Every finding on record at Stone Cottage Care Center

Based on observation, record review, resident and staff interviews, the facility failed to maintain the dignity for one of three residents reviewed (Resident #8) when they failed to ensure to keep him from sitting in his own stool for hours before staff provided incontinence cares and failed to treat him with dignity and respect by using profanity. The facility reported a census of 35 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] identified Resident #8 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Traumatic Spinal Cord Dysfunction, Quadriplegia, Neurogenic Bladder and Diabetes Mellitus. The MDS also identified Resident #8 to be totally dependent on staff for assistance with all activities of daily living which included personal hygiene, dressing, eating, transfer from chair to bed. The MDS documented that the resident had an indwelling urinary catheter. On 5/14/26, the Care Plan identified Resident #8 with the problem of falsely accusing the staff of excessive call light wait times and directed staff to respond to call lights promptly and acknowledge resident's concerns respectfully. Approach the resident calmly using non-confrontational tone and trauma-informed communication. In an observation and interview on 5/20/26 at 11:30 AM Resident #8 sat up in bed wearing a hospital gown with red stains near neckline. The suprapubic catheter was connected to a drainage bag in a dignity bag below the bladder level. He stated he did not have a pressure ulcer, but when he had to sit 1.5 hours in his stool, this makes him very angry, makes him feel embarrassed, and his dignity is pretty much stripped from him. In an interview on 5/20/26 at 2:46 PM, Staff K, CNA reported last month, she came to Resident #8's room to help with wound are. He then asked why the Director of Nursing (DON) was in his room that he did not want her there. She heard the DON tell Resident #8 that he was an alcoholic narcissist and if he didn't like it he could f___ing leave. In an interview on 5/21/26 at 2:53 PM, Resident #8 reported the DON asked why he told the hospital they refused occupational therapy. Her tone was angry and visibly upset. It was not a pleasant exchange, it was accusatory and angry. This made him feel upset because he never said anything like that, it just confirms that the DON does not like him and she hates him. Resident #8 stated the DON has treated him like this the first month he was here. Resident#8 reported there were so many instances where he would sit in his feces for over an hour not once, but many times. In an interview on 5/26/26/ at 1:03 PM, Staff B, RN reported Resident #8 informed her that last month, the Director of Nursing told him that if he did not like it here, he can f___g leave. The DON also said he was a narcissistic alcoholic. In an interview on 5/29/26 at 7:55 AM, the Director of Nursing reported when asked about the interaction she had with Resident #8 where he reported she called him a narcissistic alcoholic a__hole and that if he didn't like it here, he could f___g leave. She reported she did not use those words toward him, that she was clarifying those the words his ex-spouse had used. The Facility Policy titled: Quality of Life: Dignity, dated as last revised on August 2009 had documentation of the following:Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by promptly responding to the resident's requests.

Based on observation, record review, resident and staff interview, the facility failed to provide oral cares to one of three residents reviewed (Resident #6) and failed to provide peri cares for one of three residents reviewed (Resident #8). The facility reported a census of 35 residents.Findings include:1. The Minimum Data Set (MDS) Assessment tool with reference date 2/19/26 revealed Resident #6 admitted to the facility 11/14/25 with diagnoses that included quadriplegia, seizure disorder, anxiety, depression, asthma, skin graft failure and stage 4 pressure ulcer, scored 15 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated intact cognition and without symptoms of delirium present, always able to make himself understood and always able to understand others. The assessment revealed the resident had deficits of bilateral upper and lower extremities, totally dependent on staff assistance for all cares that included repositioning in bed, transfers to and from bed or chair, bathing, dressing, eating, toileting and personal hygiene, the resident unable to stand or ambulate. The Nursing Care Plan included a problem labeled (Resident's name redacted) requires total assistance with activities of daily living due to impaired mobility related to quadriplegia. (Resident's name redacted) has a history of expressing inaccurate or inconsistent statements regarding care interactions, creating potential risk for misinterpretation and emotional distress for both the resident and staff. initiated 11/24/25, with 6/5/26 goal: (Resident's name redacted) will remain free from physical injury, psychological harm, and perceived or actual care concerns through consistent use of two-person assistance and clear communication strategies. The Nursing Care Plan directed staff to provided care that included: 1. Explain each step before and during hands-on care. 2. Offer choices when possible. 3. Maintain privacy (doors closed, curtains pulled). 4. Provide cares in pairs for all personal care tasks including: transfers, hygiene and peri-care, dressing, bed mobility, bed bath and repositioning. 5. Validate concerns without arguing or escalating. 6. Reinforce expectations and boundaries respectfully. 7. Avoid defensiveness if reports are made, respond per policy. Another problem labeled as (Resident's name redacted) has actual impairment to skin integrity related to quadriplegic status, dependent for all cares and repositioning unstageable right heel pressure wound initiated 2/19/26, with 6/5/26 goal: (Resident's name redacted will have no complications related to skin impairment. The Nursing Care Plan directed staff with interventions that included: 1. Encourage adequate nutrition and hydration, collaborating with dietary services as appropriate to support skin integrity and wound healing. 2. Keep skin clean and dry, providing hygiene and incontinence care as needed to prevent moisture-related skin breakdown. 3. Offload pressure from the left heel by floating heels on pillows while resident in bed to reduce pressure and promote healing. 4. Reposition resident routinely according to facility protocol and resident's tolerance to prevent prolonged pressure on the affected area. Observations revealed: 5/21/26 at 9:48 a.m., Resident positioned on his back, in bed with feet/heels floated on a pillow. Cell phone used as his call light positioned on his chest area with his hand next to the phone, teeth had visible food residue on the frontal surface of upper and lower teeth. 5/26/26 at 2:28 p.m. Resident mouth dry, teeth with visible residue/film on frontal surface of upper and lower teeth. Resident in bed, on back, feet on pillow, cell phone on his chest area. Resident interviews revealed: During an interview 5/21/26 at 9:48 a.m., the resident stated he was dependent on staff for all care due to quadriplegia. He usually had to ask for care that he required, such as oral care, repositioning and getting a drink. He had not had his teeth brushed since the evening of 5/18/26. They discussed his care needs at a recent care conference and staff were supposed to brush his teeth and provide oral care every evening. The resident had to use his cell [NAME] to call when he required assistance, he used [NAME] to voice activate his cell phone to call the facility to elicit a staff response. 5/26/26 at 2:28 p.m. the resident stated the last time he had oral care was Thursday and Friday evenings, 5/21/26 and 5/22/26. Staff interviews revealed: 5/26/26 at 3:10 p.m. Staff D, CNA stated they were supposed to provide residents with oral hygiene care/brush teeth at least once a shift or as directed on the Kardex. Staff were supposed to reposition residents that couldn't position themself at least every 2 hours, or as directed. 5/27/26 at 1:15 p.m. Staff K, CNA stated she did oral care on the resident yesterday morning, used a toothette and that's normally how she provided the care. When asked how often he was supposed to have oral hygiene care/teeth brushed she stated she wasn't sure. Staff K looked in the Kardex at that time, the care plan said staff were supposed to brush his teeth daily in the evening. 5/28/26 at 8:26 a.m. the Director of Nursing (DON) stated she would expect staff to follow the care plan/Kardex for resident care including oral hygiene, they'd just had a care conference for the resident, she'd updated his care plan and staff were directed to brush teeth/provide oral care daily in the evening. When asked about the resident having to request the care, that staff didn't provide the care routinely the DON stated the resident liked to stay up later in the evening and would call the facility with his cell phone when he was ready to lay down, that is when staff would do the care. The Administrator was interviewed 5/28/26 at 9:15 a.m. stated she would want her teeth brushed after a meal, expected staff to provide the care at least in the morning and evening, or as directed on their care plan or per their request. When asked why the resident's oral care was not done as directed on his care plan the Administrator stated there shouldn't be any reason why it wasn't done, it's addressed on the all the Kardex which all the staff had access to. 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #8 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Traumatic Spinal Cord Dysfunction, Quadriplegia, Neurogenic Bladder and Diabetes Mellitus. The MDS also identified Resident #8 to be totally dependent on staff for assistance with all activities of daily living, which included personal hygiene, and had an indwelling urinary catheter. On 3/4/26, the Care Plan identified Resident #8 with the problem of verbalizing concerns that staff are not completing cares and directed staff to document care provided in the log when entering the room per plan of care. A review of the Interdisciplinary Team Progress Note dated 5/22/26 at 4:11 PM, had documentation that staff documentation should reflect ongoing peri-care assistance provided by staff, including resident-maintained signature logs documenting staff assistance during care episodes. Resident had been educated on what peri-care entails. Multiple peri-care audits completed by nursing management. The facility did not provide documentation to show peri care audits had been completed. A review of the notebook where staff documented dates times and cares provided revealed no peri care documented on May 14, 15, 16, 17, 18, 19, 20, 2026. In an observation and interview on 5/20/26 at 11:30 AM Resident #8 sat up in bed wearing a hospital gown with red stains near neckline. The suprapubic catheter was connected to a drainage bag in a dignity bag below the bladder level. He reported he usually gets peri care once a shift. He had peri care done at today at 5:00 AM, however, prior to that he did not have peri care for five days. The area to his groins and scrotum appear reddened. In an interview on 5/21/26 at 2:53 PM, Resident #8 reported the last time he got peri care was yesterday at 5:00 AM. They cleaned around his supra pubic catheter area, but no one touched his groin area. In an interview on 5/26/26/ at 1:03 PM, Staff B, RN reported Resident #8 told her that he had not received peri care in the last 5 days. In an interview on 5/26/26 at 12:18 PM, Staff C, CNA reported Resident #8 told her that he had not received peri care in the last 5 days. In an interview on 5/26/26 at 1:58 PM, Staff A, CNA reported Resident #8 should get baths 3 times a week and he has reported he does not get them on Fridays when Staff A is off. She could not explain why this was not getting done. Resident #8 also reported he did not have peri care in 5 days and said he should not have to ask, that should be that part of his care. She also reported Resident #6 also complained that last Friday he did not get a shower. He did say he filed a grievance about that. In an interview on 5/27/26 at 8:07AM, the state ombudsman reported Resident #8 stated that he wasn't getting incontinence care and that he had several urinary tract infections. Per response from staff he is receiving it routinely, he did report he has had several UTIs. Resident #8 also reported the DON (Director of Nursing) said peri care was being done and he was on 15 minute checks and he said this never happened. In an interview on 5/28/26 at 9:15 AM, the Administrator reported the following: She would expect staff to provide oral cares to the residents least every morning and evening. There should not be any reason why this is not being done. It's addressed on the all the Kardex which all the staff have access to. She would expect staff to provide peri care to the residents after every incontinent episode and upon rising and before they go to bed. When asked why Resident #8 did not have any peri care for 5 days, she reported he just had peri care just before he made that statement. A review of the Facility Policy titled: Oral Care with the last revision date of 5/15/20 had documentation of the following: For a patient who can't expectorate or is dependent for oral care If necessary, insert a bite block or mouth prop to hold the patient's mouth open during oral care. Brush the patient's teeth, gums, and tongue with a soft compact-head toothbrush and toothpaste at least twice per day but ideally four times per day. Brush the teeth for at least 2 minutes at each session using the brushing method described above. A review of the Facility Policy titled: Perineal Care dated as last revised February 2018 had documentation of the proper procedure, but failed to direct staff on the frequency that perineal care should be provided.

Based on clinical record review, facility policy review, and staff and resident interviews, the facility failed to separate 2 residents (Resident's #11 and #12) from one another after one of the residents made verbal threats that she would hit the resident, and subsequently observed behind the resident with her arm raised in the air as if to strike the resident. As a result of the failure to separate the residents, Resident #11 was able to strike Resident #12 in the head in the dining room during the breakfast meal, at a time when staff were in the area and could have taken action to prevent it. Resident #12 sustained a bruise on her face and requested transfer to another facility. The facility reported a census of 35 residents. Findings include:The Minimum Data Set (MDS) Assessment tool with reference date 4/16/26 revealed Resident #11 had diagnoses that included hypertension (high blood pressure), diabetes, anxiety, asthma and insomnia, scored 14 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated intact cognition, without symptoms of delirium present. The assessment revealed the resident required substantial staff assistance for transfers to and from bed or chair, dressing, toileting, bathing and walking 10 feet or less. The resident used a wheelchair and walker for mobility. The resident was always able to make herself understood and always understood others. The Nursing Care Plan included the following problems:(Resident's name redacted) does not acknowledge or perceive that they exhibit behaviors that may interfere with care, socialization, or safety (e.g., verbal aggression, exit seeking, refusal of care.), initiated 7/15/25, with 8/8/26 goal: Staff will respond to behaviors using nonconfrontational, supportive techniques. The Nursing Care Plan directed staff with interventions that included:A. Avoid using the word behavior when speaking with the resident, initiated 7/15/25, revised 1/8/26. B. Offer preferred activities based on past interests, initiated 7/15/25. C. Provide a structured routine to reduce confusion and agitation, initiated 7/15/25. D. Redirect without confrontation, initiated 7/15/25. 2. (Resident's name redacted) exhibits episodes of physical aggression toward peers related to impaired coping skills, poor impulse control, behavioral dysregulation, cognitive impairment, and/or psychiatric diagnoses, placing self and others at risk for injury, initiated 5/26/26, with 8/8/26 goal: (Resident's name redacted) will be free from any altercations with peers through the next review period. The Nursing Care Plan directed staff with interventions that included: A. Monitor/document behaviors, triggers, antecedents, environmental stressors, peer interactions, and effectiveness of interventions, initiated 5/26/2026. B. Remove resident from overstimulating or triggering environments as needed tomaintain safety, initiated 5/26/2026.C. Staff to approach resident calmly with non-threatening communication and utilize de-escalation/redirection techniques at earliest signs of agitation, initiated 5/26/2026. The facility's undated Abuse Policy directed staff, in part: 1.Abuse is defined as the willful infliction of injury, unreasonable confinement,intimidation, or punishment with resulting physical harm, pain or mental anguish.Abuse also includes the deprivation by an individual, including a caretaker, of goodsor services that are necessary to attain or maintain physical, mental, and psychosocialwell-being. Instances of abuse of all residents, irrespective of any mental or physicalcondition, cause physical harm, pain or mental anguish. It includes verbal abuse,sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabledthrough the use of technology. 2.The resident has the right to be free from abuse, neglect, misappropriation of residentproperty, and exploitation as defined in this subpart. This includes but is not limited tofreedom from corporal punishment, involuntary seclusion and any physical or chemicalrestraint not required to treat the resident's medical symptoms. 3.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. 4.Prevention- Provide staff, residents, and family members information on how to andwhom to report concerns, incidents, and grievances without fear of retribution, andprovide feedback regarding the concerns; identify, intervene, and correct situations ofalleged, suspected, or substantiated abuse; supervision of staff, monitoring ofresident's with needs and behaviors, communication deficits, and/or those totallydependent on staff. 5.The Facility shall have processes in place to include screening, training, prevention,identification, protection, investigation, reporting and response to allegations of potential oractual abuse and neglect. 6.The facility will coordinate investigation outcomes with the Quality Assurance and QualityImprovement committee for purposes of review and to determine the need for further actions. 7.All reports of resident abuse, neglect, exploitation, misappropriation of resident property,mistreatment and/or injuries of unknown source ( abuse) or a reasonable suspicion of a crime shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by the administrator and or designee. Those who report allegations of potential or actual abuse and neglect shall be free from retaliation or reprisal. Nursing Progress Notes revealed the following entries: 5/25/26 at 8:28 a.m., transcribed by Staff B, Registered Nurse (RN): Resident#11 noted by staff to have hit a fellow resident in the head with her water jug. Resident#11 removed from the dining room and away from fellow resident. This resident had already called 911 on fellow resident stating she was going to hit her. No reasoning given as to why she was wanting to hit her. 5/25/26 at 11:41 a.m., transcribed by the Director of Nursing (DON): Resident#11observed seated in the dining room during meal service. Resident then quietly propelled herselfacross the dining room toward her roommate (Resident#12) who was seated at another table. Without verbal interaction or identifiable provocation, resident raised her water cup and struck fellow resident in the head. Staff immediately intervened and separated both residents to prevent further escalation. Resident was removed from the dining area for safety and monitored following incident. Resident unable/unwilling to provide explanation for behavior when approached by staff. During an interview on 5/27/26 at 11:50 a.m. the resident stated Resident #12 was her roommate for about 2 weeks and they didn't get along. Resident#12 (R12) would yell, wake her up at all hours of the night, Resident #11 thought R12 was doing it on purpose, would tell her to stop yelling, that she was trying to sleep, but R12 wouldn't stop yelling. Resident #11 stated she thought R12 had some control over what she did and said and was tired of getting woke up by Resident #12. Resident #11 stated she hit R12 with her coffee mug in the Dining Room and held the mug up to indicate what she hit R12 (an approximate16-20 oz sized metal thermal cup with handle, lid and straw in it). Staff interviews revealed: 5/28/26 at 8:42 a.m. Staff K, Certified Nursing Assistant (CNA) stated she worked day shift on 5/25/26, she got Resident #12 up with Staff C, CNA, as her roommate, Resident #11 had been verbal with Resident #12 over waking her up and said she was going to hit her. Nothing happened while they were in the room. As they backed Resident #12 in her wheelchair out of the room Resident #11 was in the hall and had her arm raised up in the air behind her as if she was going to hit R12 and they were able to separate them at the time. She told the nurse on duty, Staff B, because she had never seen Resident #11 become physical before. She asked the nurse if they should move 1 of the resident's from the room they shared to separate them. 5/28/26 at 8:54 a.m. Staff C, CNA stated she worked day shift on 5/25/26, she was with Staff K in the room with Resident's #11 and #12, Resident #11 yelled at Resident #12 about waking her up and said she was going to hit R12. When they took R12 out of the room Resident #11 was behind them in the hall with her arm raised up as if to hit R12 and they were able to keep them separated. Staff K reported it to the nurse, Staff B because they had not seen the resident get physical like that. Staff C was in the Dining Room during breakfast but didn't see Resident #11 strike R12. Resident #11 can self propel in her wheelchair and she got herself over to R12's table, that's where she hit her with her Yeti. 5/28/26 at 7:31 a.m. Staff L, CNA stated she worked day shift on 5/25/26, when Staff K got Resident #12 up, her roommate Resident #11 said she was going to hit her. Staff C helped get the resident up and she heard it too. Staff L stated Staff K told the nurse on duty, Staff B, that Resident #11 said she was going to hit R12, but no changes were made before Resident #11 hit R12 with her coffee mug. 5/28/26 at 12:28 p.m. Staff B, RN, stated she didn't recall that staff informed her that Resident #11 said she would hit R12 on 5/25/26, and she couldn't make any resident room changes, management would have to do that. Once they were up and out of their room R12 sat on the opposite side of the Dining Room from Resident #11, and then R12 stayed out by the TV throughout the day while Resident #11 went back to her room and they would have stayed apart that way. 5/28/26 at 12:17 p.m. Staff M, CNA stated she worked day shift on 5/25/26. She was at the table with R12, the resident fed herself oatmeal after she sat her up, Resident #11 was in her wheelchair, came up to the table and hit R2 in the face with her thermos mug. She didn't say anything before she did it but afterwards she asked if she was bleeding or if she had hurt her. R12 cried and said she didn't feel safe there. Staff said that Resident #11 had been fighting with R12 about waking her up that morning but they didn't say that she said she was going to hit her. 5/27/26 at 5:48 a.m. Staff N, Licensed Practical Nurse (LPN), stated she worked the night shift from 6 p.m. on 5/24/25 to 6 a.m. on 5/25/26, to her recollection she did not recall that R12 was awake, or might have yelled out 1 time. Resident #11 had a history of not getting along with her roommates, she wants to sleep at night and when R#12 has yelled and kept her awake Resident #11 yells back at her to be quiet, that she wanted to sleep and she could hear those exchanges from the Nurse's desk area. She had not heard Resident #11 that night, she can be very verbal but she had never known her to physically threaten anyone, and she was surprised to learn that Resident#11 hit R12 that morning. 5/28/26 at 8:26 a.m. the Director of Nursing (DON), stated If a resident threatened to hit or hurt another resident she expected staff to separate the residents, maintain the residents safety/separation and notify her or the Administrator for further direction. 2. The Minimum Data Set (MDS) Assessment tool with reference date 4/30/26 revealed Resident #12 had diagnoses that included hypertension (high blood pressure), cerebrovascular accident (a stroke), diabetes, seizure disorder, anxiety, depression, acute pain due to trauma, other fractures and sedative, hypnotic or anxiolytic abuse, uncomplicated and cocaine abuse in remission. The assessment revealed the resident was always able to make herself understood and always understood others, scored 11 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated mild cognitive impairment, without symptoms of delirium present. The resident required maximal staff assistance to reposition in bed, transfer to or from bed or chair, dressing, toileting and hygiene and the resident unable to stand or ambulate. The Nursing Care Plan included a problem labeled as (Resident's name redacted) has a behavior problem, initiated 4/28/26, with 7/29/26 goal: the resident will have no evidence of behavior problems by review date. The Nursing Care Plan directed staff to provide interventions that included:Administer medications as ordered. Observe for/document side effects and effectiveness, initiated 4/28/26.Anticipate and meet the resident's needs, initiated 4/28/26.Explain all procedures to the resident before starting and allow the resident time to adjust to changes.Provide a program of activities that is of interest and accommodates resident's status, initiated 4/28/26. A Nursing Progress Note transcribed by Staff B, RN, on 5/25/26 at 8:28 a.m. stated: resident sustained a hit in the head from a fellow resident. Resident was sitting at the dining room table eating when fellow resident approached her and hit her in the head with her water cup, two residents separated after incident. The next entry in the Nursing Progress Notes by Staff B on 5/25/26 at 8:30 a.m. stated resident voiced she wants to be transferred to another facility due to incident, moving to our sister facility. An Incident Report dated 5/25/26 at 8:28 a.m. described the incident, reported no injuries observed at the time, a pain assessment Painad score of 5 (Pain Assessment in Advanced Dementia) is an observational tool used to evaluate pain in patients with severe cognitive impairments or dementia who cannot verbally communicate their pain. It scores five specific physical behaviors on a scale from 0 to 2, totaling 10 possible points. The Incident Report revealed a bruise on the top of the scalp post-incident reported, without further description or remarks. The facility's 5-day Investigation Summary, completed by the Administrator, stated, in part: Resident's name redacted had a purple bruise next to her right eye 3 centimeters (cm) by 1 cm. Call placed to local law enforcement with case number assigned. Resident's name redacted reports that she does not want to go to the Emergency Room. Ice pack and first aid were offered to resident, and she declined.

