Every finding on record at South Hills Rehabilitation Center

Based on interview and record review it was determined the facility failed to ensure resident discharge planning processes were implemented effectively for 1 of 3 residents (# 95) reviewed for discharges. This placed residents at risk for inefficient and delayed discharges. Findings include:Resident 95 was admitted to the facility on [DATE] with diagnoses including stroke. An undated NOMNC was issued indicating the resident's skilled stay would end on 12/31/25 which was signed by the resident on 12/30/25. A 12/29/25 Social Services Note revealed a friend was searching for a memory care opening and would contact the facility to send a packet for review. A 12/31/25 Progress Note revealed the resident had mild dementia features. On 1/1/26 the resident started paying out of her/his personal funds for care. A 1/5/26 document on facility letterhead revealed a 12/24/25 cognitive assessment with global deficits, moderate cognitive impairments, consistent with dementia. Record review revealed from 12/29/25 through 1/11/26 no documentation related to discharge efforts for Resident 95 other than two requests asking the provider to switch to oral medication instead of insulin injections to make memory care placement possible. The provider declined these requests because of the amount of insulin Resident 95 needed. A 1/12/26 Social Services Note revealed a packet concerning Resident 95 was sent to a facility for their review. A 1/16/26 Social Services Note revealed another packet was sent to another facility for their review. A 1/19/26 Social Services Note revealed they faxed a packet to an assisted living facility (ALF), and requested orders be filled out. Signed orders were not completed until 1/21/26. A 1/21/26 Discharge Evaluation revealed the resident was eager and felt safe and ready to leave the facility for a memory care unit. A 1/30/26 Nursing Note revealed the resident was moved upstairs for long term care until the family found placement. There was no documentation to explain why the resident was not discharged . A 2/16/26 Progress Note revealed the resident would be evaluated by a memory care facility on 2/17/26. Discussed with the DNS that changing from insulin to oral medication was not probable as the resident was stable with insulin. A 2/17/26 Nursing Note revealed a facility came to evaluate the resident. There was no additional documentation from 2/18/26 through 2/24/26 related to discharge, including what the evaluation revealed or why the other facility did not accept the resident. A 2/25/26 Progress Note revealed staff found new placement. The resident was pleasantly confused but aware she/he was leaving and was excited to move. A 3/2/26 Nursing Note revealed the resident signed the discharge papers and medication was sent with the resident. A 3/3/26 Discharge Evaluation Note listed the wrong facility the resident was discharged to and mirrored the 2/25/26 note. On 7/23/2026 at 1:23 PM Witness 5 (Complainant) stated there were multiple concerns and delays related to the resident's discharge. She/he stated the facility stopped communicating at points, wouldn't respond timely when asked to provide documentation and wouldn't consider switching the resident to oral diabetic medication instead of insulin. The resident was privately paying for care and Witness 5 felt the facility was financially exploiting Resident 95 with their delays. Witness 5 provided documentation of e-mail exchanges with the facility about delays, lack of follow up and willingness of an outside provider to take the resident off insulin. On 7/23/26 at 4:04 PM Staff 23 (Business Office Manager) stated on 1/1/26 the resident switched to private pay when her/his insurance stopped. Resident 95 had to pay $550 per day for care because she/he did not qualify for Medicaid. Staff 23 stated she recalled the family wanted the resident to discharge to memory care, but she/he was insulin dependent. Facility staff approached the physician to try to switch but she wouldn't due to it being unsafe for the resident and the memory care facilities wouldn't accept the resident on insulin. On 7/23/2026 at 6:18 PM Staff 1 (Former Interim Administrator) stated he recalled something related to difficulties with the resident's insulin and why the resident wasn't able to discharge. He indicated the family and friends thought the facility was holding up the resident's discharge, but they were trying to get the resident placed. Staff 1 stated he would try to find out more about the discharges. 07/27/2026 11:08 AM Staff 57 (Company Administrator/Interim Social Services Director) stated it took approximately two to three months for the resident to discharge. Staff 57 didn't know why but there were a lot of staff who stopped working at the facility. On 7/28/2026 at 9:55 AM Witness 6 (Executive Director) stated the facility staff were not helpful getting information to their facility. There were months of communication back and forth with the previous administrator, the family, and other facility staff. Witness 6 stated the resident was discharged on insulin, and she/he was concerned with the facility's lack of coordination of Resident 95's care. On 7/28/26 at 10:15 AM Staff 1 stated there were inconsistencies with Resident 95's discharge and he could not provide any additional information to explain the inconsistencies. He stated he would expect the discharge to be thorough and as short as possible to ensure the resident did not continue amassing daily costs.

Based on interview and record review it was determined the facility failed to revise care plans and involve and inter-disciplinary team in the care planning process for 2 of 7 sampled residents (#s 10 and 13) reviewed for care planning and dental. This placed residents at risk for unmet needs. Findings include: 1. Resident 10 was admitted to the facility in 3/2026 with diagnoses including Post Traumatic Stress Disorder and depression. The 3/31/26 admission MDS indicated Resident 10 had a BIMS score of 15 (cognitively intact). The 4/29/26 comprehensive care plan indicated Resident 10 was to discharge home or another facility. Staff are to discuss the discharge planning process, encourage residents to discuss feelings and concerns regarding discharge, and monitor for psychosocial changes related to the anticipated discharge. The 6/2/26 care plan indicated Resident 10 expressed a desire to remain in the facility for long-term care. On 7/20/26 at 10:08 AM, Resident 10 stated she/he was able to clearly communicateher/his needs. On 7/22/26 at 2:31 PM, Staff 32 (LPN) stated Resident 10 was alert and oriented and able to clearly communicate her/his needs. Staff 32 stated Resident 10 wanted to remain at the facility for long-term care and had expressed concern about having to discharge. Staff 32 stated Resident 10 felt she/he was not being heard. On 7/22/26 at 2:58 PM, Resident 10 stated she/he did not want to discharge from the facility and was frightened by the possibility of discharge because she/he had no place to go. On 7/22/26 at 4:12 PM, Staff 4 (Social Worker) stated she recently discussed Resident 10's discharge goals but the care plan had not been revised. On 7/28/26 at 10:58 AM, and 12:22 PM, Staff 1 (Administrator) and Staff 3 (Regional Nurse Consultant) reviewed Resident 10's medical record and confirmed the care plan was not accurate. Staff 3 acknowledged the facility failed to revise Resident 10's comprehensive care plan to accurately reflect her/his current communication abilities and expressed goal to remain in the facility for long-term care. 2. Resident 13 was admitted to the facility in 12/2025 with diagnoses including schizophrenia (a severe mental illness) and metabolic encephalopathy (brain dysfunction caused by changes in body chemistry). The 6/24/26 Quarterly MDS indicated Resident 13 had a BIMS score of zero and was severely cognitively impaired. A 3/12/26 State Medical Power of Attorney (POA) and Advance Directive revealed Witness 2 (Family Member) was Resident 13's POA for health care. A 5/15/26 IDT (Interdisciplinary Team) Care Plan Conference Evaluation revealed Resident 13 recently readmitted to the facility, Witness 2 was unable to attend the care conference and Staff 4 (Former Social [NAME] Director) was the only staff in attendance. No information was documented related to Resident 13's care. On 7/20/26 at 11:58 AM, Witness 2 stated there was a lack of communication from the facility related to Resident 13's care and she/he was unaware who to contact to obtain updated care information. On 7/24/26 at 9:31 AM, Staff 4 stated e-mails were sent to remind team members to attend resident care conferences and required staff often did not attend. Staff 4 confirmed resident care conferences lacked staff participation and feedback. 07/28/26 at 10:07 AM, Staff 2 (Interim DNS) stated she expected a minimum of three separate team disciplines represented at every resident care conference.

