 22, Resident 91, Resident 135, Resident 31, Resident 111, Resident 16, Resident 129, Resident 30, Resident 1, Resident 67, Resident 29, Resident 63, Resident 83, Resident 81, Resident 142, and Resident 9) when gnats (tiny flying insects) and flies were observed in their rooms.This deficient practice had the potential to create unsanitary conditions for the residents, staff, and visitors.Findings: During an observation on 12/2/25, the following were observed:- At 10:48 a.m., room [ROOM NUMBER] was observed with gnats flying around back and forth.- At 10:54 a.m., room [ROOM NUMBER] was observed with gnats flying back and forth.- At 11a.m., room [ROOM NUMBER] was observed with gnats flying.- At 11:30 a.m., room [ROOM NUMBER] was observed with gnats flying around.- At 12: 34 p.m., room [ROOM NUMBER] was observed with gnats flying.- At 3:14 p.m., room [ROOM NUMBER] was observed to have flies and gnats in the roomDuring an observation on 12/3/25, the following were observed.- At 8:30 a.m., room [ROOM NUMBER] was observed with gnats flying around.- At 8:40 a.m., room [ROOM NUMBER] was observed with gnats flying around.- At 3:04 p.m., room [ROOM NUMBER] was observed with gnats flying around.During an interview on 12/2/25 at 10:45 a.m. with Certified Nurse Assistant (CNA)1, CNA 1 stated, Gnats are everywhere.During an interview on 12/2/25 at 10:56 a.m. with CNA 2, CNA 2 stated, .gnats are everywhere in this place; they are also in other rooms and other hallways too.During an interview on 12/2/25 at 10:58 a.m. with Resident 63, Resident 63 stated, I see them (gnats) all the time, not only in my room, also in the hallway. They are everywhere.During an interview on 12/2/25 at 11:05 a.m. with Resident 1, Resident 1 stated, Gnats are everywhere.During an interview on 12/2/25 at 11:40 a.m. with Resident 81, Resident 81 stated, Gnats are here every day flying around. It is nasty because it lands in your food or water.During a concurrent observation and interview on 12/2/25 at 3:04 p.m. with CNA 4, observed four to five gnats flying above Resident 9's head of bed. CNA 4 confirmed this finding and stated it is a problem in the building.During an interview on 12/3/25 at 8:15 a.m. with Maintenance Supervisor (MS), the MS stated, pest control treatment was performed at hallway 600 where there were reported gnats/pests. MS stated and confirmed Pest Control company did not provide any pest control treatments on other hallways. MS stated, gnats could be a problem for residents because they could get on their food and make the residents sick.During an interview on 12/3/25 at 2:27 p.m. with the Infection Preventionist (IP), the IP stated that Gnats have been an issue in the building for three to four months.During an interview with Director of Nursing (DON) on 12/4/25 at 4:20 p.m., the DON stated, the maintenance should inspect all rooms and hallways to evaluate pest situation. Pests must be treated right away to protect the residents living in the facility.During a review of the facility's policy and procedure titled. Pest Control, revised May 2008, indicated, .Our facility shall maintain an effective pest control program.this facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview and record review, the facility failed to ensure infection prevention measures were implemented for a census of 161 when:1. Resident 156's nebulizer mask was unbagged and undated on the bedside dresser,2. Resident 93's foley bag was on the floor,3. Resident 20, Resident 170 and Resident 163's catheter tubing was on the floor,4. Resident 47's distilled water for CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) was not labeled with a date and stored on the floor,5. Resident 47's oxygen tubing was not labeled with a date, and;6. Resident 81's nasal cannula was wrapped around the side rail and not securely stored in an oxygen tubing storage bag. These failures had the potential to cause the spread of infection among a vulnerable resident population.Findings: 1. During Review of Resident 156's admission Record (AR), AR indicated, Resident 156 was admitted to the facility in March of 2022, with diagnosis including chronic obstructive airway disease (COPD-a disease that can cause difficulty in breathing). During a review of Resident 156's Minimum Data Set (MDS-A federally mandated resident assessment tool), dated 9/22/25, indicated Resident 156 had moderate cognitive impairment. During a review of Resident 156's Order summary Report (OSR) dated 12/5/25, OSR indicated order for Albuterol Sulfate Nebulizer Solution (a medication given via mask that makes it easier to breathe) 3 ml (milliliter-a unit of measurement) inhale orally via nebulizer (a machine that turns liquid medication into a mist) every four hours for shortness of breath. During a concurrent observation and interview on 12/2/25 at 3:14 p.m. in Resident 156's room with Licensed Nurse (LN) 4, a nebulizer mask (a face mask used to deliver medication) was found on the bedside dresser unbagged and undated. LN 4 stated that it should be in a plastic bag and have a date on it. LN 4 stated that having the mask left out of the bag would be an infection control issue. During an interview on 12/3/25 at 9:40 a.m. with Infection Preventionist (IP), the IP stated that her expectation would be that Resident 156's nebulizer mask should be in a dated plastic bag. The IP added that improper storage of the nebulizer mask could expose his roommates to respiratory bacteria and increase the risk of infection. During a review of the facility's Policy and Procedure (P&P) titled, Departmental (Respiratory Therapy)-Prevention of Infection, dated November 2011, indicated, related to Medication Nebulizer.store the circuit in plastic bag, marked with date and resident's name, between uses. 2. During a review of Resident 93's (AR), indicated, Resident 93 was admitted to the facility in December 2022 with diagnoses including chronic kidney disease and neuromuscular dysfunction of bladder (a condition where nerve damage disrupts signals between the brain and the bladder, leading to problems emptying the bladder). A review of Resident 93's MDS dated [DATE] indicated, Resident 93 had severe cognitive impairment. A review of Resident 93's OSR dated 12/5/25 indicated an order for Indwelling Catheter (a flexible tube inserted into the bladder used to drain urine). During a concurrent observation and interview on 12/2/25 at 2:37 p.m. with Certified Nurse Assistant (CNA) 3, Resident 93's foley bag (a urine collection bag) was found lying on the floor. CNA 3 confirmed the foley bag was on the floor and stated it should not be on the floor. During an interview on 12/3/25 at 9:32 a.m. with the IP, IP stated her expectation was that Resident 93's foley bag should be off the floor and in a plastic basin. The IP further stated that improper storage of the foley bag could expose Resident 93 to bacteria, increasing the risk of illness. A facility policy and procedure was requested and not provided. 3. During a review of Resident 20's AR, the AR indicated, Resident 20 was re-admitted on [DATE] with diagnoses which included benign prostatic hyperplasia (enlarged prostate gland), hydronephrosis (swelling of one or both kidneys due to urine not draining properly), hydroureter (swelling of the ureter-thin tube that carries urine from kidney to bladder) and retention of urine. During a review of Resident 20's OSR, the OSR indicated that Resident 20 had an order to have the Foley catheter (a type of urine catheter) and drainage bag changed on the first day of every month. During a review of Resident 170's AR, the AR indicated Resident 170 was admitted on [DATE] with diagnoses which included urinary tract infection (UTI- an infection in the bladder/urinary tract), neuromuscular dysfunction of bladder (the nerves and muscles controlling the bladder is not communicating well) and retention of urine. During a review of Resident 170's OSR, the OSR indicated that Resident 170 had an order for Foley catheter for neuromuscular dysfunction of the bladder. During a review of Resident 163's AR, the AR indicated, Resident 163 was admitted on [DATE] with diagnoses which included UTI and retention of urine. During a concurrent observation and interview on 12/2/25 at 10:38 a.m. with Licensed Nurse (LN) 2 in Resident 20's room, Resident 20's catheter tubing was observed lying on the floor. LN 2 stated that the tubing was touching the floor and stated that catheter tubing should not be kinked or in contact with the floor. During an interview on 12/2/25 at 10:40 a.m. with IP, IP stated that catheter tubing should not touch the floor because there was a risk for transmission of bacteria or infection if it came into contact with the floor. During a concurrent observation and interview on 12/2/25 at 10:47 a.m. with Resident 170 in Resident 170's room, Resident 170 was seated in a wheelchair and stated he had just gone to an appointment that day and that his foley catheter had been changed. It was observed that the catheter tubing was lying on the floor and the Foley bag with the dignity bag was also on the floor. During a concurrent observation and interview on 12/2/25 at 11:04 a.m. with IP in Resident 163's room, Resident 163's catheter tubing was observed lying on the floor, and the catheter bag, which was inside a dignity bag, was on the floormat (a cushioned floor pad designed to help prevent injury should a person fall). This was confirmed by the IP. The IP stated that even when a catheter bag is placed inside a dignity bag, it should not be touching the floor because of the risk for infection. The facility's policy and procedure for the prevention of infection for indwelling urinary catheters was requested but was not provided. 4.During a review of Resident 47's AR, Resident 47 was admitted to the facility May 2025 with multiple diagnosis including asthma (a chronic lung disease that inflames and narrows airways, causing symptoms like wheezing, coughing, chest tightness, and shortness of breath). During a review of Resident 47's Physician's Orders, the Physician's Orders indicated Resident 47 had a CPAP. During a concurrent observation and interview on 12/2/25 at 12:21 p.m. in Resident 47's room, an open bottle of distilled water was on the floor. The bottle was not dated with an open or use by date. Resident 47 stated she used the distilled water with her CPAP. Resident 47 further stated she was not sure how long the opened bottle had been there. LN 7 confirmed the bottle of distilled water should have been labeled and not stored on the floor. During an interview on 12/5/25 at 9:29 a.m. with Director of Nursing (DON), DON stated the expectation was for open bottles of distilled water to be stored on a clean surface and labeled with open and use by dates. DON acknowledged risk for infection when distilled water was not stored on the floor and not labeled. During a review of the facility's P&P titled Departmental (Respiratory Therapy) – Prevention of Infection, revised November 2011, the P&P indicated, .distilled water used in respiratory therapy must be dated and initialed when opened, and discarded after twenty-four (24) hours. During a review of the facility's P&P titled Policies and Practices – Infection Control, revised October 2018, the P&P indicated, .maintain a safe, sanitary.environment for.residents. 5. During a review of Resident 47's Physician's Orders, the Physician's Orders indicated Resident 47 had oxygen. During a concurrent observation and interview on 12/2/25 at 12:21 p.m. in Resident 47's room, LN 7 administered oxygen to Resident 47 by connecting unlabeled oxygen tubing to a portable tank on Resident 47's wheelchair. LN 7 acknowledged the oxygen tubing should have been labeled with a date. During an interview on 12/5/25 at 9:29 a.m. with DON, DON stated the expectation was for oxygen tubing to be labeled with a date and there was a risk for infection when this was not done. During a review of the facility's P&P titled, Departmental (Respiratory Therapy) – Prevention of Infection, Revised November 2011, the P&P indicated, .change the oxygen.tubing every seven (7) days. Findings: A review of Resident 81's AR, indicated, she was admitted [DATE] with diagnosis of acute and chronic respiratory failure with hypoxia (the body or a part of it is not getting enough oxygen to work right) A review of Resident 81's MDS, dated [DATE] indicated, she had no memory impairment. During an observation on 12/2/25 at 11:40 a.m., in Resident 81's room, Resident 81 had an oxygen concentrator ( a machine that takes normal air, filters out the nitrogen[invisible, odorless gas that makes up most of the air we breathe] and delivers concentrated purer oxygen at bedside. Resident 81's oxygen tubing was wrapped around her side rail and was not placed in a secured storage bag when not in use. During an interview with Infection Prevention (IP) nurse on 12/3/25 at 3:40 p.m., the IP stated, oxygen tubing must be placed in a secured storage bag when not in use to prevent contamination. A review of the facility's policy and procedure titled, Receipt and Storage of Supplies and Equipment, revised November 2009, indicated, .all supplies and equipment must be stored in accordance with the manufacturer's recommendations. No Policy and Procedure were provided related to Infection Prevention using nasal cannula or face masks when requested.

Based on observation and interview, the facility failed to ensure six of 32 sampled residents (Resident 1, Resident 81, Resident 67, Resident 68, Resident 114 and Resident 122) residents' rights were respected when:1. Resident 1, Resident 81, Resident 67, and Resident 122 were not informed ahead of time of the construction plan and the significant noise associated with it and, 2. The facility threw away food brought in by the Resident 68 and Resident 114's family. These failures caused anxiety among the residents and resulted in residents not getting enough rest and had the potential to result in the residents not attaining their highest practicable physical, psychosocial, and emotional well-being. Findings: A review of Resident 1's admission record (AR), indicated, she was admitted 11/24 with diagnosis of acute and chronic respiratory failure with hypoxia (hypoxia - a condition where the body or a part of it does not get enough oxygen.) Resident 1's Minimum Data set (MDS- a federally mandated resident assessment tool), dated, 11/26/25 indicated, she had no memory impairment. A review of Resident 81's AR, indicated, she was admitted 1/25 with diagnosis of acute and chronic respiratory failure with hypoxia. Resident 81's MDS, dated [DATE] indicated, she had no memory impairment. A review of Resident 67's AR, indicated she was admitted 2/20 with diagnosis of Diabetes Mellitus Type 2 (DM 2- a chronic condition where the body either doesn't make enough insulin [hormone that turns food into energy and manages blood sugar level] leading to high blood sugar levels. Resident 67's MDS, dated [DATE] indicated, she had no memory impairment. A review of Resident 122's AR indicated, she was admitted 7/21 with diagnosis of DM 2. Resident 122's MDS, dated , 2/16/25, indicated, severe cognitive impairment. During a concurrent observation and interview on 12/2/25 at 11:05 a.m. with Resident 1 in her room, Resident 1 was observed flushed and restless. Resident 1 stated, the constant noise from the roof construction triggered her anxiety. Resident 1 stated she was not informed ahead of time of the early construction and loud noise. Resident 1 also stated, the banging noise started before 8 a.m. daily for over two weeks. Resident 1 further stated, if she was informed ahead of time, she'll be more understanding and will help alleviate her anxiety. During an interview on 12/2/25 at 11:40 a.m. with Resident 81, Resident 81 stated, no one has informed her about the roof construction and the noise ahead of time. Resident 81 stated that the banging noise was very loud and affected her. Resident 81 also stated she cannot get some rest or get naps. Resident 81 further stated, If I am informed ahead of time, it will make me feel valuable and respected and would understand that the construction and noise were expected and necessary. During an interview on 12/2/25 at 11:44 a.m. with Resident 122, Resident 122 stated, it's hard for her to sleep at night, and she wakes up early because of the banging on the roof. Further stated, . don't know what's going on up there. During an observation on 12/3/25, at 7:45 a.m., in the conference room, there were construction workers on the roof, and the banging noise was loud. During an interview on 12/3/25 at 2:30 p.m. with Resident 67, Resident 67 stated, she was not informed ahead of time about the roof construction and the loud noise. Resident 67 stated, she was restless since they started the roof work. Resident 67 further stated, They start so early, and we are not even awake yet. Resident 67 further stated, It will make me feel important and cared better if my voice was heard and can agree with a better start time. During an observation on 12/4/25 at 11:15 a.m. at the Resident Council meeting, residents in attendance were grimacing and frowning because of the loud noise. The residents had to speak very loudly to be heard. Resident 58 was mouthing the words, I can't hear, too loud. During an interview on 12/4/25 at 4:20 p.m. with the Director of Nursing (DON), DON confirmed that the residents have the right to be fully informed including advance notice of changes affecting daily life, including disruptive construction due to noise. During a review of the facility's policy and procedure titled, Resident Rights, revised, December 2021, indicated, .Federal and state laws guarantee certain basic rights to all residents.These rights include the resident's right to be treated with respect, kindness, and dignity.right to be informed of. and participate in his or her care. During a review of the facility's policy and procedure titled, Noise Control, revised April 2014, indicated, .The facility strives to maintain comfortable sound levels that enhance privacy.and that do not interfere with resident's hearing.resident care and services should be provided in a manner that promotes calm, organized, and comfortable levels. 2. During a review of Resident 68's admission record, the admission record indicated Resident 68 was admitted to the facility March 2025 with multiple diagnosis including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 114's admission record, the admission record indicated Resident 114 was admitted to the facility August 2022 with multiple diagnosis including Chronic Kidney Disease (CKD - a gradual loss of kidney function over time). During an interview on 12/2/25 at 11:01 a.m. with Resident 114, Resident 114 stated his wife brought ham, black eyed peas, macaroni and cheese, and soda to the facility for Thanksgiving dinner on 11/27/25. Resident 114 further stated he gave the food to facility staff to label and date. Resident 114 further stated he watched facility staff place the labeled food in the resident refrigerator on 11/27/25. Resident 114 further stated on the morning of 11/28/25, the food that his wife brought in on 11/27/25 was thrown away by facility staff. Resident 114 further stated the incident was upsetting and affected his dignity. During an interview on 12/2/25 at 11:09 a.m. with Resident 68. Resident 68 stated on 11/27/25 he gave a plate of leftover food to Licensed Nurse (LN) 7 to label and put in the resident refrigerator. Resident 68 further stated the food was thrown away on 11/28/25 by facility staff. Resident 68 further stated this upset him because he was looking forward to enjoying his leftover Thanksgiving dinner. During an interview on 12/2/25 at 11:17 a.m. with LN 7, LN 7 verified she labeled and dated Resident 68's food on 11/27/25 before placing it in the resident refrigerator. LN 7 further stated the policy is for resident food to be kept at least 2 days before being thrown away. During an interview on 12/2/25 at 11:23 a.m. with Assistant Director of Nursing (ADON), ADON confirmed the resident refrigerator was emptied before 10 a.m. on 11/28/25. ADON acknowledged policy and procedure for resident food was not followed and this affected residents' dignity. During an interview on 12/2/25 at 12:24 p.m. with Administrator (ADM), ADM confirmed Resident 114's food was thrown away on 11/28/25. ADM further stated Resident 114 should have been consulted or notified before his food was thrown away. During an interview on 12/5/25 at 9:33 a.m. with Director Nursing (DON), DON confirmed the facility did not follow policy when residents' food was thrown out before 48 hours. DON acknowledged the incident affected residents' dignity. During a review of the facility's policy and procedure (P&P) titled Food Brought by Family/Visitors, revised 3/28/24, the P&P indicated, .When food items are intended for later consumption, the responsible staff member will.Label the foods with resident's name, and the current date and use by date.Items will be thrown out after 48 hours.

