Every finding on record at Sunnyview Care Center

Based on interview and record review, the facility failed to ensure the information on the Minimum Data Set (MDS - a resident assessment tool) related to Health Conditions, was accurately documented to reflect Resident 1's fall on 1/16/2026. This failure had the potential to result in inaccurate facility quality measures and could result in Resident 1 not receiving necessary care and services. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage (a collection of blood in the brain caused by head trauma), repeated falls, restlessness and agitation.During a review of Resident 1's History and Physical (H&P) dated 1/10/2026, the H&P indicated Resident 1 had the mental capacity to understand but could not make medical decisions.During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had severe cognitive (ability to think and reason) impairment, no acute change in mental status, and no hallucinations or delusions. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) to transfer from lying to sitting on the side of the bed, transfer from sitting to standing, and to walk ten feet in his room. The MDS indicated Resident 1 did not have any falls since admission, reentry or the prior assessment.During a review of Resident 1's Change of Condition (COC - a communication tool used by healthcare workers when there is a change of condition among the residents) dated 1/16/2026, the COC indicated on 1/16/2026 at 8:30 a.m., Resident 1 got out of bed to go to the bathroom without using the call light and his knees buckled which caused the resident to make contact with the floor. The COC indicated Resident 1 sustained a small bump and superficial cut to his nose with minimal bleeding. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's short-term memory was intact and had no acute mental status change. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) to transfer from lying to sitting on the side of the bed and to transfer from sitting to standing. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) to walk ten feet in his room. The MDS indicated Resident 1 did not have any falls since admission entry, reentry or the prior assessment.During a concurrent interview and record review on 3/25/2026 at 11:50 a.m., with the MDS Coordinator, Resident 1's COC dated 1/16/2026, Resident 1's MDS dated [DATE], and the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2025 were reviewed. The MDS Coordinator stated the definition of a fall was any unintentional contact with the ground. The MDS Coordinator stated on 1/16/2026, Resident 1 sustained an unwitnessed fall and sustained a small bump and cut on his face. The MDS Coordinator stated the MDS assessment dated [DATE] should have reported Resident 1's fall but did not. The MDS assessment should have also reflected that Resident 1 had fallen since the prior assessment on 1/14/2026. The MDS Coordinator stated there was no significant error assessment to correct the inaccuracy. The MDS Coordinator stated MDS assessments guided the care planning process and the inaccuracy had the potential to result in Resident 1's care plans not addressing his fall on 1/16/2026. Resident 1's MDS was inaccurate, and this inaccuracy had the potential to result in inaccurate facility quality measures.During a concurrent interview and record review on 3/25/2026 at 3:30 p.m., with the Director of Nursing (DON), the facility's P&P titled, Charting and Documentation dated 7/2017 was reviewed. The DON stated facility assessments must be accurate and complete. The DON stated the P&P was not followed when Resident 1's MDS assessment did not indicate Resident 1's fall in the facility on 1/16/2026. During a review of the facility's P&P titled, Charting and Documentation dated 7/2017, the P&P indicated documentation in residents' medical records should be objective, complete, and accurate. The P&P indicated events, incidents, and accidents involving residents should be documented in the resident's medical record.During a review of the facility's P&P titled, Comprehensive Assessments, dated 3/2022, the P&P indicated comprehensive assessments were conducted to assist in developing person-centered care plans. The P&P indicated a significant error is an assessment where the resident's overall clinical status was not accurately represented and/or results in inappropriate plan of care and was not corrected via submission of a more recent assessment.