Based on observation, interview and record review it was determined the facility failed to assess, develop, reassess and implement a person-centered care plan for dementia care needs to ensure resident safety for 4 of 4 sampled residents (#s 1, 2, 3, and 4) reviewed for elopement. As a result, Resident 1 left the faciity on [DATE] without staff knowledge, had an incident involving her/his power wheelchair getting stuck outside on [DATE], and on [DATE] left the facility again, which placed the resident at risk for serious injury. Resident 1 lacked a comprehensive assessment and person-centered care plan for her/his dementia with Lewy bodies. There were no interventions developed and implemented to ensure the appropriate supervision and monitoring were in place to prevent an injury. Resident 1 was found deceased on [DATE] less than one mile from the facility and constituted substandard quality of care. A determination was made that the facility's noncompliance placed Resident 1 in immediate jeopardy, beginning [DATE]. On [DATE] at 12:10 PM, Staff 1 (Administrator) Staff 2 (DNS), Staff 4 (Regional Nurse Consultant), and Staff 48 (Regional Director of Clinical), were notified of the immediate jeopardy situation and provided a copy of the IJ template related to the facility's failure to assess Resident 1 who was a wander risk with diagnosis of dementia. Findings include:The facility's Elopements and Wandering Residents policy and procedures dated 7/2026, stated that residents who exhibit wandering behavior and/or are at risk for elopement receive appropriate interventions to attempt to mitigate accidents or elopements .The facility shall establish and utilize a systematic approach to be alert for and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary .The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Adequate supervision will be provided to help prevent accidents or elopements. The facility's Accident Hazard/Supervision/Devices policy and procedures undated, stated that the facility will provide an environment that is as free of accident hazards as is possible and provide supervision and assistance devices to avoid preventable accidents .Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks related to hazards in the environment. Interventions will be modified when necessary .Evaluation of hazards and accident risk data, which may include prior accidents/incidents and trends .Interventions will be based on the results of evaluation and analysis of information related to hazards and risks. 1. Resident 1 was admitted to the facility in 6/2026 with diagnoses including depression, hallucinations, and dementia with Lewy bodies (symptoms can include thinking speed, understanding, judgment, visual perception, hallucinations, changes between alertness and confusion which can happen unexpectedly). a. On [DATE] at 11:58 AM, Staff 6 (CNA) stated Resident 1 left the faciity on [DATE] due to a hallucination involving a party she/he wanted to attend and required staff assistance to return. b. On [DATE] at 8:22 AM, Staff 12 (CNA) stated on [DATE], Resident 1 was outside and got her/his power wheelchair stuck in the facility's garden area. Staff 12 stated the resident required assistance to get removed from the area. c. A Progress Note dated [DATE] at 11:11 PM, indicated Resident 1 was missing around 7:45 PM on [DATE] and staff last saw her/him at 4:30 PM. Police arrived around 10:00 PM to assist with the search for Resident 1. Resident 1's clinical record included admission documents from Resident 1's previous discharge location as follows: -An undated Summary Report indicated Resident 1 had severe physical limitations and recent cognitive decline. Resident 1 had a recent diagnosis of dementia with hallucinations and required 24-hour supervision to manage her/his hallucinations. Resident 1 was identified as a high fall risk due to cognitive impairment and total immobility. Resident 1 experienced frequent visual hallucinations three to four times a week, which required staff reassurance and redirection. Resident 1's cognitive status appeared stable, and she/he required a consistent environment to manage anxiety related to hallucinations. Resident 1 was considered independent in decision-making and could communicate her/his needs. -A [DATE] Assessment Summary indicated Resident 1 had hallucinations that began in 11/2025 and had been transferred to the emergency room a couple of times. Resident 1's hallucinations occurred approximately three to four times a week. Resident 1 reported difficulty navigating due to poor vision and poor depth perception, and Witness 2 (Family Member) stated Resident 1 could not navigate her/his wheelchair outside independently. Physicians had informed Resident 1 she/he should not use her/his wheelchair outside unassisted due to impaired cognition. Resident 1 stated she/he went outside once a month and needed staff assistance when she/he became stuck navigating corners or going through gates. The facility's [DATE] admission Evaluation indicated Resident 1 was care planned at risk for wandering with interventions to monitor location as necessary and attempt diversional activities. A [DATE] Occupational Therapy Evaluation and Plan of Treatment indicated Resident 1 had recent cognitive decline, impaired safety awareness, and limitations due to impaired attention. Resident 1's cognitive impairment was identified as a barrier likely to affect discharge planning. Resident 1's Care Plan dated [DATE] indicated she/he was at risk for elopement behaviors. On [DATE], Resident 1's elopement behaviors resolved. Resident 1's care plan did not include any person-centered care needs related to the resident's dementia with Lewy bodies or hallucinations in order to identify specific interventions to ensure the resident's safety. Resident 1's [DATE] Physician Orders indicated the resident was prescribed memantine (a medication to treat dementia) 5 mg at bedtime for dementia with hallucinations. Resident 1's admission MDS dated [DATE] indicated Resident 1 was severely cognitively impaired, with a BIMS of 5, and suffered from long-term hallucinations. Resident 1 had dementia and was able to communicate needs and had adequate vision. Resident 1 was dependent on all care and had a fall prior to admission. Resident 1's 6/2026 Cognitive Loss Dementia CAA stated the resident had a diagnosis of neurocognitive disorder with Lewy bodies, and the resident was able to communicate and make her/his needs known. Resident 1's CAA was not comprehensive and did not address the needs, functional status, strengths, weakness and goals related to the resident's dementia. Staff witness statements dated [DATE] indicated Resident 1 was last seen between 3:00 PM and 4:30 PM. Staff began searching for Resident 1 around 5:00 PM to 5:30 PM. A Resident Leaving the Facility investigation dated [DATE] indicated Resident 1 had dementia with Lewy bodies and longstanding history of hallucinations and psychosis. The facility's investigation noted Resident 1 currently had mild cognitive decline, with decreased hallucinations due to the use of memantine, and only one instance of exit seeking and wandering on [DATE]. Staff 7 (Resident 1's CNA) stated Resident 1 made no statements about leaving the facility and easily returned to the facility. Staff 7 indicated that based on her interactions with Resident 1, Staff 7 did not feel the resident had wandered in a confused capacity. Staff 7 provided education to Resident 1 about the risks of being outside in her/his power wheelchair. The investigation included a statement regarding Resident 1 being found deceased on [DATE], which indicated abuse and neglect was ruled out. The investigation noted that Resident 1 was appropriately evaluated upon admission and was found to be a low risk for elopement. On [DATE] at 7:49 AM, Witness 2 (Family) stated on [DATE] he had talked to Resident 1 and the resident was stating she/he had gone outside because there was a little lost boy. Witness 2 stated Resident 1 had significant visual impairment, was only able to see approximately ten feet and was unable to move her/his head. On [DATE] at 12:47 PM, Staff 7 (LPN) stated Resident 1 was found in her/his motorized wheelchair on [DATE] approximately a block away. On [DATE] at 12:53 PM, Staff 8 stated around 8:00 PM on [DATE] she was working downstairs and a person came into the building and reported Resident 1 was down the street. Staff 8 stated Resident 1 appeared confused and frustrated due to wanting to find a party and not knowing how to get there. On [DATE] at 10:19 AM, Staff 37 (Nurse Practitioner) stated Resident 1 appeared cognitively intact during her two visits with the resident and stated the resident's dementia medication would not improve cognition in a meaningfully way. On [DATE] at 10:43 AM, Staff 31 (LPN) stated she had completed Resident 1's admission assessment and Resident 1 appeared cognitively intact and was not able to recall Resident 1 having a history of hallucinations or a diagnosis of dementia. On [DATE] at 11:05 AM, Staff 34 (Physical Therapist) stated if a resident navigated their wheelchair into a flower bed, supervision should occur until cognitive assessments such as a MoCA (cognitive impairment screening tool) of SLUMS (screening tool for mild cognitive impairment) were completed. Staff 34 stated these types of assessments were not completed for Resident 1. On [DATE] at 12:45 PM, Witness 7 (Anonymous Staff) stated Resident 1 knew she/he was not supposed to go outside without someone supervising her/him. Witness 7 stated staff were not checking residents' BIMS score, as required. On [DATE] at 2:00 PM, Witness 11 (Pharmacist) stated memantine was used to slow the decline of dementia with hallucinations, not restore cognition. On [DATE] at 8:39 AM Staff 23 (LPN Unit Manager) stated dementia with Lewy bodies required a personalized care plan due to fluctuating cognition. Staff 23 confirmed Resident 1 could present fully cognitive while having low safety awareness due to her/his dementia. Staff 23 stated she had not completed a dementia and hallucination-related care plan for Resident 1. There was no documented evidence to show Resident 1's cognitive abilities and safety were re-assessed after [DATE] when the resident left the facility and after [DATE] when the resident got her/his power wheelchair stuck outside in a garden area. At the time of the [DATE] elopement, no further assessment or care plan revisions were in place to ensure Resident 1's safety. On [DATE] a 1:53 PM, an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions:-The interdisciplinary team (IDT) identified every current resident with a diagnosis of dementia, BIMS of 8 or less, wandering behavior, exit-seeking behavior, or previous elopement risk.-Each identified resident received an immediate comprehensive nursing re-assessment, including current cognitive status, wandering/exit-seeking behaviors, supervision requirements, wheelchair safety (if applicable), and ability to safely leave the facility.-Physician notification was completed for residents whose re-assessment identified a need for changes in supervision or interventions.-Care plans were revised to reflect individualized supervision needs and person-centered interventions.-All facility entrance and exit doors remain secure with functioning locking mechanisms requiring staff intervention before residents may exit the building, consistent with the facility's elopement response plan.-The DNS and IDT completed an audit of all residents with dementia diagnosis, Alzheimer's, Lewy body dementia, vascular dementia, cognitive impairment, BIMS less than 8, documented wandering, exit-seeking behaviors, and previous elopement.-Every resident with a dementia experiencing any significant event within the last 30-days will receive an IDT re-assessment.-Beginning on [DATE], all staff will be provided mandatory education on dementia assessments, identifying significant change, re-assessment of resident incidents, individualized supervision, care planning, wandering vs exit-seeking, notification requirements, notification, resident-specific interventions and elopement definitions. -QAPI, audits, and continued monitoring for compliance will be conducted weekly for four weeks by the DON or designee. On [DATE] at 2:06 PM, the IJ was removed as confirmed by onsite verification by the surveyor. Following the removal of the immediacy, the remaining noncompliance continued at the scope and severity of actual harm that is non immediate jeopardy. 2. Resident 2 was admitted to the facility in 11/2025 with diagnoses including dementia with behavioral disturbance, and delusional disorders. An admission MDS dated [DATE] indicated Resident 2 was severely cognitively impaired. Resident 2's 11/2025 Cognitive Loss Dementia CAA noted impairment, placement on palliative care (care focused on comfort), and therapy goals to achieve possible improvements. The resident's CAA was not comprehensive and did not address the needs, functional status, strengths, weakness and goals related to the resident's dementia. Resident 2's Care Plan dated [DATE] indicated the resident was at risk for elopement and had impaired visual function. Resident 2's care plan did not address or identify interventions related to the resident's dementia care needs. On [DATE] at 1:48 PM, Staff 15 (CNA) stated she wished she knew resident's cognitive abilities when working with them. On [DATE] at 9:03 AM, Staff 23 (LPN Unit Manager) stated residents' dementia care plans needed to be more detailed. 3. Resident 3 was admitted to the facility in 4/2026 with diagnoses including dementia. A [DATE] admission MDS indicated Resident 3 was moderately cognitively impaired. Resident 3's 4/2026 Cognitive Loss Dementia CAA indicated she/he was able to make needs known, asked for assistance when needed, and had a BIMS score of 12. The resident's CAA was not comprehensive and did not address the needs, functional status, strengths, weakness and goals related to the resident's dementia. A [DATE] Follow-up Note indicated Resident 3 had dementia, deconditioning, and fall risk remained high. Resident 3 had a fall on [DATE] and [DATE]. Resident 3's Care Plan dated [DATE] indicated the resident was at risk for elopement and a fall risk. Resident 3's care plan did not address or identify interventions related to the resident's dementia care needs. On [DATE] at 11:16 AM, Resident 3 entered from the door adjacent to the smoking section and stated she/he had gone to the store. Resident 3 stated it takes her/him a couple of hours to get there and back to the facility. On [DATE] at 11:11 AM, Staff 21 (CNA) stated she was Resident 3's assigned CNA and was not aware of the resident's supervision needs and was unaware she/he left the faciity on [DATE] to go to the store. On [DATE] at 11:50 AM, Staff 23 (LPN Unit Manager) stated CNA staff were expected to know the location of their assigned residents, she would at least expect before and after meals and as needed. If they did not know the resident location, they should see if they had signed out of facility. 4. Resident 4 was admitted to the facility in 7/2020 with diagnoses including schizophrenia. A Psychiatry Progress Note dated [DATE] indicated Resident 4 had vascular dementia (memory-thinking changes caused by reduced blood flow to the brain). A [DATE] MDS indicated Resident 4 had severe cognitive impairments and dementia. Resident 4's Care Plan revised on [DATE] indicated the resident was an elopement risk due to impaired cognition and previous history of wandering. Resident 4's care plan did not address or identify interventions related to the resident's dementia care needs. On [DATE] at 9:03 and [DATE] at 10:00 AM, Staff 23 (LPN Unit Manager) stated residents' dementia care plans needed to be more detailed. Staff 23 stated Resident 4 had a temporary decline in 3/2026 and was currently moderately impaired. On [DATE] at 1:53 PM, Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Regional Director of Operations) were informed of the findings related to the lack of comprehensive assessments and person-centered care plans for residents with dementia. Staff 3 stated residents' assessments and care plans were not comprehensive for residents with dementia. Staff 1 and Staff 2 provided no additional information.

Based on interview and record review it was determined the facility failed to develop, implement, and maintain an effective training program related to behavior health care and services for 1 of 1 training program reviewed for staff training. This placed residents at risk for unmet behavioral health care needs. Findings include: Review of the facilities annual and new hire staff training revealed no behavioral health care training.On 7/15/26 at 12:30 PM Staff 4 (Regional RN) verified the facility did not have a behavioral training program in place.On 7/15/26 at 12:33 PM Staff 1 (Administrator) stated the facility cared for a large number of residents with behavioral concerns.

Based on interview and record review it was determined the facility failed to develop assessments that were comprehensive and failed to complete assessments in a timely manner for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) reviewed for MDS assessments. This placed residents at risk for unassessed and unmet care needs. Findings include: 1. Resident 1 was admitted to the facility in 6/2026 with diagnoses including depression, cataracts, contracture of foot, hallucinations, dementia with Lewy bodies (symptoms can include thinking speed, understanding, judgment, visual perception, hallucinations, changes between alertness and confusion without warning, slow movement, stiff limbs, unsteadiness, fainting and swallowing problems.) Resident 1's 6/12/26 CAAs indicate the following for each care areas: -Delirium CAA indicated the resident suffered from long-term hallucinations and monitors were in place for adverse reactions. -Visual Function CAA indicated the resident had cataracts in both eyes and could obtain an eye appointment if she/he chose. -Functional Abilities CAA indicated the resident was dependent on all ADLs, working with therapy, and required set-up for eating. -Urinary Incontinence indicated the resident was dependent on all care and could not move much. -Fall CAA indicated the resident had a fall prior to admit, was on high-risk medications which could increase risk for falls, and monitors were in place. -Psychotropic Drug Use CAA indicated the resident was taking medication for depression. Resident 1's CAAs were not comprehensive and did not include the resident's needs, strengths, goals, risk factors, or preferences. The resident's assessments did not document any findings and decisions to develop an individualized care plan. On 7/15/26 at 11:56 AM, Staff 43 (Former MDS Coordinator) stated she felt Resident 1's CAAs were comprehensive. 2. Resident 2 was admitted to the facility in 11/2025 with diagnoses including dementia with behavioral disturbance, and delusional disorders. Resident 2's 11/28/25 CAAs indicated the following for each care areas: -Functional Abilities CAA indicated the resident was at risk, needed assistance with most ADLs, and was working with therapy. -Psychotropic Drug Use CAA was blank with no documentation. Resident 2's CAAs were not comprehensive and did not include the resident's needs, strengths, goals, risk factors, or preferences. The resident's assessments did not document any findings and decisions to develop an individualized care plan. On 7/15/26 at 12:01 PM Staff 43 (Former MDS Coordinator) stated she felt Resident 2's CAAs were comprehensive enough for a CAA and covered a broad spectrum. 3. Resident 3 was admitted to the facility in 4/2026 with diagnoses including dementia. Resident 3's 4/10/26 CAAs indicated the following for each care areas: -Functional Abilities CAA indicated the resident required assistance with ADLs and was working with therapy to regain strength and balance. -Psychotropic Drug Use CAA indicated the resident took medication for depression. -Cognitive Loss/Dementia CAA indicated the resident was able to make needs known, asked for assistance when needed, and had a BIMS score of 12. Resident 3's CAAs were not comprehensive and did not include the resident's needs, strengths, goals, risk factors, or preferences. The resident's assessments did not document any findings and decisions to develop an individualized care plan. On 7/15/26 at 12:02 PM, Staff 43 (Former MDS Coordinator) stated she thought Resident 3's CAAs were comprehensive and the assessment covered the majority of stuff. On 7/15/26 at 1:53 PM, Staff 3 (Regional Director of Operations) confirmed residents' CAAs were not comprehensive. 4. Resident 4 was admitted to the facility in 7/2020 with diagnoses including schizophrenia. Resident 4's Annual MDS dated [DATE] had been completed on 7/14/26, which was overdue by 8 days. On 7/15/26 at 12:03 PM, Staff 43 (Former MDS Coordinator) verified Resident 4's Annual MDS had been completed late. 5. Resident 5 admitted to the facility in 4/2026 with diagnoses including heart failure. Resident's 5's Progress Note dated 5/29/267 indicated Resident 5 started hospice services. Resident 5's Significant Change in Status Assessment MDS was completed on 6/26/26, which was 14 days overdue. On 7/15/26 at 12:07 PM, Staff 43 (Former MDS Coordinator) verified the resident's 6/10/26 SCSA MDS was 14 days late.

