Every finding on record at Spring Hill Care and Rehab

The facility identified a census of 29 residents, including three residents sampled for abuse. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remained free from staff-to-resident abuse on 10/11/25, when Certified Nurse Aide (CNA) M verbally, mentally, and physically abused R1. This deficient practice placed R1 in immediate jeopardy.Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of displaced fracture (traumatic bone break where two ends of the bone separate out of their normal positions) of the first cervical (neck) vertebra (bone of the spinal column), bilateral hearing loss, dementia (a progressive mental disorder characterized by failing memory and confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).The admission Minimum Data Set (MDS) dated [DATE], documented R1 had moderate hearing difficulty. R1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R1 had no behaviors. R1 required partial or moderate assistance with sitting to standing, chair/bed-to-chair transfers, and toilet transfers. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of 14, which indicated intact cognition. R1 had no behaviors. R1 had impairment on both sides for upper and lower extremities. R1 required substantial or maximal assistance with sitting to standing, chair/bed-to-chair transfers, and toilet transfers. The ADL (Activities of Daily Living) Functional / Rehabilitation Potential Care Area Assessment (CAA) dated 02/19/25, revealed R1 required assistance of one staff for all activities of daily living and transfers.The Communication CAA dated 02/19/25 revealed R1 had moderate hearing loss, made her needs known, and she understood others.The 07/21/25 Care Plan revealed R1 had a communication problem related to bilateral hearing loss and included the following staff interventions:07/21/25- Staff encouraged R1 to state her thoughts even if R1 had difficulty.07/21/25- Staff provided a safe environment for R1, kept R1's call light within reach, and provided R1 with adequate low glare light.The 07/21/25 Care Plan revealed R1 had an ADL self-care performance deficit related to impaired balance and included the following staff interventions:07/21/25- Staff provided one assistance to R1 for transfers.07/21/25- Staff encouraged R1 to use her bell to call for assistance.R1's EMR revealed the following: An admission Note on 08/14/25 at 06:29 PM documented R1 returned from an acute hospital stay. R1 had a hard cervical collar in place. R1's speech was difficult to understand. A Progress Note on 08/17/25 at 07:00 AM documented R1 had a fall which resulted in a C1 (first cervical vertebra) fracture. The plan directed staff continued R1's cervical collar immobilization. A Nursing: Progress Note on 10/12/25 at 04:45 AM documented staff observed R1 raising her recliner and almost falling out of it while trying to self-transfer. Staff educated R1 on the importance of the call light button for safety. R1 became upset from being monitored on the camera. R1 blocked her doorway when staff summoned additional help. R1 started to hit, kick, scratch, pull, and grab staff. Staff helped remove R1's hands from the other staff. Staff assisted R1 to her recliner and later requested to sit at the nurse's station. A Progress Notes note on 10/13/25 at 07:00 AM documented R1 had a cervical spine collar in place. R1 had an episode of aggressive behaviors the past weekend which was unlike her. Staff expressed concerns R1 might have had a urinary tract infection (UTI- an infection in any part of the urinary system) but she remained afebrile (without a fever), had no urinary symptoms, and had the one isolated incident. R1 recalled the event very well and she reported being very angry. A Progress Notes note on 10/20/25 at 07:00 AM documented R1 continued to have a cervical spine fracture for which she wore a collar. The plan included the following: R1 continued cervical spine collar use, R1 had repeat cervical spine imaging scheduled that week, and the facility was to coordinate with orthopedic (pertaining to bones) spine specialists regarding R1's collar discontinuation timing.A Nursing note on 10/23/25 at 03:59 PM documented R1 saw the orthopedic provider and received instructions to wear the cervical collar during all of R1's physical therapy exercise. R1 should be conservative with her neck movements for an additional six to eight weeks. Orthopedics released R1 from their services.The facility's Investigation dated 10/24/25 documented on 10/20/25 at approximately 10:00 PM, R1's representative sent Administrative Nurse D video recordings from 10/11/25. Upon review of the video footage, Administrative Nurse D observed an altercation between CNA M and R1. At 02:54 AM, R1 sat in her recliner, holding her remote. At 02:57 AM, CNA M entered R1's room and stated they were done with R1 pushing the call light. R1 responded it was her right. The video showed R1 attempted to keep her blanket on and hold onto her chair remote while CNA M assisted her with putting on her shoe. CNA M instructed R1 to leave the remote alone and when R1 did not release the remote, CNA M appeared to attempt to take the remote from her forcefully. R1 responded by kicking towards CNA M then CNA M told R1 Do not kick me, stop. CNA M held onto R1's leg. She released R1's leg but continued to retrieve the remote, stating they had the right to do that. R1 responded they did not have the right, to which CNA M stated Yes she did. R1 leaned forward as though she might bite CNA M, then CNA M told to R1 to bite her, she was done. R1 bit CNA M's shoulder and CNA M yelled R1 stop your biting, that hurt. The exchange continued until LN G and CNA M assisted R1 to stand and escorted her to the nurse's station. During the course of the incident, CNA M demonstrated verbally aggressive behavior toward R1. In several instances, CNA M's tone and language appeared confrontational. Additionally, there were moments in the recordings that suggested potential physical aggression toward R1 as CNA M's actions appeared forceful while attempting to remove the remote from R1's grasp. On 10/20/25 at approximately 11:20 PM, the facility notified law enforcement. Following the facility's internal investigation and review of the video evidence, the facility terminated CNA M's employment on 10/21/25 at 01:30 PM. The facility conducted abuse, neglect, and exploitation (ANE) training with all staff after the incident to reinforce proper resident rights, communication standards, and intervention procedures in accordance with the facility's policy and state regulations. CNA N's notarized Witness Statement dated 10/21/25, stated on 10/11/25 at approximately 02:00 AM, R1 called many times that night and CNA M seemed frustrated. She stated she and CNA M went into R1's room, and CNA M raised her voice at R1 and told R1, she (R1) was going out to the nurse's station. CNA N stated R1 refused, and CNA M continued to try and get R1 out of her chair. R1 bit CNA M on the shoulder and CNA M screamed ouch that hurt. CNA N stated CNA M pulled back. CNA N stated she was going to step in, but she was afraid to get into trouble. She stated LN G entered R1's room to find out what happened. CNA N stated R1 ended up going out of her room and sleeping in a recliner.LN G's notarized Witness Statement dated 10/21/25, stated on 10/11/25 at approximately 02:00 AM, CNA M complained that R1 bit her and CNA M stated she was done with R1. LN G stated CNA M yelled at R1, and she did not intervene because she did not consider the behaviors abuse. LN G stated CNA M should have taken a time out and not have raised her voice at R1.Review of the video recordings revealed on 10/11/25 from 02:57 AM to 03:01 AM R1 sat in her recliner with her legs reclined and a blanket on her. R1 wore a cervical neck brace. CNA M walked into R1's room and asked, What do you want [R1]? R1's response was unintelligible. CNA M stated to R1, Huh? CNA M grabbed the recliner remote and started sitting R1 up in the recliner. R1 stated to CNA M, I didn't call you. CNA M stated to R1, Okay, well you're going up front. R1 responded but some of her response was unintelligible. R1 stated again, I didn't call you. R1 tugged on the recliner remote cord. CNA M stated to R1, Stop. We have the right to do this. R1 responded to CNA M, You don't have no. and the rest was unintelligible. CNA M stated to R1, Yes, I do. R1 responded to CNA M again, You don't have no. and the rest was unintelligible. CNA M stated to R1, Well, we're done with you pushing the light and everything and saying stuff. R1's response was unintelligible. R1 grabbed the recliner remote cord and stated to CNA M, No, I need the light. CNA M stated to R1, Quit. Quit! CNA M grabbed the remote cord further down, closer to R1's hand on the cord and R1 let go of the cord. CNA M pulled the blanket off of R1. CNA M moved the remote under R1's right arm and hung the remote off the right side of the recliner. CNA M grabbed a shoe from R1's wheelchair seat, located to the left of the recliner, and started putting the shoe on R1's left foot. R1 reached beside her to the right and grabbed the recliner remote cord and pulled on the cord. CNA M stated to R1, Leave it alone. CNA M grabbed the remote with her right hand while R1 continued to hold it in her right hand, both tugged on the remote. CNA M stood to the left side of R1's legs and held onto the recliner remote. R1 grabbed CNA M's left wrist with her left hand while her right hand remained on the recliner remote. CNA M pulled R1's right hand off of the recliner remote. R1 continued to hold onto CNA M's left wrist with her left hand. CNA M stated to R1, Leave it alone. [R1]. No! R1's response was unintelligible. CNA M stated to R1, You are going up front, I am not playing your games. R1's response was unintelligible. R1 leaned forward towards CNA M's right arm. CNA M leaned in towards R1's face and stated to her, Bite me. I'm done. R1 leaned forward and bit CNA M's right shoulder. CNA M jerked upward and rapidly pushed her right forearm towards R1's head while yelling, OW! R1's head and neck, wearing her cervical neck brace, bounced off of the recliner (head rest). CNA M held onto R1's right hand and leaned it towards R1's upper body while she yelled at R1, [R1], stop your biting. CNA M continued to hold onto R1's right hand and moved R1's hand to the right and yelled loudly into R1's face, That hurt. There's no sense in that. Why did you bite me? Why? R1's response was unintelligible. CNA M stated, Well, you are pushing the light, and we can't get nothing done when you're doing that [R1]. R1's response was unintelligible. CNA M talked over R1 and chastised her, CNA M stated to R1, You're acting like a two-year-old.Review of the EHR and facility provided information revealed the facility staff did not report the incident to Administrative Staff.Review of CNA M's timesheet revealed CNA M continued to work with residents after this incident on the following dates:On 10/10/25 at 06:45 PM through 10/11/25 at 07:09 AM, with a lunch break.On 10/11/25 at 06:48 PM through 10/12/25 at 07:02 AM, with a lunch break.On 10/12/25 at 06:54 PM through 10/12/25 at 11:32 PM.On 10/27/25 at 03:14 PM, R1 sat in her wheelchair in the meeting room. She stated she remembered the incident from a couple weeks ago when she wanted to go to the bathroom and CNA M told her she had to go with her. R1 stated she told her no and CNA M tried to get her up to go to the nurse's station and R1 stated she did not want to get up. R1 stated CNA M yelled loudly at her and said she did not want to play that game anymore. R1 became occasionally difficult to understand but she answered questions appropriately when she was directly asked. R1 stated CNA M made her feel bad and she fought back against CNA M. R1 stated she felt very scared of CNA M when CNA M yelled at R1, and felt CNA M acted abusively towards her. R1 started to cry and became visibly shaken when recounting the incident on 10/11/25 involving CNA M. R1 became difficult to understand when she was upset. On 10/27/25 at 01:04 PM, R1's representative stated she was out of the country during the incident and when she returned, she received a call from the facility reporting something happened with R1. She stated she looked back at the videos and the incident was something else than what was reported to her. R1's representative stated R1 reported to her that the staff ganged up on her and tried to tell R1 what to do. She stated R1 became hard to understand and she looked at the videos. On 10/27/25 at 01:24 PM, R1's representative stated at the time of the incident on 10/11/25, R1 wore a neck brace. She stated the camera that faced the bed showed her recliner and the video showed the CNA pushed R1's head. R1's representative reported R1's neck was healed about 50% and R1 only wore the neck brace during therapy now.On 10/27/25 at 01:53 PM, CNA O stated if she witnessed a staff member getting frustrated with a resident, she asked them to step out. She stated if a resident became agitated with her, she asked another CNA to approach the resident. CNA O stated she did not try to force anything, and she reapproached the resident to give them the care they needed. She stated R1 became harder to understand when she became impatient with staff. She stated as long as staff did not rush R1, she remained calm. CNA O stated R1 stayed up most of the night and pushed the call light often. She stated she asked R1 what else she needed help with prior to leaving her room to help R1 not push the call light as often. CNA O stated if she saw staff forcing a resident to do something or becoming verbally aggressive towards a resident, she stepped into the situation and would ask that staff member to step out. She stated she reported staff altercations with residents including verbal altercations, immediately to the nurse or to Administrative Nurse D. She stated Administrative Nurse D told her if she even questioned a situation, to report it to her.On 10/28/25 at 02:32 PM, CNA M stated R1 sat in her recliner at night, and she kept sitting the recliner up where she could have slid out of the recliner. She stated she asked R1 to put her chair back down but R1 would not listen, and she kept moving the recliner up and down. CNA M stated she told R1 she had to put her call light on for help so she would not fall and R1 said she did not have to put the call light on. She stated on 10/11/25, she leaned forward so she could see R1 face to face because R1 got drowsy at night. She stated she bent down to talk to R1 and R1 started getting testy with CNA M and R1 leaned forward a little bit. CNA M stated she told R1 not to bite her and when CNA M leaned up to try and help R1, R1 bit CNA M on the shoulder. She stated R1 did not want to get up to go to the nurse's station, but Administrative Nurse D told CNA M if R1 did not sit still staff brought her to the front, even if she did not want to go. CNA M stated she had a loud voice and to anybody watching the video, they would think she yelled at R1. On 10/28/25 at 05:19 PM, CNA N stated she vaguely remembered what happened on 10/11/25 as it was her first day. She stated she recalled that R1 called quite a bit and CNA M seemed frustrated. CNA N stated CNA M told her that Administrative Nurse D said if R1 kept calling then R1 had to go out to the living room for staff to watch her. She stated CNA M was very forceful and very verbally aggressive. CNA N stated CNA M went to pick R1 up and wrapped her arms around R1 when R1 bit CNA M on the shoulder. She stated CNA M screamed and stated ow [R1] that hurt. CNA N stated R1 made it clear she did not want to get up and she did not want to leave her room. She stated CNA M's actions made her very uncomfortable. CNA N stated she did not report it because she had a history at other jobs where she expressed concerns and got into trouble. CNA N stated LN G did go into R1's room to figure out what happened. She stated R1 had behaviors the next night too and CNA M got into R1's face to ask what was going on and R1 scratched CNA M. CNA N stated she thought R1 continued to be upset with CNA M from the night before. On 10/27/25 at 02:16 PM, LN H stated if she saw staff getting frustrated with a resident, she pulled the staff member away and told them to take a break or a breather. She stated she provided support to staff and offered to help if needed. LN H stated if she saw a resident escalated or became agitated with staff, she intervened right away. She stated if a resident did not want to do something, she reapproached them later, tried a different approach, or had another staff member approach the resident. LN H stated she did not force a resident to get up or pull remotes out of their hands. She stated if she witnessed a CNA do that, she would immediately pull the CNA out of the resident's room. She stated she reported verbal abuse as staff were not allowed to raise their voices at residents or speak to them in a derogatory manner. She stated she reported abuse immediately to Administrative Nurse D. LN H stated R1 did not like to wait if staff helped other residents and sometimes LN H had to pull staff from the other hall to help R1. She stated R1 became anxious and tearful and when that happened, she had a meltdown and became hard to talk to. LN H stated at the time of the incident on 10/11/25, R1 wore the cervical neck brace all the time except when she took it off herself.On 10/28/25 at 05:17 PM, LN G was unavailable for interview. On 10/27/25 at 12:51 PM, Administrative Nurse D stated LN G stated to her that she did not consider CNA M's actions on 10/11/25 to be abuse but looking back on the situation, LN G stated she should have intervened. Administrative Nurse D stated CNA N stated to her that she was scared to report CNA M's actions because she did not want to get into trouble. Administrative Nurse D stated no staff reported the incident between CNA M and R1 on 10/11/25. She stated R1's representative reported the incident and R1 stated staff forced her out of her room and told her she did not have the right to stay in her room. Administrative Nurse D stated she never told staff they could force R1 out of her room.On 10/27/25 at 03:28 PM, Administrative Nurse D stated R1 did not have any behaviors the week before the incident. She stated she received a report that R1 bit CNA M which she found odd because R1 had never tried to hit or bite anybody. Administrative Nurse D stated when R1's representative returned to the country, she contacted R1's representative and asked her to review the videos. She stated R1's representative sent her the videos and she called Administrative Staff A to tell him the facility needed to report the incident. Administrative Nurse D stated the facility suspended CNA M then terminated her. She stated the facility educated staff immediately and wrote up LN G and CNA N Administrative Nurse D stated she expected staff to walk away if they got frustrated with a resident and not continue to stand there to argue and raise their voice with the resident. She stated CNA M should not have tried to make R1 get out of her recliner, but CNA M should have answered R1's call light every five minutes if that was what R1 needed. Administrative Nurse D stated she expected LN G and CNA N to tell CNA M to walk away from R1 and report the incident immediately to her. On 10/27/25 at 03:41 PM, Administrative Staff A stated Administrative Nurse D called him the evening of 10/20/25 and reported she received videos from R1's representative in regard to R1 and CNA M. He stated the incident needed to be reported immediately and the facility reported it to the State Agency (SA) and the police. Administrative Staff A stated after he reviewed the videos, he talked to human resources, and they agreed to terminate CNA M. He stated he invited CNA M into the facility for termination and she stated to him that she felt like she tried to protect R1 from further injury of her neck. He stated CNA M stated to him that she did not feel like she yelled at R1 but felt like she raised her voice. Administrative Staff A stated he expected LN G and CNA N to intervene and tell CNA M they got it and take five minutes. He expressed disappointment in LN G not taking charge of the situation and not calling him and Administrative Nurse D immediately to report what she had witnessed with CNA M and R1. He stated LN G should have removed CNA M to a non-patient care area until she received further direction from him and Administrative Nurse D. He stated it was not LN G's position to determine if the incident was mental or verbal abuse, but it was her responsibility to separate CNA M and R1 then report it immediately. Administrative Staff A stated it was clear that CNA M was out of control.The facility's Abuse Prevention Program, effective August 2025, directed residents had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical condition. Administrative Staff A received the Immediate Jeopardy Template on 10/27/25 at 04:30 PM and was notified of the facility's failure to ensure R1 remained free from staff-to-resident abuse, placed R1 in immediate jeopardy at F600. The immediate jeopardy at F600 also constituted Substandard Quality of Care at 42 CFR 482.The facility identified, implemented, and completed following interventions on 10/21/25:1. The facility immediately suspended CNA M on 10/20/25.2. The facility terminated CNA M on 10/21/25. 3. The facility conducted all-staff education on ANE on 10/21/25.4. The facility completed disciplinary action for LN G and CNA N on 10/21/25.Due to the facility's corrective actions completed prior to the onsite visit, the deficient practice was cited at past noncompliance and existed at a J (isolated, immediate jeopardy) scope and severity.