Based on interview and record review, the facility failed to implement their Policy and Procedure (P&P) titled, Safety and Supervision of Residents which indicated the facility would ensure interventions to reduce accident risks would be implemented for one of three sampled residents (Resident 1) by failing to provide one on one sitter (1:1- one staff delegated to supervise a single resident) for Resident 1 according to the residents care plan and Physician's Order.This failure resulted in Resident 1 sustaining an unwitnessed fall on 1/16/2026 and had the potential to cause injuries or hospitalization for the resident. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage (a collection of blood in the brain caused by head trauma), repeated falls, restlessness and agitation.During a review of Resident 1's Rehab Fall Risk Assessment, dated 1/9/2026, the assessment indicated Resident 1 required extensive assistance to perform bed mobility and transferring tasks. The assessment indicated Resident 1 used a wheelchair and did not use proper safety while using the assistive device. The assessment indicated Resident 1 did not use the call bell properly, did not demonstrate safety techniques during transfers, and did not show sufficient strength and correct posture in sitting or standing.During a review of Resident 1's History and Physical (H&P) dated 1/10/2026, the H&P indicated Resident 1 had the mental capacity to understand but could not make medical decisions.During a review of Resident 1's Physician Orders dated 1/13/2026, the orders indicated Resident 1 required 1:1 monitoring every shift due to the resident constantly attempting to get out of bed unassisted.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/14/2026, the MDS indicated Resident 1 had severe cognitive (ability to think and reason) impairment, no acute change in mental status, and no hallucinations or delusions. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) to transfer from lying to sitting on the side of the bed, transfer from sitting to standing, and to walk ten feet in his room. During a review of Resident 1's Care Plan titled, Resident non-compliance manifested by: unassisted transfers. Resident at risk of fall/injuries related to unassisted transfers from bed.has frequent episodes of self-transfers from bed, dated 1/14/2026, the care plan indicated Certified Nursing Assistants (CNA) would provide a 1:1 sitter for Resident 1.During a review of Resident 1's Census tab, dated 1/14/2026, the Census indicated Resident 1 was assigned to Room A from 1/14/2026 through 1/26/2026.During a review of the facility's Nursing Assignment for the 11:00 p.m.-7:00 a.m. shift dated 1/15/2026, the assignment did not indicate a 1:1 sitter was assigned to Room A. During a review of Resident 1's Progress Notes dated 1/15/2026 and 1/16/2026, the Progress Notes did not indicate 1:1 supervision was provided from 1/15/2026 at 11:00 p.m. through 1/16/2026 at 7:00 a.m.During a review of the facility's Nursing Assignment for the 7:00 a.m.- 3:00 p.m. shift dated 1/16/2026, the assignment indicated CNA 1 was assigned as a 1:1 sitter for Room A.During a review of Resident 1's Change of Condition (COC - a communication tool used by healthcare workers when there is a change of condition among the residents) dated 1/16/2026, the COC indicated on 1/16/2026 at 8:30 a.m., Resident 1 got out of bed to go to the bathroom without using the call light and his knees buckled which caused the resident to make contact with the floor. The COC indicated Resident 1 sustained a small bump and superficial cut to his nose with minimal bleeding. The COC did not indicate Resident 1 had a 1:1 sitter present nor witnessed the fall incident.During a concurrent interview and record review on 3/25/2026 at 9:58 a.m., with CNA 2, Resident 1's Physician Orders dated 1/13/2026, and Resident 1's COC dated 1/16/2026 were reviewed. CNA 2 stated Resident 1 constantly tried to get out of bed without assistance and exhibited unpredictable behavior. CNA 2 stated Resident 1 had an order to always have a 1:1 sitter within reach of the resident for every shift from 1/13/2026 through 1/31/2026. CNA 2 stated Resident 1 needed a sitter to prevent falls, minimize injuries, and witness accidents. CNA 2 stated Resident 1's sitter should have remained within reach of Resident 1 until the sitter was replaced by the next assigned CNA or another staff member. CNA 2 stated Resident 1 sustained an unwitnessed fall during change of shift on 1/16/2026 at around 7:00 a.m.During a concurrent interview and record review on 3/25/2026 at 11:50 a.m., with the MDS Coordinator, Resident 1's COC dated 1/16/2026 was reviewed. The MDS Coordinator stated the definition of a fall was any unintentional contact with the ground. The MDS Coordinator stated Resident 1 sustained an unwitnessed fall and sustained a small bump and cut on his face on 1/16/2026.During a concurrent interview and record review on 3/25/2026 at 12:20 p.m., with the Director of Nursing (DON), the DON stated Resident 1 needed a 1:1 sitter due to the Resident's high fall risk and impulsive behavior. The DON stated a sitter could have prevented Resident 1's fall and minimized injury.During an interview on 3/25/2026 at 3:57 p.m., with CNA 1, CNA 1 stated she was Resident 1's assigned sitter on 1/16/2026 from 7:00 a.m. through 3:00 p.m. CNA 1 stated Resident 1 was weak and required maximal assistance to get out of bed and walk to the bathroom. CNA 1 stated Resident 1 required a sitter because he was impulsive, did not call for help, had a history of falls, and was a high fall risk. CNA 1 stated there was no sitter from the previous shift or staff present in the room when she arrived at Resident 1 room on 1/16/2026 at 7:00 a.m. CNA 1 stated Resident 1 told her about a fall he experienced earlier that morning, and no staff were present to assist the resident or prevent the fall or injury.During a subsequent concurrent interview and record review on 3/25/2026 at 4:50 p.m., with the DON, the facility's Nursing Assignment for the 11:00 p.m.-7:00 a.m. shift dated 1/15/2026, was reviewed. The DON stated Resident 1 did not have a 1:1 sitter on 1/15/2026 from 11:00 p.m. through 1/16/2026 at 7:00 a.m. The DON stated Resident 1's physician orders and care plan were not followed when Resident 1 fell on 1/16/2026.During a review of the facility's P&P titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated the care team shall target interventions to reduce individual risks related to environmental hazards, including adequate supervision and assistive devices. The P&P indicated interventions to reduce accident risks should be implemented correctly and consistently.