Based on observation, record review, resident and staff interview, the facility failed to answer call lights timely for two of three residents reviewed (Residents #6 reported he had to wait at least 30 minutes to get his call light answered 3 to 4 times a week and Resident #8 reported to has to wait over an hour to get his call light answered on a daily basis). The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool with reference date 2/19/26 revealed Resident #6 admitted to the facility 11/14/25 with diagnoses that included quadriplegia, seizure disorder, anxiety, depression, asthma, skin graft failure and stage 4 pressure ulcer, scored 15 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated intact cognition and without symptoms of delirium present, always able to make himself understood and always able to understand others. The assessment revealed the resident had deficits of bilateral upper and lower extremities, totally dependent on staff assistance for all care that included repositioning in bed, transfers to and from bed or chair, bathing, dressing, eating, toileting and personal hygiene, the resident unable to stand or ambulate. The Nursing Care Plan included a problem labeled (Resident's name redacted) requires total assistance with activities of daily living due to impaired mobility related to quadriplegia. (Resident's name redacted) has a history of expressing inaccurate or inconsistent statements regarding care interactions, creating potential risk for misinterpretation and emotional distress for both the resident and staff. initiated 11/24/25, with 6/5/26 goal: (Resident's name redacted) will remain free from physical injury, psychological harm, and perceived or actual care concerns through consistent use of two-person assistance and clear communication strategies. The Nursing Care Plan directed staff to provided care that included: 1. Explain each step before and during hands-on care. 2. Offer choices when possible. 3. Maintain privacy (doors closed, curtains pulled). 4. Provide cares in pairs for all personal care tasks including: transfers, hygiene and peri-care, dressing, bed mobility, bed bath and repositioning. 5. Validate concerns without arguing or escalating. 6. Reinforce expectations and boundaries respectfully. 7. Avoid defensiveness if reports are made, respond per policy. Resident interviews revealed: During an interview 5/21/26 at 9:48 a.m., Resident #6 stated he was dependent on staff for all care due to quadriplegia, used [NAME] to activate his cell phone to call the facility when he required assistance, it could take 30 or more minutes at least 3 to 4 times a week for staff to respond to his calls for help and it often was at least 15 minutes before staff responded. The resident stated they did not have enough staff at the facility, there was only 1 nurse and 2 aides on the night shift and they were often busy. He usually had to call to ask for assistance to reposition on the night shift, with delayed staff responses he hadn't been repositioned for over 2 hours several times. 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #8 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Traumatic Spinal Cord Dysfunction, Quadriplegia, Neurogenic Bladder and Diabetes Mellitus. The MDS also identified Resident #8 to be totally dependent on staff for assistance with all activities of daily living and had an indwelling urinary catheter. On 5/14/26, the Care Plan identified Resident #8 with the problem of falsely accusing the staff of excessive call light wait times and directed staff to respond to call lights promptly and acknowledge resident's concerns respectfully. In an observation and interview on 5/20/26 at 11:30 AM Resident #8 sat up in bed wearing a hospital gown with red stains near neckline. The suprapubic catheter was connected to a drainage bag in a dignity bag below the bladder level. Resident #8 reported the following The longest he had to wait for staff to answer his call light was 4.5 hours. On 4/17/26 at 4:00 AM he turned on his call light, due to pain in his legs from spasms. No one responded until 5:30 AM. They always say they were busy or couldn't hear his call light because they were in another resident's room. c .On 4/24/26 at 1:15 PM he turned on his call light and staff did not come in until 1.5 hours later at 2:45 PM. d .On 5/9/26 at 12:20 PM, he told a CNA that he needed to get cleaned up after a BM and no came to his room until 1:25 PM. e. On 5/9/26 at 5:35 PM, he had another BM, he asked a CNA to clean him up. At 6:50 PM, no one still had come in, so he turned on his call light again. At 7:05 PM, they responded. He stated he did not have a pressure ulcer, but he has to sit 1.5 hours in his stool. f. On 5/9/26 at 7:40 PM, I hit my call light and at 9:06 PM, one CNA came in and said she was going to get help and 2 hours later they finally came in to clean him up. He had to sit in his stool for a total of four hours that one day. g. On 5/9/26 at 7:10 PM, he told the aides that he had not had a bed bath on May 8 or 9 and by 10:30 PM came around, they never got around to giving him a bed bath. That was 2 weeks in a row, they missed giving him his bed bath on Fridays and never made up for it on Saturday like they're supposed to. In an interview on 5/21/26 at 2:53 PM, Resident #8 reported the following: On 5/20/26 at 4:20 PM, he turned on the call light and no one came in until 6:15 PM On 5/20/26 at 6:40 PM, he had another BM, he initiated his call light again. At 7:15 PM a CNA came in and said she was going to get help and left the room. 30 minutes later, no one came to his room and he turned on his call light again and no one came until 7:55 PM. He had to wait 1 hour and 15 minutes before they cleaned him up. c. On 5/21/26 at 11:10 AM he let a CNA know that he needed to be cleaned up. At 11:40 AM the staff cleaned him up. In an interview on 5/22/26 at 8:28 AM, the DON (Director of Nursing) stated there have been problems with staffing, she knows they're going to get tagged on it because there are staff that call in sick daily especially on 2nd and 3rd shift. Management staff have had to work on off shifts to help fill in the gaps. Corporate will not approve her plan to request 3.6 staffing for the acuity of residents that the facility has, they have a lot of psych residents that are demanding. In an interview on 5/26/26 at 12:18 PM, Staff C, CNA reported she did not feel there was enough staff to provide residents with the are they need. On night shift there are typically two nurses and two CNAs. There used to be 3 CNAs, but one aide is on light duty. During the day shift on weekends, there is usually just two CNAs to take are of 30+ residents. They will schedule agency, but most of the time they will call in sick or just a no call, no show. One of the aides has worked 14 days in a row to help out on the weekends. At least half of the residents require two aides for cares. In an interview on 5/26/26 at 1:58 PM, Staff A, CNA reported staff should answer call lights within 15 minutes and that Resident #8 will complain daily that it takes too long for staff to answer his call light. In an interview on 5/26/26 at 3:02 PM, Staff D, CNA reported staff should answer a resident's call light within 15 minutes, but it takes at least 30 to 45 minutes, this is part of the reason she left. Typically on day shift, there is one nurse, one CMA (Certified Medication Aide) and 3 CNAs but there are quite a few call offs. She also said she has worked by myself with over 35 residents before they could find someone to come in. People would call in sick at least once every weekend. A few weekends ago, she worked 6:00 AM to 6:00 PM, they were short, she ended up working until 2:00 AM as no one came in to relieve her at 10:00 PM. She did not feel there was enough staff to give residents the are they need as at least half of the residents require cares in pairs and eleven residents require transfers with a mechanical lift. In an interview on 5/28/26 at 9:15 AM, the Administrator reported she would expect staff to answer call lights within 15 minutes. She reported she looked through all the grievances, resident council meeting minutes and could not find any complaints about call lights. A review of the Facility Policy titled: Answering the Call Light dated as last revised September 2022 had documentation of the following: Answer the resident call system immediately. If the resident needs assistance, indicate the approximate time it will take for you to respond. If the resident's request requires another staff member, notify the individual. If the resident's request is something you can fulfill, complete the task within five minutes if possible. If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance.

Based on clinical record review, staff and resident interview the facility failed to provide occupational therapy for one ofone residents reviewed for occupational therapy services. (Resident#8). The facility reported a resident census of 35. Findings include:The Minimum Data Set (MDS) dated [DATE] identified Resident #8 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Traumatic Spinal Cord Dysfunction, Quadriplegia, Neurogenic Bladder and Diabetes Mellitus. The MDS also identified Resident #8 to be totally dependent on staff for assistance with all activities of daily living and had an indwelling urinary catheter. A review of the Physician Orders revealed an order dated 11/6/25 for Occupational Therapy to evaluate and treat as ordered. A review of Occupational Therapy progress notes revealed the last entry was dated 4/2/26. The Care Plan with the last revision date of 3/4/26 identified Resident #8 with the problem of being a quadriplegic, however, failed to address the order for Occupational Therapy dated 11/6/25. On 5/20/26 at 11:30 AM Resident#8 reported that he had not received occupational therapy for activities of daily living. In an interview on 5/26/26/ at 1:03 PM, Staff B, RN reported the following: Resident was getting OT and getting a TENS unit, however the Occupational Therapy Assistant has not worked with him for at least several weeks and could not explain why the OTA has not seen him when he continues to get physical therapy. In an interview on 5/26/26 at 3:43 PM, the Occupational Therapy Assistant reported it has been a month she worked with Resident #8 last on upper body, muscle to get him to do a grasp and maintain tone in his muscles. The visits stopped because the recertification was not done and she cannot provide services until the Occupational Therapist completes the recertification. The Occupational Therapist had a family illness which is why they are behind on the recertifications. Resident #8 is on her schedule definitely for tomorrow. In an interview on 5/28/26 at 9:15 AM, the Administrator reported regarding Resident #8's occupational therapy, the Occupational Therapist does need to write up a recertification. The facility did not have full time in house therapy staff, they are as needed (PRN) for but work for the facility.

