Every finding on record at Southwind Nursing & Rehabilitation Center

Based on record review, observations, and interview the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (#62) of 3 (#1, #37, #62) residents reviewed for respiratory care. The deficient practice was evidenced by the facility failing to ensure: 1. Staff obtained an oral nasal cannula for resident's Trilogy machine (non-invasive breathing support equipment in a timely manner; and2. The resident had a Cough Assist Device (CAD) available.Findings:Review of the facility policy and procedure titled Following Physician Orders Policy and Procedure with no review date read in part:Purpose: The primary objective of this policy is to ensure all physician orders for resident are consistently and accurately followed to promote their health and well-being.Policy: 1. Order verification - all physician orders will be verified for accuracy, clarity, and completeness. 2. Physician orders will be implemented in a timely manner. 4. Treatment plans: treatment plan outline by physicians will be followed rigorously, and any other prescribed treatments. Nursing staff will ensure that resident's receive the specified treatments as ordered. 9. Responsibilities: nursing staff and other relevant healthcare providers are responsible for ensuring the accurate and timely implementation of physician orders for residents. Review of the electronic medical record revealed resident #62 was admitted to the facility on [DATE] with diagnoses including ALS (Amyotrophic lateral sclerosis), sleep apnea, muscle weakness, chronic neuromuscular respiratory failure. Review of physician notes dated 08/14/2026 read in part.Impression: resident with chronic neuromuscular respiratory failure due to ALS. Ensure resident has Cough Assistant Device (CAD) at the facility. Resident would benefit from mechanical cough assist device daily and as needed for emergent clearance of aspirated secretions or food. Please provide resident with cough assist device and suction supplies. Plan: Find out Durable Medical Equipment (DME) for facility - ensure CAD, Average Volume Assured Pressure Support (AVAPS), suction available. Review of another physician progress note from the ALS clinic dated 8/14/2026 read in part. she is getting some contractures in both of her hands. Further review of physician progress note from the ALS clinic dated 08/14/2026 read in part.resident has difficulty clearing her airways and does not believe she has a CAD since moving into the facility. Review of the admit Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that resident #62 was cognitively intact. Further review of the MDS revealed she required two person assistance with activities of daily living, bed mobility, and transfers. Further review of Resident #62's electronic medical record failed to reveal refusal of care or attempts of wearing the hand splints and Trilogy machine. On 08/23/2026 at 9:00 a.m., an observation of the resident's room was conducted. Further observation of the resident's room failed to reveal a suction machine, or any equipment for CAD. On 08/25/2026 at 8:31 a.m., an interview was conducted with Resident #62. She stated that she went to the ALS clinic on 08/14/2026. She added that she was waiting to receive a different cannula for her Trilogy machine because she was not satisfied with the fit of her current mask. Resident #62 was asked if staff had been applying her bilateral hand splints at night, and she stated staff had not been applying her hand splints or applying her Trilogy mask at night. She stated she had not worn her Trilogy mask for about one month. On 08/25/2026 at 9:16 a.m., a phone interview was conducted with S6LPN who stated Resident #62 was supposed to have bilateral hand splints applied at night. S6LPN added that the resident also had an order to apply a Trilogy mask at night. S6LPN was asked if she was applying the hand splints and Trilogy mask at night, and she stated she had not applied the hand splints or Trilogy mask as ordered. On 08/25/2026 at 2:40 p.m., an interview was conducted with S7LPN who stated she was caring for Resident #62. When asked if the resident was supposed to have a suction machine available and CAD, she stated not that she was aware of. S7LPN stated that when the resident goes to the ALS clinic, the summary is sent via fax machine. The nurse is supposed to retrieve the fax and review for orders. If the nurse notes the orders, she was supposed to write it on a carbon copy form and enter the order into the computer. Resident #62 visit at the ALS clinic on 08/14/2026 was reviewed with S7LPN who stated she did not see those recommendations or plan of care. On 08/25/2026 at 2:45 p.m., an interview and observation of the physician note dated 08/14/2026 was conducted with S3DON. S3DON stated the physician plan was just that, a plan. She stated it was not like an order that the resident need to have CAD, AVAPS, and suction available. Review of the section of the physician note under a section impression read in part.ensure resident has CAD at the facility. S3DON stated the facility has suction and it only take two minutes to setup. She stated it's not like it stated to have suction at the bedside. On 08/25/2026 at 4:12 p.m., a phone interview was attempted with S10LPN who received the summary via fax on 08/19/2026 from the ALS clinic. Call went to voice mail. No return call.

Based on observations, interviews, and record reviews, the facility failed to store food in accordance with professional standards, and ensure sanitary conditions were maintained in the kitchen by failing to:Appropriately store, label and date refrigerated, frozen, and dry food items;Ensure kitchen staff wore appropriate hair and beard covering in the kitchen; Cleaning fryer after it was used; andThaw frozen foods in the refrigerator and not at room temperature. The deficient practice had the potential to affect 103 residents who consumed foods from the kitchen.Findings:1.On 08/23/2026, a review of the facility's policy titled, Kitchen Food Storage Areas Policy and Procedure with a last reviewed date of 02/11/2026, read in part: Policy: Dry storage areas will be kept in a condition which protects stored foods from infestation. Procedure.10. Containers with tight-fitting covers should be used for storing cereal, grain products, dried vegetables and broken lots of bulk food.Care of the storeroom: 1. The staff will maintain care of the storeroom according to the following directions.c. Refrigerated and frozen foods are dated upon delivery. Foods with expiration dates are used prior to the date on the package.On 08/23/2026 at 8:53 a.m., a tour of the facility's kitchen was conducted with S4Cook.An observation of the walk in refrigerator revealed the following:-two packages of chopped lettuce that were opened and wrapped in a clear plastic wrapper with no expiration or used by date.-a large pan that was half full of chopped lettuce and covered with clear plastic with no expiration or used by date.-chopped unlabeled and undated food item in a clear plastic wrapper that S4Cook identified as chicken.-red thickened substance that was not in the original container with a date of 08/15/2026.-a large clear unlabeled and undated covered container with cucumber slices and chopped onion.-a chef salad on a plate that was unlabeled and undated.-an unlabeled and undated container with food item that S4Cook identified as marinated chicken.-four clear unlabeled and undated glasses with white liquid on a tray that were covered with plastic wrapper. S4Cook stated the liquid was thickened milk.-five clear unlabeled and undated glasses with white liquid on another tray that were covered with plastic wrapper. S4Cook stated the liquid was regular milk.-two unlabeled Styrofoam cups that were covered with lids. S4Cook stated one was soy and the other thickened water.-a container that was dated 08/17/2026.S4Cook confirmed all the above items. She stated that items were supposed to be labeled with the content and date they were placed in the refrigerator and discarded after three days in the refrigerator. On 08/23/2026 at 8:58 a.m., an observation of the freezer revealed an open plastic bag with 30 exposed cookies.S4Cook confirmed the item and acknowledged the potential for freezer burn. She stated they should have been placed in a zipped up plastic bagOn 08/23/2026 at 9:07 a.m., an observation of the dry storage room revealed an unlabeled and undated brown dry substance wrapped in clear plastic. S4Cook stated it was brown sugar. She further stated the item should have been placed in a covered container and labeled with the content and expiration date. 2.On 08/23/2026, a review of the facility's policy titled, Sanitary Practices Policy and Procedure with a last reviewed date of 02/11/2026, read in part: Policy: All kitchen employees will practice standard sanitary procedures. Procedure: All employees shall 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food.On 08/23/2026 at 8:31 a.m., an observation was made of S15DS in the kitchen's dishwashing area. He was cleaning the dirty dishes, silverware and trays and storing the clean ones that were used to serve lunch. S15DS had a beard that was not covered. On 08/23/2026 at 8:45 a.m., a second observation was made of S15DS as he continued cleaning and storing the residents dishes, silverware and trays. His beard remained uncovered. S15DS confirmed that his beard was not restrained and stated that he should have been wearing a beard restraint.On 08/23/2026 at 11:20 a.m., an observation was made of S18DS on the lunch food line. He received the trays with the residents' lunch from the steam table, covered the plates, and placed the cold drinks on the tray. S18DS was wearing a cap on the top of his head and had long exposed dread locks in a ponytail down to his mid back. The ponytail was not covered. An interview was immediately conducted with S4Cook. She stated that S18DS was supposed to wear two hairnets or a hairnet with his cap to secure all his hair. 3.On 08/23/2026, a review of the facility's policy titled, Cleaning Instructions Fryers Policy and Procedure with a last reviewed date of 12/22/2025, read in part: Policy: Fryers will be cleaned on a regular basis and cared for in such a way to maintain optimum production.On 08/23/2026 at 10:18 a.m., an observation was made of the kitchen's fryer with S4Cook revealed two dirty fryer baskets with large amounts of food particles sticking to the basket. The right side of the fryer had grease dripping down the side. S4Cook confirmed the findings and stated the fryer was last used on Friday (08/21/2026) and should have been cleaned then. 4.On 08/23/2026 at 8:36 a.m., an observation was made of a two-tiered rolling storage cart parked in front of a large coffee machine. The top shelf of the cart had three large boxes of frozen pre-cooked meatballs and three clear plastic bags of frozen pepperoni slices. An interview was immediately conducted with S14DS. S14DS stated that the evening staff were supposed to have removed the meatballs and pepperoni from the freezer and placed in the refrigerator to thaw overnight for dinner preparation, but did not. She confirmed that she intentionally removed the items from the freezer to thaw at room temperature.On 08/23/2026 at 8:37 a.m., an interview was conducted with S4Cook. She stated that the evening staff forgot to remove the items from the freezer and placed in the refrigerator to defrost for dinner. She stated she instructed S14DS to leave the items at room temperature until they started sweating, then place them in the refrigerator to finish defrosting. S4Cook confirmed that it was not appropriate to thaw the frozen meatballs and pepperoni at room temperature.

Based on observation, interviews and record review, the facility failed to ensure the resident's person-centered care plan was followed for 1 (#62) of 39 sampled residents. This was evidenced when the facility failed to apply bilateral hand splints per plan of care. Findings:Review of the electronic medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including ALS (Amyotrophic lateral sclerosis), sleep apnea, muscle weakness, chronic neuromuscular respiratory failure. Review of Resident #62's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognition was intact. Review of Resident #62's care plan read in part: I have ALS - Interventions: I need bilateral hand splints as ordered. Further review of Resident #62's electronic medical record failed to reveal the resident's refusal to wear the hand splints. Review of physician notes from the ALS clinic dated 08/14/2026 read in part, she is getting some contractures in both of her hands. On 08/24/2026 at 8:05 a.m., an observation and interview was conducted with the Resident #62 in her room. Upon observation, it was noted on top of the resident's refrigerator were two hand splints. The resident was asked if staff had applied her hand splints the night before, and the resident shock her head no. On 08/25/2026 at 8:41 a.m., 9:19 a.m., and 10:30 a.m., a phone interview was attempted with S11LPN. S11LPN was the nurse on shift on 08/22/2026 and 08/23/2026. As of the exit date and time, S11LPN had not returned the call. On 08/25/2026 at 9:21 a.m., a phone interview was conducted with S6LPN. S6LPN last worked with the resident on 08/19/2026, 08/20/2026, and 08/21/2026 and stated Resident #62 is supposed to have bilateral hand splints applied at night. S6LPN was asked if she had been applying the hand splints at night, and she stated she had not been applying the hand splints as ordered by the physician. On 08/25/2026 at 2:45 p.m., an interview was conducted with S3DON who stated that staff should have been applying the bilateral hand splints as ordered by the physician.

Based on record review and interviews, the facility failed to ensure an allegation of neglect was reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 (Resident #10) of 39 sampled residents.Findings: On 08/25/2026, a review of the facility's policy titled Abuse and Neglect Policy and Procedure, with a last review date of 11/06/2025, read in part: . 5. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples: . failure to provide adequate monitoring and supervision.7. Reporting/Response. Immediately means as soon as possible, in the absence of a shorter state time frame requirement, but not later than 2 hours after the allegation is made.Review of Resident #10's Electronic Health Record (EHR) revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included, but were not limited to, anoxic brain damage, stiffness of unspecified joint, and muscle weakness (generalized). On 08/23/2026 at 10:04 a.m., a phone interview was conducted with Resident #10's RP (Responsible Party). Resident #10's RP stated she was here on 08/21/2026 until 11:37 p.m. She stated that Resident #10's room is electronically monitored, and when she reviewed the cameras the next day, she did not see a staff member enter Resident #10's room from 08/21/2026 at 11:37 p.m. until 6:00 a.m. on 08/22/2026. Resident #10's RP stated she notified S20CNASup of this allegation of neglect on 08/22/2026. On 08/24/2026 at 11:13 a.m., an interview was conducted with S20CNASup. She stated that when she answered the phone on Saturday 08/22/2026, it was Resident #10's RP. S20CNASup stated she was told by Resident #10's RP that when she left the faciity on [DATE] at around 11:36 p.m. until the next morning at 6 a.m. no one checked in on Resident #10. She stated that after receiving this allegation of neglect on Saturday 08/22/2026, she immediately notified S1Admin.Review of the facility's self-reported incidents to the state agency revealed no entries related to Resident #10's incident of an allegation of neglect on 08/22/2026.On 08/24/2026 at 1:00 p.m., an interview was conducted with S1Admin. S1Admin confirmed on 08/22/2026 that he was notified by S20CNASup of Resident #10's RP reporting an allegation of neglect. S1Admin stated he was told by S20CNASup that Resident #10's RP reported that Resident #10 was not cared for by staff on 08/21/2026 from 11:30 p.m. until 6:00 a.m. on 08/22/2026. When S1Admin was asked if Resident #10's RP reporting an allegation of neglect should have been reported to the state agency immediately, but no later than 2 hours, S1Admin stated probably.