Based on interview and record review, the facility failed to provide treatment and services to maintain mobility and prevent further decrease in range of motion for one of 32 sampled residents (Resident 134), when Resident 134 did not receive restorative nursing assistant (RNA, exercises to improve or maintain resident's functional abilities) services per her care plan interventions.This failure placed Resident 134 at risk for further complications and decline in their physical functioning and mobility.Findings:During a review of Resident 134's admission record, the admission record indicated Resident 134 was admitted to the facility July 2024 with multiple diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the right side.During a review of Resident 134's Care Plan initiated 7/15/25, the care plan indicated, .Interventions.Restorative Nursing Program: Active Range of Motion - Right Upper Extremity. RNA will assist resident with AROM [Active Range of Motion] to Right Upper Extremities, 3 times a week.During an interview on 12/4/25 at 8:55 a.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 confirmed Resident 134 should have received RNA services three times a week for right upper hand range of motion. RNA 1 further stated she did not provide RNA services to Resident 134 that week. RNA 1 also stated she was not sure if Resident 134 received RNA services from another RNA because there was no documentation available.During a review of Resident 134's medical record, there was no documented evidence that Resident 134 was offered RNA services from 7/15/25 through 12/4/25.During an interview on 12/4/25 at 12 p.m. with Assistant Director of Nursing (ADON), ADON confirmed there was no documentation indicating Resident 134 received RNA services per care plan.During an interview on 12/5/25 at 9:34 a.m. with Director of Nursing (DON), DON stated the expectation was for care plan interventions to be followed and documented. DON acknowledged Resident 134 had a risk for decrease in mobility and activities of daily living when RNA services were not provided or documented.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan, dated 8/25/2021, the P&P indicated, .the facility's Interdisciplinary Team.must develop and implement a comprehensive person-centered care plan.to meet resident's.physical.needs.During a review of the facility's P&P titled, Nursing Documentation, dated 6/27/2023, the P&P indicated, .Purpose.To communicate patient's status and provide, complete, comprehensive, and accessible accounting of care and monitoring provided.Documentation includes.interventions.timely entry of documentation must occur as soon as possible after the provision of care.

Based on interviews and record reviews, the facility failed to ensure: 1. Staff were aware of what was sepsis (a serious complication of an infection, without prompt treatment, it can lead to organ failure, tissue damage and death) and its symptoms. 2. Staff were monitoring for signs and symptoms of Urinary Tract Infection (UTI, A condition in which bacteria invade and grow in the urinary tract system, which removes waste from the blood, in the form of urine) for one out of two sampled residents (Resident 1). These failures resulted in Resident 1 hospitalization on [DATE], due to Sepsis. A review of Resident 1's Discharge Summary Note from the hospital, dated 7/1/24, indicated she presented at the hospital with a fever and had met the criteria for severe sepsis (when sepsis causes your organs to malfunction, usually because of low blood pressure, a result of inflammation- body's response to injury or infection, throughout your body, with fever, tachypnea (rapid, shallow breathing), leukocytosis (high white blood cell count due to an infection) and Acute Kidney Injury (AKI, when your kidney- the organ that removes waste and extra water from the blood as urine and helps keep chemicals balanced in the body, suddenly stops working properly). A review of the Physician's Order, dated 6/8/24 at 3:23 p.m., indicated to monitor Resident 1 for signs and symptoms of UTI. Findings: A review of Resident 1's face sheet (demographics) indicated an admitted [DATE]. Her diagnoses included Hyperlipidemia (HLP, an elevated level of lipids (fats, like cholesterol and triglycerides, in your blood), Major Depression (a serious mental disorder that negatively affects how you feel, think, act, and perceive the world) and Anxiety (a feeling of fear, dread, and uneasiness). Resident 1's Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) condition of residents), dated 6/5/24, score was 13, indicating intact cognition. Resident 1 required the assistance of staff when performing her Activities of Daily Living (ADLs, the tasks of everyday life. Basic ADLs include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). During an interview on 7/2/24 at 2:36 p.m., Licensed Staff B stated some residents did not present with symptoms of UTI. Licensed Staff B stated, if a resident was complaining of not feeling well, generalized fatigue or malaise or showing a slightly altered mental status (AMS, a change in mental function that could stem from illness), staff should monitor the resident closely and should investigate what was causing these symptoms. Licensed Staff B stated untreated infections could lead to sepsis. Licensed Staff B stated a resident should be suspected of having sepsis if they had a fever, altered mental status, increased heart rate and respiration. Licensed Staff B stated sepsis was an emergency. Licensed Staff B stated sepsis indicated the infection had already worsened. During an interview on 7/2/24 at 4:17 p.m., Licensed Staff C stated, although some residents did not show symptoms of UTI, staff should monitor residents closely when they complained of not feeling well or if staff noted a resident to be complaining of generalized malaise or feeling tired. Licensed Staff C stated staff should monitor these residents closely because this could be a symptom of an infection. Licensed Staff C stated sepsis developed gradually. Licensed Staff C stated sepsis was an infection that was not treated and had worsened. Licensed Staff C stated an untreated UTI could lead to hospitalization and sepsis. During an interview on 7/2/24 at 5:16 p.m., the Assistant Director of Nursing (ADON) stated sepsis could be prevented with the right treatment. The ADON stated the best defense to sepsis was prevention, meaning the existing infection should be treated so it did not worsen. The ADON stated sepsis was a response of the body in severe infection. The ADON stated an untreated UTI could lead to sepsis and hospitalization . The ADON stated sepsis could be life threatening. During an interview on 7/15/24 at 3:20 p.m., Licensed Staff E stated, even if a resident did not present with symptoms of UTI , there would still be changes in the resident such as altered mental status, the color of the urine and its smell, or mild discomfort in the lower abdomen or when peeing. Licensed Staff E stated, if there were any subtle changes in a resident's status, then nurses should monitor the resident closely and request of the Physician a urinalysis to check if the resident had a UTI. Licensed Staff E stated untreated UTIs could lead to hospitalization , sepsis, and death. Licensed Staff E stated sepsis was due to an infection that was left untreated, had worsened, and had gotten into the blood stream. Licensed Staff E stated sepsis was a medical emergency, which could lead to septic shock or worse, death. Licensed Staff E stated, if a resident was sent out to the hospital and was diagnosed with sepsis, it meant the resident already had an infection at the facility that was missed, was left untreated and had worsened. During an interview on 7/15/24 at 3:42 p.m., Licensed Staff G stated an asymptomatic (when you have bacteria in your urine but do not have symptoms) UTI could present as a general feeling of tiredness or feeling unwell. Licensed Staff G stated it could also present as pain in the lower abdomen, and frequency of urination. Licensed Staff G stated residents who had history of UTIs were more likely to get UTIs. Licensed Staff G stated, since some UTIs did not present with classic symptoms, the nurses should monitor residents closely for any change in condition. Licensed Staff G stated sepsis was an infection of the bloodstream and was always an emergency. Licensed Staff G stated sepsis could occur if a resident had an infection that was missed or left untreated, and it had worsened. Licensed Staff G stated, if a resident was sent out to the hospital and was diagnosed with sepsis, it could mean the resident already had an infection brewing at the facility, and the infection was not treated and had worsened. Licensed Staff G stated, untreated infections could lead to sepsis, septic shock hospitalization and death. Licensed Staff G stated the best way to address sepsis was prevention and treating the existing infection. During an interview on 7/15/24 at 4:03 p.m., Licensed Staff I stated a complaint of a general feeling of unwellness or being tired should always be monitored closely. Licensed Staff I stated some UTIs did not present with classic symptoms, but staff needed to monitor residents closely if they were showing AMS. Licensed Staff I stated an untreated UTI could lead to worsening of the infection. Licensed Staff I stated sepsis was the result of an untreated infection. Licensed Staff I stated, if a resident was admitted to the hospital for sepsis, it meant the resident already had an infection at the facility that was missed and not treated. Licensed Staff I stated sepsis could lead to hospitalization , septic shock or even death. During a telephone interview on 7/16/24 at 11:28 a.m., the Director of Staff Development (DSD) verified Resident 1 was transferred to the ED on 6/20/24, due to AMS. The DSD stated staff were not monitoring Resident 1 for signs and symptoms of a UTI. The DSD verified there was no urinalysis (UA, a test of your urine, used to detect and manage a wide range of disorders, such as Urinary Tract Infections) done to check whether Resident 1 had a UTI. The DSD stated sepsis was an infection that was not treated and had worsen. During a telephone interview on 7/17/24 at 8:37 a.m., when asked if Resident 1 could have had an infection prior to transfer to the hospital on 6/20/24, where she was diagnosed with sepsis, the Director of Nursing (DON) stated, Yes. The policy and procedure for sepsis was requested but was not provided. A review of the facility's policy and procedure (P&P) titled, Change of Condition, revised 8/25/21, the P&P indicated, The facility must immediately consult with the Physician where there was a significant change in residents physical, mental and psychosocial status such as deterioration in health, mental or psychosocial status in either life threatening condition or clinical complication. A review of the facility's policy and procedure (P&P) titled, Urinary Tract Infection/Bacteriuria (presence of bacteria in the urine) Clinical Protocol, revised 4/2018, the P&P indicated, The staff and practitioner will identify individuals with possible signs and symptoms of UTI .signs and symptoms of a UTI may be specific to the urinary tract and/or generalized .acute deterioration in stable chronic urinary symptoms may indicate an acute infection .

Based on observation, interviews, and record reviews, the facility did not provide one of three sampled residents, Resident 1, a resident who was unable to carry out some ADLs (Activities of Daily Living- e. g. showers, bed baths, etc.), the necessary services to maintain good grooming and personal hygiene, when Resident 1 reported to this surveyor that the last shower she got was approximately a year ago, and was not given any explanation why she was only getting bed baths instead of showers. This failure resulted physical harm to Resident 1 as evidenced by the presence of skin conditions such as rashes, open lesions, and dry and scaly skin. Findings: A review or Resident 1's MDS (Minimum Data Set- a standardized assessment tool that measures health status in nursing home residents), dated 12/13/23, indicated on Section C (Cognitive Patterns) that Resident 1 had a BIMS (Brief Interview for Mental Status) score of 14, meaning she had no cognitive (relating to or involving the processes of thinking and reasoning) impairment. A review of Resident 1's MDS Section GG (Functional abilities and Goals), dated 12/20/23, under Letter E, Showers/bathe self: The ability to bathe self, including washing, rinsing, and drying self (includes washing of back and hair), does not include transferring in/out of tub/shower, indicated that Resident 1 needed substantial/maximal (Helper does MORE THAN HALF the effort) assistance. Under letter F. Upper body dressing: The ability to dress and undress above waist including fasteners (e. g. buttons, zippers, etc.) if applicable, it indicated Resident 1 needed substantial/maximal assistance. Under letter G. Lower body dressing: The ability to dress and undress below the waist, including fasteners, does not include footwear, it indicated Resident 1 was dependent (Helper does ALL of the effort. Resident (Resident 1) does none of the effort to complete the activity) on staff assistance. During an interview on 12/8/23, at 10:40 a.m., with Resident 1, she stated that the last actual shower she got was about a year ago and had reported this to a family member. Resident 1 stated that the staff had no explanation why she was not getting showers. Resident 1 stated that the rashes on her forearms and other skin issues were caused by not getting showers. During an interview on 12/8/23, at 1:05 p.m., with Certified Nursing Assistant A (CNA A), he stated that when he started working at this facility, the staff had been giving Resident 1 a bed bath so that was what he was doing when he got assigned to Resident 1. CNA A stated he gave Resident 1 a bed bath yesterday, (12/7/23) and noticed that Resident 1 had blisters on legs, stomach, and forearms. CNA A stated that Resident 1 told him that she probably got these because nobody has been giving her bed baths. CNA A stated when a staff gave a resident a shower or a bed bath, that CNA would fill out a shower sheet and place this on the shower binder. A review of a facility document titled, Shower Schedule, undated, indicated even numbered rooms gets showers on AM (morning shift) and odd numbered rooms gets showers on PM (afternoon shift). Based on this document, since Resident 1 resided on an even numbered room on bed C she would get showers twice a week on Wednesdays and Saturdays. On 1/5/24, at 2 p.m., the Director of Nursing (DON) stated that Resident 1 had agreed to have her skin checked by the surveyor and agreed to have pictures of her wounds taken by the surveyor. During a concurrent observation and interview on 1/5/24, at 2:43 p.m., with Resident 1, assisted by CNA B, Resident 1 verified that she did agree to have the surveyor check her skin issues and take pictures if needed. The observation revealed open skin lesions on bilateral (both) forearms, upper and lower legs, and abdomen; red, raw, rash on her left abdominal fold, abdomen, and left hip, dry, scaly skin on both feet. No pressure ulcers observed during this skin inspection. (Photographic evidence of the skin issues were taken during this skin inspection). During a concurrent record review and interview on 1/5/24, at 4:10 p.m., with the DON, she provided all the shower sheets for Resident 1 from September 6, 2023 to January 2, 2024, which indicated the following dates when showers/bed baths were performed on Resident 1: 1. 9/6/23 2. 9/20/23 3. 9/23/23 4. 9/30/23 5. 10/11/23 6. 10/14/23 7. 10/25/23 8. 11/1/23 9. 11/15/23 10. 11/22/23 11. 12/9/23 12. 12/13/23 13. 12/16/23 14. 12/20/23 15. 1/2/24 The record indicated that Resident 1 would sometimes get showers/bed baths 17 days (11/22/23-12/9/23) in between, sometimes 14 days between (9/6/23-9/20/23 and 11/1/23-11/15/23) showers/bed baths. The DON's stated her expectation was that staff who performed the showers/ bed baths document that activity. The shower sheets indicated that the assessment data (e. g. reddened areas, sores, etc.) on Resident 1's skin obtained during the showesr/ bed baths, were not thoroughly filled out. The DON stated she was aware that if the showers/bed baths were not documented, then it meant that it did not happen. During a follow-up interview on 1/12/24, at 9:30 a.m., with CNA A, he stated that when a resident agreed to have a shower or refused to have shower, he would make a shower sheet, indicating if the shower was done or refused, and he would give this shower sheet to the licensed nurse for signature. He stated he would then place the shower sheet in the shower binder. During an interview on 1/12/24, at 9:38 a.m., with CNA C, she stated Resident 1 uses a mechanical lift for transfers. CNA C stated that residents get 2 (two) showers per week on their scheduled shower days and may request a shower or bed bath on Sundays. CNA C stated that she would fill out a shower sheet whether the resident agreed to have a shower or refused the shower and report to the licensed nurse if the resident refused the shower. CNA C stated that she would place the shower sheet signed by the licensed nurse on the shower binder. During an interview on 1/12/24, at 9:59 a.m., with Licensed Nurse D, she stated before she signed the shower sheet that stated the resident refused a shower schedule, she would talk to the resident and offer a bed bath. Licensed Nurse D stated that if the resident refused the bed bath, she would sign the shower sheet and document the shower or bed bath refusal on the nursing progress notes. Licensed Nurse D stated that the CNA would then file the shower sheet on the shower binder. Licensed Nurse D stated, Resident 1 needed 2-3 staff assistance with transfers using a mechanical lift. Licensed Nurse D stated, Resident 1 was totally dependent on staff assistance for showers/bed baths. A review of Resident 1's Progress Notes, dated 12/7/23 to 1/5/24, indicated that only one entry, a LATE ENTRY, on 12/20/23, Resident 1 refused a shower and was given a bed bath. Licensed Nurse D was not the author of this nursing note. A review of a facility procedure titled, Bath, Shower/Tub, dated February 2018, indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. The general guidelines indicated: 1. Be sure that the bath area is at comfortable temperature for the resident. 2. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. 3. Use the emergency call light for assistance, if needed. 4. When transporting the resident to and from the bath area, make sure that the resident is covered and his or her privacy is maintained. Documentation: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual (s) who assisted the resident with the shower/tub bath. 3. All assessment data (e. g. any reddened areas, sores, etc. on the resident's skin) obtained during the shower/ tub bath. 4. How the resident tolerated the shower/tub bath 5. If the resident refused the shower/ tub bath, the reason why and the intervention taken. 6. The signature and title of the person recording the data. A review of a facility policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, indicated under policy, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, investigation and record review, the facility failed to ensure residents were receiving care to prevent pressure ulcers and did not develop pressure ulcers, for one out of three sampled residents (Resident 1). This failure resulted in Resident 1 acquiring a Stage 4 pressure ulcer (PU, the most serious type of pressure ulcer. This ulcer extends below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments and in more severe cases, they can extend as far down as the cartilage or bone) on her sacrum (the bottom of the spine and is a triangular-shaped bone) which at one point got infected and was treated with debridement (the removal of dead (necrotic) or infected skin tissue to help a wound heal), antibiotics (medicines that fight infections caused by bacteria in humans and animals by either killing the bacteria or making it difficult for the bacteria to grow and multiply. Bacteria are germs.) and vacuum-assisted closure (VAC, an alternative method of wound management, which uses the negative pressure to prepare the wound for spontaneous healing or by lesser reconstructive options). This failure also led to the development of a Stage 3 pressure ulcer (PU that extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) on both of her legs. Resident 1 stated these pressure sores left her feeling depressed. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated she was [AGE] years-old with a diagnoses of Sacrum Pressure Ulcer Stage 4, Epilepsy (a brain disorder in which a person has repeated seizures- a sudden change in the electrical and chemical activity in the brain, over time) and anxiety disorder (a persistent and excessive worry that interferes with daily activities). Her Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents), dated 7/12/23, Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) score was 15, indicating intact cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning). Resident 1 ' s MDS skin condition assessment, dated 7/28/22, indicated she had no pressure sores when she was initially admitted . Resident 1 needed staff assistance when performing her Activities of Daily Living (ADL ' s, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During an observation on 8/15/23 at 10:50 a.m., Resident 1 was in bed, lying on her back. During an interview on 8/15/23 at 12 p.m., Licensed Staff E stated the facility policy for wound prevention included turning and repositioning every two hours and briefs checked and changed every two hours and as needed. Licensed Staff E stated one of the reasons residents got pressure sores was due to the resident not being turned or repositioned every two hours or more often as needed and residents being left sitting in their soiled briefs for long periods of time. Licensed Staff E stated pressure sores on sacrums or buttocks could get infected if a resident was left soiled and soaked in urine for prolonged periods. During an interview on 8/15/23 at 12:08 p.m., Licensed Staff C stated the facility policy for pressure ulcer prevention was to check and change residents' briefs every two hours and as needed and turn and reposition residents every two hours. Licensed Staff C stated urinary tract infections (UTI, a common infections that happen when bacteria, often from the skin or rectum [anus], enter the urethra [the tube that lets urine leave your bladder and your body] and infect the urinary tract [the body's drainage system for removing urine]) and pressure sore infections could be caused by residents not being cleaned on time and being left soaking in urine or feces for prolonged periods. During an interview on 8/15/23 at 12:21 p.m., Resident 2 stated staff did not turn and reposition her every two hours and staff certainly do not check and change her brief every two hours. Resident 2 stated staff were lying if they said residents were being turned and repositioned every two hours and briefs were changed every two hours. Resident 2 stated there were a couple of times where she was left soaked in urine and feces for a long time. During a concurrent observation and interview on 8/15/23 at 12:30 p.m., Resident 1 was in bed, still lying on her back. Resident 1 stated she had not been turned or repositioned by staff since this morning. Resident 1 requested to sit in a wheelchair during the interview. Licensed Staff F stated there was no wheelchair assigned for Resident 1. Licensed Staff F stated Resident 1 was always lying in bed. Licensed Staff F stated it had been a while since Resident 1 was seen sitting on a wheelchair. Licensed Staff F stated Resident 1 was not assigned her own wheelchair and had not been sitting in a wheelchair for a long time. Licensed Staff F stated Resident 1 was usually just in bed. During an interview on 8/15/23 at 12:33 p.m., Unlicensed Staff G stated the development of pressure sores on the sacrum could be caused by residents sitting in their urine or feces for prolonged periods and staff not turning or repositioning residents frequently. Unlicensed Staff G stated this could also cause infection of the pressure ulcer. Unlicensed Staff G stated the facility ' s policy for pressure ulcer prevention included changing or checking residents' briefs every two hours and as needed and turn and reposition residents every two hours and as needed. During an interview on 8/15/23 at 12:39 p.m., Licensed Staff F stated for pressure ulcer prevention, it was the facility ' s policy to turn and reposition residents and check and change briefs every two hours and as needed. Licensed Staff F stated residents could develop infections and pressure sores due to residents being left soiled in feces or urine for prolonged periods and not being turned and repositioned every two hours or more often as needed, timely and consistently. During a concurrent observation and interview on 8/15/23 at 12:53 p.m., Resident 3 stated she had a bowel movement and was waiting for staff to clean her and change her brief. Resident 3 was thankful she did not have a pressure ulcer on her back and buttocks. Resident 3 stated it was uncomfortable sitting in her feces. Resident 3 stated she had been sitting in her feces for over 20 minutes. Resident 3 stated staff did not check and change residents' briefs every two hours and as needed. Resident 3 stated she pressed her call button so staff could come and clean her up. Resident 3 stated she would be lucky if there was anyone passing by who she could call attention to so she could get cleaned and changed. Resident 3 stated staff did not turn and reposition her every two hours and as needed. Resident 3 stated staff usually left her soaking wet or soiled in feces for prolonged periods. Resident 3 stated this really made her angry. During an interview on 8/15/23 at 1:05 p.m., Unlicensed Staff H stated it was the facility ' s pressure ulcer prevention policy that residents be turned, repositioned, briefs checked and changed every two hours and more often as needed. Unlicensed Staff H stated one of the reasons residents develop pressure sores, infected wounds and UTIs was because residents were being left soaked in feces or urine for prolonged periods. During a concurrent observation and interview on 8/15/23 at 1:32 p.m., Resident 1 came into the conference room sitting in a wheelchair, no pressure relieving device on the chair was noted. Resident 1 stated she had clear skin, free of wound and pressure sores when she was initially admitted at the facility last year. Resident 1 stated she developed a pressure sore on her buttocks in the facility. Resident 1 stated the reason she developed a pressure sore on her buttocks was because staff were leaving her soiled in feces and soaked in urine for prolonged periods. Resident 1 also stated she was not being turned and positioned every two hours. Resident 1 stated that aside from the pressure ulcer on her buttocks, she also had a pressure ulcer on both of her legs now. Resident 1 stated the pressure ulcer on her buttocks developed, worsened and got infected when she had COVID (an infectious disease caused by the SARS-CoV-2 virus) last year. Resident 1 stated during that time, staff barely came into her room, and she was frequently left soiled and soaked in urine for prolonged periods. Resident 1 stated there was also no turning and repositioning going on at that time. Resident 1 recalled the pressure sore on her back was very painful. Resident 1 stated it was depressing knowing she had pressure ulcers on her body. Resident 1 stated staff did not really ask her if she wanted to sit in a wheelchair, so she was always lying on her bed. Resident 1 stated she did not even have a wheelchair to use anyway even if she requested to sit up in a wheelchair. During an interview on 8/15/23 at 3:07 p.m., the Director of Nursing (DON) stated it was the facility ' s policy to ensure residents were being checked and changed every two hours and as needed and turned and repositioned every two hours or more frequently if needed, to prevent pressure sores and wound infections from developing. The DON stated, not being turned frequently and being left soiled in feces or soaked in urine for long periods of time, could result in pressure ulcer development, wound infection, and UTIs to name a few. During a concurrent interview, and record review of progress notes, admission notes and Braden Scale (a tool that could be used to identify patients at-risk for pressure ulcers) for Predicting Pressure Sore Risk, on 8/31/23 at 1:45 p.m., the assistant Director of Nursing (ADON) stated Resident 1 was initially admitted on [DATE], with no pressure sores or wounds. The ADON stated Resident 1 ' s Braden Scale score, dated 7/21/22, was 15, indicating she was at risk for developing pressure sores. The ADON stated Resident 1 developed her pressure sores at the facility. The ADON stated that sometime in 8/2022, Resident 1 developed a Stage 2 pressure ulcer on her buttocks. The ADON stated Resident 1 had altered mental status and was running a temperature on 9/14/22, and Resident 1 was then sent out to the hospital for further evaluation and treatment. While at the hospital, Resident 1 ' s temperature was 99.8, and she was tachycardic (heart rate over 100 beats a minute), indicating Sepsis- highest suspicion was for infection related to her sacral pressure ulcer, which was treated with Zosyn and vancomycin antibiotic while she was at the hospital. While at the hospital, she also underwent bedside debridement (the removal of dead (necrotic) or infected skin tissue to help a wound heal) on 9/15/22, followed by botox (Botulinum toxin A (BTX-A) can be injected subcutaneously to improve the local blood supply, to reduce pain, and to promote wound healing) and debridement on the same day in the operating room under anesthesia (the use of medicines to prevent pain during surgery and other procedures) .The ADON stated Resident 1 was readmitted on [DATE], with a diagnosis of community-acquired Stage 4 pressure ulcer on her sacrum and Sepsis. The ADON stated Resident 1 was ordered to receive antibiotics for at least 12 more days, a total of at least two weeks of antibiotic therapy. The ADON stated Resident 1 was also discharged from the hospital with wound VAC to treat her sacral pressure ulcer. The ADON stated the facility ' s policy to prevent pressure ulcer development was to check and change briefs every two hours and as needed and to turn and reposition residents every two hours or more frequently as needed. The ADON stated, if residents were not being turned and repositioned frequently or were being left soaked in urine or soiled for prolonged periods, then the facility policy was not followed. The ADON stated these could also contribute to residents developing pressure sores and wound infections. During an interview on 8/31/23 at 2:10 p.m., the Director of Staff Development (DSD) stated the facility policy was to ensure residents were turned and repositioned every two hours and checked and changed every two hours and as needed. The DSD stated, if these were not being done, the facility policy was not followed. The DSD stated, if residents were not turned and repositioned every two hours, their briefs not checked and changed every two hours and as needed, and were being left soiled in feces and soaked in urine for long periods of time, it could lead to pressure ulcer development, UTIs and wound infections. During an interview on 8/31/23 at 3:07 p.m., Licensed Staff B stated Resident 1 developed her pressure ulcers at the facility. Licensed Staff B stated Resident 1 ' s pressure ulcer developed due to decline in mobility. Licensed Staff B stated Resident 1 was bed bound. Licensed Staff B stated Resident 1 admission Braden score was 15, indicating she was at risk for developing pressure ulcer. Licensed Staff B stated if a resident was not being turned and repositioned every 2 hours or more frequently if needed or if residents were being left soaked and soiled for prolonged period, it could contribute to the development of pressure ulcer. During a concurrent interview, admission note, Braden Scale for Predicting Pressure Sore Risk and care plan record review on 8/31/23 at 3:09 p.m., Licensed Staff A and B stated Resident 1 was admitted on [DATE], with clear skin, free of wounds or pressure ulcers and her Braden score then was 15, indicating she was at risk for developing pressure ulcers. Licensed Staff A and B stated that on 8/17/22, Resident 1 developed a Stage 2 pressure ulcer (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (a yellow/white material in the wound bed) on her buttocks measuring 2.0 centimeter (cm, a unit of measurement) by 1.07 cm. Licensed Staff B stated Resident 1 would refuse to get up from bed. When asked if she was aware Resident 1 did not even have an assigned wheelchair for her to use, Licensed Staff B was silent. Licensed Staff B stated that at the moment, she could not locate a care plan or a nursing note or a log addressing Resident 1 ' s refusals to get up in bed or to be turned and repositioned frequently, prior to Resident 1 acquiring the pressure ulcer on her sacrum. A review of Resident 1 ' s IDT notes and Skin and Wound notes indicated staff first noted an open area on Resident 1 ' s left buttocks on 8/17/22. On 9/9/22, it was noted Resident 1 ' s open area on her buttocks had yellow gray tissue on the wound bed however, staff did not stage the wound. On 9/10/22, the documentation indicated Resident 1 now had a wound on her sacrum but was not staged, and finally on 9/18/23, staff documented Resident 1 ' s wound on sacrum was a Stage 4. The documentation indicated the first time a right leg discoloration appeared was on 3/8/23. On 3/9/23, it indicated there was a new wound on her left calf. On 3/17/23, it indicated Resident 1 was readmitted to the facility, and there was a documentation the wound on Resident 1 ' s left and right posterior calf was Deep Tissue Injury (DTI- purple or maroon localized area of discolored intact skin or blood-filled blister (a pocket of fluid between the upper layers of skin) due to damage of underlying soft tissue from pressure and/or shear). There was no documentation for Resident 1 ' s left calf on 3/24/23, 3/30/23, 3/31/23, 4/14/23, 4/21/23. The note on 5/5/23, indicated Stage 4 wound on her sacrum, and the DTI to her left lower extremity was stalled (stable). There was no documentation on Resident 1 ' s right calf wound. A Skin and Wound note, dated 5/18/23, indicated Resident 1 had a Stage 4 pressure sore on her sacrum measuring 2.98 centimeter (cm, a unit of measurement) by 1.95 cm x 0.5 cm. and an unstageable pressure ulcer, due to eschar and slough on both posterior legs, right calf measuring 2.92 cm by 2.33 cm and left calf measuring 0.74 cm by 0.56 cm. The IDT skin note on 8/18/23, indicated right and left posterior leg pressure ulcers were now at Stage 3. A review of Resident 1 ' s MDS assessment, dated 7/28/22, indicated she had no pressure ulcer when she was initially admitted to the facility. Resident 1 ' s succeeding MDS assessments indicated she had acquired a pressure ulcer at the facility. Resident 1 ' s MDS, dated [DATE], indicated she had one unstageable pressure ulcer due to slough and/or eschar. Resident 1 ' s MDS assessment on 10/2/22, indicated she had one Stage 4 pressure sore. Resident 1 ' s MDS assessments, dated 3/28/23 and 4/11/23, indicated she had one Stage 4 pressure ulcer and one unstageable pressure sore due to deep tissue injury. Resident 1 ' s MDS assessment, dated 7/12/23, indicated she had one Stage 4 pressure ulcer and two unstageable pressure ulcers due to slough and eschar. A review of Resident 1 ' s Weekly Skin checks, dated 8/24/22, 8/31/22, 9/7/22, 10/15/22, 10/17/22, 10/20/22, 10/24/22, 10/31/22, 11/7/22, 11/14/22, 11/21/22, 11/28/22, 12/5/22, 12/12/22, 1/18/23, 1/25/23, 2/1/23, 2/10/23, 2/17/23, 2/24/23, 3/3/23, 3/10/23, 3/17/23, 3/24/23, 3/31/23, 4/8/23, 4/15/23, 4/22/23, 4/28/23, 5/27/23, 6/2/23, 6/9/23, 6/16/23, 6/23/23, 6/30/23, 7/7/23, 7/14/23, 7/21/23, 7/28/23, 8/4/23 and 8/11/23, indicated staff were not measuring Resident 1 ' s wounds. A review of Resident 1 ' s weekly skin checks on 8/24/22, 8/31/23 and 9/27/22, indicated she had a pressure ulcer on her left buttock. There was no mention of a Stage 2 pressure sore on Resident 1 ' s left buttock after 9/27/22. It was not until 10/15/22, that the weekly skin check indicated Resident 1 had a Stage 4 pressure sore on her sacrum. A review or Resident 1 ' s Wound IDT indicated there was no IDT note for the Stage 2 pressure ulcer on her buttocks. The IDT note did not indicate an option on how staff would address Resident 1 when she refused care, and there was no discussion of why Resident 1 was refusing care. The IDT did not discuss how to prevent Resident 1 from acquiring and worsening of pressure sores. Further review of Resident 1 ' s wound IDT notes indicated there were missing weekly IDT notes for the weeks of 8/10/23, 7/27/23, 6/30/23, 6/9/23, 4/27/23, 4/7/23, 10/20/22, 10/26/22, 10/7/22, 9/14/22, 9/1/22, 9/6/22, 8/24/22 and 8/3/22. The IDT notes did not evaluate the basis of Resident 1 ' s refusals, and the identification and evaluation of potential alternative to address the refusals were not discussed. A review of Resident 1 ' s care plan (a form where you can summarize a person's health conditions, specific care needs, and current treatments), dated 10/27/22, indicated staff would monitor Resident 1 ' s wound for increase in size; however, Resident 1 ' s weekly progress notes indicated there were no wound measurements on these dates: 8/31/23, 8/25/23, 8/18/23, 8/4/23, 7/21/23, 7/14/23, 7/7/23, 6/23/23, 6/16/23, 6/2/23, 5/26/23, 5/19/23, 4/21/23, 4/14/23, 3/31/23, 3/24/23, 3/20/23, 3/17/23, 3/9/23, 3/8/23, 3/3/23, 3/1/23, 2/28/23, 2/24/23, 2/23/23, 2/17/23, 2/10/23, 2/3/23, 1/27/23, 1/20/23, 1/13/23, 1/6/23, 12/28/23, 12/23/22, 12/16/22, 12/9/22, 12/2/22, 11/25/22, 11/24/23, 11/18/23, 11/14/22, 11/11/22, 11/10/22, 11/4/22, 11/3/22, 10/17/22, 10/14/22, 10/12/22, 9/22/22, 9/19/22, 9/13/22, 9/12/22, 9/11/22, 9/10/23, 8/21/22, 8/20/22, 8/18/22, and 8/18/22. Further review of Resident 1 ' s care plan indicated it did not have interventions in place to address Resident 1 ' s refusal of care, prior to her acquiring a pressure sore. During an interview on 9/12/23 at 11:32 a.m., Licensed Staff A stated the IDT met every Fridays with the DON, ADON, Registered Dietician (RD), and the treatment nurse. Licensed Staff A stated it was the facility ' s policy to complete IDT skin meetings weekly. Licensed Staff A stated sometimes they were not able to complete the IDT skin weekly documentations. A review of the facility ' s policy and procedure (P&P) titled ,Pressure Injury Wound Guidelines Risk Assessment, revised 6/2018, the P&P indicated it was the facility ' s philosophy to ensure that resident ' s skin is assessed and appropriate interventions are developed and implemented to maintain skin integrity, promote healing and prevent avoidable skin breakdown. A review of the facility ' s policy and procedure (P&P) titled, Pressure Ulcer Risk Assessment, revised 11/2012, the P&P indicated pressure ulcers are usually formed when a resident remains in the same position for an extended period of time .pressure ulcers are often made worse by continual pressure, heat moisture .nurses will conduct skin assessment at least weekly to identify changes .if the resident is refusing care, an evaluation of the basis of the refusal, and the identification and evaluation of potential alternative is indicated.