Based on interview and record review, the facility failed to ensure transportation was notified of 1 of 8 sampled residents (Resident 1) pick-up time after hemodialysis treatment every Mondays, Wednesdays and Fridays. This failure resulted in Resident 1 having to wait for transportation for long periods of time after hemodialysis treatments.This failure also resulted in the hemodialysis center to utilize an Uber (a company that connects riders with drivers, couriers, and delivery providers through a smartphone app) transportation to take the resident back to the facility.This failure had the potential for Resident to experience being tired, uncomfortable, hungry and placed the resident's health and safety in jeopardy.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included end stage renal disease with dependence on renal dialysis (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hypertension (high blood pressure is when the pressure in your blood vessels is too high), and repeated falls. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 12/29/2025, the MDS indicated Resident 1 had clear speech and had the ability to express ideas and wants, and was able to understand. The MDS indicated Resident 1 used a walker or wheelchair and required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, upper body dressing and shower/bathe self. During a review of Resident 1's Hemodialysis Flowsheet dated 1/7/2026, the Hemodialysis Flowsheet indicated on 1/7/2026, Resident 1 started hemodialysis at 10:48 a.m., and completed his treatment at 2:56 p.m. During a review of the Hemodialysis Center Uber receipt dated 1/7/2026, the receipt indicated on 1/7/2026, Resident 1 was picked up by Uber from the Hemodialysis Center at 5:29 p.m. and arrived at the facility at 6 p.m. During a review of the Hemodialysis Social Worker (HSW) note, dated 1/9/2026, the HSW note indicated on 1/7/2026 (time not specified), Resident 1 experienced long wait times after the hemodialysis treatment. The HSW note indicated on 1/7/2026, Resident 1 was not picked up by transportation and the Hemodialysis Administrator assisted Resident 1 with arranging transportation through Uber. During an interview on 1/12/2026 at 11:47 a.m., with Social Service Director (SSD), the SSD stated Resident 1 had been having problems with hemodialysis transportation due to his insurance. The SSD stated transportation pick-up had been arriving too early (time not specified) while Resident 1 is still getting hemodialysis treatment, to transport Resident 1 back to the facility. The SSD stated she called the transportation agency to follow up but the SSD was unable to provide documentation. During an interview on 1/13/2026 at 12 noon with Resident 1, Resident 1 stated during his dialysis schedule, the transportation had been arriving too early or late or does not arrive at all to pick up. Resident 1 stated the SSD was aware of the problem but had not done anything to fix the problem. Resident 1 stated he had waited 3 hours for the transportation pick-up after hemodialysis treatment (date not specified). Resident 1 stated after the hemodialysis treatment, he is tired, weak, hungry and he felt ignored. During an interview on 1/16/2026 at 9:50 a.m., with the HSW, the HSW stated the problem could be that the facility did not inform the transportation and arrange pick up at 2:45 p.m. because Resident 1's hemodialysis ends at 2:30 p.m. During a concurrent telephone interview and record review on 1/16/2026 at 2:15 p.m., with the SSD, a document containing Resident 1's Insurance, Hemodialysis schedule (Flyer) and transportation information was reviewed. The document indicated Resident 1's hemodialysis chair time (dialysis schedule) at 10:30 a.m. every Monday, Wednesday and Friday. The document indicated Resident 1 required transportation pick-up from the facility at 9:45 a.m. The document did not indicated Resident 1's pick up time from the hemodialysis center. The SSD acknowledged Resident 1's Flyer did not indicate a pick-up time from the hemodialysis center. The SSD stated that waiting for a late transportation pick-up or a transportation pick-up that that was not arranged will not make Resident 1 feel good. During a review of the facility's policy and procedure (P&P) titled Transportation, Social Services, dated 12/2008, the P&P indicated the Social services should help residents arrange needed transportation. The P&P indicated concerns about transportation should be referred to the social services.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Skin Breakdown when licensed nurses did not perform weekly skin progress reports for one of four residents (Resident 1) who had moisture-associated skin damage (MASD - skin damage caused from prolonged exposure to moisture).This failure had the potential to result in the worsening of Resident 1's MASD and a delay in care or services for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness (lack of strength), and candidiasis (a common fungal skin infection caused by yeast, appearing as red, itchy rashes) of skin.During a review of Resident 1's History and Physical (H&P), dated 8/19/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions.During a review of Resident 1's Bowel and Bladder (B&B) Program Screener, dated 10/18/2025, the Screener indicated Resident 1 was never continent of bowel or bladder, had some redness on his genitals, perineal, or buttock skin, was immobile, and had predisposing factors (underlying, long-term conditions that increase risk of complications).