Based on record reviews and interviews, the facility failed to ensure the State Long Term Care Ombudsman Office was notified of a transfer for 2 (Resident #27 and Resident #111) out of 39 sampled residents.Findings: Resident #27 Review of the facility's policy titled, Emergency Transfer Notice Policy and Procedure, with a last review date of 01/06/2026, read in part, Written notice will be provided to the residents and representatives when an emergency transfer occurs within a practical time frame. Procedure: 3. Identified residents will be placed on the Emergency Transfer Log. A review of Resident # 27's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included but were not limited to muscle wasting and atrophy, not elsewhere classified, multiple sites; vascular dementia, unspecified severity, with agitation; other muscle spasm; muscle weakness (generalized). A review of Resident # 27's nurse's notes revealed on 05/12/2026 at 6:36 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 05/12/2026 at 9:25 a.m., the resident returned from the hospital to the facility. A review of the Ombudsman Notification Log from May 2026 revealed Resident's #27 transfer to the hospital on [DATE] was not identified on the list. On 08/24/2026 at 3:08 p.m., an interview and record review was conducted with S12SSD, who stated she was responsible for completing the Ombudsman Notification Log and sending the log to the State Long Term Care Ombudsman. S12SSD reviewed the Ombudsman Notification Log for May 2026 and confirmed Resident #27 was not listed as having been transferred on 05/12/2026. Resident #111 Review of Resident #111's medical record revealed an admission date of 03/31/2026 and a discharge date of 06/19/2026 with diagnoses that included in part, unspecified dementia, chronic kidney disease, and anxiety disorder. Review of Resident #111's nurses' notes revealed on 06/19/2026 at 9:55 a.m., Resident discharged to another Long-Term Care facility, left per facility van with all personal belongings, medication and narcotics. On 08/25/2026 at 12:10 p.m., an interview was conducted with S12SSD. S12SSD stated she reviewed her emails and she had not sent/emailed a notice to the Long term Care Ombudsman when Resident #111 was transferred to another facility and she should have.

Based on observations, interviews, and record review, the facility failed to ensure that services were provided to meet professional standards of quality as evidence by:1. The staff nurse left 7 medications unattended at the bedside for 1 (Resident #93); and 2. the facility failed to ensure nurse's documentation was accurate for 1 (Resident #62) of 39 sampled residents.Findings: Resident #93; Review of the facility's policy titled, Medication Administration – General Guidelines with the last review date 04/30/2026, read in part, Policy Statement: Medications are administered as prescribed in accordance with good nursing principles and practices.The facility has.a medication distribution system to ensure safe administration of medications.Procedure: 2. Administration. P. The resident is always observed after administration to ensure that the dose was completely ingested. Review of Resident #93's EHR (electronic health record) revealed she was admitted to the facility on [DATE], and had diagnoses that included in part, type 2 diabetes mellitus, hypomagnesium, vitamin D deficiency, essential hypertension, and constipation. Further review of Resident #93's EHR did not reveal an assessment for medication self-administration. Review of Resident #93's most recent Quarterly MDS (Minimum Data Set) for 07/29/2026, revealed the resident's BIMS (Brief Interview for Mental Status) score was 15, indicating her cognition was intact. Review of Resident #93's EHR physician orders revealed the following medication orders: Isosorbide mononitrate extended release tablet 24 hour 30 mg, give 1 tablet orally one time a day; glipizide 5mg, give 1 tablet by mouth one time a day; amlodipine besylate 10mg, give 1 tablet by mouth one time a day; docusate sodium 100mg, give 1 tablet by mouth two times a day, magnesium oxide 400 mg, give 1 table by mouth two times a day; cholecalciferol 5000 unit, give 1 tablet by mouth one time a day; metoprolol tartrate 100 mg, give 2 tablets by mouth two times a day. On 08/24/2026 at 9:07 a.m., an observation was made of Resident #93's room. The surveyor observed a white paper souffle cup of pills on the bedside table. Resident #93 stated those were her pills that the nurse left on her table to take. Resident #93 stated that her nurse left those pills at 7:00 a.m. this morning and she forgot to take them before she left for her doctor's appointment. Resident #93 stated she returned from her doctor's visit at 9:00 a.m. and was going to take them then. On 08/24/2026 at 9:10 a.m., an interview was conducted with S13LPN in Resident #93's room with Resident #93 present. S13LPN confirmed she put Resident #93's morning medications in a cup at 7:15 a.m. and placed the cup on the bedside table and left the room. S13LPN confirmed she did not observe Resident #93 ingest the medication. S13LPN confirmed she should not have left the pills on the bedside table and left the room without observing Resident #93 ingest the pills. On 08/24/2026 at 9:14 a.m., an interview and record review was conducted with S13LPN. S13LPN identified and confirmed that the following medications were left in the paper cup on Resident #93's bedside table with the corresponding documentation on the resident's MAR (Medication Administration Record): Isosorbide Mononitrate tablet extended release 24-hour 30 mg (milligrams), administration date 08/24/2026, administration time 7:04 a.m., documentation time 7:04 a.m. Glipizide 5 mg, administration date 08/24/2026, administration time 7:03 a.m., documentation time 7:04 a.m. Amlodipine besylate 10 mg, administration date 08/24/2026, administration time 7:03 a.m., documentation time 7:04 a.m. Docusate sodium 100 mg, administration date 08/24/2026, administration time 7:03 a.m., documentation time 7:04 a.m. Magnesium oxide 400 mg, administration date 08/24/2026, administration time 7:04 a.m., documentation time 7:04 a.m. Cholecalciferol 5000 unit, administration date 08/24/2026, administration time 7:03 a.m., documentation time 7:04 a.m. Metoprolol tartrate 100mg, administration date 08/24/2026, administration time 7:04 a.m., documentation time 7:04 a.m. On 08/24/2026 at 2:30 p.m., an interview was conducted with S2CN. S2CN confirmed that a nurse should not have left medications in a cup at the bedside in a resident's room and left the room without observing the resident ingest the medications. S2CN confirmed this service provided by the nurse did not meet professional standards of quality. S2CN confirmed that Resident #93 was not assessed for medication self-administration and there was no physician order for Resident #93 to self-administer medications. Resident #62; Review of Resident #62's Electronic Medical Record (EMR) revealed that she was admitted to the facility on [DATE] with diagnoses of Amyotophic lateral sclerosis (ALS), sleep apnea, muscle weakness, chronic neuromuscular respiratory failure with hypercapnia. Review of an admit Minimum Data Set (MDS) assessment dated [DATE] read in part: Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident is cognitively intact. Review of Resident #62's care plan read in part.I have ALS with an intervention of bilateral hand splints. I have sleep apnea. I utilize a Trilogy machine. Intervention was assist with equipment every night. Review of physician notes dated 08/14/2026 read in part.resident is getting some contractures in both of her hands and she no longer wears shoes just booties for pressure relief. Review of physician orders dated 08/2026 read in part. Bilateral hand splints every night with a start date of 08/20/2026, and Trilogy (portable ventilator) mask was to be worn every night. Review of Resident #62's Medication Administration Record (MAR) revealed that on 08/20/2026 and 08/21/2026, S6LPN documented she had applied the resident's bilateral hand splints and applied the Trilogy mask as ordered by the physician. Further review revealed on 08/22/2026 and 08/23/2026, S11LPN documented she had applied the resident's bilateral hand splints and Trilogy mask as ordered by the physician. On 08/25/2026 at 8:31 a.m., an interview was conducted with the Resident #62 who communicated via her personal cell phone. Resident #62 communicated that she had not used the trilogy machine for about one month and staff had not been applying her hand splints at night. On 08/25/2026 at 8:42 a.m. and 9:19 a.m., a phone interview was attempted with S11LPN. S11LPN had not responded to voice mail left by the time of exit on 08/25/2026 at 5:15 p.m. On 08/25/2026 at 9:16 a.m., a phone interview was conducted with S6LPN. S6LPN stated that she was the nurse for Resident #62 on 08/19/2026, 08/20/2026, and 08/21/2026 and S9LPN cared for the resident on 08/22/2026 and 08/23/2026. S6LPN stated that she had not applied the bilateral hand splints, and Trilogy mask as ordered by the physician. S6LPN stated the resident would tell her to come back later when she asked the resident to apply the Trilogy mask. She added the resident would be on her phone all night and before she knew it, her shift was over and she had not applied the hand splints or Trilogy mask. S6LPN verified she should not have signed off that the bilateral hand splints and Trilogy mask were completed on the resident's MAR. On 08/25/2026 at 2:45 p.m., an interview was conducted with S3DON who confirmed the nurses should not have signed off on the resident's MAR that they had applied the hand splints and Trilogy mask during the night for dates 08/20/2026 – 08/23/2026.

Based on observation, interview, and record review, the facility failed to ensure a resident received a mechanically altered diet as ordered by the physician for 1 (Resident #73) out of 39 sampled residents.Findings:Review of the facility's policy, titled Diet Orders Policy and Procedure, with a last reviewed date of 12/23/2025, revealed in part: When there is a nutritional indication, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of the resident to achieve outcomes/goals of care.Diets will be offered as ordered by the physician.Review of Resident #73's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, dysphagia following cerebral infarction, unspecified protein-calorie malnutrition, and gastro-esophageal reflux disease.Review of Resident #73's Quarterly Minimum Data Set (MDS) dated [DATE], revealed, Section K: Swallowing/Nutritional Status was checked for mechanically altered diet.Review of Resident #73's physician's orders revealed an order dated 02/27/2026 that read, No Salt on Table (NSOT) diet, Regular Texture, Regular/Thin Consistency, Chopped Meat.On 08/25/2026 11:45 a.m., an observation was made of Resident #73's meal ticket and meal tray. Resident #73's meal ticket read in part, Diet: No Salt on Table (NSOT), Texture: Regular. Resident #73 was served two whole pieces of baked chicken on the bone on her lunch tray. The chicken was not chopped.On 08/25/2026 at 11:49 a.m., an interview and observation of the resident's meal was conducted with S7LPN. S7LPN confirmed that the chicken served on Resident #73's lunch tray was not chopped and it should have been. S7LPN reviewed Resident #73's meal ticket and confirmed that the meal ticket did not state chopped meat and it should have.On 08/25/2026 at 11:54 a.m., an interview and review of Resident #73's meal ticket and diet order was conducted with S1Admin. S1ADM confirmed Resident #73's diet order stated chopped meat and confirmed it was not listed on the resident's meal ticket, and it should have been. S1Admin further confirmed that the meat served on Resident #73's lunch tray should have been chopped.On 08/25/2026 at 12:03 p.m., an interview and review of meal ticket and diet order was conducted with S19DM. S19DM confirmed Resident #73 should have been served chopped meat for lunch. S19DM further confirmed chopped meat was not listed on Resident #73's meal ticket and it should have been.

Based on record review, observation, interviews, and review of the facility's policy and procedure, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure sterile gloves were worn during tracheostomy care for 1 (Resident #1) of 39 sampled residents. Findings: On 08/25/2026, a review of the facility's policy titled Tracheostomy Care Policy and Procedures, with a last review date of 04/15/2026, read in part: Purpose: 1. To ensure that a resident who needs tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice. 2. To minimize the risk of infection and other complications associated with tracheostomy care. 4) Tracheostomy Cleaning and Cannula Changes. xii. Apply sterile gloves (remember to ensure your dominant hand remains sterile throughout the procedure). xiii. Clean stoma site using sterile 2x2 or 4x4 gauze sponges moistened with normal saline. Gently wipe starting at the stoma site under the faceplate and move outward in circular motions. Dispose of gauze. Moisten another gauze and clean the exposed outer cannula surfaces and faceplate. Repeat each of these steps until the surrounding skin and outer surfaces of devices are clean and free of debris.Review of Resident #1's Electronic Health Record (EHR) revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included, but were not limited to, encounter for attention to tracheostomy, respiratory failure, and tracheostomy status.Review of Resident #1's most recent quarterly Minimum Data Set (MDS) dated [DATE], read in part, Section O - Special Treatments, Procedures, and Programs, revealed the resident was coded for tracheostomy care. Review of Resident #1's current comprehensive care plan revealed the following in part: I have a tracheostomy. with an intervention that read in part: perform my trach care daily and as needed.On 08/24/2026 at 11:24 a.m., an observation of tracheostomy care performed for Resident #1 by S17LPN/WC was conducted. While S17LPN/WC was applying sterile gloves, they ripped. She removed the ripped sterile gloves and applied nonsterile, disposable gloves. S17LPN/WC cleaned the secretions on the inside of Resident #1's tracheostomy with normal saline, gauze, and a cotton-tipped applicator while wearing nonsterile, disposable gloves. S17LPN/WC cleaned the stoma area with normal saline and gauze while wearing nonsterile, disposable gloves. On 08/24/2026 at 11:34 a.m., an interview was conducted with S17LPN/WC. S17LPN/WC confirmed that while applying sterile gloves they ripped, and then she applied nonsterile, disposable gloves. S17LPN/WC confirmed that while performing tracheostomy care, sterile gloves were not worn. On 08/24/2026 at 1:00 p.m., an interview was conducted with S2CN. S2CN confirmed that while performing tracheostomy care, sterile gloves should be worn.