The facility identified a census of 35 residents. The sample included three residents, with three residents reviewed for dental services. Based on observation, record review, and interviews, the facility failed to obtain emergency dental services for Resident (R) 1 after he broke a tooth on 03/27/25. This deficient practice had the risk of dental pain, difficulty eating, and unnecessary physical complications for R1.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness, difficulty in walking, and hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain).The Annual Minimum Data Set (MDS), dated 06/19/25, documented R1 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment.The Cognitive Loss/Dementia (a progressive mental disorder characterized by failing memory and confusion) Care Area Assessment (CAA), dated 07/09/25, documented R1 had some cognitive loss and was at risk for impaired memory and difficulty with communication.R1's Care Plan, dated 08/12/24, documented R1 had oral/dental health problems related to missing/broken teeth. The plan directed staff to coordinate arrangements for dental care and transportation as needed.R1's EMR revealed the following:A Nursing Note on 03/27/25 at 02:26 PM, documented the Certified Nurse Aide (CNA) notified the nurse that R1 reported he broke his tooth while eating lunch. The nurse assessed R1, and his bottom middle tooth was broken with only a small amount of tooth remaining. R1 reported he broke his tooth while biting into a pork chop. The nurse informed the dietary manager of the incident and Social Services X about needing to make R1 a dentist appointment.A Nutrition: Nutrition Note on 03/27/25 at 04:30 PM, documented the dietary manager interviewed R1 regarding the incident at lunch, where R1 had a partial loss of tooth after eating a pork chop. R1 stated he cut a strip of pork chop off and put it in his mouth, then bit it with his front teeth. He stated he heard a pop, began to chew, and felt the tooth on his tongue. No bleeding occurred, and R1 reported minimal pain. The dietary manager followed up with the charge nurse to confirm findings.There was a lack of evidence that the facility made an emergency dental appointment for R1's broken tooth between 03/27/25 and 05/07/25.A Social Services: Note on 05/08/25 at 04:40 PM, documented R1 was scheduled for a dentist appointment due to a broken tooth. Social Services X notified R1, nursing, and transportation.A Social Services: Note on 07/21/25 at 01:43 PM, documented R1 was having tooth pain, and his representative wanted R1 to be scheduled for the first available appointment by the dentist. R1's appointment is scheduled for tomorrow. Social Services X notified R1, his representative, nursing, and transportation.Upon request, the facility provided a Care Note Summary, dated 05/13/25, from R1's dental visit on 05/13/25. The summary documented R1 had a broken tooth without pain and a recommendation for full mouth endentulation (loss of teeth) and fabrication of complete dentures.On 07/22/25 at 12:47 PM, R1 sat in the recliner in his room and ate lunch. He stated he broke a tooth a while ago, but did not see the dentist until May.On 07/22/25 at 02:03 PM, R1 stated he did not have any dental pain from the broken tooth until recently, but he had difficulty eating food. He stated there was a small piece of tooth left over that came out later.On 07/22/25 at 12:59 PM, Licensed Nurse (LN) G stated if a resident had dental pain or a broken tooth, she would notify the doctor, the family, and her supervisor. She stated the facility had an in-house dentist who visited, but if a resident needed in sooner, she notified the doctor for a dentist referral if needed.On 07/22/25 at 01:12 PM, Social Services X stated the dentist visited the facility every six months, and a dental hygienist visited in between. She stated if a resident had an acute dental issue, the facility sent them to an outside dentist, depending on their preference. Social Services X stated R1 broke a tooth towards the beginning of April and saw the dentist in May for a basic exam. She stated the dentist said they would forward the information on to R1's representative for next steps, but the facility never heard anything else. Social Services X stated she was notified yesterday that R1 had dental discomfort with eating, and he was scheduled with the dentist for today. She stated she communicated with R1's representative after his tooth broke about getting him seen by the dentist, and R1's representative first told her to find a dentist that accepted R1's insurance. Then she told Social Services X that R1 would see the in-house dentist. Social Services X stated that normally, she documented all family communication and attempted communication in the EMR.On 07/22/25 at 01:44 PM, Administrative Nurse D stated R1 had a broken tooth and was sent to the dentist in May. She stated the facility did not receive any paperwork back from the dentist in May, but he went to the dentist today and was told he needed his teeth pulled for dentures. Administrative Nurse D stated he was not seen by the dentist sooner between 03/27/25 and 05/13/25 because he did not complain of any pain with his teeth during that time. She stated that if a resident broke a tooth or had dental problems, the facility notified the physician and received recommendations, then they notified the resident's representative. She stated she expected staff to document communication with the family in the notes. Administrative Nurse D stated the facility had a care plan meeting on 07/11/25, and R1's representative asked the facility what was going on with his broken tooth because he complained about pain on the right side and a bad taste in his mouth.The facility's Routine Dental Care policy, last revised October 2012, directed the facility to notify the attending physician of a resident's need for dental treatment and ordered dental consultation as appropriate.

The facility identified a census of 35 residents. The sample included three residents, with three residents reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R) 1's representative of changes in condition, plan of care changes, and results. This deficient practice placed R1 at risk for further decline and a delay in treatment.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness, difficulty in walking, and hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain).The Annual Minimum Data Set (MDS), dated 06/19/25, documented R1 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment.The Cognitive Loss/Dementia (a progressive mental disorder characterized by failing memory and confusion) Care Area Assessment (CAA), dated 07/09/25, documented R1 had some cognitive loss and was at risk for impaired memory and difficulty with communication.R1's Care Plan dated 08/12/24, documented R1 had a communication problem related to minimal hard of hearing in bilateral ears. The plan directed staff to anticipate and meet R1's needs and discussed with the resident/family any concerns or feelings regarding his communication difficulty.R1's EMR revealed the following:A Durable Power of Attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) for Health Care Decisions General Statement of Authority Granted signed and executed on 08/23/24 that documented R1's representatives were effective as DPOA effective immediately and were not affected by R1's subsequent disability or incapacity or upon the occurrence of his disability or incapacity.A Nursing: Progress Note on 03/27/25 at 02:26 PM, documented the Certified Nurse Aide (CNA) notified the nurse that R1 reported he broke his tooth while eating lunch. The nurse assessed R1, and his bottom middle tooth was broken with only a small amount of tooth remaining. R1 reported he broke his tooth while biting into a pork chop. The nurse informed the dietary manager of the incident and Social Services X about needing to make R1 a dentist appointment.A Nursing: Progress Note on 04/16/25 at 11:01 AM, documented during a post follow-up, R1 reported right shoulder pain. The facility received an order for a two-view x-ray of his right humerus (upper arm bone) and a two-view x-ray of his right shoulder.A Nursing: Progress Note on 04/17/25 at 12:35 PM, documented the facility had notified the provider of R1's x-ray results. R1's right shoulder results documented the findings were compatible with a chronic right rotator cuff (a group of muscles and tendons that hold the shoulder joint in place and allow you to move your arm and shoulder) tear. R1's right humerus results were unremarkable.A Nursing: Progress Note on 04/24/25 at 06:10 PM, documented the facility received an order to obtain a three-view right shoulder x-ray for pain and mobility limitations. The facility notified R1 of the new order.A Nursing: Progress Note on 04/25/25 at 09:55 AM, documented the facility received the results of the x-ray and sent the results to the provider. The X-ray results likely reflect chronic rotator cuff pathology.A Nursing: Progress Note on 04/25/25 at 12:40 PM, documented the facility received an order to obtain an orthopedic (pertaining to bones) evaluation for a possible arthroscopy (surgery performed for the examination of the interior of a joint).A Social Services: Note on 05/08/25 at 04:40 PM, documented R1 was scheduled for a dentist appointment due to a broken tooth. Social Services X notified R1, nursing, and transportation.A Nursing: Progress Note on 05/23/25 at 11:24 AM, documented R1 had an occasional cough with a minimal amount of white, frothy sputum (a mixture of saliva and mucus coughed up from the respiratory tract). R1's provider ordered laboratory tests, a chest x-ray, Lasix (diuretic medication- a medication to promote the formation and excretion of urine) 40 milligrams (mg) twice daily for five days, then resume 40 mg daily, and weigh R1 daily for the next seven days.A Nursing: Progress Note on 05/23/25 at 03:24 PM, documented the facility notified R1's provider of laboratory results and waited for the x-ray results.A Nursing: Progress Note on 05/23/25 at 07:46 PM, documented the facility notified R1's provider of the chest x-ray results and received no new orders.A Nursing: Progress Note on 06/15/25 at 07:29 PM, documented the facility received orders from neurology (a branch of medicine that deals with the diagnoses and treatment of disorders in the nervous system) for memantine (medication used to treat the symptoms of Alzheimer's [progressive mental deterioration characterized by confusion and memory failure) disease) five mg twice daily for dementia and start physical therapy (PT) for balance. The facility notified R1 of the orders and received consent to update his plan of care.There was a lack of documentation that R1's representative was notified of the changes in condition, new orders, and/or results in the above notes.On 07/22/25 at 12:47 PM, R1 sat in the recliner in his room and ate lunch. He stated he wanted his representative notified of any new orders and changes.On 07/22/25 at 12:59 PM, Licensed Nurse (LN) G stated she notified the resident's representative of any change in condition, new orders, and incidents. She stated she notified R1's representative of any and all changes. LN G stated that whenever she received a new order, she checked the resident's profile page to see who needed to be notified. She stated R1's representative had to be notified of changes because they were the DPOA, effective immediately.On 07/22/25 at 01:44 PM, Administrative Nurse D stated if there was a change in condition, including abnormal vital signs, skin issues, falls, and new orders, she expected the nurse to notify the physician and the resident's representative. She stated that staff found the DPOA information under their contacts. Administrative Nurse D stated R1's representative was DPOA effective immediately, and his representative was notified of any and all changes. She stated the facility had issues with R1's DPOA in the past due to nobody knew whether it was effective immediately, whether he was incapacitated or not. She stated staff used to ask R1 if he wanted them to call his representative, but now, they just call the representative.The facility's Change in a Resident's Condition or Status policy, last revised November 2017, directed the facility to promptly notify the resident, his/her attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status.