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/17/2025, the MDS indicated Resident 1 had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 had lower extremity impairment on both sides and was dependent (helped does all the effort) for personal hygiene. The MDS indicated Resident 1 had skin impairment.During a review of Resident 1's Care Plan titled, MASD. Location: Sacrococcyx (the lower back and tailbone), groin area., dated 10/21/2025, the Care Plan indicated the goal was to resolve Resident 1's skin damage and reduce the risk of skin infections. The Care Plan indicated nursing interventions included assessing Resident 1's skin condition and conducting weekly body checks. During a review of Resident 1's Interdisciplinary Team (IDT- care team that may include nurses, therapists, social workers, dietary, physicians, activities workers to plan and manage a resident's care plan) Meeting Notes, dated 10/22/2025, the IDT Notes indicated Resident 1 was at risk of skin breakdown due to fragile skin, the aging process, and functional decline. Resident 1 had MASD on the groin and sacrococcyx with interventions indicating staff would monitor Resident 1's skin condition.During a review of Resident 1's Licensed Nurses Note, dated 11/29/2025, the note indicated Resident 1 had a skin alteration and referred to the skin assessment record.During a review of Resident 1's Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident), for the month of 11/2025, the TAR indicated Resident 1 received the following treatments:Cleanse Sacrococcyx with normal saline (cleansing liquid), pat dry, apply skin barrier cream, and leave open to air every day shift for MASD from 11/1/2025 through 11/19/2025 and from 11/21/2025 through 11/29/2025.Apply Nystatin powder (antifungal skin medication) to the groin area every day shift for MASD from 11/1/2025 through 11/20/2025 and from 11/22/2025 through 11/29/2025.During a concurrent interview and record review on 12/31/2025 at 11:30 a.m., with the Treatment Nurse (TN), Resident 1's TAR for the month of 11/2025, B&B Screener, dated 10/18/2025, H&P, dated 8/19/2025, Progress Notes for the month of 11/2025 and care plan titled MASD. Location: Sacrococcyx, groin area., dated 10/21/2025, were reviewed. The TN stated Resident 1's history of DM, weakness, and scrotal cellulitis increased his risk of skin breakdown, infection, and delayed skin healing. The TN stated Resident 1 received multiple treatments for the red and irritated MASD on his sacrococcyx and groin. The TN stated Resident 1's MASD should have been assessed weekly, to verify the effectiveness of treatments. The TN stated Resident 1's MASD was not assessed and measured weekly (for the month of 11/2025). The TN stated that Resident 1 was at risk of worsening and developing an infection because it was not assessed regularly (at least weekly).During a concurrent interview and record review on 1/7/2026 at 3:26 p.m., with the Director of Nursing (DON), the facility's undated P&P titled, Alteration in Skin Integrity was reviewed. The DON stated Resident 1's MASD should have had weekly skin assessments by a Treatment Nurse and the wound specialist medical doctor. The DON stated the Resident's MASD could have worsened or not responded to treatment if it was not assessed weekly.During a review of the facility's undated P&P titled, Alteration in Skin Integrity the P&P indicated residents with alterations in skin integrity will be assessed and care plans will be developed. The P&P indicated weekly skin progress reports will be completed by licensed staff to include distribution of the skin alteration with measurements, description of affected area, and the degree of skin alteration. During a review of the facility's P&P titled, Skin Breakdown dated 5/2025, the P&P indicated the purpose was to maintain skin integrity, prevent skin breakdown, and promote timely wound healing. The P&P indicated the licensed nurse will monitor the wound progress weekly until it is resolved and documentation will include the type of skin lesion/wound such as discoloration and skin rash, the measurement, and the Resident's response to treatment.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Bed-Holds and Returns when two of four sampled residents (Resident 1, 2) were not provided written notification of bed-hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) upon admission or at transfer.This failure resulted in Resident 1 to not know their bed-hold rights during transfer to a general acute care hospital (GACH) and a potential for Resident 2 to not know their rights.