Based on observations, interviews, and record reviews, the facility failed to ensure the provided diet met the nutritional needs of each resident as evidenced by failing to ensure dietary staff used the appropriate portion size serving utensils when serving the lunch meal. Review of the facility's policy titled Accuracy and Quality of Tray Line Service Policy and Procedure, with a last reviewed date of 05/14/2025, read in part. 7. Each meal will be checked for: Proper portion sizes. On 09/15/2025 at 12:23 p.m., an observation was made of the food service line during lunch. The red beans and sausage were being served with a green handle spoodle, which was 4 ounces. The okra and tomatoes were being served with a green handle scoop, which equaled to 1/3 cup. A review of the Diet Extensions: Monday, Week 3,. 2025 for a regular diet revealed beans and sausage were to be served with a 6 ounce spoodle and the okra and tomatoes were to be served with a 4 ounce spoodle. On 09/15/2025 at 12:28 p.m., an observation of the serving utensils was conducted with S16DM (Dietary Manager). She stated that the dietary staff should have followed the recipes and/or the daily diet spreadsheets (Diet Extensions) that listed the appropriate serving sizes and use the color-coded chart for the serving utensils. She stated this would have ensured they were serving the correct portions. At that time, an observation of the serving utensils for the red beans and sausage and okra and tomatoes was also conducted with S1ADM (Administrator) and S4 CorpNurse (Corporate Nurse). They all agreed that the wrong size serving utensils were used to serve the red beans and sausage and the okra and tomatoes.

Based on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles as evidenced by failing to: 1. Discard an expired medication in 1 (Med Cart A ) of 2 (Med Cart A and Med Cart B) medication carts inspected for medication storage; 2. Discard loose tablets in 2 (Med Cart A and Med Cart B) of 2 (Med Cart A and Med Cart B); and3. Properly secure medications for Med Cart C at all times during medication pass.Findings: A review of the facility's policy titled, Medication Storage Policy and Procedure with a last review date of 08/12/2025, read in part, Purpose: To properly secure medications and biologicals according to CMS guidelines. Policy: 1. Medications and biologicals will be maintained in a secured location only accessible to designated staff. Procedure: 2. Medications carts will be checked weekly for expired medications, loose pills. a. Any expired medications or loose pills will be destroyed according to the standard guidelines. On 09/17/2025 at 9:05 a.m., an observation was conducted of Med Cart A with S3LPN (Licensed Practical Nurse) and S1ADM (Administrator), which revealed the following: 1 bottle of Lactulose 10 gm (gram)/15 mL (milliliter) with an expiration date of 06/2025 1 loose tablet On 09/17/2025 at 9:18 a.m., an observation and interview was conducted with S3LPN, who confirmed the expiration date on the bottle of Lactulose 10 gm/15 mL was 06/2025, and it should have been discarded and not in the med cart. She confirmed that there was 1 loose tablet in the med cart, and it should not have been in the med cart. On 09/17/2025 at 9:20 a.m., an observation was conducted of Med Cart B with S5LPN and S1ADM, which revealed the following: 1 loose tablet On 09/17/2025 at 9:30 a.m., an observation and interview was conducted with S5LPN, who confirmed that there was 1 loose tablet in the med cart and should not have been in the med cart. On 09/16/2025 at 4:00 p.m., an observation was made of S6LPN (Licensed Practical Nurse) administering medications from Med Cart C. During preparation of medications, S6LPN was observed leaving a medicine cup containing Levetiracetam solution (anti-seizure medication) unattended on the top of Med Cart C as she left the hall to obtain other medications from another hall. A second observation was made when S6LPN left two medicine cups containing unknown medication on the top of Med Cart C after entering a resident's room. Upon S6LPN's return to Med Cart C, she confirmed that she left the medication unsecured on top of the cart on both occasions.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents were provided respiratory care, consistent with professional standards of care for 2 (#61 and $113) of 5 (#8, #49, #61, #108 and #113) residents investigated for respiratory care. The facility failed to:1. Change an empty humidifier bottle for Resident #61, and2. Label oxygen equipment for Resident #113 Findings: On 09/17/2025, a review of the facility's policy titled, Oxygen Administration Policy and Procedure with a last reviewed date of 03/15/2025, read in part, Purpose: To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissue. Procedure.5. Prefilled, sealed, disposable humidifiers may be changed per facility procedure, weekly and as needed.g. Label humidifier with date and time opened .9. At regular intervals, check liter flow contents of oxygen cylinder, fluid level in humidifier. Resident #61: Resident #61 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to shortness of breath, myocardial infarction type 2, and encounter for palliative care. Review of Resident #61's physician orders revealed an order written on 06/09/2025 indicating the resident was admitted to hospice care. Further review revealed another order written on 06/09/2025 in part, Oxygen 4L (liters)/min (minute) per nasal cannula. Review of Resident #61's hospice Care Plan Facility Coordination of Care revealed an intervention that read in part, Oxygen: facility nurse change mask, O2 (oxygen) tubing, water bottle. On 09/15/2025 at 10:04 a.m., an observation was made of Resident #61 in his bed. The resident was receiving O2 by nasal cannula. The tubing was connected to an empty humidifier bottle which was connected to an oxygen concentrator. On 09/15/2025 at 11:57 a.m., a second observation was made of Resident #61. The resident was sitting up in his wheelchair and receiving O2 by nasal cannula. Further observation revealed the humidifier bottle remained empty. On 09/15/2025 at 11:57 a.m., an interview and observation of Resident #61's oxygen equipment was conducted with S15LPN (Licensed Practical Nurse). She confirmed the resident's humidifier bottle was empty and should not have been. On 09/17/2025 at 9:23 a.m., an interview was conducted with S2DON (Director of Nursing). She stated Resident #61's oxygen humidifier bottle was not supposed to be empty. S2DON confirmed the facility nurses were responsible for changing the humidifier bottle. Findings: Resident #113 Resident #113 was admitted to the facility on [DATE], with a diagnosis that included, but was not limited to shortness of breath. A review of Resident #113's Order Summary Report, revealed a physician's order, with a start date of 09/15/2025, for O2 (Oxygen) at 2 liters/minute/nasal cannula prn (as needed) SOB (shortness of breath)/O2 saturation less than 92% (percent) to relieve hypoxia every 12 hours as needed for SOB related to Shortness of Breath. A review of Resident #113 Care Plan Report, revealed in part: Focus: I have respiratory disease. I have diagnosis of SOB; I am at risk for excessive secretions. I require oxygen as needed; Interventions: Manage my oxygen set up per protocol. On 09/15/2025 at 9:17 a.m., an observation and interview of Resident #113's room was conducted with S14LPN (Licensed Practical Nurse). A humidifier bottle was observed connected to an oxygen concentrator with no date or time on the bottle. S14LPN observed and confirmed that the humidifier bottle should have been labeled with the date and time it was opened.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident received a nutritional supplement as ordered for 1 resident (#84) of 9 (#1, #11, #23, #30, #55, #72, #84, #89 and #94) residents investigated for dining.Findings: Resident #84 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to unspecified protein-calorie malnutrition and ataxia following cerebral infarction.A review of Resident #84's current Order Summary Report revealed a physician's order with a start date of 03/28/2025 that read Mighty Shake (nutritional supplement) with meals for weight loss related to unspecified protein calorie malnutrition, add ice cream. A review of Resident #84's meal card revealed Personal Menu Item: 4 fluid ounce Mighty Shake. On 09/17/2025 at 7:30 a.m., an observation was made of Resident #84 in the dining room with his breakfast tray and meal card in front of him. No Mighty shake supplement was observed. On 09/17/2025 at 8:00 a.m., an interview and observation was made of Resident #84's meal tray and meal card with S7CNA (Certified Nursing Assistant). S7CNA confirmed that there was no Mighty shake supplement on Resident #84's meal tray and should have been if the meal card had been followed. S7CNA stated that she had fed the resident and that no Mighty shake had been offered to him for breakfast. On 09/17/2025 at 8:03 a.m., an interview and observation was made of Resident #84's meal card and meal tray with S2DON (Director of Nursing). S2DON also confirmed there was no Mighty shake supplement on Resident #84's meal tray and should have been according to his meal card.

Based on record review and interviews, the facility failed to ensure a discharge summary was completed for a resident with a planned discharge to the community for 1 (#112) of 3 (#9, #111, and #112) closed records reviewed.Findings:On 09/16/2025, a review of the facility's policy titled, Discharge Summary Policy and Procedure with a revision date of 05/22/2025, read in part, Purpose: To document the resident status throughout the resident stay and on the resident discharge. Policy: Discharge Summary is to be completed within a timely manner of discharge. Procedure.2. Discharge Summary will be completed within a timely manner of discharge. 3. The discharge summary will include the following: 1. Type of discharge 2. A recapitulation of the resident's stay 3. A final status of the resident's status at the time of discharge 4. Reconciliation of medications via discharge instructions form when applicable. 5. Post discharge plan of care.Resident #112 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic combined systolic (congestive) and diastolic (congestive) heart failure, unspecified abnormalities of gait and mobility, and type 2 diabetes mellitus with diabetic neuropathy.Review of Resident #112's Discharge Minimum Data Set (MDS) assessment, dated 09/08/2025, revealed in Section A0310 that the resident had a planned discharge. Further review revealed in Section A2105 that the resident was discharged to home/community.Review of a Notice of Medicare Non-Coverage notification form issued by the facility, revealed that on 08/07/2025, Resident #112 signed the form notifying him that Medicare coverage of his current skilled nursing services would end on 08/09/2025.Review of Resident #112's physician orders revealed an order written on 08/09/2025 that read in part.D/C (discharge) home with all meds and Narcs. (Narcotics).Review of a social services evaluation narrative summary written by S8SSD (Social Services Director) on 08/08/2025, revealed in part.D/C Assessment: Assessment completed with resident participation.Resident wishes to dc home on Saturday 08/09/2025.Resident happy with facility and happy to be returning home.Review of Resident's #112 Electronic Health Record (EHR) revealed no discharge summary.On 09/16/2025 at 1:33 p.m., an interview was conducted with S8SSD. She confirmed Resident #112 had a planned discharge. S8SSD stated she was not responsible for the discharge summary. She stated S9LPN/QA (Licensed practical Nurse/Quality Assurance Coordinator) was usually the one who completed the discharge summary.On 09/16/2025 at 1:45 p.m., an interview and review of Resident #112's EHR was conducted with S9LPN/QA. She confirmed Resident #112 did not have a discharge summary and stated she had not completed one for the resident. 09/16/2025 at 2:55 p.m., an interview was conducted with S4CorpNurse (Corporate Nurse). She confirmed that a discharge summary was not completed for Resident #112. S4CorpNurse stated a discharge summary should have been completed and a copy placed in the resident's EHR.

Based on observations and interview, the facility failed to ensure a safe, clean, and homelike environment for 3 (#79, #88, and #90) out of 5 (#8, #33,#79, #88, and #90) residents investigated for environment. The facility failed to ensure: 1. Wheelchairs were clean for Residents #79 and Resident #90; and 2. The toilet support arm was in good working condition for Resident #88. Findings: A review of the facility's policy titled, Homelike Environment Policy and Procedure, with a last reviewed date of 06/12/2025, read in part Procedure: 1. Physical Environment a. Resident Rooms, ii. Maintain a clean and safe living space according to resident wishes. Resident #79 On 09/15/2025 at 10:15 am, an interview and observation of Resident #79's wheelchair was made with S14LPN (Licensed Practical Nurse). Her wheelchair was observed to have a large amount of dust and grime on the spokes of the wheels and on the bottom bars. S14LPN stated that the wheelchair 100 percent needed to be cleaned. Resident #90 On 09/15/2025 at 10:20 a.m., an interview and observation of Resident #79's wheelchair was made with S14LPN. Her wheelchair was observed to have a large amount of dust and grime on the spokes of the wheels and on the bottom bars. S14LPN confirmed that the resident's chair was dirty and needed to be cleaned. Resident #88 A review of Resident #88's Quarterly MDS (Minimum Data Set) with an ARD (assessment reference date) of 08/15/2025 revealed that the resident had a BIMS (Brief Interview for Mental Status) of 14, indicating the resident's cognition was intact. A review of Resident #88's Care Plan Report, revealed I require assistance for ADL's (Activities of Daily Living): I need assist with ADL care; Request for toilet support arm. On 09/15/2025 at 9:50 a.m., an observation was made of Resident #88's bathroom with S14LPN. The resident's toilet support arm was observed to move in a back and forth motion when pressure was applied indicating that it was loose. The base of the arm was connected to the wall and was observed to be partially coming out of the wall. Sheet rock damage was observed around the around the base of the arm. S14LPN confirmed the findings and further confirmed the toilet support arm was not in good working condition and needed to be repaired. On 09/15/2025 at 9:55 a.m., an interview was conducted with Resident #88. He stated the toilet support arm had been very shaky for about a week.