Based on interview and record review it was determined the facility failed to notify the resident's representative for 1 of 4 sampled residents (#1) reviewed for elopement. This placed resident representatives at risk for lack of notification and participating in treatment decisions. Findings include:Resident 1 was admitted to the facility in 6/2026 with diagnoses including depression, cataracts, contracture of foot, hallucinations, dementia with Lewy bodies. a. On 7/9/26 at 11:58 AM, Staff 6 (CNA) stated on 7/3/26 at around 8:00 PM she noticed Resident 1 was missing. Resident 1 had gone about a block away and was in the street. On 7/9/26 at 12:47 PM, Staff 7 (LPN) stated on 7/3/26 at around 8:00 PM, she noticed Resident 1 as missing. Resident 1 was approximately a block away in her/his motorized wheelchair. Staff 7 did not feel it was a resident elopement and did not report the incident. On 7/9/26 at 7:49 AM, Witness 2 (Resident 1's Representative) stated he was never notified of Resident 1 eloping from the facility on 7/3/26. There was no documented evidence Witness 2 was notified of Resident 1's elopement from the facility on 7/3/26. On 7/15/26 at 1:56 PM, Staff 2 (DNS) stated she would expect Witness 2 to be contacted for the 7/3/26 elopement. b. On 7/13/26 at 8:22 AM, Staff 12 (CNA) stated she was informed by another facility resident that Resident 1 was outside and needed help. Staff 12 stated she observed Resident 1 by the street sidewalk and had her/his power wheelchair stuck in a flower bed. Staff 12 stated other staff assisted the resident, and she reported the incident to the nurse on duty. On 7/9/26 at 7:49 AM, Witness 2 (Resident 1's Representative) stated he was never notified of Resident 1's incident on 7/4/26. There was no documented evidence Witness 2 was notified of Resident 1's incident on 7/4/26. On 7/15/26 at 1:56 PM, Staff 2 (DNS) stated she would expect Witness 2 to be contacted for the 7/4/26 incident. c. A Progress Note dated 7/6/26 at 11:11 PM by Staff 2 (DNS) indicated Resident 1 was missing from the facility around 7:45 PM on 7/5/26. Staff reported last seeing the resident at 4:30 PM. Staff 1 (Administrator) was notified and police arrived around 10:00 PM to assist with the search. On 7/9/26 at 7:49 AM, Witness 2 (Resident 1's Representative) stated the facility notified him after Resident 1 had been missing for four hours. He indicated Resident 1 left the facility at approximately 4:00 PM and they did not contact him until approximately 8:00 PM. On 7/9/26 at 1:48 PM, Staff 15 (CNA) stated she noticed Resident 1 was missing on 7/5/26 at approximately 5:00 PM and it was a chaotic day. Staff 15 stated she reported Resident 1 was missing.

Based on interview and record review, it was determined the facility failed to submit a potential allegation of neglect in a timely manner to the State Agency for 1 of 3 sampled residents (#1) reviewed for elopement. This placed residents at risk for allegations of neglect not being investigated in a timely manner. Findings included:Resident 1 was admitted to the facility in 6/2026 with diagnoses including depression, cataracts, contracture of foot, hallucinations, swan neck deformity, dementia with Lewy bodies. The facility's Incident Report dated [DATE] indicated Resident 1 eloped from the facility on [DATE] and was found three days later on [DATE] deceased . A [DATE] FRI was received by the State Agency on [DATE]. Resident 1 left the faciity on [DATE]. The FRI was submitted to the State Agency three days late. On [DATE] at 1:47 PM Staff 2 (DNS) stated she didn't report Resident 1's elopement because she did not believe it was an elopement. Staff 2 stated she would expect the facility to report incidents of elopements to the State Agency.

Based on interview and record review it was determined the facility failed to ensure an accurate assessment was completed for 1 of 5 sampled residents (#5) reviewed for MDS assessments. This placed residents at risk of unassessed needs. Findings include: Resident 5 admitted to the facility in 4/2026 with diagnoses including heart failure. Resident 5's 5/29/26 signed Hospice Care Plan indicated Resident 5 was at end of life. The 6/10/26 SCSA MDS Section J, indicated Resident 5 was not at her/his end of life. On 7/15/26 at 12:07 PM Staff 43 (Former MDS Coordinator) verified the 6/10/26 SCSA MDS assessment was inaccurate.

Based on observation, interview and record review it was determined the facility failed to ensure the resident's environment remained free from accident hazards for 1 of 5 sampled residents (#2) reviewed for elopement. This placed residents at risk for elopements and accidents. Findings include: Resident 2 was admitted to the facility in 11/2025 with diagnoses including dementia. A 3/30/26 Quarterly MDS indicated Resident 2 was severely cognitively impaired. A Care Plan, revised 5/22/26, indicated Resident 2 was at risk for elopement (leaving without permission) and had a history of attempts to leave the facility unattended. Interventions included an elopement prevention device and verifying placement every shift. Resident 2's 6/28/26 Physician Orders, indicated the resident had a Wander Guard (a device used to monitor movement) on the left ankle, with instructions to monitor placement every shift, which started on 12/7/25. There was no documented evidence Resident 2's Wander Guard was regularly checked for its functionality. On 7/13/26 at 10:03 AM, Staff 17 (CNA) stated nurses had asked CNAs to verify if Resident 2's Wander Guard was in place. Staff 17 stated she had not checked for functionality of the residents wander guard. On 7/14/26 at 9:03 AM, Staff 23 (LPN Unit Manager) stated checking for functionality was not a protocol of the facility. The facility had not realized checking the functionality was a task they were supposed to complete. On 7/15/26 at 1:55 PM, Staff 4 (Regional Nurse Consultant) stated functionality checks for WanderGaurds might not appear in a resident's clinical record and may be completed by maintenance. Staff 4 stated she would check for the report. No additional information was provided.

Based on interview and record review it was determined the facility failed to designate a staff member responsible for the coordination of hospice care for 1 of 1 sampled resident (#5) reviewed for hospice. This placed residents at risk for uncoordinated hospice care. Findings include: Resident 5 admitted to the facility in 2/2026 with diagnoses including heart failure.Resident 5's 7/14/26 Care Plan indicated the resident was on hospice. There was no documented evidence found in Resident 5's clinical record that identified a designated staff member who was responsible for coordinating care between the facility and with hospice. On 7/15/26 at 11:28 AM, Staff 44 (LPN/Unit Manager) stated the main contact for hospice staff was the charge nurse on duty that shift and the IDT team as a whole oversaw the resident's general care. Staff 44 further stated she was not the care coordinator for any hospice resident, and the facility did not have a designated care coordinator between hospice and the facility for Resident 5.

Based on observation and interview the facility failed to ensure a safe, clean, and homelike environment in a shower room for 1 of 2 halls reviewed for environment. This placed residents at risk for injuries and an unhomelike environment. Findings include: On 4/9/26 at 1:25 PM, an observation was completed with Staff 1 (Administrator) of the first-floor shower room, which identified the following:-Four broken tiles with missing pieces were noted in the shower floor. On the shower floor were three holes containing a black sludge-like substance and standing water. The fourth hole by the shower entrance contained gravel and/or rocks of various sizes. -Four holes in the shower wall near the soap dispenser container.-Black coloring noted in one corner of the shower going up along the caulking measuring approximately four to five inches and from the side to the bottom measuring approximately two inches. Other random areas of caulking around the shower had a black coloring over the caulking. On 4/9/26 at 1:26 PM, Staff 1 acknowledged the broken/cracked tiles, black sludge in the holes, the holes in the wall, and the random black coloring on the caulking around the shower and would get it fixed right away.

Based on observation and interview it was determined the facility failed to ensure food was palatable for 1 of 1 kitchen reviewed for food services. This placed residents at risk for poor food quality. Findings include:On 4/9/26 at 9:50 AM, Resident 4 stated the food was horrible and a lot of us will refuse our trays because we can't stand to eat it. On 4/9/26 at 10:01 AM, Resident 26 stated the food was pretty terrible. On 4/9/26 at 4:10 PM, Resident 27 stated the food was awful. On 4/9/26 at 10:19 AM, Staff 9 (CNA) stated residents had complained about the taste of the food. On 4/9/26 at 1:32 PM, Staff 20 (Kitchen Manager) stated she occasionally received complaints regarding the palatability of the food and reported increased complaints related to meals prepared by the cook for that day's lunch. On 4/10/26 at 9:36 AM, Staff 22 (CNA) stated the food was horrible, it is rotten and usually too tough for residents to cut. On 4/10/26 at 11:27 AM, Staff 23 (CNA) stated residents had complained about the taste of the food. On 4/9/26 at 11:53 AM, a sample meal tray was tested and found the lunch meal of pork sausage, noodles with butter, cooked spinach and spiced peaches were bland and unpalatable. On 4/9/26 at 12:15 PM, Staff 1 (Administrator) acknowledged the noodles and spinach were bland.