Based on observation, resident and staff interviews, record review, and facility policy review. The facility failed to provide 2 of 2 residents (Resident #2 and Resident #5) reviewed for accommodation of needs, with an effective call light system to meet the needs of residents who have both upper and lower extremity impairments. The facility reported a census of 32 residents. Findings include: 1. Review of the admission Minimum Data Set (MDS) assessment, dated 12/04/25, revealed that Resident #2 admitted to the facility on [DATE] from another Nursing Home. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included quadriplegia (loss of movement and sensation, affecting all four limbs and torso) and Diabetes Mellitus. The MDS identified that Resident #2 had been dependent on staff assistance for all care tasks, hygiene tasks, and for all mobility. Resident #2 had an indwelling urinary catheter and was always incontinent (unable to control) both bowel and bladder functions. Review of an admission assessment, dated 11/26/25, revealed that Resident #2 was unable to use the following listed devices: Nursing call bell; Bed controls; Side rails; TV; Telephone. The assessment documented that Resident #2 uses a cell phone to call the facility. Review of the Care Plan, date initiated 12/17/25, revealed a Focus area for activities of daily living (ADL) self care performance deficit, related to disease process (quadriplegia) and identified that Resident #2 required total dependence on staff assistance for toilet hygiene, bed mobility, bathing, oral care, personal hygiene, dressing, eating, and transferring. Review of the Care Plan, date initiated on 12/02/25 and revised on 12/17/25, revealed a Focus area for Resident #2 exhibiting verbal aggression towards staff, including yelling and name-calling, and reports dissatisfaction with call light system and perceived unmet care needs, with the goal that Resident #2 would feel heard and supported and will communicate concerns in a calm manner with more than or equal to 75% of interactions. The Care Plan listed interventions, included the following, in part: Approach Resident #2 calmly using non-confrontational tone and trauma informed communication. Date initiated: 12/02/25. Date revised: 12/17/25. Document all cares provided at the time they are completed. Date initiated: 12/02/25. Ensure two staff persons are present during care interactions or room entry as needed. Date initiated: 12/02/25. Validate Resident #2's concerns and provide reassurance regarding response time and safety. Date initiated: 12/02/25. Date revised: 12/17/25. During an interview on 12/18/25 at 2:35 PM, Resident #2 stated that during his first 8 days at the facility, he had to use his cell phone as a call light. Resident #2 reported that he had come from another facility where he could use a breath-activated call light system and when requested to use this, the facility notified him that the call light system would not be compatible with his breath-activated call light. Resident #2 reported difficulty with using his cell phone for a call light due to the cell phone not being charged or within reach for him to use when he needed help. Resident #2 stated after 8 days using his cell phone for a call light, the facility provided him with a motion sensor door bell system that was observed to be present on an overbed table next to the bed during the interview. Resident #2 demonstrated the use of the motion sensor by waving his right hand near the sensor until a red light appeared. Resident #2 stated his understanding of the door bell system was that it would ring once and sound like a church bell near the dining room/common area. Resident #2 voiced concern that staff did not hear the doorbell when activated if they were in other resident rooms or away from the common area. Resident #2 reported the following dates and times he kept documented on cell phone, in which the motion sensor doorbell had not been answered in a timely manner:On 12/08/25 at 7:00 AM, the call system was activated with no response, at 7:20 AM the call system was again activated with no response, and at 7:40 AM the call system was again activated with no response. Resident #2 stated he received assistance at 8:11 AM. On 12/09/25 at 6:00 AM, the call system was activated with no staff response until 7:00 AM. On 12/11/25 at 6:20 PM, the call system was activated with no staff response until 7:05 PM.On 12/12/25 at 11:00 AM, the call system was activated with no staff response until 11:45 AM.On 12/15/25 at 10:30 AM, the call system was activated with no staff response until 12:00 PM. During an interview on 12/22/25 at 11:30 AM, Staff A, Registered Nurse (RN), reported concern with staffing due to a high acuity of residents who required 2 staff assistance, total dependence on staff for ADLs, and had behavioral/mental health diagnoses. Staff A stated that call lights are not able to be answered in a timely manner and stated he had observed times in which it would take greater than 30 minutes for staff to be able to answer a call light. Staff A confirmed that Resident #2 used his cell phone as a call light when first admitted to the facility, but that the cell phone would run out of battery and was unable to be used. Staff A informed that Resident #2's current sensor alarm doorbell system would ring once in the common area and could be heard in the hallway but not when staff are in resident rooms. During an interview on 12/22/25 at 12:00 PM, Staff B, Certified Nursing Assistant (CNA) stated that call lights cannot be answered in a timely manner and reported that it often takes staff more than 30 minutes to answer call lights due to the number of staff working and the resident acuity. Staff B stated Resident #2's call system would ring once in the common area when activated, and reported difficulty differentiating between his bell and 2 other resident doorbells used. Staff B stated she had a hard time hearing Resident #2's doorbell when behind closed doors. During an interview on 12/22/25 at 12:19 PM, Staff C, CNA, reported difficulty during the 2:00 PM to 10:00 PM shift with answering call lights in a timely manner. Staff C stated Resident #2's call bell was hard to hear when staff were down another hallway. During an interview on 12/23/25 at 8:45 AM, the Maintenance Director, confirmed being aware that Resident #2 had requested to use a breath-activated call light system when he was admitted to the facility. The Maintenance Director stated that a motion sensor doorbell was installed and he reached out to his boss to request a system to work with the resident's breath-activated system. Review of the facility provided Sales Order, dated 12/19/25, revealed that a call light adapter was ordered and expected to be delivered in 3 days from the date ordered. 2. Review of the admission MDS assessment, dated 11/21/25, revealed that Resident #5 admitted to the facility on [DATE] from the hospital. Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included quadriplegia, seizure disorder, malnutrition, and Stage 4 (full thickness) pressure ulcer of the sacrum. The MDS identified that Resident #5 had been dependent on staff assistance for all care tasks, hygiene tasks, and for all mobility. Resident #5 had an indwelling urinary catheter and an ostomy, was listed as always incontinent of both bowel and bladder functions. Review of the Care Plan, revised on 12/17/25, revealed a Focus area for Resident #5 requires total assistance with ADLs due to impaired mobility related to quadriplegia and has a history of expressing inaccurate or inconsistent statements regarding care interactions, creating potential risk for misinterpretation and emotional distress for both the resident and staff. Interventions included the following, in part:Explain each step before and during hands-on care. Offer choices when possible. Maintain privacy (doors closed, curtains pulled). Date initiated: 11/24/25. Provide care in pairs for all personal care tasks including transfers, hygiene and perineal care, dressing, bed bath, and repositioning. Date initiated: 11/24/25. Validate concerns without arguing or escalating. Reinforce expectations and boundaries respectfully. Avoid defensiveness if reports are made, respond per policy. Date initiated: 11/24/25. The Care Plan, revealed additional Focus area for Resident #5 being at an increased fall risk and refuses use of motion detector alarm, preferring to notify staff by calling the facility with his cellular phone. Interventions included: Honor preference to use a cell phone to call the facility for assistance instead of a motion detector. Date initiated: 12/04/25. Date revised: 12/17/25. Respond promptly to Resident #5's call to the facility when he asks for assistance. Date initiated: 12/04/25. Date revised: 12/17/25. Social Services: Support Resident #5's autonomy and document ongoing preference for alternatives to alarms. Date initiated: 12/04/25. Date revised: 12/17/25. During an interview on 12/22/25 at 10:30 AM, Resident #5 stated he had a rough start when first admitted to the facility due to hygiene care and wound care not always completed in a timely manner but felt this had improved. Resident #5 reported using his voice activated program on cell phone to call the facility for help when needed and denied concerns with this call system. When Resident #5 attempted to demonstrate use of his cell phone for a call light system, after several attempts, he was unable to use the voice activation command to unlock and use his phone. Resident #5 required another person to restart his phone before the voice command system was able to be used. During an interview on 12/23/25 at 3:00 PM, the Director of Nursing (DON) revealed the expectation of staff to answer call lights within 15 minutes of resident activation. During an interview on 12/23/25 at 3:00 PM, the facility administrator reported that the facility was currently updating the call light system from a pull string lever to a push button. The administrator confirmed knowledge of Resident #2 requesting to use breath-activated call system upon admission and knowledge of Resident #2 having concern that the motion sensor alarm provided was not functioning properly. Review of the facility policy titled Answering the Call Light, not dated, revealed the policy Purpose Statement was to ensure timely responses the the residents' requests and needs. The Section A. General Guidelines, directed the following: Upon admission and periodically as needed, explain and demonstrate use of the call light to the residents. Ask the resident to return the demonstrationExplain to the resident that a call system is also located in his/her bathroom. Be sure that the call light is plugged in and functioning at all times. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.Report all defective call lights to the nurse supervisor promptly.

Based on observations, staff and resident interview, clinical record review, and facility policy review the facility failed to answer resident call lights in a timely manner for 1 of 3 residents (Resident #2) reviewed for call lights, when the resident reported waiting for assistance took greater than 15 minutes. The facility reported a census of 32 residents. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 12/04/25, revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included quadriplegia (loss of movement and sensation, affecting all four limbs and torso) and Diabetes Mellitus. The MDS identified that Resident #2 had been dependent on staff assistance for all care tasks, hygiene tasks, and for all mobility. Resident #2 had an indwelling urinary catheter and was always incontinent (unable to control) both bowel and bladder functions. Review of the Care Plan, date initiated 12/17/25, revealed a Focus area for activities of daily living (ADL) self care performance deficit, related to disease process (quadriplegia) and identified that Resident #2 required total dependence on staff assistance for toilet hygiene, bed mobility, bathing, oral care, personal hygiene, dressing, eating, and transferring. Review of the Care Plan, date initiated on 12/02/25 and revised on 12/17/25, revealed a Focus area for Resident #2 exhibiting verbal aggression towards staff, including yelling and name-calling, and reports dissatisfaction with call light system and perceived unmet care needs, with the goal that Resident #2 would feel heard and supported and will communicate concerns in a calm manner with more than or equal to 75% of interactions. The Care Plan listed interventions, included the following, in part: Approach Resident #2 calmly using non-confrontational tone and trauma informed communication. Date initiated: 12/02/25. Date revised: 12/17/25. Document all cares provided at the time they are completed. Date initiated: 12/02/25. Ensure two staff persons are present during care interactions or room entry as needed. Date initiated: 12/02/25. Validate Resident #2's concerns and provide reassurance regarding response time and safety. Date initiated: 12/02/25. Date revised: 12/17/25. During an observation on 12/18/25 at 2:35 PM, Resident #2 demonstrated the use of the motion sensor call light system, which the facility provided him. The motion sensor was observed on top of an overbed table next to the bed. Resident #2 waved his right hand near the sensor until a red light appeared to activate a bell to sound near the dining room/resident common area. At 3:20 PM, no staff had entered Resident #2's room to answer the activated motion sensor call system. During an interview on 12/18/25 at 2:35 PM, Resident #2 stated that during his first 8 days at the facility, he had to use his cell phone as a call light. Resident #2 reported that he had come from another facility where he could use a breath-activated call light system and when requested to use this, the facility notified him that the call light system would not be compatible with his breath-activated call light. Resident #2 reported difficulty with using his cell phone for a call light due to the cell phone not being charged or within reach for him to use when he needed help. Resident #2 stated after 8 days using his cell phone for a call light, the facility provided him with a motion sensor door bell system. Resident #2 stated his understanding of the door bell system was that it would ring once and sound like a church bell near the dining room/common area. Resident #2 voiced concern that staff did not hear the doorbell when activated if they were in other resident rooms or away from the common area. Resident #2 reported the following dates and times he kept documented on cell phone, in which the motion sensor doorbell had not been answered in a timely manner:On 12/08/25 at 7:00 AM, the call system was activated with no response, at 7:20 AM the call system was again activated with no response, and at 7:40 AM the call system was again activated with no response. Resident #2 stated he received assistance at 8:11 AM. On 12/09/25 at 6:00 AM, the call system was activated with no staff response until 7:00 AM. On 12/11/25 at 6:20 PM, the call system was activated with no staff response until 7:05 PM.On 12/12/25 at 11:00 AM, the call system was activated with no staff response until 11:45 AM.On 12/15/25 at 10:30 AM, the call system was activated with no staff response until 12:00 PM. During an observation on 12/22/25 at 8:48 AM, a church bell sound heard near the dining room, the bell chimed one time. No staff present in the area, staff were noted to be in other resident rooms. At 9:00 AM a higher pitched bell sound heard near the dining room, this bell chimed one time. At 9:09 AM 2 Certified Nursing Assistant (CNA) staff sat at a table in the dining room with a laptop computer and at 9:15 AM, no staff had entered Resident #2's room following activation of the doorbell call system. During an interview on 12/22/25 at 11:30 AM, Staff A, Registered Nurse (RN), reported concern with staffing due to a high acuity of residents who required 2 staff assistance, total dependence on staff for ADLs, and had behavioral/mental health diagnoses. Staff A stated that call lights are not able to be answered in a timely manner and stated he had observed times in which it would take greater than 30 minutes for staff to be able to answer a call light. Staff A confirmed that Resident #2 used his cell phone as a call light when first admitted to the facility, but that the cell phone would run out of battery and was unable to be used. Staff A informed that Resident #2's current sensor alarm doorbell system would ring once in the common area and could be heard in the hallway but not when staff are in resident rooms. During an interview on 12/22/25 at 12:00 PM, Staff B, Certified Nursing Assistant (CNA) stated that call lights cannot be answered in a timely manner and reported that it often takes staff more than 30 minutes to answer call lights due to the number of staff working and the resident acuity. Staff B stated Resident #2's call system would ring once in the common area when activated, and reported difficulty differentiating between his bell and 2 other resident doorbells used. Staff B stated she had a hard time hearing Resident #2's doorbell when behind closed doors. During an interview on 12/22/25 at 12:19 PM, Staff C, CNA, reported difficulty during the 2:00 PM to 10:00 PM shift with answering call lights in a timely manner. Staff C stated Resident #2's call bell was hard to hear when staff were down another hallway. During an interview on 12/23/25 at 3:00 PM, the Director of Nursing (DON) revealed the expectation of staff to answer call lights within 15 minutes of resident activation. During an interview on 12/23/25 at 3:00 PM, the facility administrator reported that the facility was currently updating the call light system from a pull string lever to a push button. The administrator confirmed knowledge of Resident #2 having concern that the motion sensor alarm provided was not functioning properly. Review of the facility policy titled Answering the Call Light, not dated, revealed the policy Purpose Statement was to ensure timely responses the the residents' requests and needs. Review of the facility policy, titled Staffing, Sufficient and Competent Nursing, date revised April 2025, revealed a policy Purpose Statement in which the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The Section A. Policy Interpretation and Implementation, subcategory Sufficient Staffing, directed in part: 6. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident assessments, residents plans of care, and the facility assessment. 7. Factors considered in determining appropriate staffing ratios and skills include an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity. 8. Minimum staffing requirements imposed by the state, if applicable, are adhered to when determining staff ratios but are not necessarily considered a determination of sufficient and competent staffing. 9. Other resident services (e.g. administrative, food and nutrition services, specialized rehabilitation services, activities/recreational, social, therapy, environmental, etc.) are staffed to ensure resident needs are met.