Based on observation, interviews, and record review, the facility failed to ensure a resident was safe to perform self-administration of medication for 1 (#25) of 54 sampled residents This deficient practice had the potential to affect a census of 110 Residents. Record review revealed Resident #25 was admitted to the facility on [DATE]. The resident had a BIMS (Brief Interview for Mental Status) Score was 10 meaning she had moderate cognitive impairment. Record review of Resident #25's medical record revealed the resident did not have an assessment to self-administer her medications.On 09/15/2025 at 9:03 a.m., an observation in Resident #25's room revealed a bottle of Advanced Eye Relief (Over the counter) eye lubricant on her bedside table. Resident #25 stated she used the medication to relieve her dry eyes. She stated she asked her daughter to bring her this medication. On 09/16/2025 at 10:08 a.m., an observation in Resident #25's room with S6LPN (Licensed Practical Nurse) revealed that the resident had 1 bottle of Advanced Eye Relief, 1 bottle of Refresh Relieve, 1 bottle Blink Lubricating Eye Drops and a 1 bottle of Debrox Ear wax removal Aid (over the counter medications) at the bedside. S6LPN stated the resident does not have these over the counter medications on her medication profile. S6LPN stated the CNAs (certified nurse assistants) are to go through the resident's drawers to ensure they do not have any medication. S6LPN stated the resident should not have these medications in her possession. She stated Resident #25 was not assessed to self-administer her own medications. On 09/16/2025 at 1:04 p.m., an interview with S4CorpNurse revealed nursing staff should have removed the medication from Resident #25's room if she had medication on her bedside table. She stated Resident #25 was not assessed to self-administer her own medications and should not have had medications in her room.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5%. A total of 27 opportunities were observed with 2 medication errors, which resulted in a medication error rate of 7.41%. The facility failed to ensure: 1. Resident #8 was administered the correct medication for Guaifenesin ER (Extended Release) as ordered, and 2. Resident #47 was administered Cyanocobalamin as ordered.Findings: Resident #8Review of Resident #8's health record revealed that he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to quadriplegia, encounter for attention to tracheostomy, and cough, unspecified. Review of Resident #8's Order Summary Report, revealed a physician's order for Guaifenesin ER Tablet Extended Release 12 hour 600 mg (milligrams), give 1 tablet via PEG (percutaneous endoscopic gastrostomy) tube two times a day for cough, related to cough, unspecified with a start date of 02/20/2025. On 09/16/2025 at 4:00 p.m., an observation was made of S6LPN (Licensed Practical Nurse) administering medications to Resident #8. S6LPN administered one and one half tabs of Guaifenesin 400 mg. S6LPN confirmed that Resident #8's physician order stated to administer Guaifenesin Extended Release. S6LPN stated that she was unsure if it was OK to administer Guaifenesin in replacement of Guaifenesin Extended Release. Resident #47Review of Resident #47's health record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to dementia, vitamin deficiency, and muscle weakness. Review of Resident #47's Medication Administration Record revealed a physician's order for Cyanocobalamin Tablet 500 mcg (micrograms), give 1 tablet by mouth one time a day for vitamin b deficiency related to vitamin deficiency with a start date of 03/01/2025. On 09/16/2025 at 7:53 a.m., an observation was made of S14LPN administering medications to Resident #47. Cyanocobalamin was not administered to Resident #47.A review of Resident #47's Electronic Medication Administration Record revealed that S14LPN documented that she had administered Cyanocobalamin on 09/16/2025 at 7:55 a.m. while being observed by the surveyor.

Based on record reviews, observations, and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for 1 (Resident #49) out of 54 sampled residents by failing to ensure the resident's EMAR (Electronic Medication Administration Record) was accurately documented.Findings:A review of the facility's policy titled Charting and Documentation Policy and Procedure with a last review date of 02/18/2025, revealed in part, Purpose: The purpose of charting and documentation is to provide the following: a complete account to the resident's care, treatment, response to the care, signs, symptoms, and progress of resident care.A review of Resident #49's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, wheezing, coughing, and shortness of breath.A review of Resident #49's clinical physician orders revealed an active physician's order, with a start date of 03/21/2025, which stated oxygen 2L (liters) continuous, directions: twice a day.A review of Resident #49's EMAR for September (09/01/2025 - 09/16/2025) revealed an order which stated oxygen 2L continuous two times a day. Further review of the EMAR revealed this order was checked off and initialed by an LPN (Licensed Practical Nurse) on the morning of 09/15/2025 and on the morning of 09/16/2025.On 09/15/2025 at 11:44 a.m., an observation was made of Resident #49 in her room. No nasal cannula with continuous oxygen was observed on the resident.On 09/16/2025 at 12:00 p.m., a second observation was conducted of Resident #49 in the dining room. No nasal cannula with continuous oxygen was observed on the resident.On 09/16/2025 at 12:51 p.m., a third observation was conducted of Resident #49 in her room. No nasal cannula with continuous oxygen was observed on the resident.On 09/16/2025 at 1:27 p.m., an interview and record review were conducted with S6LPN. A review of Resident #49's physician's orders was conducted with S6LPN. S6LPN confirmed that Resident #49 did have an active order for continuous oxygen. A review of Resident #49's September 2025 MAR was conducted with S6LPN. S6LPN confirmed that she had documented that she administered oxygen to Resident #49 today and yesterday. S6LPN stated she has worked at the facility since July 2025 and had never seen Resident #49 wearing oxygen. S6LPN confirmed that Resident #49 was not receiving continuous oxygen, and she inaccurately documented it in the EMAR.

Based on record reviews and interviews, the facility failed to ensure a resident taking an anticoagulant medication was monitored for bruising and/or bleeding for 1 (#1) out of 3 (#1, #2 and #3) residents reviewed for unnecessary medications. Findings: On 02/18/2025, a review of the facility's undated policy entitled, Anticoagulant Therapy Bruising Bleeding Policy and Procedure revealed, in part, Purpose: 1. To monitor for possible bruising and/or bleeding due to anticoagulant medication therapy. Policy: It is the policy of this facility to have a special requirement or monitoring tool in place to monitor for possible side effects of anticoagulant therapy such as bruising and/or bleeding. Procedure: 1. Implement supplementary documentation or monitoring tool upon implementation of anticoagulant therapy. 2. The nurse is to assess the resident for any possible side effects such as bruising and/or bleeding daily or as needed. Review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, atrial fibrillation and heart failure. Review of Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Section N - Medications: the resident was taking an anticoagulant. Review of Resident #1's Order Recap Report, revealed a physician's order with a start date of 02/13/2025 Dabigatran Etexilate Mesylate Oral Capsule 150 mg (milligram); give 1 capsule by mouth one time a day. Review of Resident #1's MAR (Medication Administration Record), from February 2025 revealed the resident was administered Dabigatran Etexilate Mesylate Oral Capsule 150 mg on 02/13/2025, 02/14/2025, 02/15/2025, 02/16/2025, 02/17/2025, and 02/18/2025. Further review of the February 2025 MAR revealed the resident was not monitored for bruising and/or bleeding from 02/13/2025 to 02/18/2025. Review of Resident #1's physician orders and comprehensive plan of care failed to reveal an order for monitoring for bruising and/or bleeding of Dabigatran Etexilate Mesylate. Further review revealed no other evidence in Resident #1's record of adequate monitoring for the administration of Dabigatran Etexilate Mesylate from 02/13/2025 to 02/18/2025. On 02/18/2025 at 10:49 AM, an interview and record review was conducted with S2LPN (Licensed Practical Nurse). She confirmed that Resident #1 was receiving Dabigatran Etexilate Mesylate and residents who receive anticoagulants should be monitored for bleeding and/or bruising and a yes or no should be documented in the MAR. She reviewed Resident #1's February 2025 MAR and confirmed the resident was not monitored for signs and symptoms of bruising and/or bleeding from 02/13/2025 to 02/18/2025, and should have been. On 02/18/2025 at 12:52 PM, an interview and record review was conducted with S1DON (Director of Nursing) who confirmed that Resident #1 was taking Dabigatran Etexilate Mesylate and it is an anticoagulant. She stated that the nurses should monitor the resident for bruising and/or bleeding and document the findings on the MAR. S1DON reviewed Resident #1's MAR from February 2025 and confirmed the nurses did not monitor Resident #1 for signs and symptoms bruising and/or bleeding from 02/13/2025 to 02/18/2025, and should have been.

Based on record reviews and interviews, the facility failed to ensure a resident was free from verbal and physical abuse for 1 (Resident #R1) out of 4 (Resident #1, Resident #2, Resident #3, and Resident #R1) sampled residents. Findings: On 12/26/2024, a review of the facility's policy titled, Abuse and Neglect Policy and Procedure with a last revision date of 12/19/2024, read in part: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse may include but are not limited to: Yelling or hovering over a resident, with the intent to intimidate. Physical Abuse includes hitting, slapping, pinching, biting, shoving, and kicking. Resident #R1 Review of Resident #R1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and Alzheimer's Disease. Review of the Quarterly MDS (Minimum Data Set) with and ARD (Assessment Reference Date) of 10/16/2024 revealed Resident #R1 had a BIMS (Brief Interview of Mental Status) score of 8, which indicated she was moderately cognitively impaired. Resident #3 Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified dementia, unspecified severity, with other behavioral disturbance, depression, and anxiety disorder. Review of the Discharge MDS with ARD of 12/10/2024 revealed Resident #3 had a BIMS score of 6, which indicated she was severely cognitively impaired. A review of facility's incident report, dated 12/10/2024 at 7:20 PM, included a note by S2DON (Director of Nursing) that revealed in part: Staff reported they over heard yelling coming from the dining room. Upon entering, Resident #3 noted sitting in her wheelchair, directly in front of Resident #R1, blocking her in. Both residents were arguing at this time. Resident #3 was immediately removed from the area. Family members of another resident stated that Resident #3 went up to Resident #R1, started arguing with Resident #3, pushing Resident #R1 with Resident #3's wheelchair, told Resident #R1 to shut up, and hit Resident #R1 in the face. A review of a facility incident report, dated 12/10/2024, included a statement by S4VIS (Visitor) that revealed in part: Resident #3 went up to Resident #R1 and started arguing and pushed Resident #R1 with her wheelchair. Resident #3 told Resident #R1 that she was going to hit her. Resident #3 hit Resident #R1. A review of a facility incident report, dated 12/10/2024, included a statement by S5VIS (Visitor) that revealed in part: Resident #3 came rolling in the wheelchair and was pushing Resident #R1 with her wheelchair and told Resident #R1 to shut up, and Resident #R1 said she did not have to. Resident #3 then slapped Resident #R1. On 12/23/2024 at 3:54 PM a phone interview was conducted with S4VIS regarding the incident on 12/10/2024 between Resident #3 and Resident #R1. S4VIS stated that Resident #3 was arguing with Resident #R1 because Resident #3 did not want the lady to be in that spot. Resident #3 raised her fist and threatened to hit Resident #R1. Resident #R1 stated she was not going to move and Resident #3 slapped Resident #R1 in the face. On 12/23/24 at 4:28 PM, a phone interview was conducted with S5VIS regarding the incident on 12/10/2024 between Resident #3 and Resident #R1. She stated that Resident #R1 was sitting by the wall, and Resident #3 told Resident #R1 to move, and when Resident #R1 said she would not, Resident #3 raised her fist. S5VIS stated that Resident #R1 could not move because she was stuck. The next thing S5VIS remembers is that Resident #R1's glasses flew off. S5VIS stated that Resident #R1 was minding her own business before the argument. On 12/26/2024 at 12:08 PM, a joint interview was conducted with S1ADM (Administrator) and SDON. Both confirmed that an argument was held between Resident #3 and Resident #R1 on 12/10/2024. Both confirmed that this incident resulted in Resident #3 hitting Resident #R1 in the face and resulted in no injury to either resident.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure an allegation of physical and verbal abuse was reported to the state survey agency no later than 2 hours after the allegation was made for 1 (Resident #R1) out of 4 (#1, #2, #3 and #R1) residents investigated for abuse. Findings: On 12/26/2024, a review of the facility's policy titled, Abuse and Neglect Policy and Procedure with a last revision date of 12/19/2024, read in part: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse may include but are not limited to: Yelling or hovering over a resident, with the intent to intimidate. Physical Abuse includes hitting, slapping, pinching, biting, shoving, and kicking. 7. Reporting/Response: The facility administrator or designee shall complete a report to be made to the mandated state agency according to state guidelines upon notification of an alleged abuse. Resident #R1 Review of Resident #R1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and Alzheimer's Disease. Review of the Quarterly MDS (Minimum Data Set) with and ARD (Assessment Reference Date) of 10/16/2024 revealed Resident #R1 had a BIMS (Brief Interview of Mental Status) score of 8, which indicated she was moderately cognitively impaired. Resident #3 Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified dementia, unspecified severity, with other behavioral disturbance, depression, and anxiety disorder. Review of the Discharge MDS with ARD of 12/10/2024 revealed Resident #3 had a BIMS score of 6, which indicated she was severely cognitively impaired. A review of facility's incident report, dated 12/10/2024 at 7:20 PM, included a note by S2DON (Director of Nursing) that revealed in part: Staff reported they over heard yelling coming from the dining room. Upon entering, Resident #3 noted sitting in her wheelchair, directly in front of Resident #R1, blocking her in. Both residents were arguing at this time. Resident #3 was immediately removed from the area. Family members of another resident stated that Resident #3 went up to Resident #R1, started arguing with Resident #3, pushing Resident #R1 with Resident #3's wheelchair, told Resident #R1 to shut up, and hit Resident #R1 in the face. On 12/26/2024 at 12:08 PM, a joint interview was conducted with S1ADM (Administrator) and SDON. Both confirmed that an argument was held between Resident #3 and Resident #R1 on 12/10/2024 and was not reported to the state survey agency. Both confirmed that this incident resulted in Resident #3 hitting Resident #R1 in the face and resulted in no injury to either resident.