Based on interview and record review the facility failed to assess skin wounds and administer medications per physician orders for 3 of 10 sampled residents (#s 1, 4 and 25) reviewed for medications and skin conditions. This placed residents at risk for worsening skin wounds and adverse medication side effects. Findings include:1. Resident 1 admitted to the facility in 6/2024 with diagnoses including malnutrition. Resident 1's 6/4/24 Care Plan indicated Resident 1 had the potential for skin integrity impairment and had a history of skin tears. Resident 1's 5/25/25 Progress Note revealed a left elbow skin tear. Resident 1's 11/24/25 Progress Note revealed a skin tear to her/his right hand. Review of Resident 1's clinical record found no documented evidence a skin assessment or evaluation had been completed for the resident's skin tears on 5/25/25 or 11/24/25. On 4/10/26 at 11:10 AM, Staff 2 (DNS) verified comprehensive skin assessments were not completed for the 5/25/25 and 11/24/25 skin tears. 2. Resident 25 admitted to the facility in 12/2025 with diagnoses including diabetes. Resident 25's 3/31/26 Care Plan indicated Resident 25 had diabetes and was insulin dependent. On 3/3/26 at 3:44 PM, the State Agency received a public complaint regarding a concern related to insulin. The facility's 2/27/26 Medication Error form indicated Staff 17 (RN) administered an extra dose of insulin to Resident 25. On 4/9/26 at 10:10 AM, Staff 18 (LPN/Unit Manager) stated Resident 25 received an extra dose of insulin on 2/27/26. Staff 18 stated Staff 4 (LPN) was working on a new admission and did not finish documenting in the DAR for Resident 25. Staff 17 (RN) arrived on shift, saw Resident 25's insulin was due and administered her/his insulin. On 4/9/26 at 10:30 AM, Resident 25 stated she/he had received a second dose of insulin on 2/27/26. On 4/10/26 at 12:48 PM, Staff 2 (DNS) stated Resident 25 was monitored and she/he had no outcome from the additional administration of insulin. On 4/13/26 at 9:42 AM, Staff 17 (RN) stated on 2/27/26 Staff 4 (LPN) asked her to chart on Resident 25. Staff 17 stated she thought Staff 4 wanted her to administer insulin to Resident 25. Staff 17 stated she administered a second dose of insulin to Resident 25. Attempts to contact Staff 4 were made on 4/12/26 at 10:10 AM and 4/13/26 at 9:43 AM and were unsuccessful. On 4/13/26 at 3:00 PM, Staff 1 (Administration) and Staff 2 (DNS) acknowledged physician orders were not followed for Resident 25's insulin administration. 3. Resident 4 was admitted to the facility in 1/2023 with diagnoses including bilateral knee osteoarthritis and anxiety disorder. Resident 4's Physician Order dated 5/20/25 revealed an order for methadone HCI 10 mg tablet (an opioid used for pain reduction) 1.5 tablets (15 mg) every morning and noon, and 1 tablet (10 mg) every evening. Resident 4's Physician Order dated 11/7/25 revealed an order for clonazepam 0.5 mg tablet (an anti-anxiety medication) 1 tablet PRN for anxiety and not to exceed three tablets in a 24-hour period. Resident 4's Medication Error forms dated 11/17/25 and 11/22/25 revealed Resident 4 was administered 15 mg of methadone at the evening dose instead of the ordered 10 mg dose. Resident 4's Medication Error forms dated 11/20/25 and 11/23/25 revealed Resident 4 was administered four tablets of clonazepam on 11/20/25 and on 11/22/25. On 4/13/26 at 3:45 PM, Staff 2 (DNS) acknowledged the clonazepam and methadone medication errors. Staff 2 stated Resident 4's MAR was updated to require nursing staff to document the total number of tablets administered within a 24-hour period. Additionally, Resident 4's methadone cards were clearly labeled to specify which card was to be used for the morning and noon doses and which card was to be used for the evening dose.

Based on record review and interviews it was determined the facility failed to follow physician's orders for 3 of 5 (#s 1, 3, and 5) sampled residents reviewed for critical lab values and medication errors. The facility failed to follow physician's orders on [DATE] to send Resident 1 to the Emergency Department after a critical lab value was received. The resident died on [DATE]. This put residents at risk for medication errors and death. Findings include: 1. Resident 1 admitted to the facility in 1/2026 with diagnoses including multiple fractures of the spine and kidney disease. A [DATE] admission MDS indicated Resident 1 was cognitively intact. Review of Resident 1's medical record indicated a critical lab value for low red blood cell count was called in to the facility on [DATE] at 12:35 PM. A hospital communication note written by Staff 3 (On Call Physician) on [DATE] at 1:48 PM indicated Staff 3 was aware of the critical lab value for Resident 1, Staff 3 completed a virtual assessment of Resident 1 and ordered Resident 1 to be sent to the Emergency Department (ED) for a possible blood transfusion. During an interview on [DATE] at 12:17 PM, Staff 5 (LPN) stated when she arrived for her shift (2-10 PM) on [DATE] the morning nurse, Staff 4 (Agency LPN), was speaking with Staff 3 about Resident 1 on an iPad. Staff 5 heard Staff 3 tell Staff 4 to send the resident to the ED, and to call her/his family. Staff 5 stated she heard Staff 3 ask to speak with the resident and Staff 4 took the iPad to the resident's room. Staff 5 stated when Staff 4 returned from the resident's room, she began gathering the necessary paperwork to send Resident 1 to the ED. Staff 5 stated Staff 4 did not inform her of the critical lab value or the need to complete Resident 1's transfer to the ED. Staff 5 stated during her shift she noticed Resident 1 was still in her/his room and assumed she/he had refused the transfer to the ED but did not ask Resident 1. Staff 5 stated Staff 7 (Certified Occupational Therapy Assistant) told her of Resident 1's low blood pressure the evening of [DATE] and she told Staff 7 to give the resident a drink of water. Staff 5 stated she gave Resident 1 medication for nausea twice throughout the evening of [DATE]. Staff 5 stated when she left her shift on [DATE] Resident 1 was communicative and responsive. During an interview on [DATE] at 12:55 PM, Staff 4 stated on [DATE] at 1:50 PM she received a call from the lab regarding a critical value for a low red blood cell count for Resident 1 and she called Staff 3 for further guidance. She stated Staff 3 spoke with Resident 1 via an iPad and completed a virtual assessment. Staff 4 stated Staff 3 told her to send Resident 1 to the ED via non-emergent transport, and Staff 3 would call the hospital to inform them Resident 1 would be coming into the ED. Staff 4 stated when she asked Staff 6 (LPN), what it meant to be non-emergent for a transport, she was told it meant the resident could be sent to the ED at any time. Staff 4 stated she wrote a nurses note and left the transfer for Staff 5 to complete on the next shift. No order for sending Resident 1 to the ED was found in Resident 1's medical chart. A nursing note was found to have been written on [DATE] at 1:28 PM (the next day) by Staff 4. The note indicated a critical lab value was called in to the facility on [DATE], she called Staff 3, Staff 3 assessed the resident, and ordered Staff 4 to send Resident 1 to the ED. During an interview on [DATE] at 2:17 PM, Staff 6 stated on [DATE] Staff 4 asked her about sending residents out via non-emergent transport. She stated she assisted Staff 4 by defining the term and finding the phone number of who to call for the transport. Staff 6 stated when she came in for her shift at about 5:45 AM on [DATE] the night shift nurse informed her Resident 1 had just died. Staff 6 stated she was not aware Resident 1 was who Staff 4 was asking about on [DATE]. A progress note dated [DATE] at 5:50 AM indicated Resident 1 died. During an interview on [DATE] at 4:37 PM, Staff 7 stated on [DATE] she informed Staff 5 of a low blood pressure reading for Resident 1 as well as changes in cognition, increased fatigue, nausea, and pale skin. She stated the nurse told her to have the resident drink water and retake the blood pressure. Staff 7 stated when Staff 5 heard the new blood pressure reading, Staff 5 stated she was no longer concerned. Staff 7 stated she did not see Staff 5 assess Resident 1 after hearing Resident 1's symptoms. During an interview on [DATE] at 1:43 PM, Staff 3 stated she was called by Staff 4 on [DATE] at 1:48 PM regarding a critical lab value for Resident 1. Staff 3 stated she completed a virtual assessment and spoke with Resident 1 who told her she/he wanted to go to the ED. Staff 3 stated she told the resident she would be sending her/him to the ED that day ([DATE]) for assessment and a possible blood transfusion. Staff 3 stated she told Staff 4 to have Resident 1 sent to the ED via non-emergent transport and called the ED to inform them about Resident 1's upcoming arrival and plan of care. Staff 3 stated her order was very clear to send Resident 1 to the ED, she expected Resident 1 to go to the ED for a transfusion, and she did not know Resident 1 was not sent to the ED as ordered. During an interview on [DATE] at 2:12 PM, Staff 2 (DNS) acknowledged at the time of the incident on [DATE], Staff 4 did not write a progress note regarding the critical lab value notification, did not put in Staff 3's verbal order to transport Resident 1 to the ED, did not act on the transport to ED order, and did not put in a progress note regarding Staff 3's verbal order to send Resident 1 to the ED. She stated her expectation for all nursing staff was for them to report all critical labs to the provider, receive guidance from the provider, inform the resident, act on the guidance from the provider, and then write a progress note. She stated her expectation for nurses was for them to put all verbal orders into the computer, follow the order as given by the provider, and then write a progress note. 2. Resident 3 was admitted to the facility in 1/2026 with diagnoses including sepsis (a life-threatening reaction to infection). A [DATE] physician order indicated Resident 3 received Cefazolin (antibiotic) every eight hours. The 1/2026 MAR indicated Resident 3 received ceftriaxone (antibiotic) every eight hours. A [DATE] FRI indicated Resident 3 was admitted with orders for Cefazolin, but the orders were transcribed as ceftriaxone. Resident 3 was administered the wrong antibiotic 11 times. On [DATE] at 12:42 PM, Staff 2 (DNS) acknowledged the errors regarding Resident 3's medication administration. 3. Resident 5 was readmitted to the facility in 1/2026 with a diagnosis including PTSD (Post-Traumatic Stress Disorder). A [DATE] physician order indicated Resident 5 received quetiapine (antipsychotic) 100mg in the morning and at bedtime. A [DATE] FRI indicated during a care conference meeting for a GDR (Gradual Dose Reduction), it was noted Resident 5 was administered more quetiapine than ordered. Orders changed on [DATE] to receive 300 mg at bedtime and to discontinue the 100mg morning administration. The morning medication was not discontinued. On [DATE] at 12:42 PM, Staff 2 (DNS) acknowledged the errors regarding Resident 3's medication administration.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#208) reviewed for medications. This placed residents at risk for unmet treatment needs. Findings include:Resident 208 was admitted to the facility in 7/2025 with diagnoses including diabetes and diabetic kidney complications. The 9/2025 DAR instructed staff to administer insulin glargine twice a day for diabetes management. During the 8:00 AM administration, Staff 5 (LPN) documented Resident 208 was absent from the facility without her/his medications on five occasions.On 11/21/25 at 1:05 PM, Staff 5 (LPN) stated Resident 208 left the facility before her shift began and returned in the afternoon following dialysis. Staff 5 reported she did not know what the night nurse had completed or whether insulin was sent with the resident to the dialysis appointment. On 11/24/25 at 10:18 AM, Staff 28 (Regional Nurse) stated she would expect the physician to be involved in developing a clinical plan for insulin administration while the resident was out of the facility.

Based on interview and record review it was determined the facility failed to provide respiratory care and services for 1 of 3 sampled residents (#201) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs. Findings include:Resident 201 was admitted to the facility in 12/2024 with diagnoses including chronic respiratory failure. A physician order dated 12/22/24 instructed staff to administer oxygen at three liters per minute continuously, every shift. A Physical Therapy Treatment Encounter Note dated 12/31/24 indicated Staff 20 (Former Physical Therapist Assistant) entered Resident 201's room and found the oxygen concentrator was not on. Resident 201's oxygen level was at 88 percent. After oxygen was administered, the level increased to 93 percent. A public complaint was received on 2/25/25, which alleged when Resident 201 was returned to her/his room, staff did not turn on her/his oxygen concentrator. Several hours later, Staff 20 came into the room and found the concentrator off. On 11/21/25 at 10:02 AM, Staff 20 confirmed the note was accurate and the oxygen concentrator was off when entering Resident 201's room on 12/31/24. On 11/24/25 at 10:17 AM, Staff 1 (Administrator) confirmed staff were expected to follow physician orders for Resident 201's oxygen use.