The facility identified a census of 36 residents. The facility failed to provide the services of a full-time certified dietary manager for the 36 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 09/09/25 at 08:23 AM, Dietary Staff BB stated she was currently in class to become a Certified Dietary Manager (CDM). Dietary Staff BB stated the Registered Dietician (RD) came to the facility monthly. The facility's Food Service Staffing policy last reviewed 10/2024 documented the facility would employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service.

The facility identified a census of 36 residents. The sample included 12 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 36 residents residing in the facility. Findings Included: - On 06/09/25 Administrative Staff A provided a Facility Assessment updated 12/2024. A review of the assessment revealed the following: The assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. The assessment lacked staffing levels required for each shift, day, and weekend. On 06/09/25 a review of the facility's Payroll Based Journaling (PBJ - Staffing Data Report) from 04/01/24 to 03/31/25 revealed excessively low weekend staffing triggered on Quarter Three (04/01/24 to 06/30/24) and Quarter Four (07/01/24 to 09/30/24). On 06/11/24 at 12:24 PM, Administrative Nurse D stated the facility assessment update was completed recently by the management team. She stated the assessment should include the staffing requirements. On 06/11/24 at 01:22 PM, Administrator A stated the assessment was recently updated to include the staffing requirement put out by the Centers for Medicare and Medicaid Services (CMS). The facility's Facility Assessment policy revised 01/2017 indicated the facility would conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents during day-to-day operations including evenings, nights, and weekends.

The facility identified a census of 36 residents. The facility identified eight residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to store Resident (R) 33, R34, R6, and R1's respiratory equipment in a sanitary manner, and the facility further failed to transport linens in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases. Included findings: - On 06/09/25 at 07:44 AM, a walkthrough of the facility was completed. On 06/09/25 at 07:57 AM, R33 laid on her right side in her bed. R33's CPAP mask was draped over the CPAP machine without a clean barrier and sanitary container. On 06/09/25 at 07:59 AM, R34 laid on his back on his bed. R34's CPAP mask laid on the floor on the right side of his bed. R34's CPAP machine without a clean barrier and sanitary container. On 06/09/25 at 08:02 AM, R6's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask hung from a thumb tack on her message board. R6's nebulizer mask was not stored in a sanitary manner. On 06/09/25 at 08:04 AM, R1's nasal cannula laid draped over her wheelchair. R1's nasal cannula was not contained in a sanitary manner. On 06/09/25 at 08:10 AM, laundry staff pushed a covered linen cart down the [NAME] Hall with bath blankets on top of the cart. The bath blankets were not stored in a sanitary manner. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated CPAP mask should be cleaned, air-dried, and placed in a plastic bag. LN G stated R33 used a CPAP. LN G stated linens should be transported in a cover cart. On 06/11/25 at 11:53 AM, Certified Nurse's Aide (CNA) M stated the CPAP mask should be placed in a drawer. She stated the nurse on duty usually took care of the respiratory equipment. CNA M stated she was unsure how linens should be transported. On 06/11/25 at 2:05 PM, Administrative Nurse D stated it was all nursing staff's duty to ensure all respiratory equipment was placed in a bag in a sanitary manner. Administrative Nurse D stated linens should be covered when transported in the halls. The facility did not provide a respiratory equipment storage policy. The facility's Handling of Clean Linen and Linen Distribution policy dated 10/24 documented clean laundry and bedding shall be handled in a manner that prevents gross microbial contamination of the air and person handling the linen.

The facility had a census of 36 residents. The sample included 12 residents, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure pressurized supplemental oxygen tanks in a safe, locked area, and out of reach of the 22 cognitively impaired independently mobile residents. The facility additionally failed to ensure fall interventions were in place for Resident (R) 12 and R4. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings included: - On 06/11/25 at 07:58 AM, a walkthrough of the facility revealed an unsecured oxygen storage room. The room contained 35 pressurized supplemental oxygen cylinder tanks stored in floor racks. The room had a key lock on the entry door. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated oxygen should be stored in a locked room in a storage rack. On 06/11/25 at 11:52 AM, Certified Nurse Aide (CNA) M stated oxygen tanks should be stored in a locked room in storage racks. On 06/11/25 at 12:05 PM, Administrative Nurse D stated she expected oxygen tanks would be stored in a locked room. The facility's Fire Safety Precaution Including Oxygen Storage policy last revised 04/2025 documented personnel would follow the facility's established fire safety precautions in order to provide safety to all concerned. - R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Significant Change Minimum Data Set (MDS) dated 01/17/25 documented a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R12 was dependent on staff assistance for transfers, dressing, and personal hygiene. The MDS documented R12 was on hospice services. The Quarterly MDS dated 04/29/25 documented a BIMS score of zero, which indicated severely impaired cognition. The MDS documented that R12 was dependent on staff assistance for bed mobility, dressing, personal hygiene, and transfers. The MDS documented R12 was on hospice services. R12's Falls Care Area Assessment (CAA) dated 02/07/25 documented she was dependent on a wheelchair for mobility related to her physical status of a fractured left hip and was on hospice services. R12's Care Plan, initiated date of 09/24/18 and a revision date of 01/19/23, documented staff would keep the call light within reach. The plan of care documented staff would provide R12 with frequent education about how to use the call light and keep the call light secured and within reach. The plan of care dated 12/19/24 documented R12 had an injury fall on 12/18/24 and the intervention that was implemented was staff would remove the Hoyer (total body mechanical lift) sling after each use from under R12. The plan of care with an initiated date 04/22/25 documented R12 had an injury fall. The intervention that was implemented was staff would recline her in the Broda chair (specialized wheelchair with the ability to tilt and recline) after she was finished eating. The plan of care also documented Dycem (a non-slip mat used for stabilization and gripping to prevent slipping) would be placed in her chair. The plan of care dated 06/05/25 documented R12 had an injury fall and the intervention implemented was the staff would ensure her bed was in the lowest position and a floor mat was in place next to the bed. On 06/09/25 at 08:15 AM, R12 laid on her back in bed. R12 call light was on the floor behind her bed. R12's floor mat was folded up and stood upright away from her bed. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated all staff have access to each resident's care plan. LN G stated it was all nursing staff's responsibility to ensure fall interventions were in place before leaving a resident's room. LN G stated staff could review the resident's fall interventions from the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). On 06/11/25 at 11:53 AM, Certified Nurse's Aide (CNA) M stated she did have access to the resident's care plans. CNA M stated if a new intervention for a fall was put in place the director of nursing would come to the floor and let all staff know. CNA M stated it was the CNA's job to ensure the interventions for falls were put in place before leaving the resident. On 06/11/25 at 12:05 PM, Administrative Nurse D stated all nursing staff have access to the care plans. Administrative Nurse D stated she would expect the person who laid the resident down to ensure all fall interventions were put in place before leaving the resident's room. The facility's Falls and Fall Risk Managing policy dated 04/24 documented based on previous evaluations and current data, the staff would identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. - R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), hypertension (high blood pressure), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), hyperlipidemia (condition of elevated blood lipid levels), dementia (a progressive mental disorder characterized by failing memory and confusion), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), pain, insomnia (inability to sleep), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time). The Quarterly Minimum Data Set (MDS) for R4 dated 03/24/25 recorded a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented R4 needed setup or cleanup for eating and substantial to maximal assistance from staff for toileting and bathing. The MDS documented R4 had falls since admission. The MDS documented R4 had two non-injury falls. R4's Falls Care Area Assessment (CAA) dated 12/22/24 documented R4's fall CAA triggered related to R4 taking an antidepressant (a class of medications used to treat mood disorders) routinely. R4's Care Plan dated 03/14/23 documented R4 had a non-injury fall and staff would place her call light within her reach. R4's plan of care dated 09/05/24 documented a non-injury fall and the facility would place nonskid strips in front of her toilet. R4's plan of care dated 05/05/25 documented R4 was at risk for falls and has had an actual fall related to sliding out of her bed, R4's bed would be placed in a low position, a fall mat would be placed beside her bed, and her wheelchair would be placed at the bedside. On 06/09/25 at 07:34 AM, R4 laid on her bed, R4's bed was in a low position. R4's call light laid on the floor, and her fall mat was folded up at the top of her bed. R4 did not have nonskid strips in her bathroom. On 06/10/25 at 02:07 PM, R4 laid in on her bed. R4's bed was at waist height. R4's fall mat was folded up at the head of her bed. R4 did not have nonskid strips on her bathroom floor. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated all staff have access to each resident's care plan. LN G stated it was all nursing staff's responsibility to ensure fall interventions were in place before leaving a resident's room. On 06/11/25 at 11:53 AM, Certified Nurse's Aide (CNA) M stated she did have access to the resident's care plans. CNA M stated if a new intervention for a fall was put in place the director of nursing would come to the floor and let all staff know. CNA M stated it was the CNA's job to ensure the interventions for falls were put in place before leaving the resident. On 06/11/25 at 12:05 PM, Administrative Nurse D stated all nursing staff have access to the care plans. Administrative Nurse D stated she would expect the person who laid the resident down to ensure all fall interventions were put in place before leaving the resident's room. The facility's Falls and Fall Risk Managing policy dated 04/24 documented based on previous evaluations and current data, the staff would identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

The facility identified a census of 36 residents. The sample included 12 residents, with two residents reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion) care. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 17 with dementia services related to supervision and accidents. The defiant practice placed R17 at risk for preventable accidents. Findings Included: - R17's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of a history of falls, muscle weakness, hypothyroidism (a condition characterized by decreased activity of the thyroid gland), insomnia (inability to sleep), dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), unsteadiness on feet, and peripheral vascular disease (PVD - slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R17 needed set-up or clean-up assistance with eating, and substantial/maximal assistance from staff for toileting and bathing. The MDS documented R17 had a fall since admission and had two or more non-injury falls. R17's Communication Care Area Assessment (CAA) dated 03/23/25 documented R17's CAA related to R17 not understanding others, and others not understanding her. The CAA documented R17 was alert to herself only. R17's Care Plan dated 07/02/19 documented staff were to keep R17's call light within her reach. R17's plan of care dated 05/29/23 documented a non-injury fall related to R17 walking unassisted and without calling for assistance, the intervention for the fall was to keep R17's door open, for staff to easily view R17. A Facility Incident Report #5635 completed on 05/27/25 revealed Licensed Nurse (LN) H walked into the television room and witnessed R17 (Severely cognitively impaired resident) in the television room with R21. LN H witnessed R21 groping R17's breast. The report indicated both residents were immediately separated. The note revealed that R17 was assessed with no injuries found. The report indicated both residents had no recollection of the incident when interviewed. The note revealed the medical provider, resident representative, and local law enforcement were notified. The report revealed that R21 was immediately placed on one-to-one supervision and started on medication to reduce his sexual behaviors. A Witness Statement completed by LN H on 05/27/25 indicated he observed the incident and separated the two residents. LN H reported in the statement he observed R21 touching R17's breast with his left hand. LN H reported in the statement that he immediately separated the residents and assessed R17. The statement revealed that R21 was agitated when asked to not touch R17. On 06/09/25 at 07:28 AM, R17's laid on her bed, and R17's call light laid on the floor. R17's call light was not within her reach. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated residents with dementia should be left alone and should be monitored frequently. LN G stated call lights should always be within the resident's reach. On 06/11/25 at 11:53 AM, Certified Nurse's Aide (CNA) M stated residents with dementia should be checked on frequently. CNA M stated resident's call light should be laid on the resident, always within the resident's reach. On 06/11/25 at 12:05 PM, Administrative Nurse D stated that residents with dementia should be monitored. Administrative Nurse D stated call lights should be within the resident's reach. The facility's Dementia Care of the Resident policy dated 10/24 documented that residents with diagnosed dementia or displays symptoms of dementia would receive necessary care and services to maintain or attain their highest practicable physical, mental, and psychosocial well-being.