Based on record review, interviews and observation the facility failed to ensure residents remain free from accidents and hazards for 1(#64) out of 4 (#16, #18, #45, #64) residents investigated for falls by failing to secure Resident #64's wheel chair during transportation. This deficient practice resulted in a harm on 08/02/2023 at 4:00 p.m., when Resident #64's wheelchair was not properly secured in the facility's transportation van. The resident's wheelchair flipped backwards and caused the resident to hit her head. Resident #64 was sent to the hospital for evaluation and was diagnosed with a new small acute subdural hemorrhage. Upon completion of evaluation, Resident #64 was transferred from a local hospital to another hospital for a higher level of care. She was hospitalized from 08/02/2023 and returned back to the facility on [DATE]. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: The facility's policy titled Transportation Vehicle Van Policy and Procedure read in part, Purpose: To provide transportation as needed in a safe manner according to state laws and guideline. Procedure: 1. Designated maintenance supervisor or other designee to be trained on all of the van's equipment based on the manufacturer's guidelines. Review of the manufacturer's guide titled Q'Straint (QRT-360) 4 -Point Wheelchair Securement System read in part . Securing Wheelchair: 1. Center wheelchair facing forward in securement zone and lock wheelchair brakes (or power off electric chair). 2. Attach 4 retractors [A1] into floor anchorage [B1] points and lock them in place, with an approximate distance of 48-54 between the front and rear retractors. 3. Completely pull out each webbing and attach J-Hooks to compliant WC19 chair securement points near seat level [A2] (or solid frame members [B2]) at an approximate 45 degree angle with floor [A3]. 4. Move wheelchair forward and back to remove webbing slack or manually tension webbing with retractor knob [A4]. A review of Resident #64's Electronic Health Record (EHR) revealed an admitted [DATE] with diagnoses that included in part, Displaced Fracture of Left Hip, Acquired Absence of Right Leg Above Knee, Type 2 Mellitus with Diabetic neuropathy, Bipolar Disorder, Tremor, Generalized Anxiety, Unspecified Dementia and Acquired Absence of Left Leg Below Knee. A review of Resident #64's Quarterly MDS (Minimum Data Set) dated 07/12/2023 revealed a BIMS (Brief Interview of Mental Status) of 13, indicating intact cognition. A review of Resident #64's care plan read in part .I am at risk for falls related to Left BKA (Below the Knee Amputation), Muscle Weakness and Right AKA (Above the Knee Amputation), Left Femur Fracture Status Post Intramedullary Nailing and Requires assistance with all transfers, bed mobility and repositioning. Further review of Resident #64's current care plan revealed the following: On 08/02/2023 fall noted, wheelchair flipped backwards in van hitting head. Later sent to emergency room with diagnosis of subdural hematoma. Interventions included in part, All transportation drivers in-serviced on how to properly secure wheelchairs in van for transportation with a start date of 08/03/2023. Review of hospital records revealed Resident #64 was admitted to the hospital with a primary diagnosis of Subdural Hematoma and secondary diagnoses including Fall from non-moving wheelchair. Further review of hospital records revealed resident was admitted to the ICU (Intensive Care Unit on 08/02/2023 and downgraded to the medical floor on 08/03/2023. A review of the facility's investigative report revealed in part, on 08/02/2023, S9CNA/Transportation Driver was transporting Resident #64 from her doctor's appointment when an incident occurred and her wheel chair flipped backwards causing the resident to hit her head. S9CNA/Transportation Driver stated that she is unsure what happened because she had properly secured resident in her wheelchair. S9CNA/Transportation Driver stated that she pulled over and picked Resident #64 up and ensured she was alright. She stated that Resident #64 told her that she hit her head, but was not in pain. S9CNA/Transportation Driver stated that she did not see anything visibly wrong with Resident #64. She then called her supervisor, S12CNASupervisor to inform her of the incident. Upon arrival back to the facility, Resident #64 was sent to the emergency room for evaluation by orders of the physician. Later that evening a phone call to the facility was received from the emergency room nurse who stated that Resident #64's CT (computerized tomography) scan of her head showed a small subdural hematoma measuring 5 mm at its thickness and that she would be transferred to another hospital for treatment. On 09/19/2023 at 10:30 a.m., a phone interview was conducted with S9CNA/Transportation Driver at the time of the incident. She stated that an incident occurred last month with Resident #64 when she was transporting her from her doctor's appointment. She stated that after loading the resident back into the van and strapping her securely, they left the hospital parking lot, but when they reached the stop sign the wheel chair with the resident in it went backwards. S9CNA/Transportation Driver stated that she pulled over in a nearby parking lot. She stated that the resident told her she hit her head but she was not in any pain. She stated that she checked the resident's head for any evidence of injury and there was no knot or bleeding. She then removed the straps off of the resident and picked her up in the wheelchair. She said that she was not sure what happened as she had strapped all 4 straps to the floor and secured with the hook to the wheelchair and the wheelchair was locked. She stated that she placed a strap around her waist first then placed a strap across her body. She stated that there was an in-service after the incident for all drivers. She stated that she could no longer provide transportation for residents until the investigation was completed. On 09/19/2023 at 10:45 a.m., an interview was conducted with S1ADM who stated that he was aware of the incident with Resident #64. He stated that an investigation and training was conducted the morning after the incident occurred. He stated that there was a QA (Quality Assurance) that had been done for 4 weeks and was completed. In addition, the staff was in-serviced on how to properly secure residents for transportation with return demonstration. He stated that he felt like it was an issue with the floor straps not secured properly, which was why this employee was no longer employed at the facility. On 09/19/2023 at 10:52 a.m., due to not having any transportation scheduled, a mock demonstration of a transportation in and out of the transportation van was observed with myself and another surveyor, administrator, and maintenance supervisor with both transportation drivers S10CNA/Transportation Driver and S11CNA/Transportation Driver. Both transportation drivers utilized the proper technique for securing and checking the security of the mock participant with no issues. On 09/19/2023 at 11:29 a.m., an interview was conducted with Resident #64 and the resident's RP (Responsible Party). She stated that she had a fall in the van and but was unsure if all four straps were secured to the floor, but she knew that two were secured. She stated that after she was strapped, when the van pulled away, she heard a pop and fell backwards. She stated that the transportation driver pulled the van over and got her up and checked her out. She stated that she was fine and was not hurting. She stated that when she returned back to facility, they sent her to the emergency room because she was on a blood thinner. She said they discovered the problem with the subdural hematoma and kept her for a couple of days for treatment. Resident stated that she had been transported since then and that she was okay with it and did not have any issues with transportation. On 09/19/2023 at 03:42 p.m., an interview was conducted with S2DON. She stated that she was made aware about the incident the day it occurred on 08/02/2023. She stated S1Adm conducted the majority of the investigation, and retraining with return demonstration began the next day. Observations of wheelchair securement by facility transporters, interviews with van transporters, review of in-service records, and competency evaluations revealed the facility implemented the following Plan of Correction beginning 08/03/2023 with completion date of 09/01/2023. 1. Maintenance inspected van and straps for defects/issues. 2. All staff in-serviced on correct procedure for securing a resident in wheelchair in van, and protocol for if an incident occurs. 3. Maintenance supervisor performed competency checks for securing a resident in a wheelchair in van on all staff on driver list. 4. Quality Assurance nurse will spot check securement of straps/buckles on resident in wheelchair before doctor's appointment 3 days a week for 4 weeks. 5. Department heads will go over transport list every day in morning meeting.

Based on record review and interviews, the facility failed to ensure that a resident received the necessary treatment consistent with professional standards of practice to prevent and promote the healing of pressure ulcers for 2 residents (#3, #7) out of 7 (#1, #2, #3 #4, #5, #6 and #7) sampled residents reviewed for pressure ulcers by: 1. Failing to perform an accurate skin assessment and implement appropriate treatment on Resident #3's sacral/coccyx region after an area of concern was identified on 11/12/21; and by 2. Failing to obtain treatment in a timely manner for a Stage 2 pressure ulcer to Resident #7's right lower buttock that was identified on 11/19/2021. This deficient practice resulted in actual harm on 11/15/21 when Resident #3 was assessed to have a new unstageable pressure injury to the buttock region and two new Stage 1 pressure ulcers to the lower buttock area. On 11/12/2021, S6CNA identified Resident #3 to have a dime sized wound on her buttock region and reported it to S3RN and S5LPN. S3RN and S5LPN confirmed in separate interviews, they did not assess the resident's buttock region. On 11/14/2021, S4LPN conducted a scheduled body/skin assessment on Resident #3 while she was seated in a wheelchair. S4LPN confirmed in an interview she had not conducted a thorough assessment and failed to assess Resident' #3's buttock area. As a result, Resident #3 developed three new pressure ulcers. Findings: Review of facility policy titled Body Audit Policy and Procedure read in part . Purpose: to maintain and prevent further skin breakdown. The facility will accomplish these goals through prevention, assessment, and treatment Policy: All residents will have a skin assessment completed upon admission, re-admission, weekly, and as needed Procedure: .2. A nurse will perform the skin assessment. 3. If an issue is identified; the proper treatment protocols will be implemented per physician order's. 4. Documentation of the skin issue will be documented in the resident's chart identifying the skin issue and location . Resident # 3: Record review of Admit MDS (Minimum Data Set) dated 10/27/21 revealed Resident # 3 was admitted to the facility on [DATE] following surgical repair of right hip. Resident was at risk of developing pressure ulcers/injuries. Resident admit assessment revealed no unhealed pressure ulcers/injuries. Resident #3 had a surgical wound. A review of Resident # 3's Braden Scale Assessments dated 10/20/21, 10/27/21, 11/3/21 & 11/10/21 all revealed a score of 14 indicating that Resident #3 had a moderate risk of developing a pressure ulcer or injury. Review of November 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Right lower buttock-Clean with NS (normal saline) or WC (wound cleanser), Pat dry, apply [MEDICATION(S)] BID (twice a day) until healed Coccyx- Clean with NS or WC, Pat dry, Apply Santyl and Calcium Alginate, Pad with 4x4 gauze, cover with dry dressing QD (every day) until healed Left Lower Buttock- Clean with NS or WC, Pat dry, apply [MEDICATION(S)] BID until healed Further review of November 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 3's wound assessment reports completed by S3RN (Registered Nurse and former treatment nurse) revealed the following: Assessment on 11/3/21 read in part .1.5 cm surgical incision to right lateral distal thigh, unchanged .appears to be healing well, dry with no drainage noted . Wound resolved 11/5/21 . Further review revealed no pressure ulcers. Assessment on 11/15/21 read in part . resident noted with new unstageable pressure injury to her coccyx measuring 7.5 cm x 7.0 cm x unable to determine depth due to 100% eschar to wound bed, moderate amount of serosanguineous (bloody and clear) drainage . Further review of the document revealed on 11/15/21 resident noted with new stage 1 pressure injury to her left lower buttock measuring 4.0cm x 2.0cm, no open areas noted .apply [MEDICATION(S)] twice a day until healed . resident noted with another stage 1 pressure injury to her right lower buttock measuring 2.5 cm x 7.0 cm, no open areas noted .apply [MEDICATION(S)] twice a day until healed . A review of facility's grievance log revealed Resident # 3's daughter filed a complaint on 11/17/21 regarding resident's wounds identified on 11/15/21. The facility opened an investigation on 11/17/21. Findings of the investigation revealed a skin concern to Resident # 3's bottom region was identified on 11/12/21 by S6CNA. There was no nursing assessment documented about the area of concern, which was identified by S6CNA on 11/12/21. A review of nursing progress notes revealed there was no entry on 11/12/21 regarding the skin concern for Resident # 3. A review of an undated facility form titled Incident Witness Statement completed by S6CNA (Certified Nursing Assistant) read: S6CNA worked with the resident on Friday [DATE]. S6CNA observed a tiny dime size wound on resident's bottom region and reported the wound to S3RN with wound care. Upon further observation, S6CNA noted that the wound was bleeding and reported her findings to S5LPN. S5LPN stated that she would leave a note for the wound care nurse in the morning. Review of the form titled Incident Witness Statement completed by S5LPN dated 11/15/21 read: S5LPN called to resident's room by CNA who reported a wound seen while changing resident I assessed wound and wound was cleaned as much as possible due to it being in sacral area. Wound was reported to morning nurses. I also wrote note in jot book and stated wound needed to be seen by wound care nurse in the morning. I did not notify resident's doctor because the wound was discovered in the middle of the night and did not appear to be life threatening. Morning shift was notified that wound needed to be seen by wound care nurse or doctor during report and the incident was documented in the jot book on 11/15/21. Review of jot book revealed there was only one entry for Resident # 3 dated 11/15/21. The entry read: Resident # 3 needs wound care to look at sacrum; CNA found what looks like a pressure wound. A review of Skin inspection report completed on 11/14/21 by S4 LPN (Licensed Practical Nurse) read in part .the results of her weekly body audit revealed that the resident's skin was intact. Review of the Care Plan dated 10/20/2021 revealed that the resident was care planned for being at risk for skin breakdowns. Interventions included - turn/re-position as appropriate every two hours, pressure reducing cushion on wheelchair; shift weight while sitting up in chair; provide assistance to avoid skin friction/shearing; evaluate nutritional status; observe skin when providing routine care; need full skin evaluation as appropriate; need pillow or other supportive/protective devices to assist with positioning; keep skin clean and dry and avoid shearing/friction. The intervention to observe skin when providing routine care included role (s) of Nursing, Nursing Assistant. Further review revealed no new interventions were put in place on 11/12/21 when the wound was discovered. A review of CNA kiosk notes revealed six CNAs provided care to Resident # 3 from 11/12/21 to 11/15/21 including pericare. Only S6CNA identified new skin concern on 11/12/21 and did not document the concern. All other CNAs involved in Resident # 3's care denied seeing any area of concern to resident's bottom region. On 12/29/21 at 11:17 am, a phone interview was conducted with S3RN. S3RN who confirmed that she did not assess Resident # 3 on 11/12/21. S3RN reported that she completed Resident # 3's wound assessment on 11/15/21 and described the resident's coccyx wounds as quite intensive and very unusual in short amount of time. S3RN reported that she was informed of the area of concern to Resident # 3's buttocks on Friday 11/12/2. S3RN reported that when she looked at the area of concern as reported by S6CNA, the area resembled a bruise to Resident # 3's buttocks and she gave S6CNA barrier cream to apply. S3RN confirmed she had not documented her assessment or a progress note regarding the presence of a newly identified bruise to Resident # 3's buttocks. On 12/29/21 at 12:57 p.m., an interview was conducted with S4LPN who confirmed that she did not complete a thorough weekly skin assessment on 11/14/21 for Resident # 3. She stated that because the resident was seated in a wheelchair at the time of the assessment, she did not inspect all of the resident's skin to include her bottom region and forgot to complete the assessment before her shift ended. On 12/29/21 at 11:50 a.m., an interview was conducted with S10CNA who reported she helped Resident # 3 shower on 11/13/21 and denied seeing any skin concerns to resident's buttocks. On 12/29/21 at 1:30 p.m., an interview was conducted with S11CNA (an agency aid) who stated that she provided pericare on resident # 3. S11CNA reported she did not see any wounds or skin breakdown on the buttocks. On 12/29/21 at 5:10 p.m., a phone interview was conducted with S5LPN who confirmed that S6CNA did inform her of a skin concern on Resident #3's sacrum on the night shift on 11/12/21. S5LPN reported that she was only working a four hour shift on Friday 11/12/21 to help pass nightly meds. She confirmed S6CNA informed her of the area of concern to Resident # 3's buttocks and she did not assess the resident because S6CNA told her it was reported to S3RN before S5LPN's shift. S6CNA told S5LPN that S3RN said it was just a bruise and gave S6CNA barrier cream to apply to Resident # 3's sacrum. Therefore, S5LPN assumed S3RN had assessed the resident. S5LPN confirmed she did not enter a progress note in Resident's chart on 11/12/21. On 12/30/21 at 12:45 p.m., an interview was conducted with S6CNA who confirmed that she did see an area of concern on Resident # 3's bottom region on 11/12/21 that was dime sized and she immediately reported it to S3RN. S6CNA added that S3RN stated that the area of concern looked more like a bruise and not a wound. S6CNA added that S3RN gave her some cream that was thick and white to put on resident's buttocks. S6CNA stated that while assisting the resident later in her shift with pericare, she observed that the resident had blood in her brief and immediately reported it to S5LPN. On 12/30/21 at 2:05 p.m., an interview was conducted with S1ADM (administrator) and S2CoRN (Corporate Registered Nurse) who both confirmed S3RN and S5LPN did not assess Resident # 3 on 11/12/21. Both also confirmed S4LPN did not complete a thorough body audit on 11/14/21 for Resident # 3. S1ADM confirmed that Resident # 3's treatment orders were initiated on 11/15/21. Resident #7 Review of the Electronic Medical Record revealed that Resident #7 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS (Minimum Data Set), dated 10/13/2021, under the Skin Condition section, revealed that the resident had one unhealed Stage 1 pressure ulcer and the resident was at risk for developing pressure ulcers/injuries. Bladder and Bowel revealed that the resident was occasionally incontinent of bowel and frequently incontinent of urine. Review of the Care Plan dated 5/29/2019 revealed that the resident was care planned for impaired skin integrity. Interventions included - turn every 2 hours, pressure reducing cushion on wheelchair; shift weight while sitting up in chair; assistance to avoid skin friction/shearing; evaluate nutritional status; weekly skin assessment; bars up on both sides of the bed to aid with mobility and repositioning; keep skin clean and dry. Review of a document titled Weekly Body Audit revealed that on 11/19/2021 a Stage 2 pressure ulcer was identified on the right buttocks for Resident #7. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .clean wound to upper right buttock with normal saline, apply [MEDICATION(S)], and cover daily until healed. Review of a document titled Wound Assessment Report, dated 11/21/2021, by S9RN (weekend treatment nurse), revealed the initial assessment of the Stage 2 Pressure Ulcer on Resident #7's Right Buttocks measured 3.2 cm (centimeters) x 2.5 cm x 0.10 cm with 97% Epithelial tissue and 3% Granulation. On 12/20/2021, the wound measured 1.5 cm x 1.7 cm x 0.10 with 100% epithelial tissue. On 12/30/2021 at 10:00 a.m., was not able to observe wound care, because the treatment nurse stated that she had already completed the wound care for the day. On 12/30/2021 at 1:30 p.m., S9RN was unavailable for interview as to the reason for the delay in treatment. On 12/30/2021 at 2:00 p.m., an interview was conducted with S2CoRN (Corporate Registered Nurse) who stated that she did not have an answer as to why the assessment and treatment was delayed for Resident #7 after a Stage 2 Pressure Ulcer was identified on 11/19/2021.