Based on observation, interview, and record review it was determined the facility failed to implement infection control practices to prevent the spread of clostridioides difficile (c-diff, a bacterium that can cause severe diarrhea and inflammation of the colon) for all residents, staff, and visitors for 1 of 1 sampled resident (#78). This failure, determined to be an Immediate Jeopardy situation, placed all residents, staff, and visitors at risk for exposure to c-diff, which is highly contagious and can cause serious illness, including life-threatening colitis and death. Findings include:The online reference CDC Preventing C-Diff. revealed the best way to prevent the spread of C-Diff from person to person was for all healthcare workers to wash their hands with soap and water before and after touching contaminated surfaces and for proper disinfection of bleaching surfaces. The online reference CDC How C-Diff. spreads revealed any surface, device or material that becomes contaminated with feces could serve as a reservoir for C- Diff spores. C- Diff spores can transfer to patients by the hands of healthcare personnel who have touched a contaminated surface or item. C-Diff can live on inanimate surfaces for up to five months. A contaminated wheelchair becomes a vector for transmission to other residents, staff, and visitors. The online reference CDC The Progression of C-Diff. Infection revealed C-Diff can be colonized, but the bacteria itself can be spread through spores even in the absence of detectable toxin levels. Resident 78 admitted to the facility on [DATE] with diagnoses including C-Diff, weakness, and nicotine dependence. A review of the 7/29/25 Hospital Discharge Summary revealed Resident 78 had a diagnosis of C-Diff. The C-Diff DNA revealed it was positive, and the toxin was negative (can indicate colonization rather than active infection). The resident was to continue with oral antibiotics through 8/5/25 and was to be on isolation enteric precautions (including PPE gloves and a gown, disinfect all equipment used before it left the room and hand washing with soap and water prior to exit of the room). A review of the 7/30/25 Smoking Safety Assessment revealed the resident was assessed for smoking safety and was deemed independent, able to smoke in the designated smoking area at the facility. A review of the facility floor plan revealed the designated smoking area for the residents was located on the second floor of the facility. The 7/30/25 care plan for C-Diff indicated Resident 78 was on contact isolation precautions and all equipment used was to be disinfected before it left the room. A review of the August 2025 MAR revealed Resident 78 completed a course of antibiotics on 8/3/25.Bowel records from 8/2/25 through 8/7/25 indicated Resident 78 had 13 bowel movements; nine were loose/diarrhea; bowel movements each day. The last loose stool was on 8/7/25 at 1:00 PM.On 8/4/25 at 1:53 PM Resident 78 was observed to exit her/his room independently on the first floor and self-propel the wheelchair down the hallway to the elevator. The resident did not disinfect her/his wheelchair before it left the room, and no staff members were observed to exit the resident's room after the resident.On 8/7/25 at 1:50 PM Resident 78 was observed to exit her/his room independently on the first floor and self-propelled the wheelchair down the hallway to the elevator. The resident did not disinfect her/his wheelchair before it left the room, and no staff members were observed to exit the resident's room after the resident.On 8/7/25 at 4:13 PM Resident 78 was observed to exit the elevator independently on the second floor and self-propel towards the back exit that led to the dedicated smoking area for residents. Staff 4 (CNA) greeted Resident 78 and asked if she/he wanted assistance outside; Resident 78 accepted. Staff 4 was observed to wheel Resident 78 to the back door, open the locked back door using a key card that was on her person with non-gloved hands and assist the resident by pushing the wheelchair outside to the smoking area. Staff 4 was observed to have re-entered the facility using her key card with a non-gloved hand and proceeded to her job duties without washing her hands with soap and water after assisting Resident 78. On 8/7/25 at 4:16 PM and at 6:21 PM Staff 4 stated she was unaware Resident 78 was on contact precautions. Staff 4 stated it was not communicated to staff who worked on the second floor any resident who was on transmission-based precautions from the first floor. Staff 4 confirmed she did not wash her hands with soap and water after contact with Resident 78's wheelchair. On 8/7/25 at 4:41 PM Staff 10 (CNA) and at 4:46 PM Staff 11 (CNA) both stated they worked on the second floor and were unaware of any resident who was on contact precautions from the first floor as that was not communicated to them. On 8/7/25 at 5:09 PM Staff 12 (CNA) stated he worked on the first and second floors and was aware of Resident 78's contact precautions; however, he was unsure how that was communicated to the staff on the second floor. On 8/7/25 at 5:15 PM Staff 13 (CNA) stated she worked on the second floor only and it was not communicated to her if any residents from the first floor were on contact precautions. On 8/7/25 at 6:16 PM Staff 14 (CNA) stated she assisted any resident who was an independent smoker to the smoking area by using her key card to unlock the door. She stated she was unaware of residents on precautions from the first floor. On 8/7/25 at 7:00 PM Staff 5 (CNA) stated he worked on the first floor, worked with Resident 78, and was aware of the contact precautions in place. Staff 5 stated Resident 78's wheelchair was on a cleaning schedule for night shift to complete but was not disinfected with bleach each time the resident left her/his room. Staff 5 stated Resident 78 was an independent smoker and left her/his room often to go the smoking area on the second floor. On 8/7/25 at 8:10 PM Staff 1 (Administrator), Staff 3 (Vice President of Operations), and Staff 6 (Regional RN) were informed the facility's failure to implement appropriate precautions to prevent the spread of C-Diff constituted an Immediate Jeopardy situation. An IJ start date was determined as 7/29/25. An IJ removal plan was requested. On 8/7/25 at 10:32 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions:-Resident 78 requested to stay in her/his room except for medically necessary transport. Smoking privileges with one-on-one escort until transmission-based precautions were discontinued per Infection Preventionist (IP) order. -Resident 78 identified as having or being at risk for C-Diff was reviewed by the Director of Nursing (DON) and with the Medical Director on 8/7/25. -Contact Precautions Re-Education: All staff were reminded verbally and in writing that Resident 78 was on Contact Precautions- including gown and gloves upon room entry, hand hygiene with soap and water upon exit of room or after disinfection or contact with contaminated equipment, and disinfection of all equipment after use. -Wheelchair Disinfection: Resident 78's wheelchair was sanitized with bleach wipes prior to exit and re-entry to her/his room and after any use. A dedicated wheelchair was labeled and restricted to Resident 78 only. - Hand Hygiene Enforcement: Staff member involved in breach (Staff 4) was re-educated immediately on proper C-Diff protocol, specifically that alcohol-based sanitizer is ineffective against spores; soap and water are required. Staff 4 was removed from direct resident care until re-education was completed, and competency was validated. -Environmental Cleaning: Housekeeping performed immediate bleach-based cleaning of all surfaces touched by Resident 78 and/or the resident's wheelchair (elevator buttons, back door, and smoking area entrance). -Resident 78 was placed on one-on-one to ensure compliance with C-Diff precautions. The immediacy was removed on 8/11/25 after onsite verification of the IJ removal plan.

Based on observation and record review it was determined the facility failed to ensure adequate staffing for 15 out of 33 days for 1 of 1 facility reviewed for sufficient staffing. This placed residents at risk for unmet needs. Findings include:The Direct Care Staffing Daily Report forms 7/1/25 through 8/3/25 revealed the facility did not have sufficient CNA staffing for six out of 33 days reviewed. -7/3/25, (day shift).-7/4/25, (evening shift).-7/22/25, 7/5/25, 7/8/25, 7/19/25, (night shift). On 5/9/25 at 9:09 AM, Staff 25 (Regional Staffing Coordinator) confirmed the facility did not have sufficient staffing on the above dates.

Based on observation and interview the facility failed to ensure staff properly washed hands for 2 of 3 kitchen staff observed. This placed residents at risk for foodborne illness. Findings include:On 8/4/25 at 12:12 PM, Staff 30 (Dietary Aide) grabbed a plate cover from other staff that had left kitchen and placed it on the dirty dish counter and went back to plating lunches without washing his hands. On 8/4/25 at 12:20 PM, Staff 30 washed his hands, shut off the water with a paper towel and then dried his hands with the same paper towel. On 8/4/2025 12:23 PM, Staff 31 (Prep Cook/Dietary Aide) opened the refrigerator to remove items. After completing her task she washed hands, turned off the faucet with wet hands then dried her hands with a towel. On 8/4/25 a 12:25 PM, Staff 30 washed his hands, turned off the faucet with wet hands and dried his hands with a paper towel before returning to plating food. On 8/4/2025 at 12:36 PM Staff 30 stated he was trained to turn off the faucet with a paper towel then dry his hands with it and had not been aware the towel he used to turn off the faucet was contaminated. On 8/4/25 at 12:41 PM, Staff 19 (Corporate Dietary Manager) was present in the kitchen during lunch preparation and stated Staff 30 and Staff 31 did not follow the correct hand washing procedure.

Based on observation, interview and record review the facility failed to assess a resident for safe self-administration of medication for 1 of 1 sampled resident (#15) reviewed for choices. This placed resident at risk for adverse side-affects. Findings include: Resident 15 was admitted to the facility in 7/2025 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and muscle weakness.No documentation was found in the clinical record to indicate the resident was assessed to self-administer her/his medication. On 8/6/25 at 8:17 AM, Resident 15 was observed sitting in her/his room with one inhaler on the bedside table and a second inhaler on the nightstand. Resident 15 stated staff were aware of the inhalers in her/his room. Resident 15 explained she/she uses the inhaler when her/his COPD flares up and expressed concern that if they had to wait 10 minutes for staff during a flareup, they would be dead.On 8/6/25 at 8:18 AM, Staff 27 (CNA) confirmed Resident 15 had an inhaler at her/his bedside and reported this to the charge nurse. Staff 27 stated she was unaware if the resident was authorized to have the inhaler and would need to confirm with the nurse. Staff 27 later confirmed Resident 15 had two inhalers at her/his bedside. On 8/6/25 at 8:20 AM, Staff 26 (LPN) stated he was aware residents are required to be assessed prior to keeping medications at the bedside but did not know if Resident 15 had been assessed. Staff 26 checked both inhalers and confirmed one inhaler had two doses remaining and the other had 200 doses remaining. Staff 26 stated he would follow up with administration to determine if the resident had been assessed to self-administer medications. Staff 26 left both inhalers in Resident 15's room. On 8/6/25 at 8:59 AM, Staff 6 (Corporate DNS) acknowledged resident 15 had two inhalers in her/his room. Staff 6 confirmed Resident 15 did not have an order to self-administer her/his inhalers and had not been assessed to self-administer medications.