Based on observation, clinical record review, and staff and resident responsible party interviews, the facility failed to provide adequate supervision and staff assistance to residents to prevent injuries from falls, for 1 of 4 residents with fall histories reviewed (Resident #4). The facility's failure to provide the appropriate supervision and assistance resulted in Resident #4's hospitalization in a hospital Intensive Care Unit with injuries that included hemothorax, fractured 6th through 10th right ribs, displaced right shoulder and compression fracture of the 10th thoracic vertebrae that resulted from an unwitnessed fall. The facility reported a census of 34 residents. Findings include:The 9/13/25 modified Minimum Data Set (MDS) Assessment revealed Resident #4 had diagnoses that included repeated falls, Wernicke's encephalopathy (a severe neuropsychiatric disorder caused by thiamine deficiency), alcohol dependence with withdrawal delirium, arthritis, irritability and anger, scored 8 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated severe cognitive impairment, with symptoms of delirium present. The Assessment revealed the resident required moderate staff assistance for toilet transfers, personal hygiene and to don or doff shoes, able to ambulate independently with walker or cane used, and had 1 fall with major injury since the previous assessment completed on 8/16/25. Resident #4's Fall Risk Assessments revealed the following scores; a score of 10 or greater indicated the resident at high risk for falls:6/10/25 score 10.06/25/25 score 11.0 7/8/25 score 11.0 8/16/25 score 11.08/30/25 score 17.09/13/25 score 17.010/1/25 score 15.010/9/25 score 13.010/14/25 score 14.010/16/25 score 13.0 The required quarterly care conferences documented in the resident's record revealed they were completed on 10/3/24, 2/20/25, 5/23/25, 8/26/25 and 9/23/25, and did not include his family or legal representative/power of attorney (POA) as required. The resident's Nursing Care Plan included the following problems and associated interventions:1. Risk for injury related to poor safety awareness as evidence by disregard for physical limitations or unsafe behaviors, initiated 7/29/2025. Goal with target date 12/22/25: Resident will remain free from injury, revised 9/25/2025. Interventions included: Staff will implement consistent safety interventions to reduce risk, initiated 7/29/2025, revised 9/25/2025. Document all safety behaviors and interventions, initiated 7/29/2025.Educate patient about safety risks and calling for help, initiated 7/29/2025.Initiate regular safety rounding, initiated 7/29/2025. Keep call light and frequently used items within reach, initiated 7/29/2025. Perform cognitive assessment frequently, initiated 7/29/2025. 2. Resident is at risk for falls related to psychoactive drug use, initiated 7/9/24, revised 1/22/2025. Goal with target date 9/22/25: Resident will be free of falls through the review date. Interventions included:Encourage resident to allow staff to pick items up off of the floor for him. He often prefers to do things himself despite the safety risks, initiated 12/30/2024. Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated: 7/9/2024. Ensure a safe environment that is free of clutter and has adequate lighting. Clean up spills promptly, initiated 7/9/2024. Resident prefers to wear gripper socks in facility, and not shoes, initiated 9/9/2024. PT/OT (Physical Therapy/Occupational Therapy) to eval and treat, initiated 1/24/2025. OT eval and treat related to fall 6/2/25 to aid in strengthening, initiated 6/2/2025.Sign placed in room to encourage resident to call for help making his bed, initiated 4/12/2025.Tape added to feet of dining room chair to help grip the floor; Yellow tape to mark his dining room chair, initiated 1/24/2025. 3. Resident has potential to demonstrate behaviors and/or experience a fall after events such as: Dr. appointments, facility gatherings, family visits, initiated 8/11/2025. Goal with target date 9/22/25: Resident will demonstrate effective coping skills through the review date, and goal with target date 9/22/25: Resident will not harm self or others through the review date. Interventions included: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later, initiated 8/11/2025. 4. The resident had an actual fall 6/10/25, 6/25/25, 6/30/25, 7/3/25, 7/8/25, 7/28/25, 8/16/25, 8/18/25, 8/21/25, 8/30/25, 9/1/25, 9/2/25, 9/30/25, 10/22/25, initiated 7/2/25, last revised 11/4/25. Goal with target date 9/22/25: Resident will have no injuries from falls through next review. Interventions included:Encourage resident to keep his door open when in his room, initiated 10/1/2025.Encourage resident to use safe transferring techniques when getting out of dining room chair, initiated 7/2/2025.Resident uses the same dining room chair, indicated by name tag on the back of the chair, initiated 7/2/2025.Medication Evaluation due to recent fall. Resident has had increased behaviors due to Hospital removing routine medication, initiated 8/30/2025. Night light in resident's room, initiated 7/24/2025. Observe for/document/report to MD signs or symptoms of pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, initiated 7/8/2025. Obtain vital signs per policy/as ordered, initiated 7/2/2025. Orthostatic B/Ps obtained due to recent fall and loss of balance, initiated 7/29/2025.Pharmacy to review medications to help identify root cause of fall, initiated 7/2/2025.Prefers independence with bathing, dressing, hygiene, grooming, toileting, ADLs (Activities of Daily Living) and mobility as the resident is noncompliant with assistance with ADLs, initiated 10/1/2025, revised on 11/4/25.PT consult for strength and mobility, initiated 7/2/2025.Redirect resident from unsafe ambulation when distressed, initiated 8/21/2025. Requests staff offer assistance only when asked or during scheduled checks, initiated 10/1/2025. Resident experiencing increased fall risk potentially related to emotional distress and decreased focus following recent family trauma. 1-on-1s with social services provided, initiated 9/2/2025.Resident is at risk for falls and is non-compliant with established fall interventions (assist with transfers, call light use, walker use, etc.). Prefers to be independent and often attempts unsafe mobility, initiated 9/30/2025.Resident refused to keep cue signage posted in room, removing or taking down signs. Resident educated on purpose of cue sign and potential fall risk. Resident verbalized preference for no signage and wishes to maintain privacy/independence, initiated 6/30/2025.Resident to utilize wheelchair independently until after strengthening from upcoming surgery to the left ankle, initiated 10/22/2025, revised 11/4/2025. Staff removed empty muscle-rub tubes being used as a door stopper to eliminate environmental clutter and prevent tripping hazards. Resident educated on fall risk associated with storing items on the floor or near door. Resident verbalized understanding. Staff will monitor environment and remove unsafe items as noted. Purposeful rounding initiated to ensure needs met and reduce urgency to move around unsafely, initiated 6/25/2025. The resident's clinical record revealed he had 20 falls between 6/10/25 and 10/24/25. Ten (10) of the 20 falls occurred in the resident's room and were unwitnessed, 3 of the 10 falls required hospitalization related to the extent of injuries that resulted from the falls on 9/2/25, 9/13/25 and 10/24/25.On 9/2/25 at 2:38 p.m., the resident was found on the floor on his back in his room, blood to shirt and hair noted. Resident stated he tried to stand to put shorts on, lost balance and fell. Laceration on top of left scalp measured approximately 3.5 centimeters (cm) by 0.5 cm. The resident sent to the hospital and then transferred to a tertiary hospital for treatment of subdural hematoma (bleeding on the brain) and closed fracture of vault of skull (skull fracture) from the fall. Physician orders on the 9/8/25 hospital Discharge Summary that directed the resident's return to the facility on 9/8/25, specifically instructed staff:Continue routine assessment of cognition and limit polypharmacy (use of multiple medications with same purpose) as feasible.Discontinue medications with risk for falls including Gabapentin (anticonvulsant medication with analgesic properties), Tramadol (controlled narcotic analgesic) and Tizanidine (a skeletal muscle relaxer). Discontinue Sertraline (antidepressant) since patient is already on Duloxetine (antidepressant). Physician orders transcribed after the resident's 9/8/25 return to the facility included:Tramadol 50 milligrams (mg) administered oral 4 times a day, order reinstated on 9/11/25 and continued through 10/24/25.Sertraline 100 milligrams (mg) administered oral daily, order reinstated on 9/12/25, order for Fluoxetine was discontinued.Gabapentin 300 mg administered oral 3 times a day, order reinstated on 9/25/25 and continued through 10/24/25.And the facility initiated new medication orders that increased the resident's risk for falls that included:Melatonin (a hormone with sedative/hypnotic properties) 5 mg administered oral daily at bedtime, order started 9/11/25.Ramelteon (a Melatonin receptor agonist, to enhance the effects of Melatonin) 8 mg administered oral daily at bedtime, order started 9/8/25.The resident's record revealed from the 20 falls previously mentioned in this document, 7 of the 20 occurred between 9/13/25 and 10/24/25, with 3 of the 7 unwitnessed and occurred in the resident's room.On 9/13/25 at 6:50 a.m., the resident was found on the floor in his room with walker beside him, frank bleeding from bridge of nose with laceration present. hospitalized until 9/14/25 with diagnoses that included fall, nasal laceration and subdural hematoma.On 10/24/25 at 7:26 a.m., the resident was found on the floor in his room, on his back next to the bed, pillow under head, blanket on top of him. Pupils unequal in size and non-reactive to light (abnormal finding). Sent to hospital and transferred to a tertiary hospital where he remained in an intensive care unit at the time of this investigation, with diagnoses that included right 6th through 10th rib fractures, pneumo/hemothorax (collapsed lung/lung filled with blood), acute compression fracture of the 10th thoracic vertebrae and right greater tuberosity fracture (shoulder). Interviews with the resident's family and Power of Attorney (POA) revealed:11/4/25 at 4:25 p.m., a family member stated the resident had many repeated falls while at the facility and injured several times. The facility staff does not listen to their family in regards to the resident's safety, they have asked for fall interventions such as moving him closer to the center of the building, fall mats, and someone to sit with him to provide 1 to 1 supervision when needed and the facility has not done any of those things, he continued to fall and currently hospitalized because of a fall. The family member stated they had not been invited to participate in a care conference or care plan meeting for the resident and that would be an opportunity to have some input for his safety.11/4/25 at 5:08 p.m., the POA stated the resident was still hospitalized for the injuries from his most recent fall at the facility, and thought the resident was overdosed or received too much sedative medication and that was why he had so many falls. They visited the resident 1 day in September and he slept sitting up in a chair from 10:11 a.m. to 3:45 p.m. During that time period staff did not wake him up for lunch or any other purpose. The POA stated they didn't think the resident received the care that he needed and they haven't done much to prevent his falls. The POA denied that they had been invited to participate in the resident's care conferences or care plan meetings, and when they tried to ask staff about the reasons for his falls, if the falls could be related to his medications the nurse said the doctor ordered his medication and he had to have it. Staff interviews revealed:On 11/5/25 at 5:31 a.m. Staff A LPN (Licensed Practical Nurse), stated she worked the night shift and knew the resident well. During the night time the resident usually stayed in his room, with the door shut, he wanted the door shut and insisted on that. Staff tried to check on him as they were able to during the night, they had to be careful because he would get angry if they woke him up. Staff A stated a fall matt placed on the floor in his room would be a tripping hazard for the resident and would cause a fall, as the resident got up on his own spontaneously. They did try to keep an eye on him at night, but it was difficult with his door shut.On 11/5/25 at 1:13 p.m., Staff B, LPN, stated she usually worked the 6 a.m. to 6 p.m. day shift, knew the resident well, he didn't understand his physical limitations and that contributed to many of the falls that he had, he wanted to be independent. He'd been having problems with his left foot/ankle hurting a lot, that effected how he could bare weight and thought that had also contributed to his falls. When he's in his room he insisted that the door remain shut, it was hard to know when he was up as he would get himself up and didn't call for assistance. When asked if she thought a baby monitor placed in his room to monitor for sound could help staff know when he was getting up or starting to move around Staff B thought that was a good idea, staff could listen and have a better chance of get into his room and assist him before he fell or was unsteady on his feet.Staff D, CNA (Certified Nursing Assistant) and Staff E, CNA were interviewed together on 11/5/25 at 5:38 a.m., both stated they regularly worked on the night shift and knew the resident well. He slept in his bed in his room, and wanted his door kept shut. He could get up independently and did so, he used his call light sometimes, and sometimes he called with his phone if he wanted something. They tried to check on him when they did rounds, around every 2 hours, they had to be careful not to wake him and it was difficult to open his door without waking him. He could get agitated if they woke him up during the night. 11/5/25 at 8:40 a.m., Staff C, CNA, stated she usually worked on the day shift but also worked during the evening, knew the resident, he wanted to be independent, he let you know if he needed or wanted help which wasn't very often. Sometimes he would let her put his support hose on. If you tried to help him he would get upset/angry and wouldn't accept the assistance. He was supposed to use a walker, sometimes he would forget it and they were supposed to remind him to use it, he got angry sometimes when they did that. When he was in his room he wanted his door closed and he didn't want to be disturbed.Staff G, Director of Nursing (DON), interviewed 11/5/25 at 8:27 a.m. stated she had been the DON there since June, 2025, knew the resident well, he was stubborn, but he was alert and oriented. When he was hospitalized after a fall in September the hospital took away all his psych medications and that made his mood/agitation/behaviors worse. The resident would sit in the common areas throughout the day to people-watch as he was very social, and staff could watch him that way as he only went to his room to use the bathroom or to lay down. When he was in his room with the door closed staff were supposed to check on him when they did rounds, every couple hours. The resident was very independent and he did not want assistance, he was vocal about that and would become agitated.11/5/25 at 1:03 p.m. Staff F, Activity director stated when resident's are due for care conferences she identified who the resident's responsible parties were, met with the resident and asks if they wanted them to participate in their upcoming care conference and if so she invited them. Each time she met with Resident #4 he didn't want his family to participate in his care conferences and they had not been invited to them.11/5/25 at 3:30 p.m., the Administrator stated the resident had a sign that he made himself and had put on his door that said to keep his door shut and had an expletive on it, she removed the sign while he was in the hospital. When asked about interventions related to his falls and fall prevention, the Administrator stated they did move him to a room in a busier hallway, there's a lot of traffic in that hall related to the residents there, their care requirements and there are more observations of him that way. The DON stated she thought the problems with his left ankle and associated pain were making him more prone to falls, as weight baring was painful and every time they had an appointment with an orthopedic physician for him to get it taken care of he'd have another fall or hospitalized and they had to reschedule the appointments. The resident had hardware in his ankle that required adjustment during a surgery in order to resolve the problem and the resident wanted to have that surgery. The Administrator and DON did not have a response when asked specifically about what had been done to increase the direct supervision of the resident related to his falls, as many of the falls occurred when the resident was in his room with the door closed, and staff allowed the resident to keep the door closed.

Based on professional certification review and staff interviews, the facility failed to employ a qualified person to serve as the Dietary Manager in the absence of a full-time dietitian. The facility reported a census of 30 residents. Findings include:As of 9/2/25, the facility lacked documentation that Staff E Dietary Manager(DM) completed the Certified Dietary Manager(CDM) course.On 9/3/25 at 11:00 a.m., Staff E stated she did not complete the CDM course. She stated she started in August 2025 and would finish in December 2025. On 9/4/25 at 12:27 p.m., the Administrator stated the DM should be certified. She stated she was enrolled last year but did not finish and was currently in the course again. She stated she did not have a policy regarding DM qualifications.

Based on review of Quality Assurance and Performance Improvement(QAPI) meeting documentation, policy review, and staff interview, the facility failed to maintain documentation that the facility carried out Quality Assurance(QA) activities to develop, implement and evaluate corrective actions or performance improvement activities and take action to conduct structured, systematic investigations, analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 30 residents.Findings include:The Centers for Medicare and Medicaid Services(CMS) 2567, dated 9/26/24, listed, in part, the following concerns from a Recertification Survey, and Complaint investigations: F658, F695, F801, F865, F887.The CMS 2567, dated 3/24/25, listed, in part, the following concerns from an investigation of a Facility Reported Incident: F550The current survey, conducted 9/2/25-9/4/25, also identified the above concerns (see F550, F658, F695, F801, F865 and F887). On 9/4/25 at 2:31 PM, the Administrator reported she and the Director of Nursing (DON) immediately pulled the previous 2567s, recognized the concerns in QAPI, investigated to find the root cause and provided staff education. The Administrator reported being in her position for 2 months. On 9/4/25, review of QAPI meeting documentation since the previous survey to present revealed a lack of documentation of QAPI activities in relation to the above identified deficient practices. The facility lacked evidence of an ongoing QAPI program related to the above areas including a process of addressing how the committee would conduct the activities necessary to identify and correct quality deficiencies. The facility lacked documentation of monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revision as needed. Review of the facility policy, titled Quality Assurance and Performance Improvement policy, dated 9/2022, revealed the facility would maintain documentation and evidence of systematic identification, reporting, investigation, analysis and prevention of adverse events. The facility would document the development, implementation and evaluation of corrective action or performance improvement activities through a data-driven QAPI program that focused on the indicators of the quality of life and quality of care.

Based on record review, resident interviews, resident council minutes, staff interviews, and policy review the facility failed to provide sufficient nursing staff to ensure resident needs were met in a timely manner. During the survey 4 of 5 residents reviewed for call lights (Residents #6, #8, #11, #12) reported waiting as long as 90 minutes for call lights to be answered. The facility reported a census of 30 residents. Findings include:1) The Minimum Data Set (MDS) for Resident #6 dated 8/23/25 documented diagnoses of epilepsy, schizophrenia, Post Traumatic Stress Disorder (PTSD), and repeated falls. The resident's Brief Interview for Mental Status (BIMS) score was recorded as 15/15 which indicated intact cognition. Section GG documented the resident needed set up assistance with lower body dressing and substantial to maximal assistance with bathing and tub/shower transfers. The resident was marked as frequently incontinent. On 9/2/25 at 4:01 PM the resident stated sometimes she spent a half an hour or more waiting for help to use the bathroom or get cleaned up. She reported it took a half hour for staff to answer her light so she could use the toilet that morning. When asked how she knew it was a half hour, the resident lifted up her watch and pointed to it. 2) The MDS for Resident #8 dated 7/10/25 listed diagnoses of stroke, paraplegia, epilepsy, and bipolar disorder. The resident's BIMS was documented as 14/15 which indicated intact cognition. Section GG indicated the resident used a wheelchair and needed substantial/maximal assistance with toileting, personal hygiene, bed mobility, and tub/shower transfers. On 9/2/25 at 4:08 PM Resident #8 reported lights could take 30 minutes or longer and stated staff just didn't take the time to make sure the resident had all they needed before they left the room. She stated she was lucky if they got 5 minutes. She also said call lights were often longer than 15 minutes and she could tell by watching the time on her phone. 3) The MDS for Resident #11 dated 8/10/25 listed diagnoses of chronic kidney disease, anxiety disorder and depression, and unsteadiness on their feet. The resident's BIMS was documented as 13/15 which indicated intact cognition. Section GG indicated the resident used a wheelchair and was dependent on staff assistance for toileting, personal and oral hygiene, dressing, bed mobility, and transfers. On 09/02/2025 at 11:08 AM Resident #11 stated she was not happy with the care. She indicated her call light that morning was long, well over 15 minutes, and the night shift light times were the worst. She reported call light wait times as long as 1.5 hours. The resident knew they were that long because she had a clock on her wall and watched the time. She pointed out the commode in her room and said even with that staff took so much time she didn't always make it. She stated staff were kind, there were just not enough of them to help everyone when they needed it. The resident gave the example she thought staff were supposed to come see if she had to go to the bathroom every 2 hours or so but they did not do that. 4) The MDS for Resident #12 dated 8/28/25 listed diagnoses of heart failure, UTI (Urinary Tract Infection) in the past 30 days, and schizoaffective disorder. The resident's BIMS was documented as 15/15 which indicated intact cognition. Section GG indicated the resident used a wheelchair and needed substantial/maximal assistance with transfers to her chair, bed, and toilet. On 09/02/2025 at 12:31 PM the resident stated she had a call bell not a call light and that other people had them too. She stated they all made the same sound with no distinction, so staff don't know where to go. She reported she has had to wait a half hour or more to get help. She used her cell phone to monitor the time. That morning she pulled the cord in her bathroom and waited almost exactly 20 minutes. The resident also reported times she was in the hallway, saw call lights go on for other residents, and saw staff remain seated at the nurses station not answering them right away even though they could see the light indicator.A document titled Resident Council Meeting Summary dated May 2025 documented residents identified for nursing that participants needed the weekend aides to be quicker answering call lights. The document did not include follow up with the residents.During an interview on 9/3/25 at 5:00 PM Staff A, Certified Medication Aide (CMA) reported staff were trained to answer call lights within 15 minutes. She indicated there were more residents in the facility with behavioral needs now and sometimes there were sacrifices on their end to address all of the needs. She stated that answering lights took longer as those needs increased, especially second shift. She confirmed residents had complained about the call lights, some about how long it took to answer them and some about not being able to spend enough time with them.On 9/4/25 at 9:05 AM Staff B, Licensed Practical Nurse (LPN) confirmed staff were trained to answer call lights within 15 minutes. She stated anyone could answer a call light and if they were on for more than 15 minutes it was probably because the resident wanted it kept on until the cares were done. She was not aware of the facility doing call light audits.During an interview on 9/4/25 at 10:04 AM the Director of Nursing (DON) stated they tried to get to call lights faster than 15 minutes. She stated resident complaints about call lights should include completing a grievance with follow up education for the staff. The DON reported it was hard to have a toileting program due to resident behaviors. She confirmed there had not been call light audits since she had been there.A policy titled Call Lights: Accessibility and Timely Response dated 12/1/23 documented all staff members who saw or heard a call light or the call system were responsible for responding. If the staff member could not provide what the resident needed, they should notify appropriate personnel. Staff were directed to first turn off the call light, then listen to the resident's request and respond accordingly. If further assistance was needed, the staff responding to the light were to inform the appropriate personnel or summon additional help using the call light and stay with the resident until help arrived.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to interact with a resident in a respectful manner for 1 of 3 residents reviewed for dignity(Resident #26). The facility reported a census of 30 residents.Findings:The Quarterly Minimum Data Set(MDS) assessment tool, dated 7/17/25, listed diagnoses for Resident #26 which included heart failure, diabetes, and hemiplegia(one-sided paralysis) and listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 8/19/25, stated the resident had chronic obstructive pulmonary disease and directed staff to administer aerosol or bronchodilators(medications that treated breathing conditions) as ordered. On 9/4/25 at approximately 8:45 a.m., Staff A Certified Medication Assistant(CMA) provided the resident her Symbicort inhaler(a medication inhaled which helped with breathing conditions) and the resident inhaled 2 puffs. After this, Staff A provided the resident a glass of water and the resident swished her mouth and swallowed the water. The resident then said she had to spit and spit into a tissue. Staff A then turned to the State Agency(SA) with a disgusted look on her face as she gestured with her head toward the resident and said ew loogie. The staff member and the resident were near the dining room where other residents and staff were present. The facility policy Resident Rights, revised June 2023, stated employees shall treat residents with kindness, respect, and dignity. On 9/4/25 at 11:02 a.m., when queried regarding Staff A's comment and behavior toward the resident, the Director of Nursing(DON) stated it was not appropriate.