Based on record review and interview the facility failed to ensure that the plan of care was followed by not performing two person assistance when providing ADL care for resident #122 who was assessed for two person physical assistance with bed mobility, transfer, and toilet use. On 12/24/12 at 1900 p.m. an actual harm occurred when the resident sustained [REDACTED].#122) of 3 investigated for falls (#16, # 39 and #122). Findings: Record review of the clinical record for resident #122 revealed the following Diagnoses: [REDACTED]. Review of the Care Plan revealed the following: Problem onset 3/27/12: Potential for falls related to [DIAGNOSES REDACTED]. Goal Target Date: Resident will be at decreased risk for further falls through this quarter 6/21/12, 9/5/12, 11/20/12 and 2/10/13. Approaches: Complete fall assessment and as needed; 2 RA's required with all transfers via mechanical lifter; Ensure resident safety prior to all transfers, lock wheels prior to transferring. Problem onset 3/27/12: Potential for skin breakdown r/t incontinence episodes and decreased mobility. Goal Target Date: Resident will be free from skin breakdowns this quarter 6/21/12, 9/5/12, 11/20/12 and 2/10/13. Approaches: Check for incontinent episode q 2 hour; 2 RA's required with all repositioning , bed mobility to prevent skin friction; Assist resident with toileting and pericare. Review of the Quarterly MDS Assessment Functional Status dated 11/21/12 revealed the following: Bed Mobility - self 4 total dependence, support 3 two + persons physical assist; Transfer - self 4 total dependence, support 3 two + persons physical assist; Toilet use - self 4 total dependence, support 3 two + persons physical assist; Review of the Fall Risk Assessment revealed that on 11/8/12 the resident was assessed as having a total score of 10 - a total score of 10 or above represents High Risk. Review of the Nurses Notes dated 12/24/12 at 8:18 p.m. revealed the following documentation: "@ 1900 p.m. This nurse was on hall 700 giving meds when called to room [ROOM NUMBER] by RA -pt on floor "on belly-on-face"! Noted blood about right facial area no other injuries noted patient is awake and talking with noted alertness and is laughing. Patient assisted to bed with x 5 staff assist patient cleaned and made comfortable vital signs WNL 99.7 ax, 90-22-126/70 O2 Sat 97% . No noted SOB or C/O pain, skin warm and dry with adequate coloring right temporal laceration cleansed with NS and steri-strips applied and covered with island dressing - no further bleeding to area . Dr. ... per phone and ordered neuro checks per protocol and to keep bed low to floor per protocol. Also call me if needed. daughter-Sue per phone and made aware." @1930 p.m. - "1945 p.m. Patient is asleep and arouses slowly. Dressing to right temporal laceration dry and intact. Patient is "slow to respond" neuro status has changed. Dr. ... made aware and this nurse is to send patient to ... ER. Daughter ... made aware." @1950 p.m." -2020 p.m. All documents per protocol - .... ambulance called and here patient transferred to ... ER as ordered per stretcher in stable condition with medics in attendance." Review of the Louisiana Nursing Home Malpractice and General Liability Trust I&A Reporting Form dated 12/24/12 revealed the following documentation: Time of Incident - 1900 p.m.; Exact Location of Incident - resident's room [ROOM NUMBER] A floor next to bed; Was Restraint In Use - no; Was Bed Rails Ordered - no; Were Bed Rails Present - no; Was Height of Bed Adjusted - yes down; Describe Exactly What Happened - @ 1900 p.m. while being turned & cleaned -patient fell off bed to floor on belly- face on floor, noted right temporal laceration, cleansed and dressed- Review of Type of Injury- right temporal laceration with bluish discoloration - non-displaced impacted distal fifth metacarpal fracture; Review of the Radiology Department CT Head Without Contrast Report done 12/28/12 revealed the following: 1. No definite acute intracranial abnormality identified; 2. Generalized Cerebral and Cerebellar atrophy; 3. Intracranial [MEDICAL CONDITION]; 4. Periventricular white matter small vessel ischemic changes; 5. Tiny subcutaneous collection of gas noted to the right lateral periorbital region suspicious for soft tissue injury. Clinical correlation indicated; 6. Partial opacification of the mastoid air cells bilaterally suggestive of mastoiditis 7. Osteopenia. Review of the Sittig Mobile X-Ray and Cardiology Inc. Left hand 3 Views Report date 12/31/12 revealed the following: Impression: Soft tissue [MEDICAL CONDITION] is seen with mild irregularity of the distal fifth metacarpal. This could reflect an impacted nondisplaced fracture however it is not definite. If there is focal pain at that location recommend follow up imaging in 5-7 days after which time expected [DIAGNOSES REDACTED] would make a nondisplaced impacted fracture more evident. Review of the Investigation Follow-up revealed the following documentation: Description of Situation - S7 RA was changing resident, she turned her back to grab a towel to clean resident, When she turned back around to finish cleaning her - the resident had fallen out of bed -landed face down on the floor. Neuro checks initiated, wound care provided. Summary of Investigation - Resident bed bound-does not move unassisted,. RA admitted to changing resident without assistance, however resident requires 2 person assistance. RA stated bed was in lowest position. Neuro checks initiated at time of incident then resident was sent to ER d/t decline in neuro status; Past Interventions Attempted - 2 persons assist with care; Apple fall program;. Bed in lowest position at all times; Residents skin is thin and fragile. Recommendations/New Interventions 1/2 SR up x 2 while in bed to provide a sense of security- family's request; padding applied to side rails to protect upper extremities; RA suspended x 1 week d/t not following facility policy; Sent to ...Hospital - 12/24/12, wound care as ordered until laceration healed; CT Scan done - negative for injury; Neuro checks; 24 ' Follow up multiple bruises to bilateral. upper extremity, bilateral to care for, hands facial laceration with sutures intact, dressing dry & intact. Review of the Eye Witness Statement revealed the following documentation: Name: S7 RA; Date: 12/24/12; Resident: (#122); Statement: I was changing resident (#122) and I turn to grab a towel. then I noticed she fell out of bed. I ran to notify the nurse S11 LPN. Review of the Nurses Department Notes dated 12/25/12 at 9:02 a.m. the following documentation: @ 7:30 a.m. resident lying in bed on her back with eyes closed, easily aroused when name called out, answered appropriately when I told her, "Good Morning and Merry Christmas" when asked her if her head was hurting she states, "yes, a little". [MEDICATION NAME] 325 mg 2 tabs 650 mg administered as ordered PRN for pain, neuro checks in progress, equal hand grasp, pupils respond adequately, bruises noted to face and hands/arms from fall, bed in lowest position, dressing to side of right eye intact, no drainage noted, will continue to monitor, BP 132/66, P 66, R 18, T 98. 8:09 a.m. Order #24 Pain reliever 325 mg tablet pain level 5 was administered c/o headache pain. Further review of the Nurses Department Notes revealed that the resident did not have to be administered pain medication previous before the incident with the fall. Record review of the MAR for December 2012 revealed that resident #122 did not receive any pain medication previously. The MAR indicated [REDACTED]. In an interview on 1/14/2013 at 1:11 PM with S9 LPN it was learned that the resident had a Fall on 12/24/12 and hit her head and had a bruise and was sent to the hospital for evaluation. She indicated that Neuro checks were done. In an interview on 1/17/13 at 11:15 a.m. with S10 Corporate Nurse, she confirmed that the resident did have the laceration to the right forehead and a fracture to the left 5 th finger. She revealed that it was possibly caused from the fall because the resident had not had any other previous falls. She revealed that the staff knew before the fall incident that occurred with resident #122, that the resident required two person assistance with care, transfers, repositioning, and toileting. S10 Corporate Nurse stated that on 12/24/12 there was no staff shortage. She indicated that she was personally here on that date. She stated that the RA that cared for resident #122 did have another RA on the hall that could have assisted her. In an interview on 1/17/12 at 1:00 p.m. S10 Corporate Nurse revealed that she was informed that the other RA was in the room and left to answer the call bell. She indicated that the RA that remained in the room with resident #122 turned her back to get something and the resident fell . In an interview on 1/17/13 at 1:40 p.m. with S7 RA revealed that she was assigned to care for resident #122 on 12/24/12 and worked the 2-10 shift. She stated that she was routinely assigned to care for her. She revealed that the resident was totally dependent and required two persons for care. S7 RA stated that on the day of the incident with resident #122, she and S8 RA went into resident #122's room together and provided care first to resident #122's roommate. She indicated that after they provided the care for the roommate, S8 RA left the room. She revealed that she started to change resident #122 on her own and she turned the resident on her side. S7 RA stated that she then turned to get some soap and a towel and when she turned it was when resident #122 fell . She admitted that she turned the resident by herself. S7 RA stated that she stayed in the room and went to the door to call the nurse and that is when S8 RA and the nurse S11 LPN came and they picked the resident up off the floor and placed her back in the bed. She stated that she was sent home and could not return until 1/2/13. In an interview on 1/17/13 at 1:55 p.m. S8 RA revealed that she was assigned to assist S7 RA with resident #122. She stated that she and S7 RA went into resident #122's room and changed resident #122's roommate. S8 RA indicated that she left the room to answer a call bell and during the time that she left the room was when resident #122 fell . S8 RA stated that she left S7 RA in the room with resident #122 to answer the call bell. She stated that before she left the room, the resident #122 was lying on her back. She indicated that when she heard S7 RA call for help, she went back in resident #122's room alone with the floor nurse and they picked resident #122 up off the floor and placed her back in bed.