Based on interviews and record reviews, the facility failed to ensure: 1. an abuse allegation was investigated for one out of three sampled residents (Resident 1) on two separate occasions on these dates: 2/2023 and 9/19/23; and, 2.facility staff was aware of the correct reporting time frame for abuse allegations. These failures put the residents at risk for further potential abuse as the alleged perpetrator had continued access to the alleged victim and/or other vulnerable residents. It also resulted in Resident 1 feeling abused, angry, upset, and unsafe. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated she was [AGE] years-old with a diagnoses of Sacrum (the bottom of the spine and is a triangular-shaped bone) Pressure Ulcer stage 4 (PU, the most serious type of pressure ulcer. These ulcer extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments and in more severe cases, they can extend as far down as the cartilage or bone), Epilepsy (a brain disorder in which a person has repeated seizures- a sudden change in the electrical and chemical activity in the brain, over time) and Anxiety disorder (a persistent and excessive worry that interferes with daily activities). Her Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents), dated 7/12/23, Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) score was 15, indicating intact cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning). Resident 1 needed staff assistance when performing her Activities of Daily Living (ADL ' s, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During an interview on 8/15/23 at 1:32 p.m., Resident 1 stated her right hand and right shoulder was injured last 2/2023, while she was being changed by a female Certified Nursing Assistant (CNA, staff that helps patients with direct health care needs, often under the supervision of a nurse). Resident 1 stated the CNA, while attempting to clean her, turned her on her right side forcefully and abruptly, her right shoulder and right hand hit the bedrail. Resident 1 stated, when the CNA turned her forcefully on her right side, her right shoulder and right hand was smashed in the bed rails. Resident 1 stated she was grateful she did not have to work with this CNA after this incident. Resident 1 stated she was unsure whether this CNA continued to work with other residents after this incident. Resident 1 stated she reported this incident but could not recall the nurse she reported this incident to. Resident 1 stated she was not aware of the outcome of this complaint. Resident 1 stated she felt angry and upset about this incident, but mostly she felt unsafe. Resident 1 stated she did not even receive an apology from the CNA nor the Administrator. During an interview on 8/15/23 at 3:07 p.m., the Director of Nursing (DON) stated she could not recall an incident between Resident 1 and a CNA, where Resident 1was abruptly and forcefully turned by the alleged CNA on her right side while cleaning her and in doing so, Resident 1 hit her right shoulder and right hand on her bed rail. The DON stated this appeared to be an abuse allegation. The DON stated incidents like this should be reported to the State, the Ombudsman (usually appointed by the government, often with a significant degree of independence, to investigate complaints and attempt to resolve them, usually through recommendations (binding or not) or mediation) and the local law enforcement. The DON stated she would look for any records pertaining to this incident. During an interview on 8/31/23 at 1:45 p.m., the Assistant Director of Nursing (ADON) stated the incident between Resident 1 and the CNA was an abusive situation. The ADON stated she did not find any documentation pertaining to this incident. The ADON also stated she did not find any report to the State, the Ombudsman, and the local law enforcement about this abuse allegation. The ADON stated abuse allegations should be investigated fully. The ADON stated, if a CNA turned Resident 1 on her side forcefully and abruptly, that behavior was unacceptable. The ADON stated, if an abuse allegation was not reported and investigated, it could lead to the alleged perpetrator's continued access to residents. The ADON stated residents ' safety would be at risk. During an interview on 8/31/23 at 2:10 p.m. the Director of Staff Development (DSD) stated the incident between Resident 1 and the CNA should be treated as an abuse allegation and should have been reported to the State, the Ombudsman and local law enforcement. The DSD stated this incident should have been investigated as well. The DSD stated, if this allegation was not investigated and reported, then the facility policy was not followed. The DSD stated this endangered the residents because alleged perpetrators could have continued access to the residents. The DSD stated not investigating and reporting this allegation could result in this incident occurring again. The DSD stated this could also result in residents losing faith in staff and would think staff did not care. The DSD stated residents should feel and be safe at the facility all the time. During an interview on 8/31/23 at 3:05 p.m., Licensed Staff A stated, if a staff turned and repositioned a resident abruptly and forcefully and the resident ended up hitting her shoulder on the bed rail, this incident would be considered an abuse allegation. Licensed Staff A stated abuse allegations should be reported to the State, Ombudsman and the local law enforcement within 24 hours of discovery. Licensed Staff A stated, if an abuse allegation was not investigated and reported, the abuse could happen again. Licensed Staff A stated residents could be harmed. During an interview on 8/31/23 at 3:06 p.m., Licensed Staff B stated it was an abuse allegation if a staff turned and repositioned resident abruptly and forcefully and the resident ended up hitting her shoulder on the bed rail. Licensed Staff B stated this should be reported to the local law enforcement, the Ombudsman, and the State within 24 hours. Licensed Staff B stated, if an abuse allegation was not investigated and reported, residents would feel nobody cared. Licensed Staff B stated it would put the resident ' s safety at risk. During an interview on 8/31/23 at 4:10 p.m., the Administrator stated the incident that occurred between Resident 1 and a CNA was considered to be an abuse allegation and should have been reported to the State, the Ombudsman and the local law enforcement. The Administrator stated he was not aware of this allegation, and the DON also did not mention anything about this allegation to him. The Administrator stated, since there appeared to be no information about this allegation, the DON should have initiated the investigation when she found out about it. The Administrator stated he would investigate and report this incident to the State, the Ombudsman, and the local law enforcement. During an interview on 8/31/23 at 4:15 p.m., Licensed Staff C stated an abuse allegation time frame for reporting was within 24 hours. Licensed Staff C stated, if an abuse allegation was not reported or investigated, it could put residents ' safety at risk. During an interview on 8/31/23 at 4:20 p.m., the ADON stated abuse allegations should be reported within 24 hours. The ADON stated, if the abuse allegation was not investigated and reported, it could lead to further abuse, and the abusive behavior would continue. The ADON stated it also posed a risk the abuse could happen to another resident. The ADON stated this put the residents at risk for harm. During an interview on 8/31/23 at 4:30 p.m., the Social Services Director (SSD) stated the time frame for abuse reporting was within 24 hours. The SSD stated it did not matter how long ago the abuse allegation occurred, abuse allegations still needed to be investigated. The SSD stated the goal was to keep residents safe. The SSD stated, if an abuse allegation was not reported and investigated, it could lead to continued abuse. The SSD stated residents would feel they did not matter and would lose trust in the staff. The SSD stated staff abruptly and forcefully turning a resident on her side, which resulted in the resident hitting her shoulder and hand on the bedrail was an abuse allegation and should have been reported to the State, the Ombudsman and the local law enforcement. During an interview on 9/25/23 at 3:35 p.m. Resident 1 stated on the morning of 9/19/23, Unlicensed Staff J from the registry (a staff provided by an agency who receives compensation from a third party to work at a nursing care institutions) came at 7 a.m., to ask if she could change Resident 1 ' s brief. Resident 1 stated she refused because she was changed at 5 a.m., and she was still dry at that time when Unlicensed Staff J asked to change her brief. Resident 1 stated Unlicensed Staff J threatened that if she did not allow her to change her brief at that time, Unlicensed Staff J would not go back to change her brief for the entire shift. Resident 1 stated when she refused to be changed, Unlicensed Staff J also told her, Let God be with you. Resident 1 stated this made her upset and angry. Resident 1 stated she reported this incident to Licensed Staff F at around 7:30 a.m. or 8:30 a.m. Resident 1 stated, after talking to Licensed Staff F, her care was transferred to another staff. Resident 1 stated her brief was finally changed at around 2:20 p.m. Resident 1 stated her roommate knew about this incident. Resident 1 stated she felt abused by Unlicensed Staff J. During an interview on 9/25/23 at 4:30 p.m., Resident 5 confirmed an incident between Unlicensed Staff J and Resident 1. Resident 5 stated Unlicensed Staff J asked to change Resident 1 ' s brief in the morning but Resident 1 refused. Resident 5 stated Unlicensed Staff J threatened she would not be back to change Resident 1 ' s briefs at all during her shift if she would not allow her to change her brief right at that moment. Resident 5 stated this made her upset. During an interview on 9/25/23 at 4:58 p.m., the DON stated staff telling a resident they would not be back to change her brief the entire shift was unacceptable, constituted a threat and should have been reported to the State, the Ombudsman and local law enforcement. The DON stated, if this was not reported, there could be a potential for this to occur with other residents and the abuse could continue. During a telephone interview on 9/26/23 at 3:26 p.m., the Administrator stated he was made aware about the incident between Resident 1 and Unlicensed Staff J when the DON notified him yesterday. He stated as soon as the DON reported this allegation to him, he already initiated the investigation and had submitted the SOC 341 to the Ombudsman and the State. The administrator stated Resident 1 ' s allegation was supported by Resident 5. When asked why the nurse did not recognize this incident as an allegation of abuse, the Administrator had no answer. During a telephone interview on 9/26/23 at 4:27 p.m., the DON stated, prior to me reporting the incident between Resident 1 and Unlicensed Staff J, she was not able to find any documentation on Resident 1 ' s chart about this incident. The DON stated there was no SOC 341 completed for this allegation. The DON stated this incident was not investigated and was not reported to the State, the Ombudsman and the local law enforcement. When asked if this meant the facility was not in compliance with the abuse regulation and per their policy, the DON stated, Yes. The DON stated Unlicensed Staff J was allowed to finish her shift on 9/19/23. During the sign-in sheet morning shift record review, dated 9/19/23, it indicated Resident 1 was under the care of Licensed Staff F and Unlicensed Staff J. During a telephone interview on 9/29/23 at 3:55 p.m., the DON confirmed Unlicensed Staff J was allowed to work at the facility and had continued access to their residents even after the incident with Resident 1 on 9/19/23. The DON verified Unlicensed Staff J worked on these dates: 9/19/23, 9/23/23, 9/24/23, 9/25/23, 9/26/23 and 9/27/23, for a total of six days. Based on the facility ' s policy and procedure (P&P) titled, Abuse Prohibition and Prevention Policy and Procedure, revised 3/2018, the P&P indicated under section F. Investigation, all incidents of suspected or alleged abuse will be promptly investigated .under section G, Reporting/Response, the facility will report allegations of abuse even if there ' s no reasonable suspicion .immediately-no later than two hours for all abuse (actual, alleged or potential) OR results in serious bodily injury.

Based on observation, interview and record review, the facility failed to keep four residents safe when: 1. The facility did not revise the plan of care to reflect the IDT (interdisciplinary team) recommendations and did not assess the effectiveness of the interventions to prevent two out of six sampled residents (Resident 15 and Resident 19) from falling as evidenced by: a.) Resident 15 had eight falls within a 11-month period from 4/1/21 to 3/9/22. Resident 15 sustained a [CONDITION(S)] from the fall on 11/17/21 which required Resident 15 to be sent to an acute care hospital and underwent a surgical repair of the [CONDITION(S)]. After 11/17/21, Resident 15 had two more falls on 2/25/22 and 3/9/22; and b.) Resident 19 had four falls during a 10-month period from 5/26/21 to 3/10/22. Resident 19 sustained a [CONDITION(S)] and a bump on the back of her head on 11/24/21 which required Resident 19 to be sent to an acute hospital for evaluation. Resident 19 had one more fall after 11/24/21. 2. The facility did not have an active plan to diminish aimless wandering for two out of two sampled residents (Resident 12 and Resident 55) who were prone to wandering (common behavior in Alzheimer's or dementia disease where an individual was prone to potential injury). These failures resulted in resident-to-resident altercations. These failures also had the potential to result in elopement (resident leaves the facility without facility awareness), physical injuries or even death. Findings: 1a. During a review of Resident 15's, Admission Record, dated 8/16/17, indicated Resident 15 had been admitted to the facility on [DATE] with a history of high blood pressure, dementia (a group of thinking and social symptoms that interferes with daily functioning), falls and cognitive communication deficit. During a review of Resident 15's quarterly Minimum Data Set (MDS) (clinical assessment process which provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 8/16/21, indicated Resident 15's Brief Interview of Mental Status (BIMS) of 00 (severely cognitively (memory and thinking skills) impaired) and needed one-person physical assistance to transfer from the bed to wheelchair and or toilet. During a review of Resident 15's, Plan of Care dated 8/21/20, Resident 15 had been identified as high risk for falls related to confusion, incontinence, unaware of safety needs and impulsivity. Interventions dated 8/21/20 included: anticipate and meet Resident 15's needs, be sure Resident 15's call light was within reach and continue to remind to use call light, educate Resident 15 about safety reminders, encourage Resident 15 to participate in activities which promote exercise and physical activity for strengthening and improved mobility, and fall protocol. Evidence Related to Fall 1 A review of Resident 15's, Nursing Progress Notes, dated 4/2/21 indicated Resident 15 had an unwitnessed fall without injury. During a review of Resident 15's, Plan of Care dated 4/2/21, indicated Resident 15 had a fall on 4/1/21. The interventions indicated on the Plan of Care were to continue at risk plan, continue neurological assessment checks, monitor her for pain, bruises or change in mental status for the next 72 hours and report to the doctor any changes. No new interventions to prevent further falls were indicated other than immediate first aide needs with regards to suspected injury. Evidence Related to Fall 2 A review of Resident 15's, Nursing Progress Notes, dated 4/6/21, indicated by nursing staff that Resident 15 had slid from her bed to the floor onto her bottom. The nursing progress note indicated Resident 15 was assessed by the nurse and did not have an injury. A review of Resident 15's, Plan of Care, dated 4/6/21, indicated Resident 15 had a fall due to poor balance, unsteady gait and poor safety awareness, the interventions were to continue at risk plan, document. Interventions for monitoring and identifying potential injury was included in the plan of care. A new intervention which was added on 4/6/21, indicated to keep floor mats at the side of her bed for safety. Previously identified interventions to prevent falls were not identified regarding the effectiveness of preventing the fall on 4/6/21. Evidence Related to Fall 3 During a review of Resident 15's, Nursing Progress Notes, dated 6/30/21, indicated Resident 15 had an unwitnessed fall in the hallway. The nursing progress note indicated Resident 15 was found lying on her back with both arms on her side. Nursing staff assessed Resident 15 and indicated there were no injuries and she was assisted back to her bed. During a review of Resident 15's, Nursing Interdisciplinary Team Fall Investigation Notes, dated 6/30/21, indicated Resident 15 did not have an injury and the Plan of Care had been updated. A review of Resident 15's, Plan of Care dated 6/30/21 indicated an updated intervention was having frequent reminders on safety awareness or frequent monitoring. Nothing further to explain or clarify how often frequent reminds or frequent monitoring would be carried out. Resident 15's plan of care did not address interventions which were not working to keep her from falling. Interventions associated with monitoring for identifying potential immediate injury were included. Evidence Related to Fall 4 During a review of Resident 15's, Nursing Progress Notes, dated 8/14/21, indicated Resident 15 had a fall and was found on the side of her bed, sitting on the floor. Resident 15 was assessed and indicated to have no injuries because of the fall. A review of Resident 15's, Plan of Care, dated 8/14/21, indicated a new intervention of placing the bed in the lowest position was added to the plan of care. Resident 15's current interventions to keep from fall further was not addressed in the plan of care. Evidence Related to Fall 5 During a review of Resident 15's, Nursing Progress Notes, dated 9/7/21, indicated Resident 15 had a fall on 9/7/21. A review of Resident 15's, Interdisciplinary Team Fall Investigation Notes, dated 9/7/21, indicated Resident 15 was observed by staff sitting on the floor mat at bedside with no injury indicated. The interdisciplinary fall investigation notes indicated Resident 15's plan of care had been updated. No explicit update to Resident 15's plan of care was identified. A review of Resident 15's, Plan of Care dated 9/7/21, indicated Resident 15 had a fall, but there were no new interventions added to prevent Resident 15 from falling to her plan of care other than immediate first aide monitoring for potential identification of injury. Resident 15's plan of care did not address the effectiveness of the interventions which was in place to prevent her from falling. Evidence Related to Fall 6 During a review of Resident 15's, Nursing Progress Notes, dated 11/17/21, indicated Resident 15 was being monitored for an unwitnessed fall where she had been complaining of pain to her right lower extremity. Resident 15 was unable to bear weight on her right lower extremity so a portable x-ray (a test which produces images of the structures inside of the body, particularly the bones) was ordered. A review of Resident 15's, Interdisciplinary Team Fall Investigation Notes, dated 11/18/21 indicated Resident 15 was found on the floor of her room, laying on her right side. Resident 15 was assisted back to bed. Resident 15 had complained of pain to right hip/leg area and was given pain medication. Conclusion of Interdisciplinary Team Fall Investigation Notes indicated Resident 15 should be educated on the use of the call light, she continued to require frequent redirection and reminders to ask for assistance, frequent visual monitoring, keep the call light within reach while in bed, to continue with the toilet program in place to prevent falls related to incontinence (inability of the body to control urine or defecation), keep floor mats at bedside and bed in low position. During a review of Resident 15's, Nursing Progress Notes, dated 11/18/21, indicated Resident 15 had a broken hip/leg bone and was sent to a higher level of care by ambulance. During a review of Resident 15's, Nursing Progress Notes dated 11/29/21, indicated Resident 15 had returned to the facility after having surgery to repair her broken hip. During a review of Resident 15's, Plan of Care dated 11/17/21, indicated she had fallen and suffered a right [CONDITION(S)]. New interventions added to Resident 15's plan of care indicated the nurse practitioner was notified and x-rays were ordered, frequent visual monitoring (no further definition was indicated on the plan of care) A review of Resident 15's BIM assessment dated [DATE] indicated she consistently had difficulty with focusing attention or being able to keep track of what has been said. Resident 15 was indicated to have consistent disorganized (rambling, irrelevant conversation, illogical flow of ideas and unpredictable switching from subject to subject) thinking. Evidence Related to Fall 7 During a review of Resident 15's, Nursing Progress Notes, dated 2/25/22, indicated Resident 15 was found on the floor of her room. Resident 15 was indicated to be trying to get up from her bed, no injury was assessed by nursing staff. During a review of Resident 15's, Plan of Care, there was no indication Resident 15 had fallen. There were no new interventions included in the plan of care. Evidence Related to Fall 8 During a review of Resident 15's, Nursing Progress Notes, dated 3/9/22, indicated Resident 15 had an unwitnessed fall in her room. Resident 15 was assessed by nursing staff and did not have any injuries. A review of Resident 15's, Plan of Care, dated 3/10/22, indicated Resident 15 had a fall with no injury related to poor balance, unsteady gait and poor safety awareness. New intervention dated 3/10/22 indicated to provide Resident 15 with activities which promote exercise and strength building where possible (no further clarification was provided in Resident 15's plan of care). During an observation on 4/6/22 at 8:32 a.m., in Resident 15's room, she was observed to be laying in her bed, wearing a patient gown and unable to have a conversation by not acknowledging greeting or answering any questions. During an interview on 4/6/22 at 9:33 a.m., with Staff H, she stated Resident 15 was very sneaky and would often try to get out of bed without using the call light. Staff H stated Resident 15 would attempt to get out of bed multiple times during the shift, when she knew the staff was down the hallway busy with other residents. Staff H stated after Resident 15 had the fall and broke her hip, she did not understand she was not strong enough to get out of bed by herself. Staff H stated Resident 15 did not have any safety awareness to understand that she could hurt herself if she tried to get out of bed without help but would continue to try and get out of bed. Staff H stated she was unsure why Resident 15 would attempt to get out of bed, since many times Resident 15 would just say she didn't know why. During an interview on 4/6/22 at 4:55 p.m., with Activity Director (AD), she stated Resident 15 used to get up and attend activities but not since she went to the hospital (due to broken hip). AD stated Resident 15 would be visited daily by someone from the Activity Department and the activity included delivering a piece of paper with information on it titled, Daily Chronicle. AD could not explain a specialized activity program for Resident 15 or if Resident 15 could read the information on the paper. During an interview on 4/12/22 at 10:06 a.m., with Staff J, she stated Resident 15 used to attempt to get out of bed all day until Resident 15 went to the hospital (for broken hip) now she hardly gets out of bed. During an interview on 4/6/22 at 3: 41 p.m., with Nurse N, he stated he was not that familiar with Resident 15 since he had not worked at the facility for very long (less than six months) and did not see Resident 15 out of bed. During a concurrent interview and record review on 4/8/22 at 2:43 p.m., with Director of Nursing (DON), she stated the usual process for when a resident suffers a fall would be to conduct a fall investigation, place the resident on the Falling Star Program for 90 days and if after that time frame there wasn't a fall, the resident would be taken off the program. DON stated after a resident falls, the results of the investigation would determine recommendations, but those recommendations would not always be included as interventions on the resident's plan of care. Resident 15's falls were reviewed from the nursing progress notes and care plan. DON stated the frequent safety checks identified on Resident 15's plan of care for the fall on 6/30/21, meant that when other staff were walking past Resident 15, they would check on her to see if she was okay and not falling. DON stated frequent checks was not something the staff would document on Resident 15 or check on her at specific times during the shift. Resident 15's fall on 8/14/21 was reviewed and the fall was indicated to be on her plan of care. DON stated the fall on 8/14/21 was an example of when the recommendations from the fall investigation were not captured on Resident 15's plan of care. DON could not explain how that might impact Resident 15's plan of care. DON stated Resident's fall on 9/7/21 did not include new interventions to keep her from falling further. DON stated after Resident 15 fell on [DATE], when she returned from the hospital the staff were supposed to check on her every 2-3 hours to offer to go the bathroom. DON stated she could not find any record of Resident 15's fall on 2/25/22. DON stated she could not think of additional interventions to keep Resident 15 from falling and thought the facility had exhausted all measures to keep her safe from falling. DON stated there were no new interventions or assessment of interventions which were or were not working to prevent Resident 15 from falling on 3/9/22. DON stated she had not thought of increased supervision and did not think of providing more supervision would keep Resident 15 from continuing to fall. DON stated Resident 15 had zero safety awareness and thought the facility was keeping her safe from falling. 