Based on observation, clinical record review, policy review, and staff interivew, the facility failed to ensure a resident rinsed their mouth in accordance with professional standards for 1 of 1 residents reviewed for the administration of an inhaler(Resident #26). The faciltiy reported a census of 30 residents. Findings:The Quarterly Minimum Data Set(MDS) assessment tool, dated 7/17/25, listed diagnoses for Resident #26 which included heart failure, diabetes, and hemiplegia(one-sided paralysis)and listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Provision of Physician Ordered Services, dated 12/23, stated the purpose of the policy was to provide physician ordered services according to professional standards of quality. The September 2025 Medication Administration Record(MAR) listed a 3/24/22 order for Symbicort Aerosol 160-4.5 micrograms[mcg] (budesonide-formoterol fumarate, an inhaler which treats lung conditions) 2 puffs twice daily. The MAR directed staff to ensure the resident rinsed their mouth with water after the inhalation and not to swallow.The Symbicort Highlight of Prescribing Information, retrieved from https://drd9vrdh9yh09.cloudfront.net/50fd68b9-106b-4550-b5d0-12b045f8b184/a4b62ab8-1314-4583-91b4-294ec239f790/a4b62ab8-1314-4583-91b4-294ec239f790_viewable_rendition__v.pdf on 9/4/25 at 1:50 p.m. stated the medication could cause infections of the mouth and throat and directed staff to advise the resident to rinse their mouth with water without swallowing after inhalation to help reduce the risk. On 9/4/25 at approximately 8:45 a.m., Staff A Certified Medication Assistant(CMA) provided the resident her Symbicort inhaler(a medication inhaled which helped with breathing conditions) and the resident inhaled 2 puffs. After this, Staff A provided the resident a glass of water and the resident swished her mouth and swallowed the water. Staff A did not provide her a cup to spit into or encourage her to spit out the water she swished with. On 9/4/25 at 11:02 a.m., the Director of Nursing(DON) stated staff should have residents swish and spit after utilizing a Symbicort inhaler. She stated with Resident #26 they should remind her to spit out the water.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to notify the physician of a resident's refusal of an ordered diet and failed to carry out specialized Speech Therapy(ST) services for a diagnoses of dysphagia(difficulty swallowing) for 1 of 2 residents reviewed for a change in condition(Resident #10). The facility reported a census of 30 residents. Findings include:The Quarterly Minimum Data Set(MDS) assessment tool, dated 8/16/25, listed diagnoses for Resident #10 which included dysphagia(difficulty swallowing), Parkinson's disease(a disease which caused tremors and lack of mobility), and anxiety disorder. The MDS stated the resident had a mechanically altered diet and listed his Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The facility policy Provision of Physician Ordered Services dated 12/23, stated the facility would provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. A 7/16/25 5:40 p.m. Nursing Note stated the resident reported that he ate roast beef for lunch and it felt like it was caught in his esophagus. A 7/17/25 2:52 p.m. Nursing Note stated the resident requested a scope due to the roast beef which was stuck and stated he had this happen his whole life. The resident's provider ordered a transfer to the ER for evaluationA 7/17/25 6:26 p.m. Nursing Note stated the resident would transfer to another hospital for a scope. A 7/19/25 5:02 a.m. Nursing Note stated the resident had an endoscopy(a scope inserted through the mouth to visualize the upper digestive system) completed and was on a liquid diet for two weeks and then would advance to a pureed diet. A 7/24/25 Care Plan entry stated the resident had a swallowing problem.An 8/5/25 Care Plan entry stated the resident refused his pureed diet and wanted a mechanical soft diet. An 8/5/25 Fax cover Sheet from the facility to the provider stated the resident completed 2 weeks of a full liquid diet and started a pureed diet today. The form inquired how long the resident was to have a pureed diet before advancing to a regular diet. The provider then inquired if they had Speech Therapy (ST) and directed ST to advance the diet if able. A note on the fax stated the resident had an order for ST. On 9/3/25 at 11:25 p.m., during the noon meal service, Staff D [NAME] prepared a mechanical soft meal consisting of ground chicken alfredo for Resident #10. The Dietary Manager stated the resident refused his ordered pureed diet so they provided him with mechanical soft foods. The facility lacked documentation of the initiation of Speech Therapy (ST) services and lacked communication to the provider that the resident refused his ordered pureed diet. On 9/4/25 at 11:02 a.m., the Director of Nursing(DON) stated the provider wanted the facility to follow up with ST for the resident. She stated she was not sure how often ST came into the building. On 9/4/25 at 1:36 p.m., Staff C Occupational Therapy Assistant(OTA) stated she received an order for ST at the end of July or the beginning of August and had not been able to get a therapist to visit.

Based on record review, resident interviews, staff interviews, and the facility policy, the facility failed to adequately supervise a resident after they went outside without oxygen for 1 of 1 residents reviewed for elopement (Resident #22). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS revealed medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The MDS indicated the resident utilized oxygen therapy. The Care plan revealed a focus area revised on 11/13/24 for a diagnosis of COPD and is at risk for shortness of breath, impaired breathing and respiratory infections and utilizes O2. The interventions dated 7/9/24 indicated to administer supplemental oxygen (02) as ordered per physician. The Care Plan revealed a focus area revised on 11/13/24 for impaired cognitive function and/or impaired thorough processes as evidenced by short/long term memory deficit, impaired decisions making and/or impaired ability to understand others related to a diagnosis of dementia. The interventions dated 7/8/24 indicated cueing, orienting and supervise as needed. The BIMS exam conducted on 3/24/25 resulted in a score of 2 out of 15, which indicated cognition severely impaired. The EMR revealed the following Physician Orders: a. ordered 4/8/25- Oxygen via n/c 1-5L PRN to keep oxygen greater than 89%.The BIMS exam performed on 4/10/25 resulted in a score of 3 out of 15, which indicated cognition severely impaired. The Weather on 7/24/25 around the facility was the following:a. 1:52 PM: 82 degrees Fahrenheit (F) with 76% humidityb. 2:23 PM: 81 degrees F with 77% humidityc. 2:52 PM: 82 degrees F with 76% humidity The Behavior Note dated 7/24/25 at 3:12 PM, revealed this nurse was summoned by aide of resident was wanting to go outside to the back patio and was refusing to stay indoors due to heat and humidity. Aide assisted resident out to the back door and resident utilized her four wheeled walker and went ot sit on the bench near the patio door. Resident was persistent on going outside and refusing to come in. She stated I just want some fresh air. Educated resident that due to her COPD that she will need her oxygen as she has been having increase difficulty breathing and the humidity will make her breathing worse. Resident stated she did not care and she was fine. Notified aide to monitor resident and will try again later. Nurse she also attempted to talk to resident and she refused to come in. Resident was offered water frequently and oxygen but refused. Notified her to monitor resident for behaviors and place resident on Hot chart. The Nursing Note dated 7/24/25 at 4:20 PM, revealed this nurse notified at this time by another resident and CNA's (Certified Nurse Aide) that resident was no longer sitting outside where she had been. CNA's went out and saw resident walking behind the facility on the side walk with her walker. CNA's tried to get resident to turn around and come back in but resident refused and just kept walking being aggressive towards CNA with her walker if they got in her way. CNA's walked with resident back by the kitchen entrance and resident sat on a bench there. This nurse brought out resident's O2 (oxygen) tank and offered her water. After a little bit of time this nurse and staff were able to get resident to walk inside. DON (Director of Nursing) and Administrator notified of above. Residents daughter returned call to facility and this nurse also notified daughter of the above information with reassurance that resident is without injury and vitals are stable and she will continue to be monitored closely and observed for any changes or concerns. The Incident Note dated 7/24/25 at 5:52 PM, revealed received a call from [name redacted] ADON (Assistant Director of Nursing) at 4:15 PM regarding resident had left the facility grounds by another resident and staff went to go encourage her to return to the facility. [Name redacted] reported resident was refusing to come back into facility at this time. Notified [name redacted] will return to facility. Resident was then able to be redirected back to facility. Nurse obtained oxygen for resident and resident was assisted by aides back inside and into dining room chair. This nurse arrived shortly after. Vitals obtained and resident assessed. Resident had an elevated b/p (blood pressure) of resident reports to have bilateral edema in feet. This nurse assessed feet and noticed to have non-pitting edema. Resident denied having any pain or discomfort. Spoke with on call physician [name redacted] ARNP (Advanced Registered Nurse Practitioner) and notified of incident and obtained a verbal order for UA (urinalysis) with C & S (Culture and sensitivity). L M (left message) with daughter [name redacted] to return call. Notified [name redacted] with [name redacted] hospice of incident. Notified aides to start resident on 15 minute checks until further reassessment. EMar-Medication Administration Note dated 7/24/25 at 7:12 PM documented the following; Ipratropium-Albuterol inhalation Solution 0.5-2.5 (3)milligrams/3milliliters 1 vail inhale orally two times a day for wheezy/shortness of breath administered.The BIMS exam conducted on 7/24/25 at 8:44 PM by the DON and resulted in a 13 out of 15, which indicated cognition intact.The Behavior Note dated 7/25/25 at 4:24 AM, revealed resident eloped from the facility prior to supper. She has not attempted to leave the facility since this nurse came on to shift at 1800. She received her scheduled Morphine and has been resting quietly in bed all shift. BP (blood pressure) 149/69 T (temperature) 97.2 P (pulse) 75 R (respirations) 18 O2 (oxygen) 96% 4L/NC (liters/nasal cannula). Resident continues on 15 minute checks. During an interview on 9/3/25 at 4:40 PM, Staff K, Business Office Manager (BOM) stated Resident #1 told staff one of the residents was on the loose. Staff K stated no one was with Resident #22 went she started walking towards the back of the building and Resident #22 didn't have her oxygen on. Staff K stated it took 5 staff to get Resident #22 back into the building. During an interview on 9/3/25 at 5:16 PM, Staff A, Certified Nurse Aide (CNA) stated Resident #22 pushed her way outside and it was really hot that day. Staff A stated she hollered for the DON and the DON said Resident #22 could sit out there. Staff A stated she had to get residents up for dinner so every time Staff A got someone up, Staff A would go and check on Resident #22. Staff A stated Staff L, CNA came in around 3:30 PM and Resident #1 told Staff L that Resident #22 left. Staff A stated Resident #22 used her walker to walk around the building and Staff A and other staff went outside to get Resident #22. Staff A stated Resident #22 was outside between an hour and an hour and half by herself. During an interview on 9/4/25 at 8:55 AM, Staff B, Licensed Practical Nurse (LPN) queried if Resident #22 cognitive and Staff B stated not all the time. Staff B stated Resident #22 doesn't always wear her oxygen and when Resident #22 didn't wear her oxygen her pulse oximetry dropped. Staff B stated Resident #22 should wear oxygen if she was outside. Staff B stated she was not aware Resident #22 was outside that day and when Staff B found out, Staff B took Resident #22 oxygen concentrator outside and checked her pulse oximetry and she thought it read in the 70s or 80s, but couldn't remember exactly. Staff B stated Resident #22 coherent when Resident #22 oxygen was low. Staff B stated Resident #22 should have staff with her when outside. During an interview on 9/4/25 at 9:18 AM, Staff L, CNA stated Resident #22 might not be able to sit outside without supervision. Staff L stated her and Staff A went outside to help Resident #22 come in. Staff L stated some days Resident #22 knows everything and other days, Resident #22 was confused. Staff L stated Resident #22 could be outside if someone watched her through the window or sat outside with Resident 22. Staff L stated Resident #22 needed her oxygen all the time and Resident #22 needed oxygen when she was outside. During an interview on 9/4/25 at 10:03 AM, the DON stated Resident #22 cognitively intact and independent. The DON stated Resident #22 not always cognitive, but at the time of the incident, Resident #22 was based on her BIMS score. The DON stated She was not concerned with Resident #22 being outside by herself except for her walking safety. The DON stated Resident #22 wanted to go outside on the hot day and refused her oxygen. The DON stated she was not at the facility the whole time while Resident #22 was outside, but she came back to the facility and did assessments on her after Resident #22 came back in. During an interview on 9/4/25 at 11:13 AM, Resident #1 stated he saw Resident #22 start walking around the building and Resident #1 alerted staff. During an interview on 9/4/25 at 1:03 PM, Staff M, CNA stated when Resident #22 didn't wear her oxygen, Resident #22 got more confused. Staff M stated Resident #22 should not be outside without her oxygen because she got more confused and short of breath when she walked down the hallway without oxygen. During an interview on 9/4/25 at 1:09 PM, Staff N, CNA queried if Resident #22 cognitive and Staff N stated it varied. Staff N asked if Resident #22 could be outside unsupervised and Staff N stated no because she needed oxygen and to make sure Resident #22 didn't go anywhere. Staff N stated Resident #22 was confused that day she went outside and earlier in the day Resident #22 kept trying to go outside, but they didn't let Resident #22 got unsupervised. Staff N stated Resident #22 was confused that day and not herself. During an interview on 9/4/25 at 1:25 PM, Staff J, CNA queried on if Resident #22 could be unsupervised and Staff J stated she didn't think Resident #22 could. Staff J stated she didn't think it would be a good idea for Resident #22 to go outside by herself for a couple of months now. Staff J stated she would of asked the nurse about Resident #22 not having oxygen while outside and then she would of stayed with her or checked on her. Staff J stated she would of kept eyes or had someone else keep eyes on Resident #22 while she was outside without oxygen. During an interview on 9/4/25 at 1:29 PM, Staff A, CMA stated she believed Resident #22 would be alright unsupervised except for not having her oxygen and with the weather being so hot that day. During an interview on 9/4/25 at 2:15 PM, the DON stated she performed a BIMS after Resident #22 went outside because she always did thorough assessment on residents with any changes. The Facility Oxygen Administration Policy (no date identified) revealed: a. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration.b. Review the resident's care plan to assess for any special needs of the resident.c. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. The Facility Accidents and Incidents- Investigating and Reporting dated July 2017 revealed: a. All accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises shall be investigated and reported to the administrator. b. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.