Based on record review and interview the facility failed to ensure that the resident remains as free of accident hazards as possible and receives adequate supervision and assistance to prevent accidents by failing to: follow the plan of care for resident #122 who was assessed for two person physical assistance with bed mobility, transfer, and toilet use. On 12/24/12 at 1900 p.m. an actual harm occurred when resident #122 sustained a fall with a laceration to the right forehead and a fracture to the left metacarpal while the RA was changing the resident without assistance in 1 (#122) of 3 investigated for falls (#16, #39, and #122). Findings: Record review of the clinical record for resident #122 revealed the following Diagnoses: [REDACTED]. Review of the Fall Risk Assessment revealed that on 11/8/12 the resident was assessed as having a total score of 10 - a total score of 10 or above represents High Risk. Review of the Care Plan revealed the following: Problem onset 3/27/12: Potential for falls related to [DIAGNOSES REDACTED]. Goal Target Date: Resident will be at decreased risk for further falls through this quarter 6/21/12, 9/5/12, 11/20/12 and 2/10/13. Approaches: Complete fall assessment and as needed; 2 RA's required with all transfers via mechanical lifter; Ensure resident safety prior to all transfers, lock wheels prior to transferring. Problem onset 3/27/12: Potential for skin breakdown r/t incontinence episodes and decreased mobility. Goal Target Date: Resident will be free from skin breakdowns this quarter 6/21/12, 9/5/12, 11/20/12 and 2/10/13. Approaches: Check for incontinent episode q 2 hour; 2 RA's required with all repositioning , bed mobility to prevent skin friction; Assist resident with toileting and pericare. Review of the Quarterly MDS Assessment Functional Status dated 11/21/12 revealed the following: Bed Mobility - self 4 total dependence, support 3 two + persons physical assist; Transfer - self 4 total dependence, support 3 two + persons physical assist; Toilet use - self 4 total dependence, support 3 two + persons physical assist; Record review of the Nurses Notes dated 12/24/12 at 8:18 p.m. revealed the following documentation: "@ 1900 p.m. This nurse was on hall 700 giving meds when called to room 306 by RA -pt on floor "on belly-on-face"! Noted blood about right facial area no other injuries noted patient is awake and talking with noted alertness and is laughing. Patient assisted to bed with x 5 staff assist patient cleaned and made comfortable vital signs WNL 99.7 ax 90-22-126/70 O2 Sat 97% . No noted SOB or C/O pain, skin warm and dry with adequate coloring right temporal laceration cleansed with NS and steri-strips applied and covered with island dressing - no further bleeding to area . Dr. .... per phone and ordered neuro checks per protocol and to keep bed low to floor per protocol. Also call me if needed. daughter-Sue per phone and made aware." @1930 p.m. -" 1945 p.m. Patient is asleep and arouses slowly. Dressing to right temporal laceration dry and intact. Patient is "slow to respond" neuro status has changed. Dr. .... made aware and this nurse is to send patient to .... ER. Daughter ....made aware." @1950 p.m. "-2020 p.m. All documents per protocol - ... ambulance called and here patient transferred to ... ER as ordered per stretcher in stable condition with medics in attendance." Review of the Louisiana Nursing Home Malpractice and General Liability Trust I&A Reporting Form dated 12/24/12 revealed the following documentation: Time of Incident - 1900 p.m.; Exact Location of Incident - resident's room 306 A floor next to bed; Was Restraint In Use - no; Was Bed Rails Ordered - no; Were Bed Rails Present - no; Was Height of Bed Adjusted - yes down; Describe Exactly What Happened - @ 1900 p.m. being turned & cleaned -patient fell off bed to floor on belly- face on floor, noted right temporal laceration, cleansed and dressed- Review of Type of Injury- right temporal laceration with bluish discoloration - non-displaced impacted distal fifth metacarpal fracture; Review of the Radiology Department CT Head Without Contrast Report done 12/28/12 revealed the following: 1. No definite acute intracranial abnormality identified; 2. Generalized Cerebral and Cerebellar atrophy; 3. Intracranial Atherosclerosis; 4. Periventricular white matter small vessel ischemic changes; 5. Tiny subcutaneous collection of gas noted to the right lateral periorbital region suspicious for soft tissue injury. Clinical correlation indicated; 6. Partial opacification of the mastoid air cells bilaterally suggestive of mastoiditis 7. Osteopenia. Review of the Sittig Mobile X-Ray and Cardiology Inc. Left hand 3 Views Report date 12/31/12 revealed the following: Impression: Soft tissue edema is seen with mild irregularity of the distal fifth metacarpal. This could reflect an impacted nondisplaced fracture however it is not definite. If there is focal pain at that location recommend follow up imaging in 5-7 days after which time expected [DIAGNOSES REDACTED] would make a nondisplaced impacted fracture more evident. Review of Investigation Follow-up revealed the following documentation: Description of Situation - S7 RA was changing resident, she turned her back to grab a towel to clean resident, When she turned back around to finish cleaning her - the resident had fallen out of bed -landed face down on the floor. Neuro checks initiated, wound care provided. Summary of Investigation - Resident bed bound-does not move unassisted. RA admitted to changing resident without assistance, however resident requires 2 person assistance. RA stated bed was in lowest position. Neuro checks initiated at time of incident then resident was sent to ER d/t decline in neuro status; Past Interventions Attempted - 2 persons assist with care; Apple fall program;. Bed in lowest position at all times; Residents skin is thin and fragile. Recommendations/New Interventions 1/2 SR up x 2 while in bed to provide a sense of security- family's request; padding applied to side rails to protect upper extremities; RA suspended x 1 week d/t not following facility policy; Sent to ..... Hospital- 12/24/12, wound care as ordered until laceration healed; CT Scan done - negative for injury; Neuro checks; 24 ' Follow up multiple bruises to bilateral. upper extremity, bilateral to care for, hands facial laceration with sutures intact, dressing dry & intact. Review of the Eye Witness Statement revealed the following documentation: Name: S7 RA; Date: 12/24/12; Resident: #122; Statement: I was changing resident #122 and I turn to grab a towel. then I noticed she fell out of bed. I ran to notify the nurse S11 LPN. Record review of the Nurses Department Notes dated 12/25/12 at 9:02 a.m. the following documentation: @ 7:30 a.m. resident lying in bed on her back with eyes closed, easily aroused when name called out, answered appropriately when I told her, "Good Morning and Merry Christmas" when asked her if her head was hurting she states, "yes, a little". Acetaminophen 325 mg 2 tabs 650 mg administered as ordered PRN for pain, neuro checks in progress, equal hand grasp, pupils respond adequately, bruises noted to face and hands/arms from fall, bed in lowest position, dressing to side of right eye intact, no drainage noted, will continue to monitor, BP 132/66, P 66, R 18, T 98. 8:09 a.m. Order #24 Pain reliever 325 mg tablet pain level 5 was administered c/o headache pain. Further review of the Nurses Department Notes revealed that the resident did not have to be administered pain medication previous before the incident with the fall. Record review of the MAR for December 2012 revealed that resident #122 did not receive any pain medication previously. The MAR revealed that the resident was administered Acetaminophen 650 mg at 8:09 a.m. on 12/25/12. In an interview on 1/14/2013 at 1:11 PM S9 LPN revealed that the resident had a Fall on 12/24/12 and hit her head and had a bruise and was sent to the hospital for evaluation. She indicated that Neuro checks were done. In an interview on 1/17/13 at 11:15 a.m. S10 Corporate Nurse confirmed that the resident did have the laceration to the right forehead and a fracture to the left 5 th finger. She revealed that it was possibly caused from the fall because the resident had not had any other falls previous. She revealed that the staff knew before the fall incident that occurred with resident #122, that the resident required two person assistance with care, transfers, repositioning, and toileting. S10 Corporate Nurse stated that on 12/24/12 there was no staff shortage. She indicated that she was personally here on that date. She stated that the RA that cared for resident #122 did have another RA on the hall that could have assisted her. In an interview on 1/17/12 at 1:00 p.m. with S10 Corporate Nurse revealed that she she was informed that the other RA was in the room and left to answer the call bell. She indicated that the RA that remained in the room with resident #122 turned her back to get something and the resident fell . In an interview on 1/17/13 at 1:40 p.m. with S7 RA she revealed that she was assigned to care for resident #122 on 12/24/12 and worked the 2-10 shift. She stated that she was routinely assigned to care for her. She revealed that the resident was total dependence and required two persons for care. S7 RA stated that on the day of the incident with resident #122, she and S8 RA went into resident #122's room together and provided care first to resident #122's roommate. She indicated that after they provided the care for the roommate, S8 RA left the room. She revealed that she started to change resident #122 on her own and she turned the resident her side. S7 RA stated that she then turned to get some soap and a towel and when she turned was when resident #122 fell . She admitted that she turned the resident by herself. S7 RA stated that she stayed in the room and went to the door to call the nurse and that is when S8 RA and the nurse S11 LPN came and they picked the resident up off the floor and placed her back in the bed. She stated that she was sent home and could not return until 1/2/13. In an interview on 1/17/13 at 1:55 p.m. S8 RA revealed that she was assigned to assist S7 RA with resident #122. She stated that she and S7 RA went into resident #122's room and changed resident #122's roommate. She indicated that she left the room to answer a call bell and during the time that she left the room was when resident #122 fell . S8 RA stated that she left S7 RA in the room with resident #122 to answer the call bell. She stated that before she left the room, the resident #122 was lying on her back. She indicated that when she heard S7 RA call for help, she went back in resident #122's room with the floor nurse and they picked resident #122 up off the floor and placed her back in bed.