Based on interview and record review it was determined the facility failed to assess, monitor and provide treatment timely after spilling hot coffee for 1 of 5 sampled residents (#1) reviewed for accidents. Resident 1 required hospitalization and was diagnosed with 2nd degree burns of the left thigh and back. Findings include: Resident 1 was admitted to the facility in 7/2022 with diagnoses including quadriplegia. Review of a Care Plan dated 12/29/22 revealed the resident required assistance with set up for meals but was otherwise independent with eating and drinking. Review of a Nursing Facility Reported Incident form dated 2/25/23 revealed on 2/24/23 at 8 AM Resident 1 requested coffee reheated and then spilled the coffee on himself/herself which resulted in burns to the resident chest and legs. There was no documentation on 2/24/23 at 8 AM regarding the incident in the progress notes and no documentation the resident's wound was assessed, monitored or treated until 2/25/23 at 6:35 AM. Review of a progress note dated 2/25/23 at 6:35 AM by Staff 2 (LPN) revealed At shift change 6pm CNA stated res spilled coffee on himself/herself and the CNA would change the resident sheets. This morning at 5am CNA went in room to change resident. CNA reported fluid filled blisters and redness on the resident left side and back. The note indicated the DNS and the on-coming nurse were notified. Review of a progress note by Staff 2 on 2/25/23 at 7:02 AM revealed the resident's physician was notified. There was no documentation an incident report was initiated. Review of a skin assessment dated [DATE] at 4:56 PM revealed Resident 1 had burns to the left thigh measuring 32 cm by 12 cm. The assessment indicated the resident had just returned from a local hospital with an intact dressing over the wound. Review of an incident investigation dated 3/3/23 revealed Resident 1 sustained 2nd degree burns after spilling coffee on himself/herself. The resident requested coffee around 7-8 PM on 2/24/23. A CNA heated the coffee in a microwave, placed a lid on the cup and placed a straw through the lid to give to the resident. A CNA was notified by the charge nurse around 8 PM that the resident had spilled the coffee and needed new sheets. A CNA went to the resident's room to change the sheets and notice the resident had pink skin and informed the charge nurse. The investigation indicated the resident's burns were not assessed until the afternoon of 2/25/23. In an interview on 3/22/23 at 9:48 AM Staff 3 (CNA) stated Resident 1 requested a cup of coffee around 8:30 PM on 2/24/23 and heated the coffee in the microwave for less than a minute. Staff 3 gave the resident the coffee and told him to be careful the coffee was hot. Around 9:00 PM Staff 2 informed her the resident had spilled coffee on himself/herself and brought in new sheets and blankets to change the residents linens. Staff 3 said the resident refused the linen change and the linens did not feel wet. Staff 3 said another staff had changed the linens and at 10 PM and the resident was asleep. In an interview on 3/23/23 at 9:42 AM Staff 4 (CMA) said she administered Resident 1's medications between 7:30 PM and 8:00 PM and witnessed the resident take the medication with a cup of coffee. Staff 2 was the charge nurse from 2 PM to 10 PM and did not inform her the resident had spilled coffee. In an interview on 3/24/23 at 11:52 AM Staff 6 (CNA) said she worked on 2/24/23 on the evening shift and around 7:30 PM Resident 1 told her he/she had spilled coffee. Resident 1 said he/she told Staff 2 of the spill. Staff 2 told Staff 6 she looked at the resident's skin and Staff 6 did not know if Staff 2 did anything else. Staff 6 said she changed the resident's chux pad and sheets which were hot to the touch. Staff 6 said the resident's skin was [NAME] than normal and the chux pad was stuck to the resident's skin. Staff 6 said there was a coffee cup on the resident's bed side table. In an interview on 3/27/23 at 9:12 AM Staff 2 said she worked a 12 hour shift from 6 PM on 2/24/23 to 6 AM on 2/25/23. Staff 2 said she overheard another staff Resident 1 had spilled coffee on himself/herself around 7-8 PM. It was reported to her the resident's skin was red on the left side. Staff 2 checked on the resident around 12 AM. Staff 2 said she did not assess or monitor the resident's skin because she got busy. Staff 2 said on 2/25/23 around 5 AM she checked on the resident and noticed a large blister and redness to the resident's left side hip and lower back. Staff 2 said she was shocked and not aware of the injury. Staff 2 called Staff 1, completed an incident report and made a progress note. It was determined this citation met the criteria for Past Non-compliance based on the following: The facility was found in non-compliance with the regulatory requirement at F689 on 2/24/23 when Resident 1 spilled the coffee. The facility reported the incident to the State Agency on 2/25/23. The accident involving Resident 1 occurred after the most recent complaint survey of 2/21/23 and before this current survey of 3/7/23. The facility corrected the non-compliance by completion of an incident investigation, identified the regulatory non-compliance and in-serviced all staff on the following resident care plans and hot beverage policies and procedures. The facility conducted weekly audits to keep resident safe from further incidents and no additional incidents occurred since the accident on 2/24/23.

Based on interview and record review it was determined the facility failed to ensure residents were free from neglect related to a failure to provide proper and necessary care, goods, and services for 2 of 6 residents (#s 10 and 12) reviewed for incontinence and resident rights. Resident 10 developed multiple wounds to the buttocks. Findings include: 1. Resident 10 was admitted to the facility in 8/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 11/30/20 and 12/1/20 care plans indicated Resident 10 had actual skin impairment with interventions including use a draw sheet or lifting device to move, and boost Resident 10 up in bed and use caution during transfers. The care plan indicated Resident 10 had a [CONDITION(S)] (an opening for the colon, or large intestine, through the abdomen) and catheter. A 2/21/21 Wound Evaluation indicated Resident 10 had a blister on her/his groin (right inner thigh) which measured an area of 5.12 cm2, a length of 3.26 cm by a width of 2.41 cm. Treatment included cleaning with normal saline with no dressing and the practitioner was notified. The 2/2021 Documentation Survey Report revealed the following: Skin Observation -2/24/21 Resident 10 was identified to have an open area which was a new skin condition. There was no documentation of the location of the new skin condition. A 2/24/21 Injury Investigation document indicated Resident 10 was found by a CNA to have several open areas, including under the left side of the pannus, under both buttocks, on the thighs and one to the right inner thigh. The open areas to the buttocks were nearly identical straight line shaped wounds which appeared like a slice. Each was approximately 5 cm long by .5 cm wide and 0.5 cm deep with some scabbing to the outer edges of the wounds and open at the bases. The wounds were red and beefy at the open areas, the area on Resident 10's thighs were bright red covering the area starting between her/his thighs and wrapping around both sides to the entirety of her/his buttocks bilaterally. The area to the right inner thigh had the appearance of a small hole which looked like a large pimple had popped and left a crater in her/his skin. Resident 10 was unable to give a description. Resident 10 was oriented to person, situation, place, and time. The wounds were cleaned and dressed, and barrier cream was applied. A note on 3/3/21 indicated nursing took pictures and documented the size, shape, and depth of the wounds. The incident appeared to have been caused when Resident 10 was pulled up in her/his bed improperly with excess peri-area moisture present and possibly her/his catheter laying over her/his leg in the same place all the time irritating her/his legs. The CNAs were instructed regarding the proper way to pull a resident up in bed and reminded to frequently check the skin of the residents who frequently had moisture build up on their skin. No abuse or neglect was found at this time. A 3/3/21 Nursing Note indicated Witness 39 (Former LPN) completed wound rounds and Resident 10 had several long abrasions on her/his backside. It was Witness 39's opinion the wounds were inflicted by care staff pulling the brief out from under Resident 10 repeatedly, causing the abrasions on the fragile moist skin. Staff were informed the brief was not necessary as Resident 10 had an ostomy and a catheter in place. On 11/24/21 at 8:23 AM Witness 8 (Former CNA) confirmed in 3/1/21 she came to work and went to assist another CNA to provide a brief change and repositioning for Resident 10. Witness 8 stated Resident 10's bottom was shredded with an odor of infection. Resident 10's wounds were weeping, and it was obvious she/he was not getting repositioned. The resident's nurse came in to assess Resident 10's wounds and stated the wounds looked worse to her than the previous week. On 12/7/21 at 9:59 AM Resident 10 stated at times at night when she/he needed assistance with bed mobility and pushed her/his call light button, sometimes she/he wondered oh god are they ever going to come in. In an interview on 1/7/22 at 11:00 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they would have to be present and do their own investigation to determine if abuse and neglect was ruled out or not for Resident 10's wounds. Refer to F684 2. Resident 12 was admitted to the facility in 3/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 3/11/21 care plan indicated Resident 12 had an ADL self-care performance deficit and required extensive assistance of two staff members to dress. A 3/13/21 Admission MDS revealed Resident 12 had no concerns with behaviors and required extensive assistance with bed mobility with two-person physical assist. Resident 12 required limited assistance with dressing with two-person physical assist. A 3/13/21 Cognitive loss Dementia CAA revealed Resident 12 did not demonstrate confusion, had a pleasant mood state, was not hearing impaired, and was able to communicate her/his needs well and make her/his needs known. On 11/24/21 at 8:59 AM Witness 9 (Complainant) stated she was in the facility on 4/12/21 to visit a family member, she walked by Resident 12's room, the privacy curtain was not drawn and the door was wide open. Resident 12 was exposed and was partially covered with a brief and Witness 9 could see her/him from the hallway. Resident 12 kept saying help me, help me and the staff were walking by the room and no one stopped to assist Resident 12. Witness 9 continued down the hallway and when she returned to Resident 12's room, she/he was still calling out for help and her/his brief had fallen off fully exposing her/his genitals. Witness 9 stated she reported the incident to the charge nurse and the charge nurse stated, Believe me, I know and did nothing to assist Resident 12. On 12/13/21 at 11:09 AM Staff 41 (CNA) stated Resident 12 was a resident a lot of staff ignored. Resident 12 was bed bound and blind. Staff went in to assist Resident 12's roommate but quietly left without assisting Resident 12. Staff 41 stated the staff would not get Resident 12 dressed. Staff 41 stated almost every shift she worked at the facility Resident 12 was not dressed and was not covered. On 12/14/21 at 10:11 AM Staff 46 (CNA) stated Resident 12 would remove her/his brief. On 12/13/21 at 11:23 AM Staff 42 (CNA) stated there were instances Resident 12 did not have any clothes on; she/he took off her/his hospital gown off. Staff 42 stated Resident 12 did not use her/his call light often. Staff 42 stated during 4/2021 there were a lot of residents who needed a lot of care and it could take up to 45 minutes to assist a resident so other residents had long wait times. On 12/15/21 at 11:46 AM Staff 40 (CNA) stated Resident 12 undressed herself/himself. Resident 12 called out for assistance frequently and staff members finished what they were doing first and did not prioritize Resident 12. In an interview on 1/7/22 at 11:57 AM Staff 1 (Administrator), Staff 49 (Interim DON) and Staff 50 (Regional Nurse Consultant) stated they expected staff to go in and assist the resident right away unless they were dealing with an emergent situation and then they should ask another staff member to go in and assist.

Based on interview and record review it was determined the facility failed to thoroughly report, investigate and correct accident hazards and correctly assess and implement care plan approaches to prevent accidents for 2 of 3 sampled residents (#3 and #6) reviewed for falls. Residents 3 sustained a fall with injury that resulted in a [MEDICAL CONDITION], hospitalization and surgery. Findings include: 1. Resident 3 was admitted to the facility in 2020 with [DIAGNOSES REDACTED]. The 6/25/20 Hospital Discharge Summary indicated Resident 3's chief complaint for the admission to the hospital was frequent falls with a [DIAGNOSES REDACTED]. The 6/25/20 Nursing Morse Fall Scale Assessment had no indication Resident 3 had any history of falls and no care plan interventions for falls were selected. The 6/25/20 admission care plan indicated Resident 3 was a two person extensive assist with toileting, transfers and locomotion and totally dependent on two staff for bathing. The care plan had no indication of Resident 3's previous falls and no fall precautions were in place. The 6/29/20 incident report indicated Resident 3 had an unwitnessed fall to the floor from her/his wheelchair and landed on her/his left hip. Resident 3 was assessed with [REDACTED]. X-rays were ordered and revealed an acute left [MEDICAL CONDITION]. The 7/2/20 follow up note written on the 6/29/20 incident report indicated Resident 3 was sent to the hospital, had hip surgery and review of the care plan found current interventions were appropriate. On 2/26/21 at 1:15 PM Witness 9 (previous employee) stated Resident 3 was known to attempt to stand from her/his wheelchair, was placed near the nurses' station a few times for safety and expected that information to be on the care plan. On 3/3/21 at 11:51 PM Staff 2 (Interim DNS) confirmed she did no see any interventions for falls or impulsiveness on Resident 3's care plan and the needed interventions were not addressed. Staff 2 also stated more education was needed to show nurses where to find information to properly complete assessments. 2. Resident 6 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The 12/2020 updated care plan indicated Resident 3 required a two person hoyer lift (a lift with sling and moveable metal legs for stabilization) for transfers since 3/2017. A 10/20/20 incident report indicated Resident 6 was assisted to the floor during transfer from her/his wheelchair to the bed after a hoyer lift tipped at approximately 12:20 PM. According to the report, a CNA, a CNA instructor and nursing assistant were present but only the CNA and nursing assistant were interviewed. No names of staff or predisposing environmental factors were identified in the report. On 2/22/21 at 4:31 PM Witness 10 (CNA instructor) confirmed she was present during the incident with Resident 6 on 10/20/20, was not asked to fill out a report and told by the unidentified CNA immediately after the incident the hoyer lift legs must be kicked to completely open. On 2/23/21 at 11:28 AM Staff 20 (CNA) stated she was aware of a hoyer lift that must have the legs kicked in order to completely open, was not present during the incident on 10/20/20 and confirmed the broken hoyer lift was no longer in service. On 2/23/21 at 11:55 AM Staff 32 (Maintenance Director) stated he discovered a hoyer with a tag that indicated it was broken in the dining room during his monthly building audits on 12/1/20. Staff 32 confirmed no broken hoyer lifts were identified during the previous two months of audits. On 3/3/21 at 11:15 AM Staff 2 (Interim DNS) confirmed that the investigation was not thorough, all staff should be interviewed, environmental hazards should be identified and the follow up after the incident was not complete.