Based on record review, staff interviews, and the facility policy, the facility failed to verify oxygen orders with the hospice provider for 1 of 1 residents reviewed oxygen therapy orders (Resident #22). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS revealed medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The MDS indicated resident utilized oxygen therapy. The Care plan revealed a focus area revised on 11/13/24 for a diagnosis of COPD and is at risk for shortness of breath, impaired breathing and respiratory infections and utilizes O2. The interventions dated 7/9/24 indicated to administer supplemental oxygen (02) as ordered per physician. The EMR revealed the following Physician Orders: a. ordered 4/8/25- Oxygen via nasal canula (n/c) 1-5L as needed (PRN) to keep oxygen greater than 89%. b. ordered 8/18/25- Oxygen via n/c 3L PRN to keep oxygen greater than 90%. The Hospice Team Plan revealed the following order start date of 6/9/25a. Oxygen 2-4 Liter continuous Not otherwise specified (NOS) dyspneaDuring an interview on 9/4/25 at 2:17 PM, the Director of Nursing (DON) queried on the oxygen orders from hospice dated 6/9/25 and the DON stated she hadn't looked at them. The DON asked how they collaborated care with hospice and the DON stated hospice usually sent them to the provider and then the orders were sent to the facility. The DON stated she requested for a specific order for one setting for the oxygen instead of the variation of oxygen liters. The DON stated it was her fault because she kept the PRN (as needed) on the order. The Facility Oxygen Administration Policy (no date identified) revealed: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administrationReview the resident's care plan to assess for any special needs of the resident. The Facility Hospice Services Policy (no date identified) revealed: A provision that when facility staff are responsible for the administration of prescribed therapies, including those determined appropriate by hospice and defined in the hospice plan of care, our facility staff may administer immediately when the facility becomes aware of the alleged violation.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure the medication error rate did not exceed 5%. The facility's medication error rate calculated as 7%. The facility reported a census of 30 residents.Findings include:The Annual Minimum Data Set(MDS) assessment tool, dated 7/10/25, listed diagnoses for Resident #8 which included anxiety, hemiplegia(paralysis affecting one side of the body), and paraplegia(paralysis affecting the lower body) and listed her Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. A Care Plan entry, revised 2/1/24, stated the resident was a smoker.The September 2025 Medication Administration Record(MAR) listed the following orders:a . 7/21/25 Famotidine(a medication used to reduce stomach acid) tablet 20 milligrams(mg) two times per day.b. 7/16/25 nicotine patch(assisted in nicotine cessation) 24 hour 14 mg/hour 1 patch one time a day. On 9/3/25 at 8:16 a.m., Staff A Certified Medication Assistant(CMA) administered Resident #8's morning medications. Staff A stated that she did not have the resident's nicotine patch. Staff A also failed to administer the resident's Famotidine. A 9/3/25 eMar Medication Administration Note stated the facility waited for the resident's nicotine patch to come in.The facility's medication administration error rate calculated as 7%On 9/4/25 at 11:02 a.m., the Director of Nursing(DON) stated staff should have called the pharmacy if a medication was not available. She stated with regard to the omission of the medication, staff should check the medications better. The undated facility policy Medication Administration, stated staff would administer medications in accordance with professional standards of practice and directed staff to follow the manufacturer's product information for inhalers.

Based on record review, staff interviews, and the facility policy, the facility failed to administer a resident their prescribed controlled medication for 1 of 6 residents reviewed for medication administration (Resident #17). The facility reported a census of 30 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 scored a 10 out of 15 on the Brief Interview for Mental Status, which indicated cognition moderately impaired. The MDS revealed diagnoses for anxiety disorder, bipolar disorder, and seizure disorder or epilepsy. The MDS indicated the resident prescribed antipsychotics, antianxiety, and antidepressant medications. The Care Plan revealed a focus area revised on 9/3/25 for use of antianxiety medications related to a seizure disorder. The interventions dated 9/3/25 directed staff to give the resident anti-anxiety medications as ordered by the physician.The EMR (Electronic Medical Record) revealed the following Physician Orders: a. Ativan Oral Tablet 0.5 MG (Lorazepam) Controlled DrugGive 0.5 mg by mouth two times a day for seizure activity- ordered on 8/11/25The EMR Physician Orders lacked documentation of an order for Oxycodone (opioid analgesic/narcotic) for Resident #17.The Nurse Note dated 8/14/25 at 7:50 AM, documented the resident was given a oxymoron (Oxycodone) instead of her Vatican (Ativan) at hs (bedtime). Dr. and [NAME] (Director of Nursing) notified. Resident monitored and had no adverse reaction. The Incident Note dated 8/19/25 at 1:49 AM, revealed the resident was given and Oxy instead of and Ativan. Dr. and DON notified. No adverse reactions observed. During an interview on 9/4/25 at 11:46 AM, Staff I, Licensed Practical Nurse (LPN) queried on giving Resident #17 an Oxycodone instead of Ativan and Staff I stated she didn't remember making the medication error and it got kind of crazy at night. Staff I asked how the narcotics were stored, Staff I stated all the residents had individual cards with their names on the cards and the narcotics were locked in the narcotic box in the medication cart. During an interview on 9/4/25 at 2:03 PM, the Director of Nursing (DON) queried on the medication error with Resident #17 and the DON stated Resident #17 was given another resident's Oxycodone instead of Resident #17 Ativan. The DON stated she just did a huge skilled assessment with staff on the 5 rights of medication administration. The DON queried on what the 5 rights were and she stated right dose, right resident, right medication, right route, and right time. The Facility Medication Administration (no date indicated) revealed: Identify resident by photo in the Medication Administration Record (MAR)Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication, name, form, dose, route, and time.

Based on clinical record review, policy review, and staff interview, the facility failed to offer a Covid-19 booster to 1 of 5 residents reviewed for immunizations(Resident #3) and failed to provide information to staff regarding the Covid-19 vaccination. Findings included:1. The Annual Minimum Data Set(MDS) assessment tool, dated 6/19/25, listed diagnoses for Resident #3 which included hemiplegia(one-sided weakness), mild intellectual disabilities, and muscle weakness and listed her Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The resident's Iowa Health and Human Services vaccination list, stated the resident received a Covid-19 vaccination on 6/27/24. The facility lacked further documentation of education provided to the resident regarding an updated Covid-19 booster. 2. On 9/4/25 at approximately 11:00 a.m., Staff F Laundry Staff stated the facility did not provide information to her regarding Covid-19 vaccinations. On 9/4/25 approximately 1:00 p.m. Staff G Housekeeping staff stated the facility did not provide information to her regarding Covid-19 vaccinations. On 9/4/25 at 11:02 a.m., the Director of Nursing(DON) stated the facility utilized Centers for Disease Control and Prevention(CDC) guidelines for resident vaccinations and should offer residents a Covid booster. On 9/4/25 at 1:27 p.m., Staff H Human Resources(HR) stated she assisted with staff flu vaccinations but stated the facility did not offer or provide education to staff regarding the Covid-19 vaccination. The facility Coronavirus Disease(Covid-19)-Infection Prevention and Control Measures, revised 2023, stated the facility would encourage staff and residents to remain up-to-date with all Covid-19 vaccine doses and to provide resources and counseling about the importance of receiving the Covid-19 vaccine.

Based on clinical record review, staff and resident interviews, the facility failed to ensure a resident's right of choice and self determination regarding their health care needs for 1 of 3 residents reviewed. (Resident #1) The facility reported census was 26. Findings include: According the Quarterly Minimum Data Set (MDS) with a reference date of 2/20/24, Resident #1 had a Brief Mental Status (BIMS) score of 11 which indicated a moderately impaired cognitive status. Resident #1 required maximal assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1 was coded as always incontinent of bladder and continent bowel. Resident #1's diagnosis included cerebrovascular accident (stroke), hemiplegia, renal insufficiency and seizure disorder. In an interview on 3/20/25 at 1:33 p.m Staff B, Certified Nurse Aide (CNA), stated she was working an overnight shift on 1/20/25. It was after 10:00 p.m. and she and Staff E, CNA, had just cleaned and prepared Resident #1 for bed and had exited his room when Staff A, Licensed Practical Nurse (LPN), approached her saying Resident #1 needed a suppository since not having a bowel movement for 3 days. Staff B stated they returned to Resident #1's room and she asked Resident #1 if it was okay to get a suppository. Resident #1 stated no, clearly. Staff B stated this all happened as they were rolling Resident #1 onto his side. Staff A was saying something and Staff B stated she was unaware at that time that Staff A had a suppository in his hand. It all happened quickly and Resident #1 began swinging at Staff A as he administered the suppository. Afterwards, Staff B stated she apologized to Resident #1 and encouraged him to report what happened to the Director of Nursing (DON). Staff B stated she later talked to the DON when a similar incident happened (1/26/25). In an interview on 3/20/25 at 1:55 p.m. Staff C, Certified Nurse Aide, stated she was working a double shift (2:00 p.m. to 10:00 p.m.) on the evening of 1/26/25. There was discussion regarding Resident #1 not having a bowel movement for 4 days. Staff A stated Resident #1 needed a suppository and instructed Staff C to accompany him to Resident #1's room. Staff C stated she followed Staff A into Resident #1's room as instructed. Staff A explained to Resident #1 that it was necessary for a suppository. Resident #1 was adamant that he did not want the suppository. Staff A informed Resident #1 that we're going to give one and Staff C assisted in rolling Resident #1 onto his side and Staff A administered the suppository. Staff C stated she felt uncomfortable with the situation and on Monday, 1/27/25, she reported her concern to management. In an interview on 3/20/25 at 12:07 p.m. the Director of Nursing (DON) stated on the morning of 1/26/25, she was making rounds and asked Resident #1 how he was doing. Resident #1 stated last night he was given a suppository against his will. Resident #1 stated he had not had a bowel movement the past few days and Staff A insisted he needed a suppository. Resident #1 stated this was not the first time this has happened. The DON stated she began looking into what happened and called Staff A, who admitted he gave the suppository despite Resident #1 saying no. The DON stated residents have a choice which needs to be respected. The DON stated it is the overnight nurse's responsibility to address bowel movement issues. Point Click Care (PCC) will alert when a resident has not had a bowel movement for 3 days. The DON stated the nurse should follow standard practice by using Milk of Magnesia on day 3 without a bowel movement and a suppository on day 4. The DON stated resident refusals of care or administration of medications should be addressed by the interdisciplinary team. In an interview on 3/24/25 at 1:30 p.m. Staff A, Licensed Practical Nurse, stated on Saturday, 1/25/25 he was working the overnight shift from 6:00 p.m. to 6:00 a.m. That evening Resident #1 was complaining of constipation and a stomach ache. Staff A looked up Resident #1's bowel movement record and it had been four days since his last bowel movement. Staff A stated nurses are supposed to initiate an intervention after the 3rd day. Staff A stated between 8:00 p.m. and 9:00 p.m. Resident #1 was refusing oral medications and becoming increasingly agitated. Resident #1 was offered a suppository and refused, stating you only want to give me a suppository since I'm black. Staff A stated this was typical behavior when Resident #1 is in pain or discomfort. Staff A stated he attempted to explain why he needed the suppository and he would feel better once he had a bowel movement, but Resident #1 remained angry and obstinate. Between 10:00 p.m. and 11:00 p.m. Staff A attempted to assess Resident #1, but was denied. At 11:45 p.m. Staff A was allowed to listen to Resident #1's bowel sounds. They were sluggish and it was now day 4, so Staff A felt it was his duty to ensure Resident #1 received care to relieve his constipation and to prevent further discomfort and complications. Staff A summoned Staff C to assist. Resident #1 was placed on his left side and started getting agitated stating no, no. Staff A stated he perceived the no related to his stomach discomfort. Staff A stated he stopped and attempted to re-explain the dangers of possible bowel obstruction or perforation. Staff A stated Resident #1 seemed to calm down and he quickly inserted the suppository. Within the next two hours, Resident #1 had two large bowel movements. The following evening when Staff A returned to work, Resident #1's daughter was visiting. Resident #1 expressed appreciation for the suppository, saying thank you and that he was feeling much better. Staff A stated Resident #1 is like that. When he is in pain or discomfort, he becomes agitated, racial and unable to think things through. Once he gets the suppository and has the bowel movement, he's fine. Staff A stated Resident #1 had received another suppository on 1/20/25. He was agitated that day also, but primarily upset with the suppository taking too long to work. In an interview on 3/24/25 at 2:30 p.m. Resident#1 was queried if he ever had to use a suppository for constipation? Resident#1 responded yes and stated the LPN Staff A made him take a suppository and he did not want to. Resident#1 stated some time ago he was angry and LPN, Staff A wanted to give him a suppository. The Resident said he told Staff A no, but he gave him one anyway. Resident#1 was asked if he felt better afterwards and he stated yes. According to progress notes dated 1/20/25 at 10:27 p.m. Resident #1 was administered a suppository by Staff A. A follow up note on 1/21/25 at 5:04 a.m. indicated Resident #1 was feeling better following the suppository. According to the Medication Administration Record for January 2025, a suppository was administered to Resident #1 on 1/25/25 at 11:42 p.m. by Staff A.

Based on resident interview, staff interview, record review, facility investigation review and facility policy review the facility failed to report an allegation of abuse for 1 of 3 residents reviewed for abuse. The facility staff failed to report an allegation of abuse that occurred on 11/10/23 which alleged staff member pushed and threatened Resident #3. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of November 10, 2023 on November 27, 2023 at 3:45 PM. The facility staff removed the Immediate Jeopardy on November 28, 2023 at 3:10 PM by implementing the following actions: a. Licensed Practical Nurse (LPN) Staff A was suspended on 11/20/23 b. All staff education began on 11/27/23 by the Administrator c. Upon notification to the regional team, re-education was immediately to the Administrator on reporting allegations of abuse and neglect beginning 11/27/23 at 7:13 PM d. Interdisciplinary Team (IDT) was re-educated on abuse and neglect policies, included identification and reporting on 11/27/23 e. Staff were notified via phone on abuse and neglect reporting starting on 11/27/23 at 430 PM. All staff in the facility were immediately re-educated on abuse and neglect and requirements for reporting 11/27/23 at 4:30 PM. No staff worked without being re-educated starting 11/27/23 at 10:00PM. Ensured, no staff will work until re-educated f. Quality Assurance Progress Improvement meeting completed with Facility Medical Director 11/28/23 at 8:15 AM g. Facility Admin was suspended 10:00 AM on 11/28/23 for failure to report abuse and neglect allegation h. IDT re-educated 11/28/23 at 10:30AM i. Staff education on-going with quizzing, no staff will work without being re-educated. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 28. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses for Resident #3 included unspecified dementia, seizure disorder, anxiety, depression, respiratory and heart disease. The Brief Interview for Mental Status (BIMS) assessment scored 15 out of 15, indicating intact cognition. Functional ability section relayed Resident #3 independent with sit to stand, transferring and walking at least one-hundred fifty (150) feet. The Care Plan initiated 05/24/23 documented Resident #3 potential to be verbally aggressive, cursing resistance to care, and name calling related to ineffective coping skills and poor impulse control. Interventions included to intervene before agitation escalates, guide away from source of distress, engage calmly in conversation and if response is aggressive, staff to walk calmly away, and approach later. The Progress Note, dated 11/10/23 at 07:30 PM documented by Nurse, Staff A, Resident #3 had been exposed to staff with CoronaVirus Disease (COVID), was explained needed to test, Resident #3 started yelling, became agitated, explained if he would not COVID test he needed to stay in room, resident screamed loudly in public area. The Progress Note, dated 11/10/23 at 08:34 PM documented by staff A, reattempted to get COVID test, explained it is a test, not a vaccine. Resident #3 became angry and charged nurse with fist raised, yelling. Reported Staff A redirected resident back into room and explained that if any further violent outburst, would call police. The Facility Document titled, A Resident Grievance form dated 11/13/23 completed by Resident #3 documented on Friday 11/10/23 Nurse Staff A grabbed and tried to shove me into my room, laid his hands on me. The Facility Document titled, Final Report regarding Resident Grievance reported by (name redacted) Resident #3 dated 11/13/23 documented by the administrator stated that staff working on 11/10/23 included Nurse staff A, Certified Nurse Assistant, Staff B and other staff member on break relayed Staff B was in the building and relayed she was not a witness but did hear yelling and heard Resident #3 say don't touch me, get your hands off of me. Staff B went to see what was happening and saw Resident #3 and Staff A yelling at each other in the doorway of Resident #3 room. Documented, Staff B did not witness either touching. The interview by the administrator was noted via phone call to nurse staff A on 11/13/23. Staff A states he went into Resident #3 room to administer a COVID test, resident was sitting in his recliner, he stood up and approached nurse Staff A with a raised fist and approached to grab his neck. Nurse staff A put his hands up to prevent Resident #3 from grabbing him, contact made by Resident #3 who began yelling not to touch him, Staff A left the area. Noted, the incident report dated 11/10/23 stated Resident #3 came toward staff with a raised fist and began yelling profanities towards nurse staff A. Also noted Staff A has a diagnosis of unspecified dementia with mood disturbances and psychotic behavior and has a history of being less than truthful and is delusion. Documented ended with, my findings (refers to the administrator) is that Resident #3 became aggressive towards staff A who defended himself and did not cause any harm to the resident. The Facility Document titled, Resident Interview dated 11/13/23 completed by the Administrator documented his phone interview with Staff A. The Administrator wrote: sitting in recliner, ran up to Staff A with fist up, tried to grab neck. Staff A blocked Resident #3 fist, Resident #3 pushed him back, left room and no further incidents. The Facility Document titled, Resident Interview dated 11/13/23 completed by the Administrator documented his interview with CNA, Staff B. Noted, did not witness but saw them yelling and heard Resident #3 say Don't touch me and get your hands off me. Staff B relayed first time ever seeing Staff A that upset. Resident #3 stated people should not put their hands on him, witnessed Staff A & Resident #3 yelling at each other face to face. Interview on 11/20/23 at 12:50 PM Resident #3 stated Staff A shoved me into my room and said he is going to hold me down if I don't let him COVID test me, I told him no he's not. CNA, Staff B came in, saw us face to face and nicely asked for us to stop. Relayed Staff A said that he was going to get help and hold me down, and he was going to call the police, and I offered my phone and said call them. He didn't and he left my room. Resident #3 stated Staff A had no business grabbing me, it was degrading. Interview on 11/20/23 at 1:29 PM CNA Staff B relayed heard Resident#3 yelled get your hands off me. Stated, that is the first time I ever heard him say that. I told Nurse Staff A to give him a few minutes, they were arguing all the way down the hall. Staff A tried to attempt to test him again and both were yelling. Resident #3 has the tendency to yell or cuss us out. I never heard him say keep your hands off me don't touch me relayed, separated Resident# 3 Staff A and Staff B asked Staff A to calm down, he didn't calm down much. Staff A told me that I would have to hold down Resident #3 so he could swab him. I told him No it is not happening, I'm not holding him down that is restraint and I was not going to lose my license. Relayed reported to the Administrator on Monday morning, what occurred on Friday night. Interview on 11/21/23 at 3:00 PM Staff A relayed had worked on 11/10/23 at 6 PM, was notified that a dietary staff member was found positive with COVID and began testing the residents. Staff A stated Resident #3 started screaming and waving his hands when notified he had to test or stay in his room. Staff A stated entered Resident #3 room with test and Resident #3 did not want the test. Staff A stated he raised his voice and Resident #3 rushed me, with right hand in a fist and the left arm extended. Staff A stated he blocked Resident #3 with his right arm. Staff A stated that Staff B, CNA responded when Resident #3 was yelling don't touch me. Staff A stated he didn't expect Resident #3 to act so violently. Staff A stated he told Resident #3 that if there were further outbursts the police would be notified. Staff A stated he asked Staff B to assist. Staff A stated I wanted to get him tested . Staff A stated he was aware that a resident had a right to refuse. Staff A stated Staff B tested Resident #3 and was cooperative. Interview on 11/20/23 at 4 PM The Administrator stated that he did not report the altercation between Resident #3 and Nurse Staff A because his investigation revealed it did not happen. Stated the nurse Staff A had been here for [AGE] years without incident and resident #3 is demented. Interview on 11/21/23 at 8:00 AM, The Director of Nursing (DON) stated the expectations with staff altercations and/or verbal aggression is to separate and de-escalate. If the nurse is having the altercation, would expect them to walk away and go back with a second person and would like to be notified. The DON relayed at the Monday morning meeting we talked about Staff A grievance. If an altercation between nurse and resident then I would expect the CNA to get in between and de-escalate. I would expect the CNA to report to me. Interview on 11/28/23 at 10:00 AM, Management staff C stated staff should have immediately reported the allegation of abuse that occurred on 11/10/23 to management staff to ensure the timely report to Department of Inspections of Appeals and Licensing (DIAL). Staff C acknowledged there was no report to DIAL of the allegation. Staff C relayed feelings that the administrator ' s relationship and feelings about Nurse Staff A got in the way of what he was supposed to do to protect the residents. According to the November Nursing Schedule 2023 given to the survey team Staff A, LPN worked November 15th, 16th, 17th, and 18th. The facility policy titled, Abuse Prevention Program, last approved 9/2023 stated residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation and involuntary seclusion and any physical or chemical restraint not required to treat resident medical condition. The Facility Policy Reporting of Abuse Allegations, last approved 11/2023 stated, all suspected violations and all substantiated incidents of abuse, neglect, exploitation or mistreatment will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. An alleged violation is a situation or occurrence that is observed or reported by others but has not yet been investigated.