The facility identified a census of 36 residents. The sample included 12 residents, with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 33's continuous positive airway pressure (CPAP - ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask was stored in a sanitary manner. This placed R33 at an increased risk for respiratory infection and complications. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of the acquired absence of right foot, pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region, hematogenous osteomyelitis (a type of bone infection where bacteria travel through the bloodstream to the bones, causing inflammation and potentially bone destruction), lack of coordination, muscle weakness, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R33 had impairment on one side of her lower extremities. The MDS documented R33 needed setup or cleanup for eating, was dependent on staff for toileting, and needed substantial to maximal assistance from staff for bathing. The MDS did not indicate R33 required the use of a CPAP. R33's Functional Abilities (self-care mobility) Care Area Assessment (CAA) dated 04/21/25 documented R33 was currently taking insulin (a hormone that lowers the level of glucose in the blood), antihypertensive (a class of medication used to treat high blood pressure), anticoagulation (blood thinner), and medication for constipation which could cause an increase in falls. The CAA documented R33 had had no falls since admission. The CAA documented R33 was dependent on staff for most activities of daily living (ADL) and required the assistance of one staff. The CAA documented R33 ambulated with a wheelchair and was dependent on staff for wheeling her chair. The CAA documented R33 received medication for wound healing. The CAA documented R33 was on a regular diet, with regular texture with thin liquids. The CAA documented R33 was incontinent and required a pull-up. R33's Care Plan dated 04/18/25 documented R33 was at risk for altered nutritional and hydration status related to inadequate intake and wound healing. R33's plan of care documented staff would encourage the consumption of fluids that were provided and monitor and record meal intakes. The plan of care for R33 documented staff would provide and serve supplements as ordered. R33's plan of care lacked indication of R33's CPAP. R33's EMR under the Orders tab lacked staff direction for the use, and cleaning of CPAP and lacked staff direction for sanitary storage of CPAP. R33's EMR under Progress Notes dated 05/29/25 documented Licensed Nurse (LN) received a call from the X-ray department for a follow-up on R33's chest X-ray findings. The findings indicated left basal infiltrate/effusion (abnormal accumulation of fluid or other substances in the lower part(basal)of the lungs, specifically within the lung tissue (infiltrate) or in the space around the lungs(effusion). LN called the physician on call and received an order for the facility to continue Levaquin (antibiotic) as ordered. On 06/09/25 at 07:57 AM, R33 laid on her right side in her bed. R33's CPAP mask was draped over the CPAP machine without a clean barrier and sanitary container. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated CPAP mask should be cleaned, air-dried, and placed in a plastic bag. LN G stated R33 used a CPAP. On 06/11/25 at 11:53 AM, Certified Nurse's Aide (CNA) M stated the CPAP mask should be placed in a drawer. She stated the nurse on duty usually took care of the respiratory equipment. On 06/11/25 at 02:05 PM, Administrative Nurse D stated it was all nursing staff's duty to ensure all respiratory equipment was placed in a bag in a sanitary manner. The facility did not provide a respiratory storage policy.

The facility identified a census of 36 residents. The sample included 12 residents, with three reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 27's pressure-reducing low air-loss mattress (specialized air mattress used to reduce the pressure applied to the body) was utilized per her weight and manufacturer's safe use recommendations. The facility additionally failed to apply R9's pressure-reducing boots, which were used to off-load the heels of his feet per his care plan. These deficient practices placed both residents at risk for preventable wounds and impaired wound healing. Findings included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), muscle failure, and kyphosis (abnormal spinal curvature in the upper back). R27's Annual Minimum Data Set (MDS) dated 03/27/25 noted a Brief Interview for Mental Status (BIMS) score of 13, indicating mild cognitive impairment. The MDS noted she required partial to moderate assistance from staff for bed mobility, transfers, bathing, dressing, toileting, and personal hygiene. The MDS noted she was at risk for developing a pressure ulcer. The MDS noted she had no unhealed pressure ulcers. The MDS noted she had pressure-relieving devices for her wheelchair and bed. R27's previous Quarterly MDS completed 02/08/25 noted she had an unhealed stage-two (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure injury. R27's Pressure Ulcer Care Area Assessment (CAA) completed 03/25/25 indicated she was at risk for skin breakdown and pressure ulcers related to her limited mobility, history of pressure ulcers, and medical diagnoses. The CAA noted the facility would implement care-planned interventions to minimize the risks. R27's Care Plan initiated 05/27/24 indicated she had activities of daily living (ADL) self-care deficit. The plan indicated she required partial to moderate assistance from staff for toileting, bathing, transfers, bed mobility, dressing, and personal hygiene. The plan indicated she had bladder incontinence and was at risk for skin impairments. The plan instructed staff to provide a two-hour incontinence check and skin monitoring. The plan lacked documentation related to her risks for pressure ulcers or the use of her low air-loss mattress. R27's EMR under Assessments revealed a Braden Scale assessment completed on 03/28/25. The assessment revealed a score of 11 indicating she was at high risk for the development of pressure ulcers. R27's EMR under Weekly Skin Evaluation revealed she had a reddened area on her thoracic spine area (mid-back spine) that was resolving. R27's EMR under Vitals revealed she weighed 86.1 pounds (lbs.) on 06/04/25. A review of the low air-loss mattress manufacturer's operation (ProActive Protekt Aire 6000) manual indicated the mattress system was intended to reduce the incidence of pressure ulcers while optimizing comfort. The manual indicated the mattress pump's pressure levels and firmness were preset based on the weight range selected. The manual revealed that using the mattress while deflated placed the resident at risk for injuries. On 06/09/25 at 08:21 AM, R27 sat in her bed. The head of her bed was raised above 45 degrees as she ate her breakfast. R27's low air-loss mattress was set to 180 lbs. The mattress pump had fixed weight settings of 80lbs, 130lbs, 180lbs, 230lbs, 280lbs, 340lbs, 400lbs, and 450lbs. On 06/10/24 at 10:11 AM, R27 slept in her bed. Her mattress pump was set to 180lbs. On 06/11/25 at 10:32 AM, R27 sat in her bed as she colored in her sketchbook. She sat upright with the head of her bed raised over 45 degrees. R27's air mattress was deflated, and the low air-loss control panel was off. R27 sat directly on the frame of the bed. She stated she was not sure how long the bed was off but thought staff turned it back on when she left the room earlier in the morning. On 06/11/25 at 10:34 AM, Certified Medication Aide (CMA) entered the room and checked the bed control. She turned the panel on and stated she was not sure why the panel was off. She stated staff were expected to check the bed each shift and set it to R27's weight. On 06/11/25 at 12:05 PM, Administrative Nurse D stated the low air-loss mattresses were to be set according to the resident's weight and checked each time staff entered the room. The facility's Prevention of Pressure Injuries policy revised 08/2022 indicated the facility was to identify and implement preventative interventions for residents at risk for pressure injuries. The policy indicated the facility was to implement and provide ongoing monitoring for wound care and preventative services to ensure effective treatment and wound prevention.- R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebrovascular accident (CVA-stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) effecting left non-dominant side, pulmonary edema (accumulation of extravascular fluid in the lung tissues), pain, obesity (excessive calories), dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), sleep apnea (a disorder of sleep characterized by periods without respirations), contracture (abnormal permanent fixation of a joint or muscle) of left hand, elbow and shoulder, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and respiratory failure with hypoxia (occurs when the lungs were unable to adequately provide oxygen to the bloodstream, leading to low oxygen levels in the blood). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) should not be conducted. The MDS documented R9 was rarely or never understood. The MDS documented R9 was dependent on staff for all activities of daily living (ADL) except eating and needed setup or cleanup. The MDS documented R9 had impairment on one side of his upper body, and both sides of his lower body. R9's Pressure Injury/Ulcer Care Area Assessment (CAA) dated 01/24/25 documented R9 was always incontinent of both bowel and bladder. The CAA documented R9 required assistance with all care. The CAA documented R9 was seen by the wound physician weekly, with daily dressing changes. The CAA documented R9 was admitted to Hospice services. R9's Care Plan dated 04/05/23 documented R9 had a low air loss mattress with bolsters, staff were to check low air loss mattress for proper setting according to R9's weight. R9's plan of care documented R9 had a pressure-reducing wheelchair cushion. R9's plan of care dated 06/23/24 documented R9 had a potential and actual impairment to skin integrity related to immobility and fragile skin. R9's plan of care documented staff were to encourage and assist in turning and repositioning at least every two hours and as needed for comfort and to offload pressure. R9's Braden Scale for Prediction Pressure Sore Risk dated 04/15/25 documented a score of 13 indicating a moderate risk for pressure ulcers. R9's Weekly Wound Assessment dated 06/04/25 documented R9 had a left lateral malleolus wound. R9's physician's orders under the Orders tab revealed the following orders: Apply barrier cream to buttock one time a day for wound healing and as needed (PRN), dated 05/07/25. Cleanse right lower leg distal/lateral ankle with cleanser and apply Skin-prep (liquid skin protectant) to peri-wound. Apply Medi honey (wound dressing), then calcium alginate (highly absorbent dressing), and cover with a foam dressing one time a day for skin integrity, and as needed (PRN), dated 05/28/25. On 06/09/25 at 07:24 AM, R9 laid on his back on his bed. R9's heels were directly on his low air loss mattress. R9 had heel protector boots, one on the right-side bottom of his bed and one on the left-side bottom of his bed. On 06/10/25 at 07:50 AM, R9 laid on his back on his bed. R9's heels laid directly on his low air-loss mattress. One of R9's heel protector boots laid on his bedside table. On 06/11/25 at 7:26 AM, R9 laid on his back on his bed. R9's heels laid directly on the mattress. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated she did remind CNAs to ensure residents with wounds, or the residents that need their heels elevated have their heels elevated. LN G stated it was the nurse's responsibility to ensure boots were placed on the residents. LN G stated R9 needed to have his heels floated when in bed. On 06/11/25 at 11:53 AM, Certified Nurse's Aide (CNA) M stated if a resident needed boots on, or their heels floated, the nurse would let the CNAs know. CNA M stated the nurse also ensured heels were floating. On 06/11/25 at 12:05 PM, Administrative Nurse D stated the CNAs and nursing knew what residents needed to have their heels floated. Administrative Nurse D stated it was the responsibility of all nursing staff to ensure heels were floated or boots were on the resident when the resident was in bed. The facility's Prevention of Pressure Injuries policy dated 10/24 documented the facility would identify specific risk factors and establish goals and prevention interventions with the physician's input. The facility would establish approaches to identify, stabilize, or minimize risk factors associated with pressure injuries.

The facility identified a census of 36 residents. The sample included 12 residents, with one resident reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 9 with assistance with eating and further failed to ensure R9's call light was within his reach. This defiant practice placed R9 at risk of aspiration and unmet needs. Findings included: - R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body)following cerebrovascular accident (CVA-stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) effecting left non-dominant side, pulmonary edema (accumulation of extravascular fluid in the lung tissues), pain, obesity (excessive calories), dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), sleep apnea (a disorder of sleep characterized by periods without respirations), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), contracture (abnormal permanent fixation of a joint or muscle) left hand, elbow and shoulder, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and respiratory failure with hypoxia (occurs when the lungs were unable to adequately provide oxygen to the bloodstream, leading to low oxygen levels in the blood). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) should not be conducted, and that R9 was rarely or never understood. MDS documented R9 was dependent on staff for all activities of daily living (ADL) except eating and needed setup or cleanup from staff. The MDS documented R9 had impairment on one side of his upper body, and both sides of his lower body. R9's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 01/24/25 documented R9 required supervision while eating related to being on a mechanically altered diet. The CAA documented R9 could feed himself and required set-up and clean-up assistance. R9 was dependent on staff for all care, hygiene, toileting hygiene, wheeling the wheelchair, bathing, dressing the upper and lower body, and applying footwear. The resident currently had shown a decline in ADLs and had chosen Hospice services. R9's Care Plan dated 01/14/25 documented R9 preferred to eat in his room, and R9 preferred to stay in his room most of the time. R9's plan of care documented on 09/16/24 R9 spilled hot water on himself. R9's plan of care dated 07/15/24 documented R9 required supervisor/touching assistance with eating. R9's plan of care documented R9 used a trapeze above his bed to assist in repositioning, and staff were to maintain the call bell within his reach. R9's EMR under Orders documented the following physician's order: Elevate the head of bed thirty-forty-five degrees to prevent/treat shortness of breath while he laid in bed every shift for respiratory failure and pulmonary edema, dated 09/23/23. On 06/09/25 at 09:34 AM, R9 was laid flat in his bed on his back. R9 had a bowl of oatmeal trying to spoon the oatmeal to his mouth. R9's call light was wrapped around his trapeze arm, out of R9's reach. R9 had no staff assistance in his room to help or monitor his eating. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated call lights should always be within the resident's reach. LN G stated all residents should be raised as high as the resident could be when eating alone in their bed. She stated a resident's bed should never be laid flat when a resident was eating. On 06/11/25 at 11:53 AM, Certified Nurse Aide (CNA) M stated the CNAs and sometimes kitchen staff delivered meals to the residents' rooms. CNA M stated residents should not be laid flat when they are eating. She stated call lights should always be laid on the resident or where the resident could reach it if needed. On 06/11/25 at 12:05 PM, Administrative Nurse D stated resident's bed should be elevated when a resident was eating in bed, never laid flat. Administrative Nurse D stated call lights should be within the resident's reach. The facility's Quality of Life policy dated 04/25 documented the community environment and staff behaviors were directed toward assisting the resident in maintaining and or achieving independent functioning dignity and well-being. Residents who were unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition grooming and personal and oral hygiene.