1b. During a review of Resident 19's, Admission Record, dated 8/16/17, indicated Resident 19 had been admitted to the facility on [DATE]. Resident 19 was admitted with a history of falling, cognitive communication disorder (caused by brain injury resulting in difficulty with thinking and how someone uses language) and high blood pressure. A review of Resident 19's Annual Minimum Data Set (MDS) (a clinical assessment process that provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 8/27/21, indicated Resident 19 had a BIMS (Brief interview of Mental Status) of 00 which indicates severely impaired cognition (memory and thinking skills) impaired and needed one-person physical assistance with transferring or moving between bed and walker or walker to toilet. During a review of Resident 19's Plan of Care dated 12/3/19 indicated Resident 19 was considered a moderate risk for falls related to impaired mobility, history of falls, medication, and deconditioning (refers to all the physical, mental and social consequences associated with inactivity and being sedentary for a long period of time). Interventions dated 12/3/19 included: anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use for assistance as needed. Resident needs prompt response to all requests for assistance, ensure that the resident was wearing appropriate footwear and follow facility fall protocol. Evidence Related to Fall 1 During a review of Resident 19's, Nursing Progress Notes, dated 5/26/21 indicated Resident 19 had an unwitnessed fall where she was found in her room sitting next to her bed with her walker (assistive device used in the aid of walking for balance and stability) in front of her. Nursing staff assessed Resident 15 and indicated there was no injury. During a review of Resident 19's, Interdisciplinary Team Fall Investigation, dated 5/26/21, indicated Resident could verbalize that she slid down to the floor from the bed but did not hit her head. Recommendations included: frequent reminder to press call light, remove clutter and encourage to keep area clean and clear During a review of Resident 19's, Plan of Care, there was no indication on the 27-page document there was a fall on 5/26/21. Evidcence related to Fall 2 During a review of Resident 19's, Nursing Progress Notes, dated 11/22/21, indicated Resident 19's roommate was wheeling herself out of the room and into the hallway calling out for help because Resident 19 had fallen. Nursing staff found Resident 19 sitting on the floor next to the restroom. Nursing staff assessed Resident 19 and found no major injury. During a review of Resident 19's, Interdisciplinary Team Fall Investigation dated 11/22/21 indicated Resident 19's roommate stated Resident 19 had fallen after she returned from the bathroom. The fall investigation indicated Resident 19 had some skin abrasions (surface layer of the skin had been broken). Recommendations indicated Resident 19 should be encouraged to use her walker when ambulating short and long distances. During a review of Resident 19's, Plan of Care dated 11/22/21 indicated Resident 19 had a fall on 11/22/21 with additional interventions to remove clutter from resident's room, to use walker when ambulating and continue with toileting program. Interventions were not assessed for effectiveness to keep Resident 19 from further falls. Evidence Related to Fall 3 During a review of Resident 19's, Nursing Progress Notes, dated 11/24/21 indicated Resident 19 was found on the floor facing the opposite of the bathroom door. Resident 19 complained of right hip pain and observed to have a bump on the back of her head. The doctor/nurse practitioner was notified, and x-rays were ordered to rule out fracture. During a review of Resident 19's, Nursing Progress Notes dated 11/24/21, indicated Resident 19 had a broken hip and was sent to a higher level of care to be further evaluated. During a review of Resident 19's, Plan of Care dated 11/24/21, indicted there were no new interventions and no indication the interventions had been assessed for effectiveness in reducing falls. Evidence Related to Fall 4 During a review of Resident 19's, Nursing Progress Notes, dated 3/10/22 indicated Resident 19 had a fall. During a review of Resident 19's, Nursing Progress Notes, dated 3/11/22 indicated Resident 19 was sent to a higher level of care for further evaluation and no significant findings including no broken bones was found so Resident 19 was transferred back to the facility. During a review of Resident 19's, Plan of Care, dated 3/21/22, indicated Resident 19 had a fall on 3/10/22. No new interventions were indicated on the plan of care and the effectiveness of interventions was not evaluated. During an interview on 4/6/22 at 9:37 a.m., with Staff H, she stated she was aware of Resident 19 falling out of bed and indicated Resident 19 had fallen out of bed three or four times in one shift. Staff H stated she could not remember which date. Staff H stated she remembered a long time ago when the facility had a program to document special charting on what a resident was doing at certain time periods of the day like every hour or every two hours. Staff H stated the facility does not do that now and could not remember when the practice was discontinued. During an interview on 4/12/22 at 9:44 a.m., with Nurse G, she stated she was new to the facility and not familiar with Resident 19's falls and had not known that she had three falls since November 2021. During an interview on 4/12/22 at 10:06 a.m., with Staff J, she stated Resident 19 was always getting up out of bed by herself and falling but she had not taken care of her since she has been on the 200 hallway (hallways correspond to resident room numbers). During a concurrent interview and record review on 4/8/22 at 3:10 p.m., with DON, she stated the fall on 5/26/21 had been discussed in a fall meeting but the recommendations had not been updated to the plan of care. The DON stated the fall on 11/22/21 had the use of a walker added to the plan of care. DON stated Resident 19 had already been using a walker, but the staff were to encourage her to use the walker when getting out of bed and she would not do that. DON stated due to Resident 19's diagnosis and disease process, she will not be able to grasp the safety awareness. DON stated there were no further interventions to add to Resident 19's plan of care. During a review of the facility's policy and procedure titled, Falls Management, dated 11/2012, 2. New or existing residents scoring as high risk will have intervention implemented to reduce the potential for falls outline in their plan of care 6. Recent falls will be reviewed daily by a designated facility fall team, to evaluate cause, determine additional strategies as needed to prevent recurrence for each resident and further revise the care if needed. The fall team may document their findings or recommendations on an IDT (Interdisciplinary Team) note or on a fall investigative tool per facility protocol. 2a. During a review of Resident 12's, Admission Record, Resident 12 was admitted to the facility on [DATE] with a history of dementia (a group of thinking and social symptoms that interferes with daily functioning), [CONDITION(S)] (serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings), [CONDITION(S)] (a chronic disease which can damage brain function) and high blood pressure. A review of Resident 12's quarterly MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the residents' functional capabilities and helps staff identify health problems), dated 12/6/21 indicated Resident 12's BIM (Brief Interview of Mental Status) of 3 (severely cognitively impaired), able to move between locations in wheelchair independently and requires one person assistance in transferring to wheelchair. During an interview on 4/4/22 at 12:02 p.m., with Resident 97, he stated there was a woman (resident) in a wheelchair who comes around and takes stuff off people's bed, whatever was not nailed down and it's horrible. Resident 97 stated he thought her name was [Resident 12's name] or something like that and if he didn't yell for her to get out, then she would get away with it. During an interview on 4/4/21 at 4:28 p.m., with Resident 41, he stated there was a resident named [Resident 12] who goes into everyone's rooms and steals stuff. Resident 41 stated one time Resident 12 tried to take a quilt off his bed and she could be violent, kicking and hitting you for trying to protect your stuff. During an interview on 4/5/22 at 11:50 a.m., with Resident 89, he stated [Resident 12] would come in (resident room) and steals stuff from him. Resident 89 stated, [Resident 12] comes in her wheelchair and just grabs anything that's on his bed or nightstand. Resident 89 stated no one watches her to keep her from doing this and when she comes into his room, he would have to yell or they (staff) won't do anything. During an observation on 4/5/22 at 3:09 p.m., with Resident 12, she was observed in her wheelchair moving about the facility unsupervised, she went into room 309 (not Resident 12's room) and muffled yelling was heard and then Resident 12 exited the room. No staff were present during this observation. During an interview on 4/6/22 at 8:56 a.m., with Staff H, she stated Resident 12 wanders. Staff H stated they cannot manage her and keep an eye on her. Staff H stated Resident 12 does not listen when one tries to redirect her, she can get mad and start hitting and kicking. Staff H stated the staff would try to intervene when Resident 12 was in another resident's room before an altercation would occur. Staff H stated it would be very hard to redirect Resident 12 because she believes this place was hers and they (other residents) are in her room. Staff H stated Resident 12 does not have a routine sleeping schedule, some nights she wanders and doesn't sleep at all. Staff H stated Resident 12 can get into her wheelchair by herself and some days she might ask for assistance. During a concurrent observation and interview on 4/6/22 at 3:41 p.m., with Nurse M, Resident 12 purposefully bumped into Nurse M to request coffee. Nurse attempted to redirect Resident 12 and she left for a few moments. At 3:42 p.m., Resident 12 bumped into Nurse M again, requesting coffee and Nurse M attempted to redirect Resident 12. At 3:46 p.m., Resident 12 bumped into Nurse M for a third time, requesting coffee. Nurse M stated he did not have coffee and offered Resident 12 water which was on the medication cart where the interview was taking place. Resident 12 drank a few sips of water and then gave Nurse M back the cup of water. Resident 12 then proceeded to enter another resident's room, so Nurse M then paused the interview to redirect Resident 12 out of the other resident's room and there was yelling observed. Resident 12 did exit the room and proceeded down the hallway independently. Nurse M then returned to interview and stated when the staff were busy, no one would be watching Resident 12, it was impossible. Nurse M stated, Resident 12 did not have a set sleeping schedule and the staff would assist to Resident 12 to go to bed and then she might sleep for a few hours and then get back up and start wandering the halls. At 3:51 p.m., Resident 12 returned to Nurse M to request coffee but more upset during this encounter by continuing to position her wheelchair to collide with Nurse M's legs and Nurse M continued to keep a distance while attempting to redirect Resident 12. Resident 12 then attempted to hit Nurse M while he was setting boundaries to not hit him and then poured Resident 12 another cup of water. Nurse M stated Resident 12 does have a Wanderguard (device which alarms when it comes in contact to an area which will notify staff to redirect the resident for safety), but Resident 12 will not wear it so it is on her wheelchair. Nurse M then exited the interview to physically escort Resident 12 to her nurse to have her blood sugar tested . During an interview on 4/6/22 at 4:37 p.m., with Activity Director (AD), she stated Resident 12 usually sleeps in the mornings and sometimes attends activities in the afternoon but does not stay for the entire activity. AD stated Resident 12 would attend an activity and remain with the activity if there was a staff member who worked with her directly, since Resident 12 could not take direction toward a group. During an observation on 4/7/22 at 10:09 a.m., with Resident 12, she was observed wandering throughout the facility and was observed going into room 702 where yelling was observed and then staff intervened and redirected Resident 12 out of the room. Resident 12 was observed to state she wanted coffee and would not be redirected. Resident 12 was observed to attempt to kick staff. During an interview on 4/7/22 at 4:08 p.m., with Staff O, she stated Resident 12 was always in and out of other resident rooms and she would be hard to redirect. Staff O stated every day is different with Resident 12 in terms of her sleeping schedule, some days she might go to bed at 11:00 p.m., or 12:00 a.m., but Resident 12 would not sleep through the night. Staff O stated the staff would put Resident 12 to bed, then she would get up, the staff would put her to bed again and again she would get out of bed and into her wheelchair by herself. Staff O stated if they were too busy to meet Resident 12's needs immediately then she might take her (soiled) brief off and throw it around to get the attention of the staff. Staff O stated Resident 12 does not like it when her roommates use the bathroom in the room and would yell at them not use it and Resident 12 might try and kick the resident who was using the bathroom. Staff O stated, Resident 12 can get violent with her roommates because the other roommate would yell and kick back at Resident 12. During an interview on 4/8/22 at 1:58 p.m., with Staff L, she stated everyone watches out for Resident 12 to redirect her after she goes into another resident's room. Staff L stated it's hard to watch Resident 12 when the staff are busy in resident rooms providing care because they could not see what she was doing. During an interview on 4/12/22 at 10:06 a.m., with Staff J, she stated Resident 12 required a lot of supervision and if the staff did not watch her, Resident 12 would enter another resident's room which would prompt them to yell at her to get out. Staff J stated if she would hear yelling regarding Resident 12 being in another resident room, she would have to hurry up care being conducted and then rush to intervene with Resident 12. Staff J stated if there was no intervention then it would get physical with Resident 12 and another resident. Staff J stated other residents do not like it when Resident 12 goes into their rooms because she takes stuff and then yells at them for being in their own room, it is very hard. During an interview on 4/8/22 at 3:25 p.m., with Director of Nursing (DON), she stated the residents in hallway 100 had requested a Velcro mesh type barrier for each door to keep Resident 12 from wandering into other resident's room on that hallway. DON stated Resident 12 may drink coffee all day, but it is decaffeinated and does not keep her up all night. DON stated Resident 12's plan of care consists of redirecting her and trying to promote quiet time in the afternoon but Resident 12 does not take naps. DON stated Resident 12 belongs in a Dementia unit and her family does not want to move out of the facility. During an interview on 4/12/22 at 12:05 p.m., with Medical Doctor P (MD P), she stated Resident 12 had been evaluated for medications and behaviors about her wandering. MD P stated she was aware the staff would have to verbally and even physical redirect Resident 12 to keep her safe. MD P stated she thought Resident 12's wandering behaviors had stabilized, (meaning the behaviors had not gotten worse nor better, just the same). During a review of Nursing Progress Notes, Change in Condition, dated 6/14/21 indicated staff heard yelling from a resident room while in another room providing care. The progress note indicated the staff quickly went to the room where the yelling was coming from and found Resident 12 exiting the room with her hand on her face. The progress note indicated Resident 12 stated the resident in the room had hit her and he should not have been in that room. The progress note indicated Resident 12 was assessed for injury and escorted back to her room. During a review of Nursing Progress Notes, Change in Condition, dated 7/4/21, indicated Resident 12 was observed in hallway being slapped by another resident. Progress note indicated Resident 12 has a history of constantly having to be taken out of other residents' rooms and staff asking her to not speak badly or be verbally abusive to other residents. During a review of Behavior Note, dated 8/31/21 indicated Resident 12 was in another resident's room where she threw water on the resident after they told her she could not come into their room and use the bathroom. The behavior note indicated Resident 12 had been directed to use the bathroom in her own room. Behavior note indicated there was no water on Resident 12 or the other resident and no other injury was found. During a review of Nursing Progress Notes, dated 9/19/21 indicated Resident 12 had been moved out of her room in the 400 hallway and moved to the 700 hallways to decrease Resident 12 from continually en[TRUNCATED]

Based on observation, interview and record review, the facility failed to keep one of three sampled residents (Resident 1) safe, when important information about her risk for falls was not communicated among nursing staff. As a result, Resident 1, who was admitted to the facility with a fractured left hip from a fall at home, suffered a fall at the facility less than three hours after admission, causing her to fracture her right hip. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE], with medical diagnoses including Fracture of the Left Femur (The bone of the thigh), Fall from Slipping, Age-Related [CONDITION(S)] (A disease that thins and weakens the bones), and Dementia (Loss of memory and cognitive functioning), according to the facility Face Sheet (Facility demographic). Resident 1's MDS (Minimum Data Set-An assessment tool), dated 11/11/21, indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) was 3, indicating her cognition was severely impaired. Record review revealed Resident 1 was transferred from an Acute Care Hospital to the nursing facility on 11/09/21. Discharge recommendations from the Acute Care Hospital on 11/09/21, indicated, [Resident 1] is a 93 Y (year-old) female with past medical history significant for [CONDITION(S)], [CONDITION(S)] (An eye disorder that causes blurred vision) .and dementia. Patient s/p (Status post) fall at home, admitted for left intertrochanteric (A type of hip fracture of broken hip) femur fracture. This document was provided by the Skilled Nursing Facility on 11/30/21 at 11:30 a.m. Record review revealed a facility document titled, Admission Summary, dated 11/09/21 at 9:24 p.m., which indicated, admitted a [AGE] year old female from [Acute Care Hospital] with fracture of left Femur due to Fall .Introduced to staff and roommate. Record review revealed a Nursing Note, dated 11/09/21 at 11:59 p.m., which indicated, Resident had an unwitnessed fall from bed Found resident the floor at the bedside lying on her right side, c/o (Complaint of) pain on her Left hip with a scale of 8 out of 10. Denies hitting her head. Resident stated that she tried to go to the bathroom without asking for help. Record review revealed a Health Status Note, dated 11/11/21 at 1:25 p.m., indicating, Resident had previous fall on 11/9/21 .On 11/11/21 patient started with complaint of pain to the R (Right) hip area .Per [Acute Care Hospital] MD (Medical Doctor) to do stat x-ray of R hip area .MD with new orders to send patient out to [Acute Care Hospital] due to results of x-ray stating that patient has a R (Right) femur FX (Fracture). A facility document titled, New Admission Report, dated 11/09/21, indicated Resident 1's primary diagnosis was, Fall-FX (Fall with fracture) L (Left) femur. This report was completed by Licensed Nurse A. During an interview on 11/30/21 at 11:30 a.m., Licensed Nurse A, admitting nurse for Resident 1 the evening of 11/09/21, stated being aware Resident 1 was at high risk for falls as she had fallen and fractured her left hip recently, according to the Acute Care Hospital documents. Licensed Nurse A stated she filled out a report titled, New Admission Report, on 11/09/21, indicating Resident 1 had a fracture and was at risk for falls and provided it to Licensed Nurse B, the assigned evening shift nurse for Resident 1. Licensed Nurse A stated she did not complete the baseline care plans for Resident 1. During an interview on 11/30/21 at 2:25 p.m., with Licensed Nurse B, evening shift nurse assigned to Resident 1 at the time of her arrival, she stated she was aware Resident 1 had suffered a fall at home which had resulted in a fracture, recently, and stated she gave the form titled, New Admission Report, which contained this information, to Licensed Nurse C, who was the night shift nurse assigned to Resident 1, upon change of shift report, but stated she could not recall verbally telling Licensed Nurse C about Resident 1's recent fall with fracture. During an interview on 11/30/21 at 12:15 p.m., Licensed Nurse C, night shift nurse assigned to Resident 1, stated Resident 1 suffered a fall at around 11 p.m., which was about an hour after her shift had started. Licensed Nurse C stated, by the time of Resident 1's fall, she had not had time to review Resident 1's chart, therefore she did not know her main diagnosis or the reason Resident 1 was admitted to the nursing facility. Licensed Nurse C stated Licensed Nurse B (Evening shift nurse) did not notify her that Resident 1 was at high risk for falls or had suffered a fall recently. Licensed Nurse C stated, if she had known Resident 1 was at high risk for falls, she would have initiated special interventions to prevent Resident 1 from falling, such as asking the assigned Certified Nursing Assistant to chart by Resident 1's door to perform visual checks on Resident 1, placing a floor mat by Resident 1's bedside, anticipating Resident 1's needs and rounding on her every 10 to 15 minutes. During an observation of Resident 1's room on 11/30/21 at 2:40 p.m., it was noted the room was in front of the nursing station, however, Resident 1's bed could not be visualized from the nursing station. During an interview with Licensed Nurse B and Licensed Nurse C on 11/30/21 at 2:30 p.m., Licensed Nurse C denied having received any forms or verbal information from Licensed Nurse B indicating Resident 1 was at risk for falls or had suffered a recent fall with fracture. The Administrator, who was also present during the interview, stated it was important not only to pass on a form with this information, but to verbally inform the oncoming nurse of the resident's risk for falls. Licensed Nurse B stated, by the time she found out Resident 1 was at risk for falls, Resident 1 had already fallen at the Skilled Nursing Facility. The facility policy titled, FALLS MANAGEMENT, last revised in November of 2012, indicated, It is the policy of this facility that our physical environment remains as free of accident hazards as possible. Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls.