Based on clinical record review and staff interviews, the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents. (Resident #2) The facility reported census was 26. Findings include: The Quarterly Minimum Data Set (MDS) with a reference date of 8/24/23, documented that Resident #2 had impaired long and short term memory deficits and a severely impaired cognitive status. Resident #2 required extensive assistance of two staff members with transfers, mobility, dressing, toilet use and personal hygiene needs. The MDS documented that Resident #2's diagnoses including, Alzheimer's disease, and depression. According to Resident #2's Plan of Care, she has a self care deficit requiring total assistance for all cares, feeding and transfers with interventions which include use of a Hoyer lift and two person assist with all transfers. On 9/20/23 at 10:51 a.m. Staff B, Nurse Aide in Training (NAT), stated she was an aide in training and was shadowing Staff C Certified Nurses Aide (CNA). Staff B, Staff C and Staff D (CNA) were getting residents to their bed and entered the room of Resident #2. Resident #2 required the use of a Hoyer lift for transfers. The lift was in another room, so Staff C left to retrieve the lift. Staff D got impatient and stated fuck it and proceeded to lift Resident #2 from her wheelchair. Staff B stated she questioned Staff D whether she could do that and Staff D stated she had done it before. Staff D positioned herself in front of Resident #2 with her arms under Resident #2's arms. As she lifted, Resident #2's legs slid between Staff D's legs and below the bed frame, preventing Staff D from getting Resident #2 upright. As Staff D, went to move, Resident #2 screamed out in pain as her legs were against the bed frame. Staff B stated she grabbed Resident #2's legs and pulled them from underneath the bed and lifted them off of the floor, allowing Staff D to pivot Resident #2 and put her in to bed. Shortly after this Staff C returned to the room and questioned what had happened. Staff B stated she told Staff C that Staff D attempted to transfer Resident #2 by herself. Staff B stated Staff C stated she would report the incident to the charge nurse. On 9/21/23 at 9:29 a.m. Staff D, CNA, stated on the evening of Friday, 7/14/23, she, Staff C, CNA and Staff B, uncertified nurse aide were getting residents ready for bed. They were in Resident #2's room and Staff C left to get a hoyer lift. When Staff C did not return right away, Staff D stated she got impatient and proceeded to attempt to transfer Resident #2 by herself. As Staff D lifted Resident #2, Resident #2's legs slid under the bed frame and got caught. Staff B helped get Resident #2's legs released and Staff D got Resident #2 onto the bed. Afterwards, Staff D looked at Resident #2's legs and did not see any marks, bruising or injuries. Staff D stated Staff C returned to the room and made the comment we do that sometimes, referring to transferring Resident #2 without the Hoyer lift. Staff D stated she has witnessed other aides transfer residents without a Hoyer when they are care planned to use one. Staff D stated Resident #2 did not scream during the transfer, but does make noises which are normal for her. On 9/20/23 at 11:33 a.m. Staff C Certified Medication Aide, stated on Friday (7/14/23) she was working with an agency aide (Staff D CNA) and an aide in training (Staff B). They were getting residents to bed and took Resident #2 to her room. Staff C stated she would retrieve the Hoyer lift and left the room. Staff C stated a sling had gotten lodged in the wheel of the Hoyer, so she returned to the room to let Staff D and Staff B know it was going to take a moment to get the Hoyer lift. Staff C left the room and when she returned, Resident #2 was in her bed and Staff B and Staff D was standing at the bed. Staff C questioned how Resident #2 had got into bed and Staff D smiled. Staff C stated she was sick that evening and not thinking straight. Staff C stated she left early without telling the charge nurse of the incident. Upon returning on Monday (7/17/23) she reported the incident to the Administrator. Then on Wednesday (7/19/23) she discovered a bruise on Resident #2's left leg. The bruise was yellowing, appearing older, but she assumed it may have been caused by the improper transfer. Staff C reported the bruise to her charge nurse, Staff E (LPN). On 9/21/23 at 11:23 a.m. Staff E, Licensed Practical Nurse, stated on Wednesday, 7/19/23 she was informed by Staff C that Resident #2 had a bruise on her leg, that was probably from an unsafe transfer on Friday, 7/14/23 when an aide transferred her by herself without using a Hoyer lift. Staff E assessed Resident #2's right leg noting a 4 inch by 1 inch yellow faded bruise on her inner right calf. The Progress Notes dated 7/10/23 to 7/15/23 lacked documentation that a transfer of Resident #2 had been completed by staff in an inappropriate manner, and an assessment was not completed of the resident.