The facility identified a census of 36 residents. The sample included 12 residents, with five reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 20's Care Plan to remove his therapeutic diet. This deficient practice placed R20 at risk for uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dysphagia (difficulty swallowing), and dementia (a progressive mental disorder characterized by failing memory and confusion). R20's Quarterly Minimum Data Set (MDS) dated 04/15/25 noted a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS indicated he used a walker for mobility. The MDs noted he was dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and bed mobility. The MDS noted he was always incontinent of bowel and bladder but had a toileting program. The MDS noted he had difficulty swallowing due to holding residual food in his mouth (pocketing). The MDS noted he had a mechanically altered diet. R20's Nutrition Area Assessment (CAA) completed 01/27/25 indicated he was at risk for weight loss and nutritional impairment. The CAA instructed staff to provide adequate intake during mealtimes. The CAA noted he was on a mechanically altered diet with thin liquids. R20's Functional Abilities CAA completed 01/27/25 indicated he required cueing during his activities of daily living (ADL) and incontinence care every two hours. R20's Care Plan initiated 03/08/22 indicated he was at risk for altered nutrition related to his cognitive impairment and medical diagnoses. The plan indicated he required a regular, mechanically soft diet with pureed meat texture and thin liquids due to his difficulty swallowing. The plan instructed staff to provide set-up assistance during meals. The plan indicated he required staff assistance for bed mobility, bathing, toileting, personal hygiene, transfers, and dressing. The plan indicated he had impaired cognitive function and thought processes related to his dementia. The plan instructed staff to provide consistency with caregivers and care to reduce confusion. The plan instructed staff to notify nursing if R20 was incontinent during activities and provide care as needed. R20's EMR under Orders revealed an active dietary order stated 05/21/25. The order indicated he received a regular, mechanically soft diet with chopped meat texture. On 06/10/24 at 12:23 PM, R20 sat at the dining room table for lunch. R20 was provided his meal. R20's meat was of chopped consistency. R20 consumed his meal with no observed swallowing concerns. Staff supervised him as he ate his meal. On 06/09/25 at 11:36 AM, Licensed Nurse (LN) G stated the care plans were updated quarterly or changed. She stated the plans were to reflect to most accurate changes related to each resident's care. She stated the plan should include the type of diet and consistency for each resident. On 06/11/25 at 12:05 PM, Administrative Nurse D stated all staff had access to view the care plans. She stated the plans were reviewed by the interdisciplinary team and updated when needed. She stated the individual departments would also review the plan to ensure their areas were accurate and up to date. The facility's Comprehensive Care plan policy revised 04/2022 indicated each resident was to have a comprehensive assessment and provided individualized interventions to reflect their treatment needs. The policy indicated the care plans were reviewed and updated to reflect changes that may occur with the resident's goals and care needs.

The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to indicate on the comprehensive Minimum Data Set (MDS) that Resident (R) 33 received and required the use of a continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep). This placed R33 at risk for inaccurate reflections of the resident's status and needs to develop an individualized comprehensive plan of care. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of acquired absence of right foot, pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region, hematogenous osteomyelitis (a type of bone infection where bacteria travel through the bloodstream to the bones, causing inflammation and potentially bone destruction), lack of coordination, muscle weakness, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R33 had impairment on one side of her lower extremities. The MDS documented R33 needed setup or cleanup for eating, was dependent on staff for toileting, and needed substantial/maximal assistance from staff for bathing. The MDS did not indicate R33 required the use of a CPAP. R33's Functional Abilities (self-care mobility) Care Area Assessment (CAA) dated 04/21/25 documented R33 was currently taking insulin (a hormone that lowers the level of glucose in the blood), antihypertensive (a class of medication used to treat high blood pressure), anticoagulation (blood thinner), and medication for constipation which could cause an increase in falls. The CAA documented R33 had had no falls since admission. The CAA documented R33 was dependent on staff for most activities of daily living (ADL) and required the assistance of one staff. The CAA documented R33 ambulated with a wheelchair and was dependent on staff for wheeling her chair. The CAA documented R33 currently received medication for wound healing. The CAA documented R33 was on a regular diet, with regular texture with thin liquids. The CAA documented R33 was incontinent and required a pull-up. R33's Care Plan dated 04/18/25 documented R33 was at risk for altered nutritional and hydration status related to inadequate intake and wound healing. R33's plan of care documented staff would encourage the consumption of fluids that were provided and monitor and record meal intakes. The plan of care for R33 documented staff would provide and serve supplements as ordered. R33's plan of care lacked indication of R33's CPAP. On 06/11/25 at 12:05 PM, Administrative Nurse D stated that R33 required a CPAP. Administrative Nurse D stated all CPAPs should be indicated on the MDS. The facility Comprehensive Assessment dated 03/25 documented a comprehensive assessment of a resident's needs shall be made within fourteen days of the resident's admission. A comprehensive assessment of the resident's needs strengths, goals, life history, and preferences would be completed. A comprehensive assessment would be completed with defined significant change. Residents would receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline.

The facility identified a census of 36 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1's psychotropic (alters mood or thought) medication had an indication for administration. This deficient practice placed R1 at risk for ineffective treatment, unnecessary medication use, and unwarranted side effects. Findings included: - R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN - elevated blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), calculus (a hardened deposit, usually composed of mineral salts, that forms within the body) of the gallbladder, and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated 09/19/24 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 had received anticoagulant (a class of medications used to prevent the blood from clotting) medication, antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, antiplatelet (medication that helps prevent blood clots from occurring) medication, diuretic (a medication to promote the formation and excretion of urine) medication, opioid (a class of controlled drugs used to treat pain) medication, and hypoglycemic (a class of medication used to lower blood sugar) medication during the observation period. The Quarterly MDS dated 02/20/25 documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R1 had received anticoagulant medication, antidepressant medication, antianxiety medication, antiplatelet medication, diuretic medication, opioid medication, and hypoglycemic medication during the observation period. R1's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/07/24 documented she received anticoagulant therapy and psychotropic medications with monitoring in place. R1's Care Plan, dated 10/28/22, documented staff were educated on the administration of giving medication as ordered and the five rights of medication administration. R1's EMR under the Orders tab revealed the following physician orders: Cymbalta (antidepressant) oral capsule, delayed release particles, 20 mg give one capsule by mouth daily, dated 04/22/25. The medication order lacked an indication for administration. On 06/10/25 at 08:26 AM, R1 propelled herself in her wheelchair from her room to the dining room without difficulty. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated every medication required an indication for administration. LN G stated she would clarify an order if there was no indication for administration. On 06/11/25 at 12:05 PM, Administrative Nurse D stated she expected a physician's order to be followed. Administrative Nurse D stated every medication required and indication for administration. The facility's Free from Chemical Restraints, Unnecessary Psychotropic Medications policy last reviewed 04/2025 documented chemical restraints would only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Chemical restraints would only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience.

The facility identified a census of 36 residents. The sample included 12 residents, with one resident reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to prevent an episode of resident-to-resident sexual abuse between cognitively impaired Resident (R) 21 and R17. This deficient practice placed R17 at ongoing risk for preventable abuse and mistreatment. Findings Included: - The Medical Diagnosis section within R21's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R21's Annual Minimum Data Set (MDS) dated 04/27/25 noted a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS indicated she had bilateral lower extremity impairments and used a wheelchair for mobility. The MDS indicated he was dependent on staff for bathing, toileting, personal hygiene, transfers, and bed mobility. The MDS indicated no behavioral concerns but indicated he displayed physically aggressive behaviors on his previous Quarterly MDS completed 01/27/25. R21's Dementia Care Area Assessment (CAA) completed 01/27/25 indicated he was dependent on staff assistance for toileting, personal hygiene, bathing, dressing, and transfers. The CAA noted he had dementia with cognitive loss. R21's Care Plan initiated on 10/04/23 indicated he was at risk for a decline in cognition, activities of daily living (ADL), falls, and incontinence related to his medical diagnoses. The plan indicated he required staff assistance for mobility in his wheelchair (10/03/23). The plan indicated he had difficulty with communication. The plan instructed staff to be conscious of his position when in groups, activities, and dining to promote proper communication with others (10/03/23). The plan noted he had a history of alleged sexual accusations (10/03/23). The plan instructed staff to anticipate his needs and provide his medications as ordered (10/03/23). The plan instructed staff to intervene as necessary to protect the rights and safety of others (10/04/23). The plan instructed staff to move him from the situation to an alternate area. The plan instructed staff to monitor his behaviors and attempt to determine an underlying cause (10/04/23). R21's plan was updated on 05/27/25 with a new intervention for sexual behaviors. The intervention instructed staff to provide medication daily. A Facility Incident Report #5635 completed on 05/27/25 revealed Licensed Nurse (LN) H walked into the television room and witnessed R21 in the television room groping R17's (Severely cognitively impaired resident) breast. The report indicated both residents were immediately separated. The note revealed that R17 was assessed with no injuries found. The report indicated both residents had no recollection of the incident when interviewed. The note revealed the medical provider, resident representative, and local law enforcement were notified. The report revealed that R21 was immediately placed on one-to-one supervision and started on medication to reduce his sexual behaviors. A Witness Statement completed by LN H on 05/27/25 indicated he observed the incident and separated the two residents. LN H reported in the statement he observed R21 touching R17's breast with his left hand. LN H reported in the statement that he immediately separated the residents and assessed R17. The statement revealed that R21 was agitated when asked to not touch R17. On 06/10/25 at 07:30 AM, R21 lay in his bed. R21 had no memory of the encounter between R17 and himself. On 06/11/25 at 08:00 AM, R17 sat in her room. R17 had no memory of the encounter between R21 and herself. R17 reported she felt safe in the facility. On 06/11/25 at 11:24 AM, Certified Nurse's Aide (CNA) M stated residents with noted behaviors were not to be left alone with other residents. She stated staff were expected to monitor all residents for safety and care needs. She stated that R21 had a history of inappropriate behaviors towards females and had to be supervised. She stated the facility provided frequent dementia and abuse training for staff to complete. She stated the facility had an abuse, neglect, and exploitation (ANE) class in May 2025. On 06/11/25 at 12:24 PM, Administrative Nurse D stated R21 had inappropriate sexual behaviors toward a female. She stated residents with behaviors were to be supervised while in the common areas or placed close together. She stated that R21 had numerous behavioral incidents in the past. She stated all staff received annual ANE classes. The facility's Abuse Prevention Program revised 08/2024 indicated the facility was committed to protecting residents from abuse. The policy indicated all staff were trained to recognize and report allegations of abuse. The policy noted the facility was to provide management for dementia and behavioral symptoms for residents at risk for abuse. The policy indicated the facility promoted an environment safe for the treatment and care of the residents.

The facility identified a census of 36 residents. The sample included 12 residents, with five reviewed for dignity. Based on observation, record review, and interviews, the facility failed to provide a dignified care environment for Resident (R) 20. This deficient practice placed R20 at risk for impaired dignity and unmet care needs. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dysphagia (difficulty swallowing), and dementia (a progressive mental disorder characterized by failing memory and confusion). R20's Quarterly Minimum Data Set (MDS) dated 04/15/25 noted a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS indicated he used a walker for mobility. The MDs noted he was dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and bed mobility. The MDS noted he was always incontinent of bowel and bladder, but had a toileting program. The MDS noted he had difficulty swallowing due to holding residual food in his mouth (pocketing). The MDS noted he had a mechanically altered diet. R20's Nutrition Care Area Assessment (CAA) completed 01/27/25 indicated he was at risk for weight loss and nutritional impairment. The CAA instructed staff to provide adequate intake during mealtimes. The CAA noted he was on a mechanically altered diet with thin liquids. R20's Functional Abilities CAA completed 01/27/25 indicated he required cueing during his activities of daily living (ADL) and incontinence care every two hours. R20's Care Plan initiated 03/08/22 indicated he was at risk for altered nutrition related to his cognitive impairment and medical diagnoses. The plan instructed staff to provide set-up assistance during meals. The plan indicated he required staff assistance for bed mobility, bathing, toileting, personal hygiene, transfers, and dressing. The plan indicated he had impaired cognitive function and thought processes related to his dementia. The plan instructed staff to provide consistency with caregivers and care to reduce confusion. The plan instructed staff to notify nursing if incontinent during activities and provide care as needed. On 06/10/25 at 09:00 AM, R20 sat in the dining room and completed his breakfast meal. R20 stood up and walked toward the dining room exit. The back of R20's pants were soaked with urine down to his knees. R20 walked to the staff and reported he was sticky and needed to be cleaned. Staff asked R20 to sit on the chair next to the nurses. R20 sat down in the chair next to the nurse's cart. R20 kept repeatedly saying loudly I'm sticky, I need help as numerous staff walked past him. R20 stood up from the chair several times while waiting for staff to come assist him. At 09:10 AM, R20 was finally escorted to his room as he continued to yell out I'm sticky, please help me. On 06/11/25 at 11:20 AM, Certified Nurse Aide (CNA) M stated staff should always assist the resident with care needs as a priority and ensure they were clean. She stated that R20 should have been provided with hygiene care immediately. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated residents should immediately provide incontinence care to avoid skin breakdown and infections. On 06/11/25 at 12:24 PM, Administrative Nurse D stated staff were expected to assist or find someone to assist residents with personal care to prevent them from waiting. She stated residents were to be provided incontinence care at the time of staff being informed. The facility's Dignity policy revised 10/2022 stated the facility was to ensure an environment that maintained and enhanced each resident's dignity and respect in full recognition of each resident's individuality.