Based on observation, interview and record review it was determined the facility failed to obtain sufficient feeding tube pump supplies and follow RD recommendations and physician orders for nutrition by tube feeding for 1 of 2 sampled residents (#34) reviewed for feeding tubes. Resident 34 experienced severe weight lost of 11 pounds in less than 30 days. Findings include: Resident 34 was admitted to the facility in 2021 with [DIAGNOSES REDACTED]. The 2/10/21 Admission MDS section K indicated Resident 34 had a feeding tube on admission. Review of the February 2021 MAR indicated [REDACTED]. On 2/9/21 a Nutrition Assessment and chart notes were completed by the RD which indicated Resident 34 was to receive 70ml per hour for 12 hours daily of formula due to weight loss. Review of the February 2021 MAR from 2/9/21 through 2/20/21 revealed there were 16 out of 18 opportunities when the nutritional formula was not administered due to insufficient feeding tube supplies or adequate oral food intake. Review of Resident 34's Weight Monitor dated 3/3/21 revealed the following and an 11 pound weigh loss (6%) since admit: -2/7/21 admission weight: 187 pounds -2/10/21 weight: 185.6 pounds -2/18/21 weight 209.0 pounds -2/19/21 weight 210.3 pounds -2/22/21 weight 171.4 pounds. -2/24/21 weight 173.6 pounds -2/26/21 weight 173.8 pounds -3/1/21 weight 176.0 pounds A 2/12/21 progress note indicated both the Nurse Practitioner and RD were notified that Resident 34 had not received any nutritional formula due to insufficient feeding tube supplies since 2/11/21 despite the facility's attempts to locate supplies. On 2/25/21 at 11:05 PM Staff 5 (LPN) confirmed the facility did not have all the supplies needed for the feeding tube pump so the nutritional formula was not administered as ordered. On 3/2/21 at 11:11 AM Staff 23 (RD) was not aware the nutritional formula was held based on Resident 34's intake and stated the feeding tube was to be maintained until weight gain was seen or weight stabilized. On 3/2/21 at 12:29 PM Staff 4 (RN Unit Manager) confirmed she thought she had orders to hold Resident 34's nutritional formula if oral food intake was greater than 50% but was mistaken since no physician orders were found. On 3/3/21 at 11:15 AM and 3/9/21 at 10:41 AM Staff 2 (Interim DNS) stated the facility was still trying to get the needed pump supplies, staff should notify the Nurse Practitioner/physician if orders were missed and to follow up on any email or verbal orders to get them in writing.

Based on interview and record review it was determined the facility failed to follow a care plan supervision intervention regarding transfers for 1 of 3 sampled residents (#1) reviewed for accidents. Resident 1 was care planned for two person assistance with transfers, was transferred from bed by one staff, fell and the resident's right arm was fractured. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of an in-room care plan dated 3/16/18 revealed the resident required assistance from two staff and the use of a Sit-to-Stand device for transfers. Review of a comprehensive care plan dated 3/27/18 revealed the resident required assistance from two staff and the use of a Sit-to-Stand device for transfers. Review of an incident report dated 6/16/18 revealed during a transfer Resident 1 needed to be lowered to the floor by Staff 3 (CNA). The report indicated the resident's right arm was caught in the Sit-to-Stand device strap and the resident complained of slight arm discomfort. During the transfer the battery on the Sit-to-Stand device stopped working and the resident let go of the Sit-to-Stand and was lowered to the floor. The report indicated Staff 3 was the only person in the room at the time of the incident. Review of a nurse's note dated 6/17/18 at 2:44 pm revealed the resident complained of severe arm pain. The resident's physician was notified and the resident was sent to a local hospital for evaluation. At 10:53 pm the resident returned to the facility with a [DIAGNOSES REDACTED]. Review of an incident investigation dated 6/18/18 revealed on 6/16/18 the resident was transferred to bed with the use of a Sit-to-Stand device, needed to be lowered to the floor and caught right arm in the Sit-to-Stand strap resulting in an arm fracture. The investigation indicated Staff 3 transferred the resident alone and Staff 3 had not read the resident's care plan. In an interview on 8/16/18 at 8:34 am Staff 3 (CNA) said on 6/16/18 he was transferring Resident 1 with the use of a Sit-to-Stand device and during the transfer the resident let go of the device and started to fall. Staff 3 said he lowered the resident on the floor and called for help from the charge nurse. Staff 3 said he transferred the resident by himself and did not remember reading the resident's care plan regarding transfers. In an interview on 8/16/18 at 9:00 am Staff 2 (LPN) said on 6/16/18 Staff 3 had attempted to transfer the resident to bed using a Sit-to-Stand device, the resident let go of the device and needed to lowered to the floor. Staff 2 said the resident complained of slight right arm discomfort and had no bruising, redness or swelling of the right arm. Staff 2 said Staff 3 transferred the resident without the assistance of another staff person. In an interview on 8/17/18 at 1:00 pm Staff 1 (DNS) acknowledged the resident's care plan was not followed regarding transfers and the resident was diagnosed with [REDACTED]. It was determined this citation met the criteria for Past Non-Compliance based on the following: The facility was found in non-compliance with the regulatory requirement at F689 at the time of Resident 1's 6/16/18 fall and fracture. The facility reported the incident to the State agency on 6/16/18. Resident 1's fall and fracture occurred after the most recent complaint survey of 5/25/18 and before this current survey of 8/17/18. The facility corrected the non-compliance by completion of an incident investigation, identified the regulatory non-compliance and in-serviced all staff on following resident care plans and correct utilization of transfer devices. Agency staff were instructed to read facility policies prior to providing care for residents. The policies included using the resident care plan and resident abuse and neglect protocol. The facility conducted weekly audits for safe resident transfers, with no additional incidents since the fall and fracture on 6/16/18.

Based on interview and record review it was determined the facility failed to follow physician's orders for [MEDICATION NAME] for 1 of 3 sampled residents (#1) whose [MEDICATION NAME] medications were reviewed. Multiple staffs were involved in administering an incorrect dose of [MEDICATION NAME] to Resident 1 on multiple occasions which resulted in adverse side effects and hospitalization . Findings include: According to Division 45 Standards and Scope of Practice for the Licensed Practical Nurse and Registered Nurse. Scope of Practice Standards for All Licensed Nurses [PHONE NUMBER] (6) Standard related to the licensed nurse's responsibility to accept and implement order for client care and treatment. The licensed nurse: (a) May accept and implement orders for client care from licensed health care professionals who are authorized by Oregon statute to independently diagnose and treat; (f) Has the authority and responsibility to question any order or recommendation which is not clear, perceived as unsafe, contraindicated for the client or inconsistent with the plan of care. According to Division 63 Standards and Authorized Duties for Certified Nursing Assistants and Certified Medication Aides. (9) Standards of Care for Certified Medication Assistants. In the process of client care the CMA shall consistently apply standards for CNAs and: (d) follow written instructions of a licensed health care professional authorized to independently diagnose and treat as transcribed in the Medication Administration Record (MAR). Resident 1 was admitted to the facility on [DATE] at 3:45 pm with [DIAGNOSES REDACTED]. The hospital's Discharge Summary identified the resident was admitted to the hospital on [DATE] for [MEDICAL CONDITION]. The discharge medications included a new change in the resident's [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) order to "[MEDICATION NAME]/[MEDICATION NAME] 25/100 mg tablets at 10 tablets crushed and put into suspension and dispensed over the course of the day such that (she/he) receives 62.5 mg of [MEDICATION NAME] every hour." On 5/24/12 the resident's May 2012 MAR identified there were 12 pre-filled syringes that came with the resident from the hospital and labeled [MEDICATION NAME]/[MEDICATION NAME] 1.25 mg-5 mg/ml, 12.5 ml every hour to use until gone. The facility received the liquid [MEDICATION NAME] from a compound pharmacy and later obtained a copy of the prescription which was dated 5/21/12, and read, "([MEDICATION NAME]) Carbo/Levo 25/100 mg susp (dose) 25/100 up to 10 times daily (300 doses)" which was signed by the resident's Physician. On 7/2/12 the bottle of [MEDICATION NAME] was observed and it's label mirrored the compound pharmacy's prescription. Resident 1's May 2012 Physician Orders identified on 5/24/12 the Physician ordered [MEDICATION NAME]/[MEDICATION NAME] 1.25 mg-5 mg/ml, 12.5 ml (mixed in compounding vehicle to equal 15.63-62.5 mg per 12.5 ml) and given by mouth every hour between 6:00 am and 9:00 pm. Place each dose in water/juice and give at start of hour, may drink all at once or sip over the hour. The order was transcribed onto the resident's May 2012 MAR and identified as administered to the resident starting on 5/24/12 at 4:00 pm. According to the MAR, taking into account the resident refused the medication twice, Resident 1 would have used up the 12 pre-filled hospital syringed doses of [MEDICATION NAME] on 5/25/12 at 1:00 pm and started with the facility obtained medication starting on 5/25/12 at 2:00 pm. Resident 1's May 2012 MAR identified a nursing order, dated 5/24/12, which directed the night shift med aides to draw up 16 syringes of 12.5 ml doses of [MEDICATION NAME], this order was signed at done on 5/26/12 and 5/27/12. On 5/27/12 at 4:00 pm Nursing Notes indicated the resident was anxious, hysterical and calling out. The resident was administered Klonopin (for anxiety) with was recorded as effective. According to the MAR on 5/27/12 at 6:00 pm the resident had received 37 doses of liquid [MEDICATION NAME] after the 12 pre-filled hospital were gone. The MAR indicated on 5/27/12 the resident refused the medication at 7:00 pm and at 9:00 pm. On 5/27/12 at 10:00 pm Nursing Notes identified the resident refused medications, was paranoid stating everyone was trying to kill her/him, combative with staff, and was delusional. The notes indicated staff thought the resident was in danger to herself/himself and others, the Physician was contacted, and the resident was sent to the hospital. On 5/30/12 a facility communication to the Physician identified the resident's chart was reviewed and determined the resident received the incorrect dose of [MEDICATION NAME] from 5/23/12 to 5/27/12 from a previous prescription 25/100 mg strength, 10 times daily, when the resident should have received 15.63/62.5 mg strength, 10 times daily. "This error very likely resulted in agitation and delusion resulting in readmission to the hospital 5/27/12." In interview on 7/6/12 at 2:09 pm Witness 2, Pharmacist, reported the facility contacted the pharmacy on 5/30/12, requested a copy of the prescription, and send the resident's MARs to them for comparison. Witness 2 stated the Physician order on the MAR (dated 5/24/12) did not match the earlier prescription that was filled at the pharmacy. On 7/2/12 at 12:45 pm Staff 2, RNCM, reported the resident received an excess dose of [MEDICATION NAME] approximately 36 times. He stated the resident was very sensitive to [MEDICATION NAME] and the overdose in medication triggered agitation and paranoia. On 7/2/12 at 1:00 pm Staff 10, CMA, reported administering liquid [MEDICATION NAME] during the day on 5/25/12 from the hospital supply of pre-filled syringes. Staff 10 reported receiving the liquid [MEDICATION NAME] from the pharmacy and matching the prescriptions with the packing slip, not with the physician's orders on the MAR. On 7/2/12 at 1:35 pm Staff 9, CMA, reported on 5/26/12 she worked days and administered the resident's liquid [MEDICATION NAME] directly from the bottle. She stated she administered eight doses at 12.5 ml each. Staff 9 stated she noticed the discrepancy when comparing the bottle's dose with the physician's orders on the MAR. Staff 9 reported she brought her concern to the Charge Nurse (Staff 3) who directed her to give the 12.5 ml dose amount. On 7/2/12 at 1:45 pm Staff 3, LPN, reported Staff 9 (CMA) reported a concern the resident's bottle dose didn't match the MAR. Staff 3 stated she "didn't look at the bottle" and "didn't follow up" on the concern because she was busy with other tasks. On 7/2/12 at 2:40 pm Staff 8, CMA, reported she administered the medication to the resident on 5/25/12 using the liquid [MEDICATION NAME] which had been previously drawn up in syringes and placed in a bag with the resident's name on it and no other identifying information. In interview on 7/5/12 at 12:35 pm Witness 1, family member, reported the resident was in the late stages of [MEDICAL CONDITION] and was hospitalized prior to being admitted to the facility for medication management. Witness 1 reported the Physician changed the resident's [MEDICATION NAME] dose to a smaller, more frequent dose to address the resident's severe motor fluctuations. In interview on 7/11/12 at 8:55 am Staff 12, CMA, reported working the evening shift on 5/25/12 and 5/26/12 and administered liquid [MEDICATION NAME] to the resident from syringes found in the bottom drawer of the med cart. Staff 12 reported she did not compare the liquid [MEDICATION NAME]'s bottle with the physician's orders on the MAR and had assumed the correct dose of medication was in the pre-drawn syringes of medication. She stated it was not common practice to administer pre-drawn medication. In interview on 7/11/12 at 10:34 pm, Witness 7, LPN, reported working nights on 5/26/12 and filling syringes with the liquid [MEDICATION NAME] per the nursing order. She stated she rinsed out and re-used the resident's previously used syringes and drew up 12.5 ml from the bottle of medication. Witness 7 reported comparing the measured dose amount to the MAR's physician order and did not notice the medication strength amounts were different. Witness 7 stated she administered one 6:00 am dose to the resident on 5/26/12 from the syringed doses she drew up. In interview on 7/12/12 at 4:32 pm Staff 11, CMA, reported she worked days on 5/27/12 and administered medications to the resident approximately seven times that day. Staff 11 stated she used the pre-filled syringes that the night shift CMA had drawn up into the unlabeled syringes. Staff 11 reported she did not compare the medication's labeled bottle with the physician's order on the MAR. She stated the resident's paranoid behavior began to escalate in the afternoon which included statements from the resident that staff were spraying her/him with bug stray when they provided her/him with water. In interview on 7/12/12 at 7:16 pm Staff 4, RN, reported she initiated the nursing order to have night CMAs pre-draw the liquid [MEDICATION NAME] from the bottle for the day and evening CMAs to administer. Staff 4 did not compare the filled prescription of liquid [MEDICATION NAME] with the physician's order on the MAR. Refer to F 333