Based on interview and record review, the facility failed to care plan, reassess, manage and carry out physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, Resident 1 suffered pain levels of 5-10/10 (The numerical pain scale is a tool to help assess a resident's pain, where a level of 0/10 means no pain, 5/10 is moderate pain, and 10/10 is the worst possible pain) at the facility on 21 days in March of 2019. Findings: Record review revealed Resident 1 was admitted to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated Resident 1 had a prior admission to the facility in 2014. Record review revealed Resident 1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . These notes also indicated Resident 1 suffered from Peripheral [CONDITION(S)] (The result of damage to one or more groups of nerves). During an interview on 10/01/21 at 9:30 a.m., the Director of Nursing (DON) stated Physician G no longer worked for the facility. Record review revealed Resident 1's MAR (medication administration record) for March of 2019, indicated Resident 1 had pain levels of 5/10 or above on the following days: 3/03/19, 3/04/19, 3/05/19, 3/06/19, 3/07/19, 3/10/19, 3/12/19, 3/14/19, 3/15/19, 3/16/19, 3/17/19, 3/18/19, 3/20/19, 3/21/19, 3/27/19, 3/28/19, 3/29/19 and 3/30/19. On 3/06/19, 3/12/19 and 3/18/19, Resident 1's pain level was documented as 10/10. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/01/21 at 10:53 a.m., Physical Therapist D, who remembered Resident 1, stated Resident 1's physical therapist sessions were conducted at 3:00 p.m., during her 2019 admission. Record review revealed Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give prior to therapy and QHS (Every bed time). While in the original physician orders, no specific time was documented for administration, in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . By the time Resident 1 had physical therapy, it had been seven hours since she had received Tylenol for pain, according to the documentation. Record review revealed Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation this medication was administered on an as needed basis, throughout the month of March, 2019, despite Resident 1's documented high pain levels. The Administrator was asked to provide all nursing care plans on pain, on 8/17/21 at 12:00 p.m. The care plans on pain provided by the Administrator during an e-mail on 8/19/21 at 1:14 p.m., had been initiated in 2014 and were not active in March of 2019. During an interview with the DON on 10/01/21 at 12:45 p.m., she stated that up to the present time, the facility did not reassess pain levels after the administration of Acetaminophen (A medication used to relieve pain). After review of Resident 1's MAR for 2019, the DON stated there was no way to know if Acetaminophen was effective in relieving Resident 1's pain. The DON stated when Licensed Nurses identified high pain levels in residents, they were required to administer a PRN (As necessary) pain medication, reassess for effectiveness of the medication, and if the pain was not relieved, notify the physician. The DON stated all these steps needed to be documented. During a second interview with the DON on 10/01/21 at 1:30 p.m., she stated she was unable to find an active care plan for pain during Resident 1's admission in 2019. The DON also stated she was unable to find any pain reassessments for Resident 1, during March of 2019. During a phone interview with Family Member BB, on 9/15/21 at 8:51 a.m., he stated he felt Resident 1's pain at the facility was not managed or controlled as she showed obvious signs of pain through facial expressions, in addition to verbally complaining of pain, including during her physical therapy sessions. The facility policy titled, PAIN MANAGEMENT, last revised in November of 2017, indicated, This facility recognizes a patient's right to be free of pain and promotes pain relief through the use of the Pain Management Plan during the patient duration of stay at a facility to help the patient attain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible .The licensed nurse communicates the adequacy of pain management and/or changes in pain significance to the physician at admission and as needed based on assessment and reassessment date throughout the patient stay .Pain is assessed at least every shift, when a patient complains of pain and after an analgesic (Medication used to relieve pain) is given to determine effectiveness of the analgesic .When pain is identified , assessment and documentation includes pain scale rating, location, duration, intensity and character .A plan of care is developed for patients, documented and updated as needed.

Based on interview and record review, the facility failed to promote the prevention of pressure ulcer (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) development for one of three sampled residents (Resident 1), due to lack of interventions, and creation and revision of care plans. As a result, Resident 1 acquired multiple skin conditions at the facility, including blisters to the left leg, blisters to the left ankle, and a deep tissue injury (DTI-An injury to the soft tissue under the skin due to pressure) to her left heel. Findings: Record review revealed Resident 1 was admitted to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated Resident 1 had a prior admission to the facility in 2014. Record review revealed Resident 1's MDS (Minimum Data Set-An assessment tool) dated 3/07/19 indicated Resident 1 needed extensive assistance of two staff with bed mobility, toilet use and personal hygiene. In addition, Resident 1's MDS, indicated she was frequently incontinent (Having no or insufficient voluntary control over urination or defecation) of urine. Record review revealed a facility document titled, Admit/Readmit Assessment COMS Integration 3-18, dated 2/28/19 at 9:09 p.m., indicated Resident 1 was admitted to the facility with an abrasion to the front area of the left lower leg. No other skin conditions were documented. This document also described the different stages of pressure ulcers (Injuries to skin and underlying tissue resulting from prolonged pressure on the skin), including, Suspected Deep Tissue Injury-Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy .Stage II-Partial thickness loss of dermis (The vascular, thick layer of the skin lying below the epidermis[outer layer of the skin]) presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum (The clear liquid part of the blood that remains after blood cells and clotting proteins have been removed)-filled blister. Record review revealed a Braden Scale (A tool that predicts the risk for developing a facility-acquired pressure ulcer of injury) dated 2/28/19 at 9:10 p.m., indicated Resident 1's score was 13, which indicated she was at moderate risk for development of pressure ulcers. During a phone interview with Resident 1's Family Member AA, on 8/03/21 at 9:30 a.m., Family Member AA stated she requested pressure relieving boots (A device that relieves pressure by suspending the heel in a cavity space and may be used for pressure ulcer prevention and treatment) for Resident 1 from the very beginning of her admission on 2/28/19. Family Member AA stated the reason for her request was because Resident 1 was unable to get up from bed on her own. Family Member AA stated facility staff declined her request stating they could not find any pressure relieving boots. Family Member AA could not remember the name of the staff they made this request to. During a phone interview with Resident 1's Family Member BB, on 9/15/21 at 8:51 a.m., Family Member BB confirmed the family requested pressure relieving boots for Resident 1 since admission in 2019, but the facility declined their request. Family Member BB also stated facility staff (unable to remember identify of staff) did not use any other type of device to keep pressure off Resident 1's feet, until she developed a pressure wound. Record review revealed Resident 1's document titled, Initial Baseline Care Plan V4 , dated 2/28/19 at 9:11 a.m., was left blank except for basic personal information, and prevention measures to manage anxiety. The following areas were left blank: A. Initial Goals, C. Nutrition, D. Therapy Services, E. safety, F. Social Services, G. Activities of Daily Living, H. Equipment, I. Special Treatments/Procedures, J. Bowel & Bladder, L. Skin Integrity Concerns (except for a statement that indicated Resident 1 had surgical impairment to the right knee), M. Medical Diagnosis/Requiring Care, O. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident/Family Review/Interventions. This baseline care plan was signed by MDS Nurse F. During an interview with MDS Nurse F on 10/01/21 at 11:49 a.m., she confirmed Resident 1's baseline care plan was mostly left blank, but stated she was only the one who closed the document in the facility's computerized charting program and not the person who filled it out. MDS Nurse F confirmed there was not enough information in the care plan to direct the care required for Resident 1. During a concurrent interview and record review on 10/01/21 at 10:40 a.m., Admission Nurse A reviewed Resident 1's Initial Baseline Care Plan and stated it was Inadequate, and added, If I see it, I do not know how to take care of the patient. Admission Nurse A also stated admission nurses had started to complete the baseline care plans in 2020 because prior to that, baseline care plans were not always filled out. First Skin Condition: Record review revealed a nursing note dated 3/21/19 at 11:24 p.m., indicated, open blister to posterior of L (Left) leg Length (cm [Centimeters]): 3.0 Width (cm): 2.0. Record review revealed a change of condition evaluation dated 3/21/19 at 11:13 p.m., indicated Resident 1's left leg was noted to have a darken area to posterior of leg which was observed and noted to be an open blister. There was no mention in this document if the wound was pressure acquired, or the stage (Wounds are staged based on how deep they are, which can affect their treatment) of the wound. This was confirmed by Wound Care Nurse B during an interview on 10/01/21 at 10:10 a.m. Record review revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's Treatment Administration Record (TAR) indicated this treatment was not documented as provided on 3/26/19 and 3/27/19 as ordered, as documentation was missing for the administration of the treatment on these days. This was confirmed by Wound Care Nurse B during an interview on 10/01/21 at 10:10 a.m. During an interview with Wound Care Nurse B, on 10/01/21 at 9:53 a.m., she stated a resident with a Braden score of 13 (Moderate risk for development of pressure injuries) and multiple comorbidities needed to have a Nursing Plan of Care developed for prevention of pressure injuries from admission. The Administrator was asked to provide all of Resident 1's nursing care plans for her 2019 admission on 8/17/21 at 12:00 p.m. Four care plans for pressure ulcers were provided through e-mail by the Administrator on 8/19/21 at 1:14 p.m. The first care plan for prevention of pressure wounds was initiated on 3/22/19 (Twenty-two days after admission to the facility based on the facility Face Sheet) and indicated, Resident noted with open blister to left posterior leg. The interventions in this care plan were the following, Avoid pressure to site .MD (Medical Doctor)/RP (Representative of patient) made aware .Monitor site daily and notify MD of any changes. No other interventions were included. This was confirmed by Wound Care Nurse B during an interview on 10/01/21 at 10:10 a.m. During a concurrent interview and record review on 10/01/21 at 10:02 a.m., Wound Care Nurse B stated the care plan initiated for Resident 1's blister to her left leg needed more interventions, was not resident-centered, and, Could be better. Second Skin Condition: Record review revealed a nursing note dated 3/23/19 at 9:30 p.m., indicated, resident on charting for COC (Change of condition) popped blister on left thigh and left ankle. Record review revealed a nursing note dated 3/24/19 at 3:34 a.m., indicated, blisters also forming on left ankle. The document did not indicate if these blisters were pressure related, the measurements or number of blisters, or the stage of the wounds. This was confirmed by Wound Care Nurse B during an interview on 10/01/21 at 10:10 a.m. Record review revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review disclosed the treatment administration record (TAR) for March of 2019 indicated this treatment was not documented as administered to Resident 1 on 3/27/19, as documentation of the administration was missing. This was confirmed by Wound Care Nurse B during an interview on 10/01/21 at 10:10 a.m. The Administrator was asked to provide all change of condition evaluations for Resident 1 on 8/17/21 at 12:00 p.m. The Administrator provided all change of condition evaluations on 8/19/21 at 1:14 p.m., by e-mail, but did not provide a change of condition evaluation for Resident 1's blisters on the left ankle first documented on 3/23/19 at 9:30 a.m. During an interview with Wound Care Nurse B on 10/01/21 at 9:37 a.m., she stated a newly discovered blister on a resident's skin was considered a change of condition and required a change of condition evaluation. Record review revealed a care plan on pressure ulcers, initiated on 3/23/19, indicated, Multiple small intact blisters to left foot ankle (anterior), and contained the following interventions, MD/RP made aware .monitor site q (Every) shift and notify MD of any changes .Treatment as ordered. There were no other interventions included. This was confirmed by Wound Care Nurse B during an interview on 10/01/21 at 10:10 a.m. During a concurrent interview and record review on 10/01/21 at 10:02 a.m., Wound Care Nurse B stated the care plan initiated for blisters on Resident 1's left foot, needed more interventions, was not resident-centered, and, Could be better. Third Skin Condition: Record review revealed a nursing note dated 3/27/19 at 6:37 p.m. indicated, DTI (Deep tissue injury to left heel) was painted with [MEDICATION(S)] (Antiseptic used for skin disinfection) and left it air dry. Record review revealed a change of condition evaluation dated 3/27/19 at 7:01 p.m., indicated Resident 1 had a deep tissue injury (DTI) on the left heel. This report did not describe the injury, or provide measurements of it. This was confirmed by Wound Care Nurse B during an interview on 10/01/21 at 10:10 a.m. Record review revealed a facility document titled, Skin & Wound Evaluation, dated 4/01/19 at 5:27 p.m., indicated Resident 1 had an in-house acquired pressure deep tissue injury to the left heel and provided the following measurements for the injury, Length 5.4 cm Width 5.2 cm. This document was created five days after the facility discovered the deep tissue injury to Resident 1's left heel, on 3/27/19. During an interview with Wound Care Nurse B on 10/01/21 at 10:02 a.m., she stated the document titled, Skin & Wound Evaluation, was required to be completed within twenty-four hours of discovering a skin condition. Record review revealed a care plan on pressure ulcers, created on 3/27/19 (Twenty-seven days after Resident 1's admission to the facility (based on the facility Face Sheet), and after developing a deep tissue injury to the left heel (based on a change of condition evaluation dated 3/27/19 at 7:01 p.m.,), indicated, Resident has high risk/or at risk for pressure ulcer development or skin impairment r/t Braden Scale Score of 13, impaired/Decreased mobility and Functional ability, PVD (Peripheral Vascular Disease), [CONDITION(S)], and included the following interventions, Identify/document potential causative factors and eliminate/resolve where possible .The resident needs [line left blank](specify: pressure relieving/reducing mattress, pillows, sheepskin, padding etc) to protect skin .Turn and repositioned as determined and as needed. The care plan did not document causative factors, and did not indicate what the resident needed to protect the skin, as the line to document it was left blank. This care plan did not mention Resident 1's DTI to her left heel. Record review revealed the DTI was documented for the first time the same day this care plan was created, on 3/27/19, based on a nursing note dated 3/27/19 at 6:37 p.m. During a concurrent interview and record review with Wound Care Nurse B on 10/01/21 at 10:02, she stated the care plan for prevention of pressure injuries created on 3/27/19 was, Better, but needed to have the blank areas filled out to indicate what Resident 1 needed to protect the skin. Record review revealed a care plan initiated on 5/22/19 (51 days after Resident 1 was discharged from the facility based on the discharge summary dated 4/01/19 at 11:41 p.m.) addressed the deep tissue injury to the left heel. Resident 1 was no longer at the facility at the time of the creation of this care plan. During an interview with Wound Care Nurse B on 10/01/21 at 9:41 a.m., she discussed the interventions that were appropriate to help a pressure wound heal. The interventions she mentioned included performing lab (laboratory work including blood tests) work for the resident, reevaluating the resident's diet with the Dietician, keeping the area clean, providing treatments as ordered, keeping bandages clean and intact, keeping pressure off the pressure injury area, and repositioning the resident often. These were not interventions included in Resident 1's care plans for pressure ulcer prevention. This was confirmed by Wound Care Nurse B during the interview. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Resident 1's TAR, this order was initiated on 3/01/19 but discontinued on 3/14/19, despite obtaining a score of 13 on a Braden scale assessment dated [DATE] at 5:08 p.m. Record review revealed a Braden scale assessment dated [DATE] at 5:08 indicated Resident 1 received a score of 13, which indicated she was at moderate risk of developing pressure ulcers. Record review revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated this order was not documented as carried out on 3/28/21, as documentation was missing for this assessment. This was confirmed by the Director of Nursing (DON) during an interview on 10/01/21 at 1:30 p.m., in which she stated she was unable to find documentation of a Braden Scale assessment having been performed on 3/28/19 on Resident 1. Record review revealed Resident 1's ADLs (Activities of Daily Living-Activities related to independent living) flowsheet for March, 2019, titled, Documentation Survey Report v2, indicated Resident 1 was assisted only one time with bed mobility on 3/03, 3/05, 3/06, 3/07, 3/10, 3/11, 3/12, 3/23, 3/25 and 3/31/19. There was no documentation indicating Resident 1 received assistance with bed mobility on 3/09/19 and 3/17/19. Record review revealed Resident 1's ADLs flowsheet for March, 2019, titled, Documentation Survey Report v2, indicated Resident 1 was provided urinary incontinence care only one time on 3/03, 3/05, 3/06, 3/07, 3/10, 3/11, 3/12, 3/23, 3/25 and 3/31/19. There was no documentation indicating Resident 1 received urinary incontinence care on 3/09/19 and 3/17/19. In summary, this document did not indicate Resident 1 received bed mobility assistance or urinary incontinence care for two time periods of 24 hours each (on 3/09/19 and 3/17/19). During a concurrent interview and record review on 10/01/21 at 11:15 a.m., with Unlicensed Staff C, after reviewing Resident 1's ADL flowsheets titled, Documentation Survey Report v2, for the month of March, 2019, she stated, This is neglect, referring to the lack of incontinence care and bed mobility assistance documented for Resident 1 for the month of March, 2019. Unlicensed Staff C also confirmed the missing documentation. During an interview on 10/01/21 at 10:10 a.m., Wound Care Nurse B stated Resident 1 may not have developed skin conditions, including the DTI, if risk factors for development of pressure ulcers had been identified sooner. Record review revealed the facility policy titled, PRESSURE ULCER RISK ASSESSMENT, last revised in November of 2012, indicated, A pressure ulcer risk assessment will be completed upon admission, with each additional assessment, quarterly, annually and with significant changes .Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly, to attempt to prevent pressure ulcers. Record review revealed the facility policy titled, CARE PLAN, Baseline and Comprehensive, last revised in November of 2017, indicated, 1. A baseline care plan will be implemented within 48 hours of admission. 2. Addresses immediate resident needs including initial goals based on admission .A comprehensive person-centered care plan consistent with residents rights will include measureable (Sic) objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments. Record review revealed the facility policy titled, CARE PLAN GOALS AND OBJECTIVES, last revised in November of 2012, indicated, Care plans will incorporate goals and objectives which lead to the resident's highest obtainable level of function.