The facility identified a census of 36 residents. The sample included 12 residents, with five reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 20's Care Plan to remove his therapeutic diet. This deficient practice placed R20 at risk for uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dysphagia (difficulty swallowing), and dementia (a progressive mental disorder characterized by failing memory and confusion). R20's Quarterly Minimum Data Set (MDS) dated 04/15/25 noted a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS indicated he used a walker for mobility. The MDs noted he was dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and bed mobility. The MDS noted he was always incontinent of bowel and bladder but had a toileting program. The MDS noted he had difficulty swallowing due to holding residual food in his mouth (pocketing). The MDS noted he had a mechanically altered diet. R20's Nutrition Area Assessment (CAA) completed 01/27/25 indicated he was at risk for weight loss and nutritional impairment. The CAA instructed staff to provide adequate intake during mealtimes. The CAA noted he was on a mechanically altered diet with thin liquids. R20's Functional Abilities CAA completed 01/27/25 indicated he required cueing during his activities of daily living (ADL) and incontinence care every two hours. R20's Care Plan initiated 03/08/22 indicated he was at risk for altered nutrition related to his cognitive impairment and medical diagnoses. The plan indicated he required a regular, mechanically soft diet with pureed meat texture and thin liquids due to his difficulty swallowing. The plan instructed staff to provide set-up assistance during meals. The plan indicated he required staff assistance for bed mobility, bathing, toileting, personal hygiene, transfers, and dressing. The plan indicated he had impaired cognitive function and thought processes related to his dementia. The plan instructed staff to provide consistency with caregivers and care to reduce confusion. The plan instructed staff to notify nursing if incontinent during activities and provide care as needed. R20's EMR under Orders revealed an active dietary order stated 05/21/25. The order indicated he received a regular, mechanically soft diet with chopped meat texture. On 06/10/24 at 12:23 PM, R20 sat at the dining room table for lunch. R20 was provided his meal. R20's meat was of chopped consistency. R20 consumed his meal with no observed swallowing concerns. Staff supervised him as he ate his meal. On 06/09/25 at 11:36 AM, Licensed Nurse (LN) G stated the care plans were updated quarterly or changed. She stated the plans were to reflect the most accurate changes related to each resident's care. She stated the plan should include the type of diet and consistency for each resident. On 06/11/25 at 12:05 PM, Administrative Nurse D stated all staff had access to view the care plans. She stated the plans were reviewed by the interdisciplinary team and updated when needed. She stated the individual departments would also review the plan to ensure their areas were accurate and up to date. The facility's Comprehensive Care Plan policy revised 04/2022 indicated each resident was to have a comprehensive assessment and provided individualized interventions to reflect their treatment needs. The policy indicated the care plans were reviewed and updated to reflect changes that may occur with the resident's goals and care needs.

The facility identified a census of 36 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities in Resident (R) 1's medication which lacked an indication for administration. The facility also failed to ensure the CP identified and reported the physician's order for monitoring the pulse for an antihypertensive (a class of medication used to treat high blood pressure) medication. This deficient practice placed R1 at risk for unnecessary medication use, side effects, and physical complications. Findings included: - R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN - elevated blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), calculus (a hardened deposit, usually composed of mineral salts, that forms within the body) of the gallbladder, and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated 09/19/24 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 had received anticoagulant (a class of medications used to prevent the blood from clotting) medication, antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, antiplatelet (medication that helps prevent blood clots from occurring) medication, diuretic (a medication to promote the formation and excretion of urine) medication, opioid (a class of controlled drugs used to treat pain) medication, and hypoglycemic (a class of medication used to lower blood sugar) medication during the observation period. The Quarterly MDS dated 02/20/25 documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R1 had received anticoagulant medication, antidepressant medication, antianxiety medication, antiplatelet medication, diuretic medication, opioid medication, and hypoglycemic medication during the observation period. R1's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/07/24 documented she received anticoagulant therapy and psychotropic medications with monitoring in place. R1's Care Plan, dated 10/28/22, documented staff were educated on the administration of giving medication as ordered and the five rights of medication administration. R1's EMR under the Orders tab revealed the following physician orders: Ursodiol, (medication used to dissolve gallstones) oral capsule 300 milligrams (mg) give one capsule by mouth three times a day, dated 04/8/25. The medication order lacked an indication for administration. Tamsulosin (medication used to assist with the output of urine) capsule 0.4 mg, give one capsule by mouth daily, dated 04/8/25. The medication order lacked an indication for administration. Cymbalta (antidepressant) oral capsule, delayed release particles, 20 mg give one capsule by mouth daily, dated 04/22/25. The medication order lacked an indication for administration. Metoprolol succinate (antihypertensive) tablet extended release 24-hour 25 mg give one tablet by mouth daily for HTN, hold for systolic blood pressure (SBP - top number, the force your heart exerts on the walls of your arteries each time it beats) less than (<) 110 millimeters (mm) of mercury (Hg) and a heart rate < 60 beats per minute. Do not crush medication, dated 04/09/25. Review of R1's Medication Administration Record (MAR), Treatment Administration Record (TAR), and her EMR from 03/01/25 to 06/09/25 (100 days) lacked heart monitoring as ordered by the physician for antihypertensive medication Metoprolol revealed for 61 days. The MMR's lacked evidence of the CP identified the lack of indication for medication administration. Review of the Monthly Medication Review (MMR) from June 2024 to May 2025 documented recommendations from March 2023 to review antihypertensive medication orders for hold parameters and physician notification. The MMR's lacked CP noted the irregularities of no indication for medication administration and heart monitoring for antihypertensive medication. On 06/10/25 at 08:26 AM, R1 propelled herself in her wheelchair from her room to the dining room without difficulty. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated every medication required an indication for administration. LN G stated she would clarify an order if there was no indication for administration. LN G stated if the physician had a specific parameter for monitoring a resident's heart rate, then the heart rate should be obtained prior to medication administration. On 06/11/25 at 12:05 PM, Administrative Nurse D stated she expected a physician's order to be followed. Administrative Nurse D stated if the physician had ordered a heart rate to monitor for hypertensive medication, she expected the heart rate to be obtained prior to medication administration. Administrative Nurse D stated every medication required and indication for administration. The facility's Medication Regimen Reviews policy last reviewed 02/2025 documented the Consultant Pharmacist would review the medication regimen per state and federal guidelines. The policy directed reporting of irregularities to the attending physician, the facility medical director, and the director of nursing.

The facility identified a census of 36 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure physician parameters were followed for a hypertensive medication (class of medication used to treat hypertension (high blood pressure) for Resident (R) 1. The facility also failed to ensure R1's medication had an indication for administration. These deficient practices placed R1 at risk for the potential of unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN - elevated blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), calculus (a hardened deposit, usually composed of mineral salts, that forms within the body) of the gallbladder, and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated 09/19/24 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 had received anticoagulant (a class of medications used to prevent the blood from clotting) medication, antidepressant (a class of medications used to treat mood disorders) medication, antianxiety (a class of medications that calm and relax people) medication, antiplatelet (medication that helps prevent blood clots from occurring) medication, diuretic (a medication to promote the formation and excretion of urine) medication, opioid (a class of controlled drugs used to treat pain) medication, and hypoglycemic (a class of medication used to lower blood sugar) medication during the observation period. The Quarterly MDS dated 02/20/25 documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R1 had received anticoagulant medication, antidepressant medication, antianxiety medication, antiplatelet medication, diuretic medication, opioid medication, and hypoglycemic medication during the observation period. R1's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/07/24 documented she received anticoagulant therapy and psychotropic medications with monitoring in place. R1's Care Plan, dated 10/28/22, documented staff were educated on the administration of giving medication as ordered and the five rights of medication administration. R1's EMR under the Orders tab revealed the following physician orders: Ursodiol (medication used to dissolve gallstones) oral capsule 300 milligrams (mg) give one capsule by mouth three times a day, dated 04/8/25. The medication order lacked an indication for administration. Tamsulosin (medication used to assist with the output of urine) capsule 0.4 mg, give one capsule by mouth daily, dated 04/8/25. The medication order lacked an indication for administration. Metoprolol succinate (antihypertensive) tablet extended release 24-hour 25 mg give one tablet by mouth daily for HTN, hold for systolic blood pressure (SBP - top number, the force your heart exerts on the walls of your arteries each time it beats) less than (<) 110 millimeters (mm) of mercury (Hg) and a heart rate < 60 beats per minute. Do not crush medication, dated 04/09/25. Review of R1's Medication Administration Record (MAR), Treatment Administration Record (TAR), and her EMR from 03/01/25 to 06/09/25 (100 days) lacked heart monitoring as ordered by the physician for antihypertensive medication Metoprolol revealed for 61 days. The MMR's lacked evidence of the CP identified the lack of indication for medication administration. Review of the Monthly Medication Review (MMR) from June 2024 to May 2025 documented recommendations from March 2023 to review antihypertensive medication orders for hold parameters and physician notification. The MMR's lacked CP noted the irregularities of no indication for medication administration and heart monitoring for antihypertensive medication. On 06/10/25 at 08:26 AM, R1 propelled herself in her wheelchair from her room to the dining room without difficulty. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated every medication required an indication for administration. LN G stated she would clarify an order if there was no indication for administration. LN G stated if the physician had a specific parameter for monitoring a resident's heart rate, then the heart rate should be obtained prior to medication administration. On 06/11/25 at 12:05 PM, Administrative Nurse D stated she expected a physician's order to be followed. Administrative Nurse D stated if the physician had ordered a heart rate to monitor for hypertensive medication, she expected the heart rate to be obtained prior to medication administration. Administrative Nurse D stated every medication required and indication for administration. The facility's Unnecessary Medications policy last reviewed 04/2025 documented the resident's drug regimen would be free from unnecessary drugs. Residents or their representatives had the right to refuse ordered medications. Unnecessary Drug - was any drug used in excessive dose, including duplicative therapy or for excessive duration, or without adequate monitoring or without adequate indications for its use or in the presence of adverse consequences which indicate the dose should be reduced or discontinued or any combination of the reasons above. Adequate Indications for Use - refers to the identified, documented clinical rationale for administering a medication that was based upon an assessment of the resident's condition and therapeutic goals, and after any safer treatments have been deemed clinically contraindicated. Also, adequate indication for use means that the medication administered was consistent with the manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that are published in medical and/or pharmacy journals.

The facility identified a census of 36 residents. The sample included 12 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to provide a description of the medication and equipment provided to Resident (R) 12 by hospice. This deficient practice created a risk for missed or delayed services, impaired physical, and psychosocial care for R12. Findings included: - R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Significant Change Minimum Data Set (MDS) dated 01/17/25 documented a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R12 was dependent on staff assistance for transfers, dressing, and personal hygiene. The MDS documented R12 was on hospice services. The Quarterly MDS dated 04/29/25 documented a BIMS score of zero, which indicated severely impaired cognition. The MDS documented that R12 was dependent on staff assistance for bed mobility, dressing, personal hygiene, and transfers. The MDS documented R12 was on hospice services. R12's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/07/25 documented she was dependent on a wheelchair for mobility related to her physical status of a fractured left hip and was on hospice services. R12's Care Plan, dated 01/14/25 documented the nursing staff would notify the hospice provider of any changes in R12's condition. The plan of care documented hospice would provide nursing visits two times weekly and as needed, a bath aide would visit two times weekly, social services would visit monthly and as needed, and the chaplain would visit monthly and as needed. R12's EMR under the Orders tab revealed the following physician orders: Admit to hospice with a diagnosis of senile degeneration of the brain, dated 01/14/25. On 06/09/25 at 08:15 AM, R12 laid on her back in bed. R12 call light was on the floor behind her bed on the floor. R12's floor mat was folded up and stood upright away from her bed. On 06/11/25 at 11:35 AM, Licensed Nurse (LN) G stated hospice provider supplied a notebook for each resident on hospice services. LN G stated she would refer to the notebook provided by hospice for any information concerning R12's hospice care. LN G stated the hospice information should also be on R12's person-centered care plan. LN G stated R12's care plan should include the equipment supplied and medication covered by the hospice provider. On 06/11/25 at 11:52 AM, Certified Nurse Aide (CNA) M stated she would know which residents were on hospice services if there was a hospice notebook in the cupboard at the nurse's station. CNA M stated the items provided by the hospice provider should be included in the resident's care plan. On 06/11/25 at 12:05 PM, Administrative Nurse D stated everyone had access to the resident's care plans and their Kardex (a nursing tool that gives a brief overview of the care needs of each resident). Administrative Nurse D stated the hospice information should be the resident's care plan with the information of what services, supplies, and equipment that was provided by hospice. The facility's Hospice Program policy last reviewed 10/2024 documented the facility may contract for hospice services for residents who wish to participate in such programs, including services that would be provided and the coordination of services. The facility may limit the hospice providers as related to the coordination and communication of care within the community.