Based on interview and record review it was determined the facility failed to ensure a resident was free from a significant medication errors related to administration of [MEDICATION NAME] for 1 of 3 sampled residents (#1) whose medications were reviewed. Resident 1 received an overdose of [MEDICATION NAME], experienced adverse side effects and was hospitalized . Findings include: Resident 1 was admitted to the facility on [DATE] at 3:45 pm with [DIAGNOSES REDACTED]. The hospital's Discharge Summary identified the resident was admitted to the hospital on [DATE] for [MEDICAL CONDITION], severe motor fluctuations, failure to thrive, and [MEDICAL CONDITION]. The summary indicated the resident was hospitalized for [REDACTED]. The discharge medication list included "[MEDICATION NAME]/[MEDICATION NAME] 25/100 mg tablets at 10 tablets crushed and put into suspension and dispensed over the course of the day such that (she/he) receives 62.5 mg of [MEDICATION NAME] every hour." In interview on 7/2/12 at 12:40 pm Staff 1, DNS, reported the hospital sent 12 doses of liquid [MEDICATION NAME] with the resident to give the facility time to obtain the medication which required filling at a compound pharmacy. The facility received the liquid [MEDICATION NAME] from the compound pharmacy and later obtained a copy of the prescription which was dated 5/21/1 and read, "([MEDICATION NAME]) Carbo/Levo 25/100 mg susp (dose) 25/100 up to 10 times daily (300 doses)" and was signed by the resident's Physician. On 7/2/12 the bottle of [MEDICATION NAME] was observed and its label mirrored the compound pharmacy's prescription. There was no evidence the facility compared the liquid [MEDICATION NAME] medication when they received it to ensure it matched the current physician's orders [REDACTED]. In interview on 7/6/12 at 2:09 pm Witness 2, Pharmacist, reported the pharmacy received a prescription via the phone from the resident's Physician on 5/21/12 for liquid [MEDICATION NAME] 25/100, she stated each 5 ml dose had a strength of 25/100. Witness 2 reported the pharmacy had one prescription dated 5/21/12 and received no additional prescriptions for liquid [MEDICATION NAME] for the resident. Resident 1's May 2012 Physician order [REDACTED]. Place each dose in water/juice and give at start of hour, may drink all at once or sip over the hour. The order was transcribed onto the resident's May 2012 MAR along with a note on the back which indicated there were 12 pre-filled syringes that came with the resident from the hospital and labeled [MEDICATION NAME]/[MEDICATION NAME] 1.25 mg-5 mg/ml, 12.5 ml every hour to use until gone, then use from the bottle in the med cart. The medication was identified as administered to the resident on 5/24/12 at 4:00 pm and the 12 hospital's syringed doses would have been used up starting on 5/25/12 at 2:00 pm. On 5/25/12 during the 11:00 pm - 7:00 am shift, Nursing Notes identified the resident slept the majority of the night after pain medication was accepted. On 5/25/12 during the 7:00 am - 3:00 pm shift, Nursing Notes indicated the resident refused two doses of [MEDICATION NAME], had slurred speech, and had a 50 cc emesis after taking medications. On 5/25/12 at 10:00 pm Nursing Notes indicated the resident had a 10 cc emesis. Resident 1's May 2012 MAR identified a nursing order, dated 5/24/12, which directed the night shift med aides to draw up 16 syringes of 12.5 ml doses of [MEDICATION NAME], this order was signed as done on 5/26/12 and 5/27/12. On 5/27/12 the 7:00 am - 3:00 pm shift, Nursing Notes identified the resident was cooperative with medication but was requesting a different room. On 5/27/12 at 4:00 pm Nursing Notes indicated the resident was anxious, hysterical and calling out. The resident was administered Klonopin (for anxiety) which was recorded as effective. According to the MAR on 5/27/12 at 6:00 pm the resident had received a total of 37 doses of liquid [MEDICATION NAME] after the 12 pre-filled hospital were gone. On 5/27/12 at 10:00 pm Nursing Notes identified the resident refused medications, was paranoid stating everyone was trying to kill her/him, combative with staff, and was delusional. The notes indicated staff thought the resident was in danger to herself/himself and others, the Physician was contacted, and the resident was sent to the hospital. On 5/28/12 a hospital Neurology Consult report identified the resident was evaluated at the hospital for altered mental status. The report indicated the resident reported not sleeping the previous night and was "very afraid that there have been some errors with (her/his) medications" since admission to the nursing facility. The Physician's Impression identified the resident had possible fluctuating [MEDICAL CONDITION] and it seemed "possible that there could have been some deviation for (her/his) usual complex medication schedule" after arriving at the nursing facility. On 5/30/12 a facility communication to the Physician identified the resident's chart was reviewed and there was a medication error during the resident's stay. The communication indicated the resident received the incorrect dose of [MEDICATION NAME] from 5/23/12 to 5/27/12 from a previous prescription 25/100 mg strength, 10 times daily, when the resident should have received 15.63/62.5 mg strength, 10 times daily. "This error very likely resulted in agitation and delusion resulting in readmission to the hospital 5/27/12." In interview on 7/6/12 at 2:09 pm Witness 2, Pharmacist, reported the facility contacted the pharmacy on 5/30/12, requested a copy of the prescription, and send them the resident's MARs for comparison. Witness 2 stated the physician's orders [REDACTED]. The MAR identified the Physician had ordered a lesser strength of [MEDICATION NAME] and the facility did not compare the medication strengths listed on the filled medication to the physician's orders [REDACTED]. Witness 2 reported an overdose of [MEDICATION NAME] could exaggerate the possible side effects of the medication including psychiatric effects such as delusion, paranoia, confusion, agitation, [MEDICAL CONDITION], and dementia. On 7/2/12 at 12:45 pm Staff 2, RNCM, reported the resident received an excess dose of [MEDICATION NAME] approximately 36 times. He stated the resident was very sensitive to [MEDICATION NAME] and the overdose in medication triggered agitation and paranoia. On 7/2/12 at 1:00 pm Staff 10, CMA, reported administering liquid [MEDICATION NAME] during the day on 5/25/12 from the hospital supply of pre-filled syringes. Staff 10 reported receiving the liquid [MEDICATION NAME] from the pharmacy and matching the prescription with the packing slip, not with the physician's orders [REDACTED]. On 7/2/12 at 1:35 pm Staff 9, CMA, reported on 5/26/12 she worked days and administered the resident's liquid [MEDICATION NAME] directly from the bottle. She stated she administered eight doses at 12.5 ml each. Staff 9 stated she noticed the discrepancy when comparing the bottle's dose with the physician's orders [REDACTED]. On 7/2/12 at 1:45 pm Staff 3, LPN, stated Staff 9 (CMA) reported a concern the resident's bottle dose didn't match the MAR. Staff 3 stated she "didn't look at the bottle" and "didn't follow up" on the concerns because she was in the middle of another task. On 7/2/12 at 2:40 pm Staff 8, CMA, reported she worked evenings and administered the liquid [MEDICATION NAME] to the resident via the syringes labeled from the hospital when she/he first was admitted to the facility (on 5/24/12) . She stated the next evening (on 5/25/12) she administered the medication using liquid [MEDICATION NAME] that had been drawn up in syringes and placed in a bag with the resident's name on it and no other identifying information. In interview on 7/5/12 at 12:35 pm Witness 1, family member, reported the resident was in the late stages of [MEDICAL CONDITION] and was hospitalized prior to being admitted to the facility for medication management. Witness 1 reported the Physician changed the resident's [MEDICATION NAME] dose to a smaller, more frequent dose to address the resident's severe motor fluctuations. Witness 1 stated the resident was responding favorably to the new [MEDICATION NAME] regime in the hospital. Witness 1 reported observing the resident on 5/25/12 and indicated the resident was a little agitated and paranoid, but not concerningly so. Witness 1 stated on 5/27/12 the facility reported the resident was really agitated, refusing to take her/his medications, running around the facility and was sent to the hospital. In interview on 7/11/12 at 8:55 am Staff 12, CMA, reported working the evening shift on 5/25/12 and 5/26/12 and administered liquid [MEDICATION NAME] to the resident from syringes located in the bottom drawer of the med cart. Staff 12 stated the night shift CMAs drew up the medication from the bottle the night before and re-used syringes from the hospital initial supply. She stated some of the syringes were labeled with the hospital's label and others were not labeled at all. Staff 12 reported she did not compare the bottle of liquid [MEDICATION NAME] with the physician's orders [REDACTED]. She stated it was not common practice to administer pre-drawn medication. Staff 12 reported the resident appeared slightly more paranoid on 5/26/12 than on 5/25/12. In interview on 7/11/12 at 10:34 pm, Witness 7, LPN, reported working nights on 5/26/12 and filling syringes with the liquid [MEDICATION NAME] per the nursing order. She stated she rinsed out and re-used the resident's previously used syringes and drew up 12.5 ml from the bottle of liquid [MEDICATION NAME]. Witness 7 reported comparing the measured dose amount to the MAR's physician's orders [REDACTED]. Witness 7 stated she administered one 6:00 am dose to the resident on 5/2/12 from the syringed doses she drew up. In interview on 7/12/12 at 4:32 pm Staff 11, CMA, reported she worked days on 5/27/12 and administered liquid [MEDICATION NAME] to the resident approximately seven times that day. Staff 11 stated she used the pre-filled syringes that the night shift CMA had drawn up into unlabeled syringes. Staff 11 reported she did not compare the medication's labeled bottle with the physician's orders [REDACTED]. In interview on 7/12/12 at 7:16 pm Staff 4, RN, reported she initiated the nursing order to have night CMAs pre-draw the liquid [MEDICATION NAME] from the bottle for the day and evening CMAs to administer. Staff 4 did not compare the filled prescription of liquid [MEDICATION NAME] with the physician's orders [REDACTED]. In interview on 7/12/12 at 7:22 pm Staff 6, LPN, reported she worked evenings on 5/27/12 and sent the resident out to the hospital because the resident was hallucinating, running down the hallway, was very paranoid, and making suicidal statements.