Based on multiple observations, interviews, and record reviews, the facility failed to treat 7 of 26 residents in one hall of the facility with dignity and respect when: A. Resident 1 complained about not being fed or changed on 10/11/18 p.m. (3-11 p.m.) shift; B. Staff left one resident (Resident 2) lying in feces over 30 minutes while he repeatedly yelled out for help; C. Residents 4 and 5 complained about having to wait, hours to have their briefs (adult undergarment) changed; D. Call lights were on for over 30 minutes in three rooms, with Residents 2, 5, and 7 waiting for assistance; E. Call lights for two Residents (Residents 2 and 6) were tied up and out of reach; and, and F. Family Member Y stated she needed to be in the facility to assist Resident 8 due to a lack of timely response from staff to assist Resident 8 with meals and going to the bathroom. This failure left residents feeling, disrespected and neglected, like a second class citizens, worried about bed sores, and livid, when waking up cold and soaked in urine. Findings: During an interview on 10/18/18 starting at 11:40 a.m., Resident 1 stated on 10/11/18, he had been assigned a CNA (Certified Nursing Assistant) (Unlicensed Staff X). Resident 1 stated the facility was aware he had previously requested not to have Unlicensed Staff X take care of him. Despite his previous requests and his objection on 10/11/18, the CNA had been assigned to him. Resident 1 stated on 10/11/18 p.m. (3-11 p.m.) shift, he did not have his brief changed, and he had not been fed his dinner. Resident 1 stated facility management staff had asked him, then who will take care of you when Resident 1 had voiced his grievance with being assigned Unlicensed Staff X. Resident 1 stated his family had brought in food (Lasagna) from home earlier that day, but no one had fed him, and the food had to be thrown out. Resident 1 stated he felt disrespected and neglected by the facility. A facility document titled, physician progress notes [REDACTED]. The document revealed .patient requires assistance with all activities of daily living . The document revealed Resident 1, has the capacity to understand and make medical decisions. A facility document, untitled, dated initiated 9/23/16, provided by the facility on 12/3/18, as part of Resident 1's plan of care, revealed Resident 1, requires total staff participation in toilet use, and Resident 1, requires total staff participation to eat. Review of a Resident 1's MDS (Minimum Data Set) (an assessment tool), dated 9/25/18, revealed Resident 1 had a BIMS (Brief Interview of Mental Status) score of 15 (a score of 13-15 revealed a resident is cognitively intact; 15 is the highest score). A document titled, Nursing Staffing Assignments and sign-in sheet dated 10/11/18, 2 p.m.-10 p.m., revealed Unlicensed Staff X was assigned to Resident 1. Nine additional CNAs were in the facility for that shift. During an observation and concurrent interview with Resident 1, in a three-bed room, on 10/18/18 starting at 11:40 a.m., Resident 2 was lying in his bed with only an adult brief covering him. The brief was full of diarrhea. Diarrhea was leaking out of the brief and onto Resident 2's thighs. Resident 2 was holding a urinal which was full of urine. Resident 2 was yelling out, Help me, help me, over and over. Resident 2 was not able to reach his call light. His call light was wrapped up in the side rails of his bed behind him and out of his reach. Call lights were on in two rooms across the hall. No licensed or unlicensed staff were in the hallway. Activity staff was in the hallway, noted the call lights, and stated she would, get the CNA (Certified Nursing Assistant). The call lights remained on, and Resident 2 continued to yell, help me. Unlicensed Staff A entered the room. Unlicensed Staff A went to Resident 2 and took the urinal from him. During an interview next to Resident 2's bed, Unlicensed Staff A confirmed the call light was present but out of Resident 2's reach. Unlicensed Staff A confirmed Resident 2 needed a brief change. Unlicensed Staff A emptied Resident 2's urinal in the bathroom, left the room, and entered a room across the hall where the call light had been on. Resident 2 continued yelling for help. No other staff were in the hallway, during this time. Call lights in the rooms across the hall remained on. During an observation at 12:05 p.m., Unlicensed Staff B was in the hallway and entered Resident 2's room. Unlicensed Staff B went to Resident 2's bed, and stated, Oh. Unlicensed Staff B did not talk to, or assist, Resident 2. Unlicensed Staff B stated, These are not my rooms. The CNA is in room (across the hall) and will be here. Unlicensed Staff B left the room, leaving Resident 2, uncovered, lying in bed wearing a brief filled with diarrhea. Unlicensed Staff B turned the call light off in the room across the hall. Unlicensed Staff B did not assist the residents in the room. Unlicensed Staff B left the hall. During an observation at 12:08 p.m., Unlicensed Staff A entered Resident 2's room. Unlicensed Staff A took Resident 2's breakfast meal tray out of the room and left. No staff was in the hallway. At 12:11 p.m., Resident 2 stated, it's not fair, and continued to call out for help. During an observation at 12:12 p.m., Unlicensed Staff A entered Resident 2's room. Unlicensed Staff A assisted Resident 2 until 12:25 p.m. At 12:25 p.m., Unlicensed Staff A entered the room across the hall. The call light had been turned off by Unlicensed Staff B at 12:05 p.m., but no staff had assisted the resident until Unlicensed Staff A entered the room at 12:25 p.m. No other staff responded to the call lights during the time of the observation. Resident 2 was left soiled, uncovered, and calling for help for over 30 minutes (while the surveyor was in the room). During an interview on 10/18/18 at 12:45 p.m., Resident 3 (BIMS score 15, annual assessment, dated 11/11/18) stated the hallway was a, ghost town. Resident 3 stated there was, no staff, in that hall. During an observation and concurrent interview on 10/18/18 at 1:20 p.m., Resident 4 (BIMS Score of 15, quarterly assessment, dated 10/23/18) was in her bed. There was a strong urine odor in the room. Resident 4 stated there was, always urine odor in the room. Resident 4 stated, we have to fight to get changed. Resident 4 stated residents would have to wait four hours to get changed. Resident 4 stated call lights were a, joke. Resident 4 stated CNAs would say ,it's not my room or, it's not my assignment. CNAs would tell residents, I'll tell your CNA, turn the call light off and leave. No CNA would come to assist. Resident 4 stated on night shift (11 p.m. to 7 a.m.) she often would wait until 3 a.m. to see a CNA and get any type of assistance. During an observation on 10/18/18 at 1:55 p.m., call lights were on in two random residents' rooms. At 2:16 p.m., one unidentified licensed staff answered one of the call lights. The other call light remained on. During an interview on 10/18/18 at 2:20 p.m., Licensed Staff C stated CNAs had assignments but were, supposed to help all residents. During an interview on 10/18/18 at 2:21 p.m., Resident 4 stated the facility made her feel like, a second class citizen. Resident 4 stated it was, hard enough being an adult and having to deal with a diaper. Resident 4 stated it made her feel, bad. Resident 4 stated she, worried about bed sores. Resident 4 stated, the longer you sit around in diapers it really increases your risk, for developing bed sores. Resident 4 stated developing a bed sore was, one of my biggest fears. During an interview on 10/18/18 at 2:25 p.m., Resident 5 (BIMS score of 15, quarterly assessment, dated 8/14/18) stated she was, lucky to have her brief changed in the afternoon. Resident 5 stated she had, woken up, feeling cold, wondering why, she was cold. Resident 5 stated she had been, wet from my neck to my feet. Resident 5 had woken up because no staff had check on her or changed her brief. Resident 5 stated, when that happens, I'm livid. Resident 5 stated it was, anywhere from two to five hour wait before I get changed. When queried about asking for help and using the call light, Resident 5 laughed and stated, there is no one to ask. Resident 5 stated she could feed herself, but other residents needed assistance. (Resident 1 did not get fed and could not enjoy the food his family had brought a few days ago.) During an interview on 12/3/18 at 12:40 p.m., Family Member Y (FMY) stated she visited Resident 8 every day from 11 a.m. to 8 p.m. to assist Resident 8 with meals and up to the bathroom. FMY stated the facility had a lot of Unlicensed Staff who were from an agency. FMY stated the agency staff, don't know the residents and their routines. FMY stated she sometimes found Resident 8 wearing a wet brief when she arrived at 11 a.m., because Resident 8 had not been taken to the bathroom. FMY stated she assisted Resident 8 to the bathroom herself because Resident 8 would cry out if she had to wait a long time for assistance. FMY stated the CNAs, can't do it all. FMY stated, they have too many residents to take care off not enough help. During an interview on 12/3/18 at 12:25 p.m., Management Staff A stated, everyone answers call lights. During an interview on 12/3/18 at 1 p.m., Management Staff A stated CNAs were expected to assist all residents. CNAs were, expected to do what is needed not just their assignment. Management Staff A stated staff were, here to take care of all the residents. During an interview on 12/3/18 at 1:20 p.m., Unlicensed Staff D stated call lights should be answered, right away. During an interview on 12/3/18 at 1:22 p.m., Management Staff F stated CNAs were expected to work with the other CNA in the hallway. CNAs were expected to answer call lights and assist residents with, whatever is needed. Management Staff F stated the facility assigned CNAs to accommodate the resident's needs. During an observation and concurrent interview on 12/3/18 at 1:55 p.m., Resident 6 (BIMS score 14, quarterly assessment, 10/19/18) asked for assistance. Resident 6 attempted to use her call light. The call light was on the top of her bed above her left shoulder. Resident 6 attempted to reach the call light with her right hand. The call light was out of her reach. Resident 6's roommate turned on the call light. At 2:15 p.m., Unlicensed Staff E entered Resident 6's room, dropped off briefs, and left. During an observation and concurrent interview at 2:18 p.m., Unlicensed Staff E agreed the call light was out of Resident 6's reach. During an observation on 12/3/18 starting at 2:22 p.m., a call light was on in a random resident's room. No staff were in the hallway. One unidentified staff exited an office, walked down the hallway, past the call light, and exited the hallway. At 2:27 p.m., Unlicensed Staff E was in the hallway. Unlicensed Staff E did not answer the call light. At 2:28 p.m., Management Staff G, who identified herself as Social Services staff, exited one office and entered another office. Management Staff G did not answer the call light. At 2:32 p.m., Housekeeping Staff (HS) was in the hallway removing, Caution Wet Floor, signs from resident rooms. HS left the hallway and did not answer the call light. At 2:36 p.m., Licensed Staff entered the hallway with a medication cart and moved past the call light to the end of the hallway. At 2:37 p.m., Management Staff B entered the hallway. Management Staff B entered the resident's room to answer the call light. The call light was on for 15 minutes without staff responding. A facility document titled, Job Description - Titled: Certified Nursing Assistant (CNA), updated 8/2011, revealed, Duties and Responsibilities, 3. Ensures that all residents are treated fairly, with kindness, dignity, and respect, and their rights are protected at all times .6. Performs comprehensive resident care duties . 8. promptly answers call lights and provides appropriate responses to requests .12 assists with feeding as indicated. A facility document titled, Privacy/Dignity, dated revised 10/24/17, revealed, All employees shall treat residents' (sic) families and visitors, and fell ow workers with kindness, respect, and dignity. A facility document titled, Call light, Answering, dated Revised (MONTH) 2012, revealed, It is the policy of (facility name) that each resident call light will be answered in a reasonable and timely manner to meet the needs of the residents 2. make sure call cords are placed within the resident's reach at all times 3. All staff will promptly attend to residents requesting assistance. If the assigned nurse/aide is caring for another resident, another co-worker will answer the resident's call light.