The facility reported a census of 39 residents and identified 13 residents with full code status (requesting cardio-pulmonary resuscitation (CPR) in the event of sudden [MEDICAL CONDITION]). Of these 13, the sample included 3 residents who requested resuscitative interventions. Based on record review and interview, the facility failed to ensure 1 of 3 sampled resident's (#1) rights for self-determination, related to his/her desire for CPR, were honored. Staff entered resident #1's room, found him/her unresponsive, without a heartbeat and not breathing and failed to immediately initiate CPR per the resident's documented preference. Resident #1 expired in the facility. The facility's failure to provide CPR placed resident #1 in Immediate Jeopardy on [DATE] at 4:25 A.M. Findings included: - Resident #1's closed clinical record and electronic medical record (EMR) documented he/she admitted to the facility on [DATE] with [DIAGNOSES REDACTED].?threatening condition. characterized by acute lung inflammation, stiff lungs that increase the work of breathing, and reduced ability of the lungs to adequately oxygenate the blood), acute kidney failure (rapid loss of kidney function), diabetes mellitus (a metabolic disorder in which there are high blood sugar levels over a prolonged period), severe intellectual disability, and Down's Syndrome (a genetic disorder caused by an extra chromosome). The admission nurses data assessment dated [DATE] documented the resident was alert, pleasant but nonverbal. He/she required continuous use of oxygen (02) supplied at 2 Liters per minute (lpm) by a nasal cannula (small plastic tube for air to enter through the nostrils). The assessment documented the resident's oxygen saturation level (O2 sat) (a measure of oxygenation of the blood) was 94 percent (%) on admission. This assessment also documented the resident required assistance of one to two staff with most activities of daily living such as transfers to bed, the wheelchair, toileting, and dressing. According to the Mayoclinic.org, normal blood oxygen levels in humans are considered 95% to 100%. The (MONTH) 2019 electronic physicians order sheet (POS) documented the resident was Full Code status (desired CPR) and an order for [REDACTED].>The resident's initial care plan dated [DATE] directed staff the resident requested CPR measures to be performed. The admission nurses progress note dated [DATE], timed 12:00 P.M. documented the resident was admitted per stretcher, was alert and nonverbal, and without signs and/or symptoms of distress. His/her skin was dry and pink, and his/her vital signs were stable. Record review revealed a nurse progress note dated [DATE], timed 5:51 A.M. recorded: at 12:05 A.M. the resident had a temperature of 101.3 degrees Fahrenheit (F). At 1:00 A.M. the resident had removed his/her oxygen cannula and it was replaced. At 2:42 A.M. the resident was given Tylenol 650 milligrams (mg) for his/her elevated temperature. The note recorded direct staff P reported to staff H that he/she had checked on the resident and repositioned the resident's oxygen nasal cannula. A nurse note documented at 2:30 A.M. recorded the resident's temperature was 99.6 degrees F. At 2:30 A.M. the resident's O2 sat was 78 percent and his/her respirations were even and unlabored. The nurse note documented the resident was checked at 3:10 A.M and his/her nasal oxygen cannula was again repositioned. On [DATE] at 4:25 A.M. licensed nurse H found resident #1 unresponsive, without heartbeat or respirations (the action of breathing). Licensed nurse H left the resident's bedside to obtain the emergency cart, and then left the resident's room to call emergency medical response. The nurse note documented nurse H returned to the resident's room and began CPR. This same note documented a police officer arrived and nurse H assisted the officer with the use of AED (automatic electronic defibrillator-a device used to restart the heart muscle). EMT (emergency medical technician) and fire department personnel arrived, and took over CPR, while nurse H left the resident's room due to space limitations. A fire department employee informed nurse H at 4:50 A.M. the resident was still a flat line (terminology indicating no heart beat). Emergency response personnel informed nurse H they would continue CPR for 5 more minutes and stop resuscitative measures if there was no change in the resident's condition. Licensed nurse H placed a call to the resident's responsible family member and informed him/her of resident #1's condition, and that CPR was in progress with EMT and fire department personnel. The resident's family member was very upset. A call was placed to administrative licensed nurse D and ARNP (advanced resident nurse practitioner) X and informed of the resident's status. An order was received from ARNP X to release the resident's body to the mortuary. Direct care staff O's notarized witness statement dated [DATE] documented he/she obtained resident #1's vital signs and the resident had a temperature. His/her 02 saturation was low as well. He/she told licensed nurse H at 11:30 P.M. At 4:35 A.M. direct care staff P told staff O licensed nurse H needed assistance from the direct care staff because there was a code. Direct care staff O went into residents #1's room and licensed nurse H said to make sure the door was unlocked for the emergency personnel. After that direct care staff O did not return to the resident's room. Direct care staff P's notarized witness statement dated [DATE] documented resident #1 was found by licensed nurse H unresponsive, in bed, around 4:25 A.M. Staff P had previously left the room, not less than 30 minutes before, when he/she had taken resident#1's roommate to the bathroom. After direct care staff P helped the roommate back to bed, he/she checked resident #1's 02 tubing and he/she had pulled it out again from his/her nose. Staff P placed it back in the resident's nose and left the room and then reported to nurse H that resident #1 had pulled his/her o2 out again. That was the last time staff P witnessed the resident. Direct care staff P's second statement also dated [DATE] documented staff P visualized staff O recording vital signs on resident #1. Staff O told staff P the resident was running a temperature. The next time direct care staff P was in resident #1's room, licensed nurse H was in there with and assessed the resident's oxygen saturation. Staff P stated he/she believed it was around 72%, and no higher than 80%. Licensed nurse H then mentioned resident #1's heart rate and he/she believed it was 124 BPM (beats per minute) and the resident's oxygen saturation was 88%. At approximately 11:00 P.M. staff P saw nurse H give the resident medication for his/her temperature. Nurse H stated it was Tylenol. Nurse H and direct care staff P stayed in the room for a while and observed the resident. Staff P then advised nurse H the resident's breathing appeared different and he/she was hot to the touch. Direct care staff P suggested a wash cloth be placed on the resident's forehead. Direct care staff P then wet a cold wash rag and placed on the resident#1's forehead. From this point on until 4:00 A.M. direct care staff P repeatedly returned to the room to replace the oxygen tubing on the resident's nose. Every single time staff P checked 02 tubing he/she reported it to nurse H. Throughout the shift direct care staff P repeatedly replaced the 02. At 4;00 AM direct care staff P was down the other hall helping direct care staff O with nightly tasks when nurse H came down the hall and told both staff O and staff P that assistance was needed in resident #1's room. Nurse H stated resident #1 had coded (term used when heartbeat and breathing stops and CPR must be initiated). Direct care staff P went into resident #1's room and noticed his/her complexion was different and the resident appeared to have red spots all over his/her body. Nurse H handed staff P an orange board to place behind resident #1's back and a device to place over resident #1's mouth to force air into him/her. Nurse H instructed staff P to keep using the device. Nurse H did a few chest compressions on resident #1 and then left the room to call 911. Staff P reported the first rescue person to arrive was a police officer. The police officer asked nurse H some questions about a device that charge nurse H said he/she did not know how to use. The police officer took it out. Staff P then left the room. Licensed nurse H's notarized witness statement dated on [DATE] at 4:55 A.M. documented resident #1 had a temperature of 101.3 degrees F. and the resident's 02 saturation was 74%. The resident had been repeatedly removing his/her o2 cannula and it was repeatedly replaced. Nurse H gave the resident Tylenol 12:10 AM. Resident #1's respirations were even and unlabored and he/she was nonverbal but alert to care per nurse H's report. Nurse H checked resident #1 at 1:00 A.M. and the resident had removed his/her cannula and it was again replaced. Licensed nurse H rechecked the resident at 2:30 A.M. and his/her temp was 99.6 degrees F, oxygen saturation was 78% and his/her respirations were even and unlabored. At 4:25 A.M. nurse H checked the resident and found him/her unresponsive, without a heartbeat and respirations. Nurse H took the crash cart to resdient#1's room and placed a back board under the resident with assistance of direct care staff P. Nurse H then left resident #1's room to call 911 and returned to start CPR. A Spring Hill police officer arrived and assisted with the AED device per nurse H's report. The police officer placed the AED pads on resdient#1's chest and the AED advised no shock was needed. The pads were removed, and CPR was resumed. Nurse H reported direct care staff P used an air bag and emergency personnel (EMT) and fire dept arrived and took over CPR. The resident was placed on the floor. During that time, while CPR continued, nurse H left the room due to lack of space. A fire department employee requested the resident's information and licensed nurse H printed it and gave it to him/her. At 4:50 AM emergency rescue personnel informed nurse H the resident continued with no heartbeat or respirations. Rescue personnel informed nurse H resuscitative measures would continue for 5 more minutes. A call was placed to resident #1's responsible family member and he/she was informed of the resident's condition. The family member was told emergency personnel had performed CPR, but they were suspending CPR due to no response from the resident. The family member was upset and stated he/she needed to call family and would call back. Interviewed on [DATE] at 10:55 A.M, administrative licensed nurse D stated his/her expectation was the nurse should have immediately initiated CPR, yelled to direct care staff for help, have direct care staff gather supplies and activate emergency medical response. Nurse D stated he/she was made aware of the event on [DATE] at 6:00 A.M. Administrative nurse D stated the actions of the nurse were not in keeping with professional standards and/or facility policy. Nurse D stated licensed nurse H did not note a change of condition for the resident, and/or notify the physician. Staff D stated the lack of action by nurse licensed nurse H indicated a lack of nursing competency. Nurse D stated the facility conducted in-services on these types of events in orientation and throughout the year, the last being held in (MONTH) 2019. Nurse D stated the residents code status is displayed on the binder of the clinical record, on the electronic physician orders, in the resident care plan and throughout the clinical record The facility's Procedure for CPR -Cardiopulmonary Resuscitation policy revised ,[DATE] documented it was the policy of the facility to provide basic life support including CPR (Cardiopulmonary Resuscitation) when a resident requires such emergency care, prior to arrival of medical services. The facility failed to perform CPR in accordance the resident's advanced directives, acute medical situation and per physician's orders [REDACTED]. On [DATE] at 4:45 P.M. administrative staff A, administrative licensed nursing staff D and administrative licensed nurse E were informed the deficient practice placed all residents in immediate jeopardy. The facility provided an acceptable plan for removal of the immediate Jeopardy on [DATE] at 5:50 P.M. The onsite review on [DATE] at 1:20 P.M. revealed the facility removed the immediate jeopardy when it completed the following: Licensed nurse H was immediately suspended on [DATE] pending investigation. Identified and verified the code status of every facility resident Identified and verified the CPR certification of all applicable facility staff Developed a teaching plan for staff to ensure resident code status is honored. Developed a teaching plan to ensure all staff know emergency (code) procedures, equipment locations and their specific role in emergency plan. Conducted in-service training regarding the facility policy and measures to ensure resident code status is acted upon. Conducted hands on training and competency assessments on all applicable staff. Developed measures for monitoring and auditing desired outcomes and incorporating into the facilities Quality Assurance Performance Improvement (QUAPI) plan. The deficient practice remained at a scope and severity of a G following the removal of the immediate jeopardy.