Based on observation, record review and interview, the facility failed to ensure services were provided by qualified persons in accordance with each resident's written plan of care by failing to: 1. Ensure 1 resident (#42) was administered Vitamin K as ordered by the physician to correct a panic level lab value of a PT/INR; and 2. Ensure side rails were not used for 1 resident (#75) without a physician's order. The resident was placed on the medication [MEDICATION NAME] on 10/26/11. On 11/15/11 the resident had a PT/INR of 128.8/>12, which was a panic level, meaning the resident was in great danger of his blood not clotting properly, resulting in major bleeding and possible death if not treated immediately. Vitamin K is given to neutralize the effects of the abnormal PT/INR. An Immediate Jeopardy Situation began for resident #42 on 11/15/11 when the facility received the Vitamin K from the pharmacy, around 8:00p.m., and the nurses failed to give the medication to the resident as ordered by the physician. On 11/15/11, a nurse practitioner ordered Vitamin K 10 mg to be given by mouth for treatment of [REDACTED].>12) as soon as the Vitamin K was received from the pharmacy between 6:45 to 8:00 pm on the night of 11/15/11. The critically high PT/INR put the resident #42 in grave danger of major or fatal bleeding. According to S1DON, the Vitamin K was delivered from the pharmacy to the nursing home on 11/15/11 during the time frame from 6:45 to 8:00p.m. S3LPN, who received the order from the NP, was in the facility when the pharmacy delivered the medication, and according to S1DON, S3LPN signed the pharmacy sheet verifying the delivery of the medicine. S3LPN failed to administer the Vitamin K to the resident. S6LPN, the oncoming night nurse, also failed to administer the Vitamin K. The Vitamin K was administered to resident #42 on 11/16/11 at 9:00 a.m., after S7LPN was questioned by the surveyor if it had been administered. The Immediate Jeopardy ended on 11/16/11 at 9a.m. when the resident received the Vitamin K. The deficient practice remains at a level two, which has a potential to affect a total of 9 resident ' s receiving the medication [MEDICATION NAME], according to a Physician Order List presented by the facility on 11/15/11. Findings: 1. Resident #42 had [DIAGNOSES REDACTED]. According to the Nursing 2011 Drug Handbook, [MEDICATION NAME] is used to treat [MEDICAL CONDITION], and also [MEDICAL CONDITION]. The drug handbook also listed a black box warning indicating the medication [MEDICATION NAME] can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Persons on the medication are to be regularly monitored for INR values. The effect s can be neutralized by oral or [MEDICATION NAME] Vitamin K. The Drug Handbook also indicated the following medications taken with [MEDICATION NAME], may increase anticoagulant effects: [MEDICATION NAME], flu virus vaccine, [MEDICAL CONDITION], SSRIs, and [MEDICAL CONDITION] drugs. It was also noted PT and INR determinations are essential for proper control of the administration of [MEDICATION NAME]. INR range for chronic [MEDICAL CONDITION] Fibrillation is usually 2 to 3, and the medication should be given at the same time daily. Review of the resident ' s November 2011 MAR indicated [REDACTED]. The resident also received a flu vaccine on 11/3/11. During an interview and observation on 11/14/11 at 2:40p.m., the resident was noted to have bruised areas to the nose, and under both eyes, with the left eye encircled with bruising. When questioned what happened, the resident replied he had a nightmare in which he was fighting. He stated he fell out of bed to the floor and hit his face. The resident was alert, and oriented to person, place and time. Review of a nurses ' note indicated on 10/26/11 at 10 a.m., new orders from the Nurse Practitioner for an ultrasound of the resident ' s bilateral lower extremities to rule out a [MEDICAL CONDITION]; apply TED hose everyday and remove at bedtime; [MEDICATION NAME] 5 mg. everyday at bedtime; PT/INR every other day until INR greater than 2.0, then every two weeks. This was the beginning of the resident ' s [MEDICATION NAME] therapy. On 10/27/11 at 8:30 a.m., a PT/INR was drawn and sent to the lab. On 10/27/11 at noon the lab results were received, and the INR remained below 2.0 ... continue [MEDICATION NAME] 5 mg. at bedtime ...NP notified. According to a nurses ' note, on 10/29/11 at 1:10a.m, the resident was calling out for help from his room, and was found on the floor near his bed. Resident #42 had fallen out of bed while having a dream about fighting. The fall resulted in a laceration to his nose, and he was sent to a local hospital for treatment. The resident returned to the nursing home on 10/29/11 at 5:00 a.m. with orders for follow up with physician in 3-5 days. Blood for another PT/INR was drawn again on 10/29/11. This labwork revealed the resident ' s INR was 1.5 and PT 15. A nurses ' note on 10/31/11 indicated the NP was notified of the results of the labs drawn that day and the INR of 2.92. Orders noted to continue the same dose of [MEDICATION NAME] (5 mg. everyday) and a PT/INR to be drawn in one month. On 11/15/11 a nurses ' note timed 2:00 p.m., indicated a PT/INR was drawn. A note timed 4:15 p.m., indicate the lab had called with a panic level reading of the PT/INR (128.8/>12), and the NP was notified. New orders were obtained to hold the [MEDICATION NAME] until the INR was lower than 3; notify him if INR remained high; if patient started bleeding, or fell , send to hospital, make resident aware; PT/INR every other day, starting 11/17/11; and administer Vitamin K 10 mg as soon as comes in ... 1 po tonight. During an interview with S7LPN on 11/16/11 at 8:30a.m., she stated she thought the Vitamin K had been administered the night before, as ordered. S7 stated she was aware of the resident ' s abnormal PT/INR results, and the resident was being monitored for bleeding. S7 verified the Vitamin K had not been initialed as being administered to resident #42. S7 then stated she was going to call S3LPN because she had taken the order and was working the day before, and S6LPN, the night nurse, to question if the medication had been given. On 11/16/11 at 8:55a.m., when questioned, S7 verified the Vitamin K had not been administered the night before as ordered, and presented the blister pack with the medication still in it. S7 administered the Vitamin K to resident #42 on 11/16/11 at 9:00 a.m., During an interview with S1DON on 11/16/11 at 3:40 p.m., she stated the Vitamin K arrived from the pharmacy between 6:45 and 8 p.m., the night before (11/15/11). S3LPN had signed the medicine as being received from the pharmacy, and had also given report to the oncoming nurse S6. S1 indicated S3LPN had stayed at the nursing home after giving report to S6, as she was giving care to another resident. S1DON verified she had spoken to S3LPN and S6LPN, and they verified the Vitamin K had not been given on 11/15/11. During an interview with S1DON, and S8RN on 11/17/11 they agreed administering the Vitamin K as ordered was crucial, and a significant medication error, and not giving the Vitamin K as ordered; put the resident in danger of major bleeding. A nurses ' note dated 11/16/11 and timed 9:00 a.m., indicated missed medication [MEDICATION NAME] last p.m. ... new order noted per physician ' s nurse practitioner to administer the Vitamin K 10 mg ... medication administered. A note signed by S4RN, dated 11/17/11 at 1:55 p.m. indicated a new order for [MEDICATION NAME] 4mg by mouth at bedtime... repeat PT/INR in 7 days. 2. Resident #75: Record review indicated the resident has [DIAGNOSES REDACTED]. During an interview on 11/14/11 at 11:31a.m., S3LPN stated side rails x 2 were used in the up position for the resident when she was in bed for bed mobility. An observation of the resident on 11/14/11 at 1:17p.m. revealed the resident was lying in bed, eyes closed with side rails up times 2. A Pre-Restraining assessment dated [DATE] indicated the resident was to have a self-released seat belt while up in a wheelchair to remind resident not to get up without assistance. A restrain Consent was noted to be signed on 7/17/09 by the resident's family member. There was no indication the resident was to have side rails up x 2 while in bed. Review of the resident's monthly Physician's Orders did not indicate the resident had an order for [REDACTED]. There was no plan of care for the use of side rails x 2. Review of a Physical Restraint Elimination assessment dated [DATE] indicated the resident used a self release seat belt while up in wheelchair to remind resident not to getup without assist. A Side Rail policy was presented by the S9ADON on 11/15/11 at 1:20 p.m. which read: Each resident shall be provided with a hospital type bed which includes two side rails, both in good working order, when necessary. Side rails will be elevated at all times while a resident is in bed with the following exceptions only: 1). With a written order form the resident's physician indicating one or both rails may be released and for what length of time. 2). Residents who are alert, oriented and independent in all aspects of personal care. 3). Residents who have not given permission upon their admission for siderails to be used. . During an interview with S9ADON on 11/15/11 at 1:35 p.m., she verified the side rail policy, stating they will only use siderails if permission is given by the resident to do so, usually if the resident requests to have side rails up. During an interview with S3LPN on 11/15/11 at 2:05p.m. she stated the resident uses a self releasing belt, bed alarm, chair alarm and gel cushion in chair for [DIAGNOSES REDACTED]. On 11/15/11 at 2:10p.m. S10RA verified she worked with the resident, and the side rails x 2 were used when the resident was in bed. S11RA Supervisor verified the side rails should be in the down position, and staff had notified her yesterday, that the side rails had been used in the up position for the resident. During an interview with S5Administrator on 11/16/11 at 7:50 a.m., he verified the policy on side rails may be the latest one the facility is using, but he was going to contact S8RN to make sure there had not been a new policy written. S5 stated the facility was in the process of revising the policy to be only using small rails for mobility. S5 agreed the present side rail policy goes against Federal regulations. On 11/16/11 at 1:20 p.m., S11Maintenance was noted to be taking side rails off of beds. S11 stated he was told to take the side rails off of the beds of the residents who did not use them, or need them. On 11/16/11 at 1:45 p.m. a side rails policy was presented by S5Administrator. S5 indicated it was the actual policy the facility had been putting into place as staffing of the residents was occurring. S5 stated all side rails are being taken off beds to ensure what happened to resident #75 would not happen again or to any other resident. S5 indicated the facility was in the process of obtaining "short bars" for mobility use, and no side rails would used unless ordered by a physician with the permission of the family or resident.

Based on observation, record review and interview, the facility failed to ensure residents were free from any significant medication errors by failing to ensure 1 resident (#42) was administered Vitamin K as ordered by the physician to correct a panic level lab value of a PT/INR. On 11/15/11, a nurse practitioner ordered Vitamin K 10 mg to be given by mouth for treatment of [REDACTED].>12) as soon as the Vitamin K was received from the pharmacy between 6:45 to 8:00 pm on the night of 11/15/11. The critically high PT/INR put the resident #42 in grave danger of major or fatal bleeding. According to S1DON, the Vitamin K was delivered from the pharmacy to the nursing home on 11/15/11 during the time frame from 6:45 to 8:00p.m. S3LPN, who received the order from the NP, was in the facility when the pharmacy delivered the medication, and according to S1DON, S3LPN signed the pharmacy sheet verifying the delivery of the medicine. S3LPN failed to administer the Vitamin K to the resident. S6LPN, the oncoming night nurse, also failed to administer the Vitamin K. The Vitamin K was administered to resident #42 on 11/16/11 at 9:00 a.m., after S7LPN was questioned by the surveyor if it had been administered. The resident was placed on the medication [MEDICATION NAME] on 10/26/11. The normal lab value for an INR is 9.8 to 10.8. On 11/15/11 the resident had a PT/INR of 128.8/>12, which was a panic level, meaning the resident was in great danger of his blood not clotting properly, resulting in major bleeding and possible death if not treated immediately. Vitamin K is given to neutralize the effects of the abnormal PT/INR. Resident #2 was placed in immediate Jeopardy at approximately 8 pm on the night of 11/15/11 when the Viamain K was received by the facility and was not given to the resident. The Immediate Jeopardy ended on 11/16/11 at 9a.m. when the resident received the Vitamin K. The deficient practice remains at a level two, which has a potential to affect a total of 9 resident ' s receiving the medication [MEDICATION NAME], according to a Physician order [REDACTED]. Findings: Resident #42 had [DIAGNOSES REDACTED]. According to the Nursing 2011 Drug Handbook, [MEDICATION NAME] is used to treat [MEDICAL CONDITION], and also [MEDICAL CONDITION]. The drug handbook also listed a black box warning indicating the medication [MEDICATION NAME] can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Persons on the medication are to be regularly monitored for INR values. The effects can be neutralized by oral or [MEDICATION NAME] Vitamin K. The Drug Handbook also indicated the following medications taken with [MEDICATION NAME], may increase anticoagulant effects: [MEDICATION NAME], flu virus vaccine, [MEDICAL CONDITION], SSRIs, and [MEDICAL CONDITION] drugs. It was also noted PT and INR determinations are essential for proper control of the administration of [MEDICATION NAME]. INR range for chronic [MEDICAL CONDITION] Fibrillation is usually 2 to 3, and the medication should be given at the same time daily. Review of the resident ' s November 2011 MAR indicated [REDACTED]. The resident also received a flu vaccine on 11/3/11. During an interview and observation on 11/14/11 at 2:40p.m., the resident was noted to have bruised areas to the nose, and under both eyes, with the left eye encircled with bruising. When questioned what happened, the resident replied he had a nightmare in which he was fighting. He stated he fell out of bed to the floor and hit his face. The resident was alert, and oriented to person, place and time. Review of a nurses ' note indicated on 10/26/11 at 10 a.m., new orders from the Nurse Practitioner for an ultrasound of the resident ' s bilateral lower extremities to rule out a [MEDICAL CONDITION]; apply TED hose everyday and remove at bedtime; [MEDICATION NAME] 5 mg. everyday at bedtime; PT/INR every other day until INR greater than 2.0, then every two weeks. This was the beginning of the resident ' s [MEDICATION NAME] therapy. On 10/27/11 at 8:30 a.m., a PT/INR was drawn and sent to the lab. On 10/27/11 at noon the lab results were received, and the INR remained below 2.0 ... continue [MEDICATION NAME] 5 mg. at bedtime ...NP notified. According to a nurses ' note, on 10/29/11 at 1:10a.m, the resident was calling out for help from his room, and was found on the floor near his bed. Resident #42 had fallen out of bed while having a dream about fighting. The fall resulted in a laceration to his nose, and he was sent to a local hospital for treatment. The resident returned to the nursing home on 10/29/11 at 5:00 a.m. with orders for follow up with physician in 3-5 days. Blood for another PT/INR was drawn again on 10/29/11. This labwork revealed the resident ' s PT was 15, and the INR was 1.5. A nurses ' note on 10/31/11 indicated the NP was notified of the results of the labs drawn that day and the INR of 2.92. Orders noted to continue the same dose of [MEDICATION NAME] (5 mg. everyday) and a PT/INR to be drawn in one month. On 11/15/11 a nurses ' note timed 2:00 p.m., indicated a PT/INR was drawn. A note timed 4:15 p.m., indicate the lab had called with a panic level reading of the PT/INR (128.8/>12), and the NP was notified. New orders were obtained to hold the [MEDICATION NAME] until the INR was lower than 3; notify him if INR remained high; if patient started bleeding, or fell , send to hospital, make resident aware; PT/INR every other day, starting 11/17/11; and administer Vitamin K 10 mg as soon as comes in ... 1 po tonight. During an interview with S7LPN on 11/16/11 at 8:30a.m., she stated she thought the Vitamin K had been administered the night before, as ordered. S7 stated she was aware of the resident ' s abnormal PT/INR results, and the resident was being monitored for bleeding. S7 verified the Vitamin K had not been initialed as being administered to resident #42. S7 then stated she was going to call S3LPN because she had taken the order and was working the day before, and S6LPN, the night nurse, to question if the medication had been given. On 11/16/11 at 8:55a.m., when questioned, S7 verified the Vitamin K had not been administered the night before as ordered, and presented the blister pack with the medication still in it. S7 administered the Vitamin K to resident #42 on 11/16/11 at 9:00 a.m., During an interview with S1DON on 11/16/11 at 3:40 p.m., she stated the Vitamin K arrived from the pharmacy between 6:45 and 8 p.m., the night before (11/15/11). S3LPN had signed the medicine as being received from the pharmacy, and had also given report to the oncoming nurse S6. S1 indicated S3LPN had stayed at the nursing home after giving report to S6, as she was giving care to another resident. S1DON verified she had spoken to S3LPN and S6LPN, and they verified the Vitamin K had not been given on 11/15/11. During an interview with S1DON, and S8RN on 11/17/11 they agreed administering the Vitamin K as ordered was crucial, and a significant medication error, and not giving the Vitamin K as ordered; put the resident in danger of major bleeding. A nurses ' note dated 11/16/11and timed 9:00 a.m., indicated missed medication [MEDICATION NAME] last p.m. ... new order noted per physician ' s nurse practitioner to administer the Vitamin K 10 mg ... medication administered. A note signed by S4RN, dated 11/17/11 at 1:55 p.m. indicated a new order for [MEDICATION NAME] 4mg by mouth at bedtime... repeat PT/INR in 7 days.