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication error for two of 24 sampled residents (Resident 1 and 22) and one random resident (Random Resident 37) when: 1. Licensed staff failed to administer Insulin to Resident 22 and Random Resident 37 according to physician's orders [REDACTED]. According to the facility's list Diabetic Patients as of 01/21/2016, the facility had total of 59 residents who had diabetes and 49 of those 59 residents received Insulin. This failure also had the potential to cause 49 residents who received Insulin to have low blood sugar, coma, or death. IMMEDIATE JEOPARDY, (IJ), was identified on 1/21/16 at 3:25 p.m. under CFR 483.25(m)(2), Significant Medication Errors. The Administrator, Director of Nursing and Assistant Director of Nursing were present when the IJ was identified. The IMMEDIATE JEOPARDY was abated on 1/25/16 at 12:14 p.m. The Administrator, Director of Nursing, Assistant Director of Nursing, and the Regional Clinical Director were present when the IJ was abated. 2. Licensed staff administered 10 wrong medications to Resident 1. This failure caused Resident 1 to experience [MEDICAL CONDITION] (slow heartbeat with a pulse rate below 60 beats per minute), weakness, and shortness of breath (SOB) that required admission to an acute care hospital ICU (intensive care unit). Findings: 1. During an observation for medication pass on 1/20/16, at 7:40 a.m., Licensed Staff BB administered [MEDICATION NAME] Regular Insulin 2 units subcutaneously to Resident 22. Licensed Staff BB stated Resident 22 was her last resident to receive Insulin. Licensed Staff BB stated the breakfast tray would be delivered to the residents between 8 a.m. to 8:30 a.m. During an observation on 1/20/16, at 8:35 a.m. Resident 22 received the breakfast tray, which was 55 minutes after Resident 22 received the [MEDICATION NAME] Regular Insulin. The manufacturer's information for the physician on [MEDICATION NAME] Regular Insulin, dated 2015, indicated the injection of the Insulin should be followed by a meal within approximately 30 minutes of administration. Resident 22's admission record indicated Resident 22 was a type two diabetic (inability of the body to produce enough insulin to keep sugar in the blood from becoming too high). The physician's orders [REDACTED]. According to the interview and record review with the ADON on 1/25/16, at 2:50 p.m., there were total of 11 residents including Resident 22 who might have received Insulin from Licensed Staff BB. During an interview on 1/20/16, at 8:15 a.m., Licensed Staff CC stated she administered scheduled [MEDICATION NAME] Regular Insulin 12 units, NPH Insulin 15 units, and the [MEDICATION NAME] Regular Insulin 4 units per sliding scale to Random Resident 37 at 7:41 a.m. Licensed Staff CC stated the breakfast tray will be out soon. During an observation on 1/20/16, at 9:05 a.m., Random Resident 37 received the breakfast tray, which was one hour and 24 minutes after Random Resident 37 received the Insulin. Upon request for manufacturer's information for physician on [MEDICATION NAME] Regular Insulin, the facility provided the FDA (Food and Drug Administration) prescribing information for [MEDICATION NAME] Regular Insulin, dated 2011, indicated the injection of the Insulin should be followed by a meal within approximately 30 minutes of administration. Random Resident 37's admission record indicated Random Resident 37 was a type two diabetic. The physician's orders [REDACTED]. During an interview on 1/21/16, at 10:45 a.m., when asked about Insulin administration and Insulin acting time, Licensed Staff CC stated Regular Insulin acting at peak was approximately 15 minutes after administration and resident should receive a meal tray within 30 minutes. Licensed Staff CC stated NPH Insulin was long acting Insulin and acting at peak was approximately 35 minutes after administration. When asked the reasons for her to administer the Insulin to Random Resident 37 at 7:41 a.m. on 1/20/16 and the resident received the breakfast tray one hour and 24 minutes after the Insulin, Licensed Staff CC stated Really? The breakfast was out that late? During an interview on 1/22/16, at 9:38 a.m., the Director of Staff Development stated staff should follow the manufacturer's recommendation for Insulin administration. A meal 55 minutes or one hour and 24 minutes after Regular Insulin administration could have caused residents to have [DIAGNOSES REDACTED] (low blood sugar potentially lead to coma and death). During an interview on 1/25/16, at 11:22 a.m., the Administrator stated the facility did not have a specific policy and procedure for Insulin administration. The facility's policy and procedure titled MEDICATION ADMINISTRATION-GENERAL GUIDELINES, dated April 2008, indicated .Medications are administered in accordance with written orders of the attending physician .before or after meal orders, which are administered based on mealtimes . IMMEDIATE JEOPARDY, (IJ), was identified on 1/21/16 at 3:25 p.m. under CFR 483.25(m)(2), Significant Medication Errors. The Administrator, Director of Nursing and Assistant Director of Nursing were present when the IJ was identified. The plan of action was approved on 1/21/16, at 6:20 p.m. included: 1) All licensed staff would be re-educated regarding Insulin types, time requirements, and timing with meals prior to medication pass, 2) Insulin administration and blood glucose times would be changed to be administered shortly prior to meals per manufacturer's guidelines and included an alert to the nurses for Insulin administration, 3) Medical Director would assess residents who were involved as soon as possible, and 4) A full review of all residents who were diabetic would be completed by pharmacist and pharmacy nurse consultant. The IMMEDIATE JEOPARDY was abated on 1/25/16 at 12:14 p.m. when monitoring for the plan of action indicated staff were compliant with Insulin administration. 2. The Department's Intake Information form indicated the facility reported a medication error incident occurred on 6/8/15 involving Resident 1. Resident 1's admission record indicated that Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a concurrent interview with Assistant Director of Nursing (ADON) and Licensed Staff A on 6/17/15, at 9:30 a.m., the ADON stated that on 6/8/15 at around 11 a.m., Licensed Staff C prepared medications and handed the medications to Licensed Staff D. The ADON stated Licensed Staff D administered the medications to Resident 1. During the same interview, Licensed Staff A stated after Licensed Staff D administered the medications to Resident 1, both Licensed Staff C and D discovered that the medications were administered to a wrong resident. Licensed Staff A stated that Licensed Staff C said she told Licensed Staff D to give the medications to Random Resident 26 (by room number and bed letter), but Licensed Staff D said Licensed Staff C told her to give the medications to Resident 1 (by room number and bed letter). Licensed Staff A stated Resident 1's heart rate decreased to 38 beats per minute and was sent to a hospital emergency room at 6:45 p.m. due to the wrong medications. Licensed Staff A further stated that the nurse should not give the resident medications prepared by another nurse. During a concurrent observation and interview on 6/17/15, at 12:20 p.m., Resident 1 was in her bed and awake. Resident 1 stated she went to the hospital because she had difficulty of breathing and felt something was wrong with her heart. Resident 1 stated nobody told her about the wrong medications. She stated she received some medications in the hospital and she felt better. During a concurrent record review and interview on 6/17/15, at 2:55 p.m., Licensed Staff A reviewed Random Resident 26's MAR (medication administration record). She stated that Random Resident 26's 10 morning medications were incorrectly administered to Resident 1. The medications included: 1) Aspirin 81 mg (milligram) (a medication for pain, fever, inflammation and prevention of stroke), 2) [MEDICATION NAME] 100 mg (a medication for lowering blood pressure and heart rate), 3) B-Complex 1 tablet (vitamin supplement), 4) [MEDICATION NAME] 10 mg (a medication for allergies [REDACTED].>5) [MEDICATION NAME] 50 mg (a medication for lowering blood pressure), 6) [MEDICATION NAME] extended release 24 hour 240 mg (a medication for lowering blood pressure), 7) [MEDICATION NAME] 250 mg (a stool softener), 8) [MEDICATION NAME] Propionate Suspension (nasal spray for allergies [REDACTED].>9) [MEDICATION NAME] Sodium (a blood thinner) 5000 unit/ml (milliliter) inject one vial subcutaneously, and 10) Calcium 600+D Plus Mineral (calcium and mineral supplement) 1 tablet. Resident 1's MAR, dated 6/8/15, indicated Resident 1 also received her own morning medications including [MEDICATION NAME] (also known as [MEDICATION NAME], a medication for slowing the heart rate) 125 mcg (microgram), [MEDICATION NAME] 20 mg (a medication to decrease blood pressure), [MEDICATION NAME] 60 mg, [MEDICATION NAME] 20 mg (a medication for acid reflux), Iron-Vitamins one tablet (supplement), [MEDICATION NAME] 100 mg (a medication for gout, a form of acute inflammation of a joint), [MEDICATION NAME] 100 mg, Lactobacillus (a bacteria supplement for treating and preventing diarrhea), and Sennosides 8.6 mg (a medication for constipation). During an interview on 8/12/15, at 1:50 p.m., the ADON stated that she reviewed Resident 1's MAR and clinical chart. The ADON stated that according to the MAR, Resident 1 received her own morning medications on 6/8/15. She stated Resident 1 also received the 10 wrong medications on 6/8/15. During an interview on 6/17/15, at 12:30 p.m., the Administrator stated the two nurses made three mistakes during this medication error incident. He stated, 1) Licensed Staff C should not prepare the medications and give to another nurse to administer to the resident; 2) Licensed Staff D should not accept the medications prepared by another nurse; and 3) if Licensed Staff D accepted the medications, she should have checked the five rights (facility's Medication Pass Observation Review form, dated 10/31/10, indicated five rights: right resident, medication, dose, time, and route). The Administrator stated the two nurses did not follow the five rights and the medication pass process. He stated the medication error caused Resident 1 to be admitted to an acute care hospital for two to three days. He further stated that the two nurses were terminated from their positions. During an interview on 6/25/15, at 4 p.m., Licensed Staff D stated that on 6/8/15 at approximately 11 a.m., Licensed Staff C asked her to help to catch up medication pass. Licensed Staff D stated Licensed Staff C prepared the medications and asked her to give the medications to Random Resident 26 (by room number and bed letter), but she thought the medications were for Resident 1 (by room number and bed letter). Licensed Staff D stated she gave about 10 medications including supplement and [MEDICATION NAME] to Resident 1. She stated she did not know all the medications because she did not prepare the medications. Licensed Staff D stated after she administered the medications to Resident 1 and asked Licensed Staff C if they needed to give medications to Random Resident 26, they found out that Licensed Staff D gave the medications to a wrong resident. She stated they notified the nurse supervisor and the doctor and started monitoring Resident 1 for adverse effects. Licensed Staff D stated they (Licensed Staff C and D) breached the facility policy and procedure, which should recheck the five rights and do not give the medications prepared by another person. Resident 1's NURSE'S NOTE dated 6/8/15, indicated .at 6:30 pm, CNA (certified nursing assistant) reported that she can't get the blood pressure and resident complaint of SOB. Rechecked v/s (vital sign), unable to appreciate BP (blood pressure), O2 Sat (oxygen saturation, normal range 95-100%) was 94% on Oxygen @ 2LPM (litter per minute). Shortly after I administered her oxygen but her PR (pulse rate) was 37 and still complaint of SOB. Head of bed elevated. Called MD (medical doctor) and notified him that I have to send the resident to ER (emergency room ) for that reason . The acute care hospital discharge summary, dated 6/11/15, indicated Resident 1 was admitted to the hospital on [DATE] for treatment of [REDACTED]. Resident 1 was monitored in ICU. The cardiology consultant note dated 6/9/15, indicated Resident 1 was brought to the emergency room from a local skilled nursing facility for evaluation for complaint of generalized weakness .she was found to be bradycardic with her heart rate dropping into the 30s at times .has been feeling dizzy .The caregivers at the facility at which she resides .said that she may have gotten an extra dose of her calcium channel blocker earlier today . The cardiology consultant note under IMPRESSION AND PLAN, indicated A Fib (abnormal heart rhythm) with [MEDICAL CONDITION] related to medications, discontinue [MEDICATION NAME] and hold [MEDICATION NAME] for now, if difficult to control rate, pacemaker may be considered . During an interview on 8/11/15, at 3:45 p.m., Physician E stated the facility staff notified him of the medication error occurred on 6/8/15. Physician E stated that the [MEDICATION NAME] and [MEDICATION NAME] decreased the blood pressure and heart rate and caused Resident 1 to be sent to the acute care hospital and monitored in ICU. Physician E stated that Resident 1 was on [MEDICATION NAME], which increased the risk for lowering the heart rate. Physician E also stated that the [MEDICATION NAME] injection, which Resident 1 received by mistake, could cause Resident 1 to bleed to death. Physician E further stated that Resident 1 was also on anticoagulant (blood thinner) which was held after the medication error. He stated Resident 1 did not exhibit the side effect (bleeding) of the [MEDICATION NAME], but the risks were there. During an interview on 8/12/15, at 11:22 a.m., Resident 1's daughter stated that the facility staff notified her on 6/8/15 after they discovered they gave the wrong medications to Resident 1. She stated her mother was admitted to an acute care hospital ICU because of the wrong medications. She stated she felt so bad because her mother originally transferred to the facility from an acute care hospital ICU and she was back to ICU due to medication error. The facility policy and procedure titled MEDICATION ADMINISTRATION-GENERAL GUIDELINES, dated April 2008, indicated .Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label .Medications are administered in accordance with written orders of the attending physician .The person who prepares the dose for administration is the person who administers the dose .Residents are identified before medication is administered .The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given .

Based on observations, resident interview, staff interview, facility document review, and clinical record review, the facility violated the above regulation when it failed to implement its smoking policies and allowed a non-ambulatory resident with a mental disorder and limited judgment to possess cigarettes and lighters and to frequently smoke in bed unsupervised by staff for more than one year. These circumstances represented a fire hazard and endangered all 151 residents in the facility. On 7/2/14 at 3:46 p.m., a Department Representative met with the facility Administrator, the Director of Nurses, and the Assistant Director of Nurses and declared Immediate Jeopardy. A 4:10 p.m., the facility Administrator presented an acceptable written plan of correction. After observations revealed implementation of the plan of correction, the Department representative met with the Administrator and abated the Immediate Jeopardy on 7/2/14 at 4:13 p.m. Findings include: Observations on 7/02/14 at 11 a.m. revealed a sign at the entrance of the facility indicated, "THIS IS A TOBACCO-FREE & SMOKE FREE FACILITY." On 6/17/14 at 11:30 a.m., the initial review of Resident 1's clinical record reflected a care plan dated 6/27/13 indicated, "... SNF (skilled nursing facility) placement at young age, w/c (wheelchair) bound with contractures, evidence of confabulation ... presents with Borderline Personality traits, low intellectual functioning, and history suggests limited judgment and minimal insight into present situation and future." Plans dated 5/29/13 reflected a psychology assessment on that date indicated Resident 1, "... is not capable of making decisions for her healthcare at this time. Judgment is so impaired that she poses a safety and professional risk to the staff, as well as to herself." Observations on 6/17/14 at 12:50 p.m. revealed Resident 1 was in bed. Both lower extremities were severely contractured. The room was cluttered with clothing, pillows, linens, and personal items stacked on all furniture surfaces. There was a strong odor of tobacco in the room. During concurrent interview, Resident 1 said, "Yes I do smoke." Resident 1 stated the tobacco smell was from cigarette butts she kept in her purse. Observations revealed Resident 1 displayed a cigarette with the end broken off. When asked how she would light the cigarette butt, Resident 1 reached into her purse and obtained a lighter which she then ignited to display the flame. Review of medication administration records indicated Resident 1 received regular daily dosages of pain medications including Oxycodone, Methadone, Neurontin and Norco. Potential adverse drug interactions of these central nervous system depressants include increased sedation and drowsiness. (http://reference.medscape.com/drug-interactionchecker). A review of a care plan dated 3/5/13 indicated, "(Resident 1) at risk for incidents R/T (related to) narcotic use ... (resident) is non complian (sic) (compliant) with POC (plans of care) ie: if it is raining she stillwants (sic) to smoke depite includes (sic) to wait ...". Plans dated 6/27/13 indicated, "... Non-compliant with smoking policy and procedures ... Has habit of keeping trash (empty cigarette boxes & used cigarette (sic)". Plans dated 6/28/13 indicated, "Risk for smoking ... injury secondary to smoking in her room and bed. Resident has smoked in her room and putting it out in brief or flashing (flushing) (sic) it in the bathroom. (Resident 1) denies this but staff has been smelling smoke inside her room multiple times ... Evidence was presented (briefs with cigarette butts) ... Smoking P&P non-compliant, refuses to turn in cigarette and lighter. Wheels her self out to smoke after hours ...". Plans dated 11/20/13 documented a pattern of increase in behaviors when (Resident 1) doesn't have cigarette supplies On 6/19/14, a review of a facility document entitled, "Smoking Policy" dated 5/28/13 indicated, (Smoking is allowed only in the designated area and only during scheduled times ... Residents are not permitted to keep smoking materials, lighters, matches or any other related items in their possession ... Residents requesting to smoke will be required to wear a "smoking apron" designated to retard combustion ...). On 6/20/14, a review of physician's orders [REDACTED]. An order dated 3/15/14, "Explain to pt. the danger of smoking in bed including her burning in bed ...". Orders dated 3/15/14 indicated, "Continue to monitor smoking in the room. Monitor for cigarette smell coming from room every shift." On 7/2/14 at 1 p.m., during a second review of the clinical record, progress notes dated 1/9/14 documented, "She continues to be reported smoking in her room and this (writer) saw a lot of ashes on her bed ... her room smells like a cigarete." Notes of 2/16/14, 2/20/14, 2/26/14, 3/1/14, 3/7/14, 3/14/14, 3/15/14, 3/18/14, 3/19/14, 3/20/14, 3/21/14, 3/22/14, 3/23/14, 3/26/14, 3/31/14, 4/1/14, 4/3/14, 4/5/14, 4/12/14, 4/15/14, 4/19/14, 4/20/14, 4/22/14, 4/24/14, and 4/28/14 documented the smell of cigarette smoke coming from Resident 1's room. A review of progress notes of 3/12/14 indicated Resident 1 admitted to smoking in bed and stated, "I only took 2 hits that's all and I stop." Notes of 3/13/14 documented staff explained to Resident 1, "... that she is at highest risk to burn in her bed if she does not stop smoking in the bed." Notes of 3/15/14 at 11:56 p.m. indicated Resident 1 also had incense burning in her room. Notes of 3/19/14 indicated staff saw smoke in her room. Notes of 3/20/14 indicated, "... (Resident) is smoking in room, concerned (with) fire danger to self and facility." Notes of 3/21/14 indicated, ".. usual habit of smoking in her room ... refusing to let staff check all her bags where she keeps a lot of her belongings ...". Notes of 3/31/14 indicated, "Smelled smoke coming from her room ... re emphasized the danger of smoking inside the room, like putting herself on fire considering that she has bedsheets, linens all over her and her room full of clothes and not to mention fire which would jeopardize people (sic) life." Notes of 4/5/14 indicated, "Smell of cigarette smoke coming from room and ashes are on the blankets." and "Resident was found with smoke coming out of mouth/nose .. her cna (certified nursing assistant) saw her smoking in the (room) this afternoon with a lighted cigarette in her mouth and the cna was having difficulty breathing when she enter (room)." Notes of 4/11/14 indicated, "... reported numerous time and caught smoking in her room this week ... wouldn't give up her lighter ... This is putting the whole building at risk for possible fire and specially with her, of burning herself by secretly trying to smoke on her bed ...". Notes of 5/4/14 documented, "Discussed ... the dangers of smoking inside the room for her and other residents ...". Notes of 5/9/14 documented ashes in the bed. Notes of 5/20/14 indicated, "... continues to be reported as smoking in the room but very good at hiding it ... was ... bragging about how she can do anything she wants in that room." Review of a progress note of 5/31/14 at 4:28 p.m. indicated, "... smelled a very strong smell of smoke and noticed (Resident 1) was playing with a towel as if she was putting out the fire ... there was a small burnt mark on the towel with ashes everywhere ... when searching her room we were not able to find (her lighter)." Notes of 6/2/14 indicated, "... she has been continually been secretly smoking inside her room and she has been wrapping it inside a wet towel so she won't be caught by nursing staff every time they come to check her ... how big risk it is that she is putting the facility and the rest of the patients in this building because of her non-compliance." Notes of 6/19/14 indicated, "... on-going cigarette problem ... and risk of fire with all her clothes just laying beside her and not willing to lock it up nor hang it in the proper place ..." and, "... resident smoking in the front. I asked her to please smoke in the smoking patio and reminded her not to smoke in her room due to the hazard of possibly starting a fire in her room. I also asked her if she had a lighter and she stated that she did not have one and that she uses other residents." A review of care plan revisions dated 1/9/14 indicated, "... Now she is refusing to submit her cigarettes again once she gets her new supplies. Continues reported strong smell of cigarettes in her room and (staff member) seeing lots of ashes on her bed but adamantly denies it still ...". Written interventions included, "... Install 2 smoking alarms in her room; continues monitoring and if staff sees smoke or smells smoke in her room to immediately get inside the room and correct patients behavior." Revisions dated 3/14/14 indicated, "refused more and more to get out of bed and despite all education continues to smoke in the bed ..." Revisions dated 3/15/14 indicated, "... resident admitted she smokes in bed ... Two requests made to niece not to hand resident cigarettes and lighters and explained risk of pt catching fire". A review of the medication administration record for the month of May 2014 indicated Resident 1 was smoking in her room on at least 75 occasions. There were 19 occasions during day shift, 44 occasions during evening shift, and 12 occasions during night shift. The records for June of 2014 indicated Resident 1 had been smoking in her room on 15 occasions between 6/1/14 and 6/16/14. During interview on 6/16/14 at 2 p.m., the facility administrator stated, "She (Resident 1) will smoke in her room. You smell it. She refuses to wear a smoking apron." During interview on 6/16/14 at 2:25 p.m., when inquiry was made as to smoking in bed, Resident 1 stated, "you see how long it takes them to get me up. If they don't do it (get me up), I'm gonna do it (smoke in bed)." During interview on 7/2/14 at 11:10 a.m., the facility administrator stated there was no evidence Resident 1 continued to smoke in her room after the Department visit on 6/17/14. However, review of the medication administration records for June of 2014 indicated staff smelled smoke coming from Resident 1's room on three occasions on 6/29/14. A review of care plans reflected no further care interventions had been designed. Observations on 7/2/14 at 11:20 a.m. revealed Resident 1 was reclined in her wheelchair and smoking a lighted cigarette in the parking area in front of the building. Resident 1 was holding a lighter. Resident 1 was not wearing a smoking apron. A sign posted in the area indicated, "SMOKING PROHIBITED IN THIS AREA." About a minute later, a direct care staff member arrived with a smoking apron and moved Resident 1's wheelchair to another area of the parking lot. During concurrent interview, Resident 1 stated she keeps her own cigarettes in her bag. Resident 1 stated she usually smokes outside unsupervised. During interview on 7/2/14 at 12 noon, the Administrator stated Resident 1 still keeps her own cigarettes. The Administrator stated staff cannot search Resident 1's bags for cigarettes and lighters. Observations on the smoking patio on 7/2/14 at 3:05 p.m. revealed random residents holding personal bags containing packs of cigarettes and lighters. When Resident 1 needed to light her cigarette, she borrowed a lighter from another resident. During interview, a random resident stated he got the cigarette he was holding from, "a friend" and he thought the smoking rules were, "stupid." During an interview on 7/2/14 at 3:10 p.m., Licensed Staff Member A stated she smelled cigarette smoke coming from Resident 1's room the evening before at about 11 p.m. On 7/2/14 at 3:46 p.m., a Department Representative met with the facility Administrator, the Director of Nurses, and the Assistant Director of Nurses and declared Immediate Jeopardy. At 4:10 p.m., the facility Administrator presented an acceptable written plan of correction. After observations revealed implementation of the plan of correction, the Department representative met with the Administrator and the Immediate Jeopardy was abated on 7/2/14 at 4:13 p.m.