The facility reported a census of 39 residents. The sample included 16 residents. Based on observation, record review, and interview the facility failed to develop and implement timely interventions to prevent the development of an avoidable suspected deep tissue injury (SDTI, a localized discolored area of intact skin or a blood-filled blister) for 1 of 3 resident's sampled for pressure ulcers (#56). The facility further failed to accurately assess, monitor, and treat pressures ulcers for 1 of 3 residents sampled for pressure ulcers (#49). Findings included: - The clinical record documented resident #56 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had no MDS (Minimum Data Set) and no MDS' were due. The resident had a Braden (a numerical scale used to help determine pressure sore potential) score of 16, which placed the resident at risk for the development of pressure sores. Review of the resident's initial care plan dated 3/25/16 recorded the resident was at risk for the development of pressure sores, due to he/she required assistance with bed mobility, nutritional and hydration support, inadequate oral intake, and continued weight loss. The care plan directed staff to provide a pressure reducing wheel chair cushion, a pressure reducing mattress, thorough skin care after incontinent episodes, conduct skin assessments per facility policy, perform ordered treatments, provide assistance at meals, thickened liquids, and vitamin/mineral supplements as ordered The care plan lacked documentation related to the need for a toileting, turning or repositioning schedule, use of protective equipment such as pillows, cushions, heel protectors and dietary interventions, such as the use of supplements. Review of the nurse's initial admission data assessment dated [DATE], recorded the resident's cognition was intact and he/she was able to make his/her needs known. The assessment documented the resident required assistance of staff with activities of daily living such as bed mobility, transfers, personal hygiene, and management of a an indwelling Foley urinary catheter (a flexible tube used to drain urine). He/she weighed 98 pounds. The initial skin assessment dated [DATE] documented some slight areas of redness and dry skin on the coccyx (tailbone), but no obvious open areas. Review of the March/April 2016 electronic physicians orders documented the resident used a pressure reducing wheel chair cushion and bed mattress, but lacked documentation of additional devices (pillows, splints, braces, etcetera) and or measures (vitamin/protein, supplements, etcetera) to minimize the risk for the development of pressure ulcers. Review of the nurse's weekly skin assessments from 3/25/16 through 4/4/16 lacked documentation of any skin disruptions or irregularities. Review of the Nutrition assessment dated [DATE] (10 days after admission) recorded the resident was a new admit, weighed 98 pounds, was on a mechanical soft diet with nectar thick liquids diet, had no wounds, no labs to review, meal intake was 50 percent, and Med Pass 2.0 supplement 120 milliliters three times a day was recommended. The electronic physicians order sheet was updated with new orders on 4/6/16 to include: Med Pass 2.0 (a dietary supplement) by mouth three times a day, Skin Prep (a liquid film-forming dressing that forms a protective film over intact skin) to bilateral heels, and heel protector boots. Observation on 4/4/16 at 10:54 A.M. revealed the resident sat in his/her cushioned wheelchair in his/her room and wore non-pressure relieving tennis shoes to both feet. Observation on 4/4/16 at 12:15 P.M. revealed the resident sat in his/her wheel chair in the assisted dining room. The resident fed himself/herself and did not receive encouragement from staff. The resident consumed 40 percent of his/her meal and consumed approximately 100 milliliters of thickened liquids. The resident was not offered any dietary supplements. Observation on 4/5/16 at 2:31 P.M. revealed the resident lay in bed slightly on his/her right side, wore cotton socks, and his/her heels were in direct contact with the bed. Observation on 4/6/16 at 8:06 A.M. revealed therapy staff HH assisted the resident to sit on the side of his/her bed and the resident complained of dizziness and requested to lie down. The resident's heels were not elevated off the bed before or after he/she attempted to get up. A skin check observation on 4/6/16 at 8:29 A.M. revealed the resident had a dry, mushy, cool, left heel and a quarter sized area of purplish discoloration to the his/her right heel and the resident complained of soreness to his/her right heel. During an interview on 4/6/16 at 8:29 A.M. the resident did not recall bumping or injuring his/her right foot and stated it hurt for about a week. During an interview on 4/6/16 at 1:19 A.M. direct care staff AAA stated the resident does not drink fluids well. Direct care staff AAA stated he/she had not worked with the resident since 4/2/16 and was unaware of any skin issues with the resident. During an interview on 4/6/16 at 8:29 A.M. licensed nurse J acknowledged an area of bruising/discoloration and soreness to the resident's right heel (a suspected deep tissue injury). During an interview on 4/7/16 at 12:51 P.M. administrative licensed nurse D stated staff made him/her aware of the pressure ulcer this morning. During a telephone interview on 4/6/2016 at 3:40 P.M. the resident's physician stated the resident could be at risk for the development of pressure ulcers due to his/her medical conditions. According to the National Pressure Ulcer Advisory Panel (NPUAP) a suspected Deep Tissue injury may be preceded by tissue that was painful, firm, mushy, boggy warmer or cooler as compared to adjacent tissue. The facility failed to develop and implement timely interventions to prevent the development of a suspected deep tissue injury for this resident who required staff assistance and was identified at risk for pressure ulcers. - The clinical record documented resident #49 admitted to the facility initially on 11/21/15 with [DIAGNOSES REDACTED]. Review of the 5 day readmission MDS (Minimum Data Set) dated 12/22/15 recorded a Brief Interview for Mental Status score of 15, which indicated the resident's cognition was intact. The resident required extensive assistance of one staff with most activities of daily living, had frequent bowel and bladder incontinence, weighed 216 pounds, was at risk for the development of pressure sores, and had one unstageable pressure sore (a wound caused by pressure with dead tissue). The 2/12/16 quarterly MDS recorded the resident's cognition was intact, he/she required supervision with most activities of daily living, was continent, weighed 194 pounds, and had one unstageable pressure ulcer which measured 1.5 centimeters (cm) in length x (by) 3.0 cm in width x 0.3 cm in depth. The most recent care area assessment (CAA) dated 11/28/15 did not identify the residents left heel unstageable pressure ulcer. Review of the resident's care plan dated 2/23/16 recorded an unstageable pressure ulcer was present on the resident's left heel upon readmission to the facility 12/18/2015 and directed staff to encourage the resident to float his/her heels in bed once or twice daily, give nutritional and hydration support, provide a pressure reducing wheelchair cushion, provide a pressure reduction mattress, skin assessment per living center policy, and perform treatments as ordered. Review of the physician's orders [REDACTED]. Review of the weekly wound sheets dated 1/18, 1/26, 2/1, 2/5, 2/8, 2/15, 2/22, 2/26, 3/6, 3/13, 3/20, and 3/27/16 lacked documentation, measurements, and/or description of the resident's left heel wound. The nurse progress note dated 12/22/15 at 4:21 P.M. recorded the resident readmitted on [DATE] with an intact blister to his/her left heel and recorded the resident's nutritional intake was not always adequate. He/she uses the bottoms of his/her heels when getting in bed and when pushing him/herself up in the bed. The resident had an open wound with a dark purple area in the center of the wound bed. There was no drainage or slough (dead tissue) and the area measured 8 cm x by 5.5 cm. Orders were obtained for a wound cleanser and [MEDICATION NAME] dressing (a protective dressing). The nurse progress notes dated 1/11/16 at 1:52 p.m. recorded the wound to the resident's left heel had slough and eschar (dead tissue) with some pink around the edges. Mobile wounds came to the facility to assess the resident's left heel wound and recorded the wound measured 2.4 cm (centimeters) x (by) 5.0 cm x 0.1 cm. Observation during wound care on 4/6/16 at 11:19 A.M. revealed the resident removed the heel protector boot, sock, and [MEDICATION NAME] stocking from his/her left foot. Licensed nursing staff J removed the contaminated dressing. The wound measured approximately 1.5 cm x 0.5 cm x 0.2 cm and there was evidence of new tissue growth. Nurse J applied a greater than nickel size amount of Santyl to the wound bed and some on the wound edges, covered the wound with Vaseline gauze, and wrapped with Kerlix. During an interview on 4/5/16 at 4:04 P.M. the resident stated his/her wound developed in the hospital and noticed it when he/she came back to the facility. The resident stated he/she received weekly hyperbaric (pressurized) wound treatment to his/her left heel at the hospital. During an interview on 4/6/16 at 11:36 A.M. licensed nurse J stated the wound measurements were done weekly by the nurse and a Mobile Wound clinic also completed wound measurements. During an interview on 4/7/16 at 12:51 P.M. administrative nursing staff D stated he/she expected staff complete an admission skin assessments, weekly skin assessments on shower days, and assessments were done with wound rounds and audits. The facility Clinical Guidelines: Skin Integrity policy revised 2/25/10 recorded the licensed nurse performed skin assessment and observation, and the licensed nurse documented weekly on all wounds using the Wound Evaluation Flow sheet. The facility failed to assess and monitor this resident with a pressure ulcer.

The facility identified a census of 40 residents. The sample included 21 residents. Based on observation, record review and interview, the facility failed to implement effective interventions for protection of 1 resident (#36) to feel safe in the facility after resident #27 choked him/her. Findings included: - Resident #36 admitted to the facility on [DATE]. The April 2012 physician's orders [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The resident required supervision with locomotion, extensive assist with bed mobility, transfers, dressing, toilet use, personal hygiene and total assist with bathing. The care plan last reviewed on 3-22-12 recorded the resident with alteration in respiratory status and at risk for shortness of breath and directed the staff to administer oxygen as needed per the physician's orders [REDACTED]. The care plan lacked any specific interventions regarding keeping the resident safe. The Nurses Notes (NN) dated 12-3-11 at 11:17 P.M. recorded the nurse heard yelling coming from resident #36's room. He/she found resident #36, resident #27 and two Certified Nurses Aides (CNAs) in the resident's room. The residents were both in their wheelchairs. Resident #27 hit resident #36 with the back scratcher. Resident #36 said the other resident then grabbed him/her around the neck and almost pulled him/her out of his/her chair. There was no further documentation regarding this incident in the nurses notes. The verification of investigation form dated 12-3-11 recorded during the resident interview, #36 stated resident #27 had him/her in a choke hold and about pulled him/her out of the wheelchair. The investigation form recorded the immediate resident protection initiated was that staff removed resident #27 from resident #36's room. The investigation form recorded resident #27 had a history of [REDACTED]. The investigation recorded resident #27 grabbed resident #36 around the neck with his/her arm and stated "I am going to break your _____ neck." The investigation recorded staff assisted resident #27 out of resident #36's room and re-directed him/her to his/her own room across the hall. The social services notes (SSN) dated 12-4-11 at 1:53 P.M. recorded the resident came to activity/social services staff L's office very upset that the Director of Nursing Services (DNS) did not come in today to investigate an incident that occurred last night. The resident complained of right hip pain when he/she explained what happened. Resident #27 was in his/her wheelchair and resident #27 hit resident #36 with a back scratcher. Resident #36 stated that resident #27 then grabbed him/her around the neck and almost pulled him/her out of his/her chair while having in a headlock position. The SSN dated 12-5-11 un-timed recorded staff followed up with the resident about the incident on Saturday. Resident had a meeting with the Director of Nursing Services (DNS) and stated everything was okay. The grievance form dated 12/27/11 filed by resident #36 recorded that "{resident #27} stood out of {his/her} wheelchair and grabbed me around the neck and said "I am going to break your _____ neck." {He/she} was trying to pull me out of my chair and again said I am going to pull your _____ head off, all the time choking me so hard I couldn't yell for help. {Direct care staff N} happened to walk by and heard the commotion. {He/she} was screaming for help because {he/she} couldn't stop {him/her}. {Another staff} came in and was able to help {direct care staff N} get {him/her} off of me. I no longer feel safe nor should anyone else who comes in contact with {him/her}. {He/she} has been back in my room [ROOM NUMBER] times since then. To the best of my knowledge nothing has been done about this." The next SSN dated 12-30-11 at 11:33 A.M. (approximately 3 weeks after the incident) recorded resident #36 wanted to have a meeting with DNS, Social Service Designee, Executive Director and MDS coordinator on 1-3-12. The SSN dated 1-3-12 at 2:45 P.M. recorded that a meeting took place with resident #36, the nurse consultant, resident MDS coordinator, Director of Nursing (DON), Social Service Designee (SSD) and dietary director. The resident stated in this meeting he/she was not happy about the other resident coming into his/her room while he/she was in there, resident #27 was in 4 times since the incident occurred on 12/3/11, no aggressive behavior was displayed by the other resident, he/she only asked a few questions and asked if he/she could look out resident's window. Staff explained to the resident that they would look into possible room changes and get back with him/her as soon as possible. Staff also suggested to put Velcro across resident #36's door, but the resident was totally against that idea as well as moving him/herself to another room. Will continue to monitor. The next SSN dated 3-18-12 at 3:30 P.M. (approximately 2 1/2 months following the room change) recorded the resident smiled and appeared to be in a good mood. Resident had no concerns at this time with facility, staff, and or services. SSN dated 4-4-12, un-timed, recorded staff observed the resident today. He/she smiled and appeared to be in a good mood, had no concerns at this time with facility, staff or services. On 4-30-12 at approximately 9:30 A.M., observation revealed resident #27 self propelled his/her wheelchair down resident #36's hall and was approximately half way down the hall when staff got him/her and brought him/her back from the hallway. Observation on 4-30-12 at 11:41 A.M. revealed resident #36 in his/her room in his/her electric wheelchair. The resident did not have oxygen on at this time. On 5-1-12 at 9:34 A.M., observation revealed resident #27 in the hall going into another resident's room directly across from resident #36's room. Licensed nursing staff E, licensed nursing staff D and a therapy staff were all in the hallway and did not direct resident #27 away from the room or to return to his/her hall. Licensed nursing staff E walked right past the resident and did not speak to him/her or redirect him/her. On 5-1-12 at 1:58 P.M., observation revealed resident #27 self-propelled him/herself in the facility by the activity room on resident #36's hall. During an interview on 4-25-12 at 10:12 A.M. resident #36 stated he/she was afraid of resident #27, that he/she scared him/her. On 5-1-12 at 7:47 A.M., administrative nursing staff B stated resident #27 got very confused. Staff offered resident #36 a Velcro stop sign on his/her door, which he/she refused. Resident #27 went out to the hospital the next day, the hospital sent him/her right back and resident #27 had medication changes a couple days later. At the time of the incident, staff immediately separated the two residents and staff immediately completed assessments on both residents. Staff later moved resident #27 (about a month later) to the other end of the building. Resident #27 wandered, and staff were to redirect him/her. Resident #27 had not demonstrated other physical aggression, other than with resident #36. During an interview on 5-1-12 at 8:14 A.M. activity/social service staff L stated the day after the incident, resident #27 was sent out to the hospital and came right back. He/she met with resident #36 on 12/5/11 (1 day after the resident to resident altercation) and followed up with the resident on 12-6-11, he/she said everything was ok. On 12/28/11 we discussed either a keypad for his/her door to keep resident #27 from coming in and out of his/her room, but he/she did not want that. On 12/30/11 resident #36 wanted a meeting with us, which was held on 1-3-12. In the meeting, he/she said resident #27 continued to come in his/her room. Resident #36 wanted us to move resident #27 out of the building on the 1-3-12, and we did the room change and moved resident #27 to another hall (as he/she was in the room directly across the hall from resident #36's room); a month after the incident. Immediately following the incident, resident #27 was sent out to the hospital and came right back. Activity/social service staff L acknowledged resident #27 kept going down the wrong hallway, and that staff knew to redirect him/her back to his/her hallway. On 5-1-12 at 10:21 A.M. direct care staff M stated resident #27 wandered and staff tried to make sure he/she did not go into other residents rooms, and make sure he/she had not picked up any other residents items. On 5-1-12 at 10:40 A.M., licensed nursing staff D stated he/she was unaware of anything in particular the staff should monitor resident #27 for in regards to behaviors. On 5-1-12 at approximately 1:30 P.M. resident #36 stated social services did not follow up with him/her after the incident and stated staff watched resident #27 for a while to keep him/her off this hall, but now they do not watch him/her as much. He/she still comes down this hallway and the resident stated he/she did not feel comfortable with that. On 5-1-12 at 2:26 P.M., direct care staff N stated resident #27 had a room change in the last few months due to an incident with resident #36. Direct care staff N stated he/she went to the soiled utility room and heard resident #36 call for help. Resident #27's arm was around resident #36's neck. He/she then yelled for help and staff separated the two residents. Resident #27 went out to the hospital for evaluation. He/she still went down resident #36's hall. Staff try to keep him/her in the main area. On 5-1-12 at 2:29 P.M., direct care staff O stated resident #27 had gotten physical against some residents. Staff tried to redirect him/her the best they could. He/she was now in his/her own room. He/she was confused about the location of his/her room. He/she had about 4 different rooms within last year or so. Staff redirected him/her and tried to get him/her to stay away from resident #36's hall. On 5-1-12 at 3:50 P.M. resident #36 stated he/she felt like the facility waited too long to follow up on the resident to resident incident on 12-3-11. On 5-1-12 at 4:33 P.M. administrative nursing staff B stated they should have done better and thought the situation was handled. He/she acknowledged resident #27's room was right across the hall from resident #36's room and that he/she remained there for a month after the incident until resident #36 wanted a meeting with the facility and voiced his/her concerns. The facility-provided policy entitled Investigation and if the circumstances required it, Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property revised 7-1-10 recorded the Director of Nursing Services (DNS) and his/her designee should remove a resident suspected of being the subject of an alleged violation to an environment where the resident's safety could be protected. The facility should make reasonable efforts to determine the cause of the alleged violation and take corrective action consistent with the investigation findings to eliminate any ongoing dangers to the resident. The facility neglected the resident by failing to provide an environment free from abuse by failing to adequately supervise resident #27 and implement timely and appropriate interventions for this same resident with a history of physical abuse and failed to ensure resident #36 felt safe in the facility.