Based on clinical record reviews and staff interviews, the facility failed to complete a comprehensive assessment on a resident with a persistent and excruciating headache, motor skill decline, and a change in mental status for one of four residents reviewed (Resident #1). Due to the lack of a comprehensive assessment for Resident #1, this resulted in an Immediate Jeopardy incident. On December 7, 2022 at 3:00 PM, the Iowa Department of Inspections and Appeals notified the facility of the Immediate Jeopardy. The facility reported a census of 24. Findings include: According to the Minimum Data Set (MDS) assessment tool with an Assessment Reference Date of 10/20/22, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. Resident #1 required limited assistance with transfers, mobility, dressing, toilet use, and personal hygiene needs. Resident #1's diagnoseis included coronary artery disease, congestive heart failure, hypertension, and psychotic disorder. In an interview on 12/5/22 at 3:14 p.m. Staff A, Certified Nurse Aide (CNA), stated that on Tuesday, 11/29/22 she worked a 6:00 a.m. to 2:00 p.m. shift. That morning, Resident #1 was already up in her recliner, this was unusual as Resident #1 usually slept in until 9:00 a.m. to 10:00 a.m. Resident #1 was complaining of a headache and constantly pulling on her call light. At 6:15 a.m. Staff A reported Resident #1's complaints of a severe headache to the charge nurse who happened to also be the Administrator. The Administrator stated Resident #1 had already been given pain medication. Staff A asked the Administrator if the facility had ice packs and was told no, so Staff A got some wet washcloths and placed them on Resident #1's neck and head. Staff A stated the wet cloths helped briefly, but Resident #1 was back on her call light. One minute wanting in her bed and the next wanting back in her recliner. Staff A attempted to comfort her and told her they had given her medication that morning, but Resident #1 did not recall getting the medication. Staff A stated Resident #1 was usually cognitively alert, could carry on a conversation, was independent with most care, and could walk independently using her walker. Resident #1 was also a nurse. Resident #1 continued to complain of a severe headache and Staff A stated she continued to report to the Administrator that Resident #1 was having an excruciating headache and requesting to be sent to the hospital. Staff A indicated the Administrator seemed more interested in cleaning and organizing the medication room than attending to the resident. By 12:00 p.m. to 12:30 p.m. Resident #1 became even more agitated and was yelling she needed to go to the hospital. Her outbursts were so disruptive that residents including Resident #2 and Resident #3, were also commenting to the Administrator that Resident #1 was crying and wanting to go to the hospital. Staff A stated Resident #1 was crying in pain and stated I was a nurse and this is not normal. Staff A stated Staff B and Staff C also witnessed Resident #1's cries for help that day, but nothing was done. Staff A stated she returned to work at 5:30 a.m. the following day (11/30/22). In report, the night aide reported Resident #1 continued to complain of pain and rolled out of bed. Resident #1 was not disturbed once she seemed to calm down. At around 6:20 a.m. Staff A checked on Resident #1. Resident #1 was soaked in urine from her shoulders to her knees. The nurse, Staff E witnessed the residents lack of care and instructed Staff A to give her a bed bath. Staff A stated once she began attending to Resident #1 she knew immediately that she had had a stroke. Resident #1 was unable to talk or move her right side. There was nothing in her eyes, she was like a vegetable. Staff E had an order for a urinalysis and she assisted him with getting the urine sample. Staff A commented, I believe she has had a stroke and Staff E responded maybe. Staff A stated she changed Resident #1's bed three times that day and Resident #1 never showed any signs of improvement. Staff A stated on Monday, 11/28/22, Resident #1 was up, independent and in the dining room talking and normal and by Wednesday, 11/30/22 she was a vegetable. On 12/7/22 at 8:45 a.m. Staff A was contacted for clarification. Staff A stated that she gave a report to the on-coming aide (Staff G) at 2:00 p.m. on 11/29/22. Staff A stated she informed Staff G that Resident #1 had been up all night and complained of a severe headache throughout the day. Staff A stated Resident #1 was requesting to go to the hospital. Staff A explained that the Administrator knew of her condition and Resident #1's request to go to the hospital. In an interview on 12/5/22 at 4:55 p.m. Staff B, CNA, stated that she worked 6:00 a.m. to 2:00 p.m. on Monday, 11/28/22. Staff B stated she remembered Resident #1 being alert, conversing with staff, independently mobile using her walker, and being her normal self. Resident #1 only needed assistance with incontinence cares. On Tuesday, 11/29/22, Staff B worked from 6:00 a.m. until 2:00 p.m. That morning when she arrived, Resident #1 was complaining of a headache. As the morning progressed, Resident #1's headache worsened into a migraine. Resident #1 began requesting to be sent to the hospital. The Administrator stated they had already given her something and stated that is just Resident #1 she complains, but she is fine. Staff B stated she never saw the Administrator check on Resident #1. Resident #1 continued to complain of an excruciating headache and continually pulled on her call light throughout her shift. Resident #1 would say I was a nurse, I know they can help me, but no one did. On 12/7/22 at 11:50 a.m. Staff B was interviewed for clarification. Staff B stated when she spoke with the Administrator about Resident #1, she informed her that Resident #1 was requesting to go to the hospital. At that time the Administrator said she already gave her something for pain. The Administrator added that she complains, but she is fine. In an interview on 12/5/22 at 5:10 p.m. Staff C, Marketing, stated she arrived to work around 8:30 a.m. on 11/29/22. Several of the aides approached her with concerns related to Resident #1. The aides stated Resident #1 was complaining of an excruciating headache and requesting to go to the hospital. The aides indicated they had informed the Administrator several times, but she was doing nothing. Staff C stated she went to the Administrator and expressed her concern. The Administrator stated she had given Resident #1 a Tramadol (controlled pain medication) and they were getting an order for a urinalysis. Staff C stated that the Administrator never saw or assessed Resident #1 that day. Staff C stated that afternoon Resident #1 was grabbing at her head and screaming. Resident #1 wanted to go to the hospital. Staff C stated Resident #1 had been cognitively alert most of the day complaining of a headache, but by late that afternoon her speech had become garbled. She was not alert and confused. On Wednesday, 11/30/22, Resident #1's right side was flaccid, she was unresponsive, and she had no right-side vision. Staff C stated to her knowledge no one ever properly assessed Resident #1 or sought appropriate medical attention. On 12/7/22 at 8:08 a.m. Staff C was contacted for clarification. Staff C stated she included Resident #1's requesting to go to the hospital when informing the Administrator of Resident 1's condition that day and also reported late that afternoon when Resident #1's speech became garbled and she became confused. In an interview on 12/6/22 at 11:05 a.m. Staff D, Certified Medication Aide, stated she worked 6:00 a.m. to 2:00 p.m. on 11/29/22 and was assigned to pass medications. The scheduled nurse called in so the Administrator covered for the absent nurse. Staff D stated the Administrator remained in the medication room cleaning and organizing her entire shift. Staff D stated she started setting up medications when Resident #1's call light came on, so she responded. Resident #1 was complaining of a headache. Staff D assisted Resident #1 to the toilet. Resident #1 was having difficulties walking which was unusual for her. Staff D got Resident #1 to the toilet and returned to her medication cart. The call light came on again and Staff D returned and helped Resident #1 into her recliner, gave her a blanket. Moments later Resident #1 was hollering for help. Staff D gave her Tylenol at 7:14 a.m. and then again returned to her cart as Resident #1 continued to holler out and cry for help. Other aides voiced concerns. At around 9:00 a.m. Staff D asked the Administrator to check on Resident #1. Staff D stated the Administrator never checked on Resident #1 during her shift, despite being informed, and asked multiple times. Staff D stated she felt helpless because the Administrator would not do anything. Staff D stated she was on the assisted living unit setting up medications from about 10:00 a.m. until 12:00 p.m. Upon returning, Resident #1 was continuing to cry out in pain. Staff D said something to the Administrator and she was instructed to give Resident #1 Tramadol at 11:48 a.m. Staff D stated the Administrator did not assess Resident #1 prior to or after the administration of the controlled medication. The next day (11/30/22) an aide reported something was wrong with Resident #1. Staff D went to the room. Resident #1 was sitting in bed awake but not responsive, would not talk, and would not move. Resident #1 would not take her medications. Staff D reported her observations to Staff E. The Administrator was standing nearby, listening to the conversation, then stated the urinalysis was sent. And that she was fine. Staff F stated Staff E went to check on Resident #1. In an interview on 12/6/22 at 5:00 p.m. the Administrator stated on 11/29/22 the day nurse called in, so she took on the responsibilities of the licensed nurse from 6:00 a.m. to 6:00 p.m. The Administrator admitted she does not work the floor and was not familiar with the residents. The Administrator stated Resident #1 had a headache, was confused, and not acting right that day. Resident #1 was given as needed pain medication and the Administrator personally gave her pain medication at 6:02 p.m. The Administrator stated at one time that day (unable to specify the time of day) she noticed Resident #1's oxygen tubing knotted. She corrected it and checked the oxygen saturation which was at 91%-92%. The Administrator stated at 2:00 p.m. Staff D left, then at 6:00 p.m. Staff F arrived and took over the nursing duties. The Administrator was asked if anyone had approached her that day with concerns about Resident #1? The Administrator stated yes, they all thought she had COVID. They told her Resident #1 had a headache. The Administrator was asked if anyone told her Resident #1 wanted to go to the hospital? The Administrator stated no, if they had I would have sent her. The Administrator stated she never charted an assessment on Resident #1, consulted a physician, or notified family of Resident #1's condition. According to the Centers for Disease Control and Prevention (CDC) information on Stroke Signs and Symptoms dated March 4, 2022: During a stroke every minute counts, fast treatment can lessen the brain damage that stroke can cause. By knowing the signs and symptoms of a stroke, you can take quick action and perhaps save a life. Signs and symptoms of stroke include: *Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body. *Sudden confusion, trouble speaking, or difficulty understanding speech. *Sudden trouble seeing in one or both eyes. *Sudden trouble walking, dizziness, loss of balance, or lack of coordination. *Sudden severe headache with no known cause. Call 9-1-1 right away if you or someone else has any of these symptoms. In an interview on 12/6/22 at 4:25 p.m. Staff G, CNA, stated she worked 2:00 p.m. to 10:00 p.m. on 11/29/22. In report she was informed that Resident #1 was not doing well, was in bed, and had a headache. Staff G stated Resident #1 was complaining of a major headache that evening and she informed Staff F, Licensed Practical Nurse (LPN). Staff G stated she assisted Resident #1 to the bathroom a couple times during her shift. Staff G stated Resident #1 was normally independent, so it was unusual for her needing assistance, but that evening she was having balance issues. In an interview on 12/7/22 at 10:30 p.m. Staff H, CNA, stated she worked the overnight shift (10:00 p.m. to 6:00 a.m.) on 11/28/22. Staff H recalled that Resident #1 slept through most of the night, but had slid out of bed at around 5:45 a.m. that morning. Staff H stated she noted no change in Resident #1's condition. Staff H stated she returned that evening (11/29/22) for the overnight shift and was informed in report Resident #1 had a headache that day and that they suspected she had a urinary tract infection. Staff H stated it was not unusual for Resident #1 to have headaches and receive Tylenol. Shortly after midnight (12:29 a.m.) Resident #1 was discovered on the floor in front of her recliner. Resident #1 was disoriented, saying what, what. Resident #1 was unable to understand or respond to staff. Staff H stated this was the first time she had noticed a dramatic change in Resident #1's condition who had been independent and required minimal assistance to now require total care, have to be checked for incontinence, and get changed as needed. In an interview on 12/8/22 at 12:50 a.m. Staff F stated she was an agency nurse, but has worked several shifts at the facility and was familiar with Resident #1. Staff F stated she worked the overnight shift (6:00 p.m. to 6:00 a.m.) on 11/28/22. Staff F recalled Resident #1 being fine during her shift. Resident #1 complained of a headache and was given Tylenol at 5:45 a.m. Resident #1 slid off of her bed when she sat up to take her medication. Resident #1 was not injured. On 11/29/22, Staff F returned to the facility to work another overnight shift. In report the Administrator stated Resident #1 had been acting differently and she was wanting to get a urinalysis and put in an order. The Administrator made no mention of Resident #1's complaints of headache that day or of her change in condition. Early that evening, Resident #1 was screaming help, help, help. Resident #1 was assisted to the bathroom and completely confused. Staff F stated she attributed the confusion to a urinary tract infection based on the information she was given from the Administrator. Staff F stated she thought the change in condition had already been discussed with a physician. Staff F stated if a resident had a change in condition, they should be assessed, have their vitals checked, and a physician notified. The assessment should be documented in the progress notes. Staff F stated she thought Resident #1's change in condition had already been reported. In an interview on 12/8/22 at 4:42 p.m. Staff E, LPN, stated he has taken care of Resident #1 for several years and knows the family well. Staff E stated 6 months ago Resident #1 went through a bout of pulmonary edema and hypoxia. During that time, she was hospitalized and upon returning to the facility she was placed on oxygen supplement and her condition was such that she was placed on hospice services. Resident #1 was adamant that she did not want to return to the hospital. Eventually Resident #1 recovered and about a month ago she was taken off hospice services. Resident #1 was able to toilet independently and required minimal assistance with care. Resident #1 used an oxygen supplement, but was not always compliant. Staff E stated he worked the day shift (6:00 a.m. to 6:00 p.m.) on 11/30/22. It was the first time he had worked in four days. In report he was informed by Staff F, that Resident #1 fell , had increased disorientation, agitation, and restlessness. Following the report, Staff E went to see Resident #1. One of the first things he noticed was a strong odor of urine. Staff E stated this was unusual as Resident #1 was normally a continent. Resident #1 was in her bed restless, grabbing her blankets, and throwing them off her bed. Resident #1 was not responding to directions and was saying words, but not every answer made sense. Staff E stated he checked her pupils which seemed equal and reactive to light, but was unable to check hand grips due to Resident #1's noncompliance. Staff E stated he also noticed Resident #1 holding her right arm into her body and her right wrist slightly contractured. Staff E stated they have a standing order for a urinalysis (UA), so he collected a urine sample to rule out a possible urinary tract infection (UTI). Meanwhile Staff E stated he knew the Advanced Registered Nurse Practitioner (ARNP) would be visiting that morning and she could assess Resident #1 further. At around 9:00 a.m. to 9:30 a.m. ARNP1 visited and started Resident #1 on an antibiotic. ARNP1 stated they would see whether Resident #1 had a UTI and if so treat accordingly. Otherwise the family needed to be consulted whether they wanted more aggressive treatment or comfort care. Staff E stated by the end of that day, Resident #1's right arm was pulled up against her body and right wrist contractured. At that time Staff E suspected Resident #1 had had a stroke. Staff E stated he contacted the family informing them of her condition and that she had probably had a stroke. The family stated they did not want her hospitalized and if her condition did not change they would consider hospice. Staff E explained that according to other caregivers on 11/29/22, Resident #1 had an excruciating headache, unrelieved with medication throughout the day. She was continually on her call light and requesting to go to the hospital, Staff E stated he did not know that. Staff E stated Resident #1 putting on her call light or having a headache was not unusual, but not getting relief of her headache after receiving medication was unusual. Staff E asked what he would have done given these circumstances. Staff E stated he would have assessed Resident #1 and discussed what they could do to relieve her headache. If symptoms persisted he would notify the physician and have her sent out. In an interview on 12/6/22 at 10:05 a.m. ARNP1 reported that on 11/30/22 she visited the facility in response to Resident #1's change in condition. ARNP1 stated this was the first time she had ever seen Resident #1 and she was not familiar with the residents past abilities and condition. ARNP1 stated she was informed by Staff E that Resident #1 had become incontinent and her urine was foul smelling. Staff E stated Resident #1 gets confused when she has a urinary tract infection. ARNP1 stated she seen Resident #1 sitting at her bedside, restless, and unable to respond appropriately when spoken to. ARNP1 stated she spoke with her family who indicated they did not want Resident #1 sent to the hospital. The family indicated the resident would not want to go to the hospital. ARNP1 stated she had not been informed of Resident #1 was having an excruciating headache throughout the day on 11/29/22 and that Resident #1 was requesting to go to the hospital. ARNP1 stated she did not know that prior to the day before, Resident #1 was cognitively alert, verbal, and independently mobile using her walker. ARNP1 asked if she had been contacted about a resident having an excruciating headache, crying, and requesting to go to the hospital, would she send the resident? ARNP1 stated if the resident was cognitively aware, she would not hesitate to send her to the hospital. ARNP1 asked if a resident were having an excruciating headache 24 hours before she had an adverse condition change (stroke), would there have been any benefit to sending the resident to the hospital prior to those adverse changes. ARNP1 stated yes, there are medications which can slow the progression of a stroke down. In an interview on 12/7/22 at 11:30 a.m. the Director of Nursing (DON) stated she was at home with COVID on 11/29/22. The DON stated she has only been the DON for 3 weeks, but has worked at the facility for 3-4 months. The DON stated Resident #1 required limited assistance with changing and some care. Resident #1 could ambulate with a walker and could verbalize her wants and needs, although did not talk a lot. The DON indicated new nurses and CMAs are provided a job description upon hire and provided the surveyor the job descriptions for their CMAs, LPNs, and Registered Nurses. The DON stated residents with complaints or changes in condition are to be thoroughly assessed, treated, and documented in the progress notes. If a complaint persists or is a significant change, nurses are to contact a physician and treat accordingly. Families are also to be notified and documentation of actions recorded in the progress notes. According to the facilities undated Licensed Vocational Nurse Position Description (LPN), licensed nurses are responsible for: *The total nursing care of residents in their assigned unit. *Assumes responsibility for compliance with Federal, State, Local and company regulations. *Charts progress notes in an informative, factual manner that reflects the care administered as well as the resident's response to care. *Observes residents, records significant conditions and reactions, notifies supervisor or physician of resident's conditions and reactions to drugs, treatments and significant incidents. *Takes temperatures, pulse, blood pressure and other vital signs to detect deviations from normal and assess the condition of the resident. *Responds to emergency situations based upon nursing standards, policies, procedures and protocols. In an interview on 12/7/22 at 3:25 p.m. Staff I, LPN, stated that she works for an agency. Staff I stated when a resident has a complaint or change in condition, they are to be assessed, including checking vital signs, rating pain, and administering as needed (PRN) medications when appropriate. The assessment should be recorded in the progress notes. If the change in condition is significant or an emergency type situation, she would first attend to the resident's needs, consult a physician, and notify emergency medical services (EMS) if appropriate. Following the event, she would record the assessment and contact details in the progress notes or on an incident report form. Staff I stated she would notify family and record the communication in the progress notes. Staff I stated when giving a PRN medication, it is recorded in the electronic medical records (EMR) system. The EMR system automatically prompts a follow up needed to evaluate the effectiveness of the medication. Staff I stated she would usually wait 45 minutes to an hour and a half to revisit the resident and evaluate effectiveness. Staff I stated the follow up prompt will remain on the EMR until someone addresses it. According to Resident #1's progress notes: 11/28/22 at 8:16 p.m. administered 50 milligrams Tramadol HL as needed for a headache by Staff F. 11/28/22 at 11:04 p.m. recorded as effective by Staff F. 11/29/22 at 7:14 a.m. administered 650 milligrams of Tylenol as needed for a headache by Staff D. 11/29/22 at 11:25 a.m. recorded as effective by Staff D. 11/29/22 at 11:48 a.m. administered 50 milligrams of Tramadol HL as needed for a headache by Staff D. 11/29/22 at 5:53 p.m. recorded as effective by the Administrator. 11/29/22 at 6:02 p.m. administered 50 milligrams of Tramadol HL as needed for pain by the Administrator. 11/29/23 at 11:31 p.m. recorded as effective by Staff F. In an interview on 12/6/22 at 4:18 p.m. the primary care physician's nurse stated there was no record of anyone from the facility calling regarding Resident #1 on 11/29/22. On , the facility removed the immediate jeopardy, decreasing the scope to a D prior to the exit of the survey by a. When a resident voices a physical complaint and interventions are provided, the nurse will assess and document resolution of the symptoms. Prolonged symptoms will be reported to the medical doctor (MD) and family within two hours after interventions. b. The Charge Nurse will report to MD and family within two hours of interventions if physical symptoms are not improved. The Charge Nurse will document assessment and actions taken in progress notes and on 24 hour report. The 24 hour report and the progress notes will be reviewed Monday through Friday by the DON/designee and by the charge nurse on the weekends and will make changes in plan of care as indicated. c. The 24-hour report and progress notes will be used to address symptoms that residents report. d. The facility provided re-education to current nurses that when resident complains of symptoms, nurse must assess, document and provide interventions. When reassessing the residents, the nurse must document. If the interventions are ineffective, the nurse must call the MD and family within two hours. Immediate corrective action will include reviewing 24 hour report every Monday through Friday. The Weekend supervisor will review report and progress notes for change in status. The current licensed staff will be re-educated prior to working again with documentation of attendance.

Based on observation, record review, staff interviews, and facility policy, the facility failed to assess and prevent the development of a pressure ulcer for 1 of 3 residents reviewed with pressure ulcers (Resident #1). The facility reported a census of 36 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 9/14/16, Resident #1 had a [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 1 staff for bed mobility, transfers, walking, dressing, toilet use, personal hygiene, and bathing. The MDS also documented the Resident #1 did not have a current pressure ulcer. An admission assessment dated [DATE], did not contain any documentation to indicate the resident had any skin problems or open areas to the buttocks at that time. An observation on 10/18/16 at 1:44 p.m. revealed the resident had a reddened open area on the right buttock. Staff I RN (Registered Nurse) measured the area (length x width x depth in centimeters) as 4.9 x 2.9 x 0.1. The resident also had a reddened open area on the left buttock, which Staff I measured as 5.3 x 2.6 x 0.1. In addition, observation revealed Resident #1 had developed a raw, reddened open area on the upper left buttock/hip. Staff I stated this area was new and wasn't there last week. Staff I measured the area as 3.6 x 5.0 x 0. Progress notes dated from 9/7/16 (admission) through 9/16/16 contained no documentation of any skin problems or open areas on the resident's buttocks. A Pressure Ulcer Wound Sheet, dated 9/17/16, documented the resident had pressure ulcers on the buttocks with an onset date of 9/17/16. The form described the area as Stage 2 pressure ulcers and contained the following measurements: 6.5 cm (centimeters) and 8 cm x 2 cm x 0.1 cm. Progress notes dated 9/17/16 at 10:55 a.m. documented the resident had open areas to the buttocks measuring 6.5 cm x 2 cm on the left buttocks and 8 cm x 2 cm on the right buttock with serosanguinous drainage noted. The notes indicated the facility notified the physician and obtained an order to culture and check for infection and apply [MEDICATION NAME] cream 3 times per day for 7 days. The resident's Pressure Ulcer Wound Sheets listed the following subsequent measurements (length by width by depth in cm) for the left buttock: 9/21/16 6.0 x 2.5 x 0.1 9/28/16 8.5 x 2 x 0.1 10/7/16 7.5 x 2.0 x 0.1 10/11/16 5.7 x 2.0 x 0.1 10/18/16 5.3 x 2.6 x 0.1 The resident's Pressure Ulcer Wound Sheets listed the following subsequent measurements (length by width by depth in cm) for the right buttock: 9/21/16 6.2 x 3.3 x 0.1 9/27/16 5.5 x 2.4 x 0.1 10/7/16 7.5 x 2.0 x 0.1 10/11/16 5.3 x 2.6 x 0.1 10/18/16 4.9 x 2.9 x 0.1 A Progress note, dated 10/18/16, documented the resident had a new skin issue located on the left hip/upper buttock and described the the area as red/purple in color with multiple intact blisters. A Pressure Ulcer Wound Sheet, dated 10/18/16, listed an onset of a left hip/buttock Stage 2 pressure ulcer on 10/18/16 and described the area as multiple intact blisters scanning area with purple/red skin measuring 3.6 x 5 x 0. The resident's clinical record lacked documentation prior to 10/18/16 of skin problems or redness on the resident's left hip/upper buttock. The September 2016 Medication Administration Record [REDACTED]. The sheet also contained a 9/21/16 order for Duoderm (gel dressing), apply to open area on buttock every three days and as needed with soiling. The undated facility procedure entitled Prevention of Decubitus Ulcer Formation directed staff to identify residents with whom pressure areas were likely to develop and inspect skin frequently for signs of pressure, especially for redness over bony prominences. During an interview on 10/19/16 at 1:16 p.m., Staff A, CNA (Certified Nursing Assistant) stated she worked with Resident #1 when he/she first came to the facility. She stated the resident came into the facility with a sore bottom which was already open and stated the area had gotten worse. During an interview on 10/19/16 at 1:30 p.m., Staff J, CNA stated she worked with the resident when he/she first came to the facility and when the resident came in his/her buttocks were as red and gradually got worse. During an interview on 10/19/16 at 3:10 p.m., the Assistant Director of Nursing stated after the resident came to the facility his/her buttock started turning red but she wasn't sure when. She stated Staff L informed her of the area and she hadn't heard of any problems with the skin prior to that. She stated she completed some of the resident's assessments for skilled care but she wouldn't look at the resident's buttocks each time and would rely on the CNA's to notify her of red areas. During an interview on 10/20/16 at 7:24 a.m., Staff E LPN (Licensed Practical Nurse) stated the resident started having skin issues a couple of weeks after he/she came in. She reported prior to that, no one informed her of any skin issues or redness. During an interview on 10/20/16 at 8:10 a.m., Staff A stated she did not talk to the nurses about the resident's buttocks, but thought they were aware. During an interview on 10/20/16 at 8:32 a.m., Staff K CNA stated when the resident came in to the facility his/her bottom was red but not as bad as it was currently. She stated she did not talk to the nurses about the resident's bottom, but thought they knew. During an interview on 10/24/16 at 10:38 a.m., Staff L LPN stated on 9/17/16 a therapy staff member informed her the resident complained his/her bottom hurt and she checked it. She stated the area was open already and some drainage was present. She stated she only worked on Fridays and when she came back the next week the area had increased in size. She stated on one occasion, she checked on the resident and he/she did not have a patch on the area, so she applied a new one. She reported when she performed skilled assessments, she would not always look at the resident's buttocks unless the person had problems with the area. Staff L stated she would rely on the CNAs to inform her if a resident had reddened buttocks.