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including history of malignant neoplasm (mass, cancer) of upper lobe, right bronchus (portion of the airway) or lung, malignant neoplasm of left adrenal gland (hormone-producing organ), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P), dated 6/12/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/12/2025, the MDS indicated Resident 1 could independently make decisions regarding tasks of daily life, did not reject care, and did not exhibit verbal or physical behaviors toward others.During a review of Resident 1's Discharge Summary Report, dated 6/12/2025, the Discharge Summary Report indicated Resident 1 was transferred to the GACH on 6/12/2025 at 9:40 AM for near syncope (fainting).During a concurrent interview and record review on 7/9/2025 at 9:40 AM with the facility's Admissions Director (AD), Resident 1's Discharge Summary Report, dated 6/12/2025, was reviewed. The AD stated Resident 1 was admitted to the facility on the evening of 6/11/2025 and transferred to the hospital the following morning on 6/12/2025. The AD stated he did not follow facility policy when he did not provide Resident 1 with a written notice of bed-hold upon admission to the facility.During an interview on 7/9/2025 at 11:20 AM with Resident 1, Resident 1 stated he did not know what a bed-hold was, was not offered the option of a bed-hold, and was not provided written information about a bed-hold.During an interview on 7/9/2025 at 12:40 PM with the Medical Records Director (MRD), the MRD stated Resident 1 did not receive a written notice of bed-hold upon admission or transfer.During a concurrent interview and record review on 7/9/2025 at 1:30 PM with the Director of Nursing Designee (DOND), the facility's P&P titled Bed Holds and Returns, dated 3/2022 was reviewed. The DOND stated the facility did not provide a written notice of bed-hold upon admission or transfer to Resident 1, per facility policy. The DOND stated Resident 1 was expected to return to the facility. The DOND stated residents may not be aware of their right to a bed-hold and residents would not be able to exercise their right to a bed-hold since they did not receive a written notice. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and discharged on 6/24/2025. The admission Record indicated Resident 2 had a history of cognitive communication deficit (difficulty speaking due to cognitive impairment) and DM.During a review of Resident 2's H&P, dated 6/22/2025, the H&P indicated Resident 2 was able to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had some difficulty making decisions in new situations regarding tasks of daily life, did not reject care, and did not exhibit verbal or physical behaviors toward others.During a review of Resident 2's Discharge Summary Report, dated 6/24/2025, the Discharge Summary Report indicated Resident 2 was transferred on 6/24/2025 to the GACH on 6/24/2025 for surgical wound debridement (surgical procedure to remove non-viable tissue).During a review of Resident 2's Notification of Bed-Hold, dated 6/24/2025, the Notification of Bed-Hold indicated Resident 2 was provided a written Notification of Bed-Hold on 6/24/25.During a concurrent interview and record review on 7/9/2025 at 9:40 AM with the AD, Resident 2's Discharge Summary Report, dated 6/24/2025, was reviewed. The AD stated Resident 2 was admitted in the evening of 6/21/2025 and transferred to the GACH in the afternoon of 6/24/2025. The AD stated he did not provide Resident 2 with a written notice of bed-hold upon admission, per facility policy. The AD stated Resident 2's rights were violated when he was not informed of his rights to a bed-hold.During a concurrent interview and record review on 7/9/2025 at 1:30 PM with the DOND, the facility's P&P titled Bed-Holds and Returns, dated 3/2022 was reviewed. The DOND stated the facility did not follow the P&P when the facility did not provide a written notice of bed-hold upon admission to Resident 2.During a concurrent interview and record review on 7/9/2025 at 1:57 PM with the AD, Resident 2's Notification of Bed-Hold dated 6/24/2025, and the facility's P&P titled Bed-Hold and Returns dated 3/2022, were reviewed. The AD stated the P&P was not followed when Resident 2 was not provided written notification of bed-hold upon admission to the facility.During a review of the facility's P&P titled Bed-Holds and Returns, dated 3/2022, the P&P indicated all residents must be informed of their right to a bed-hold upon admission and at the time of transfer.During a review of the facility's P&P titled Resident Rights, dated 3/2023, the P&P indicated the facility shall inform residents about his or her rights and must support residents in exercising their rights.

Based on interview and record review, the facility failed to implement their policy and procedure (P/P) titled Care Plans, Comprehensive Person-Centered, 1. to conduct an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) and 2. to document a post fall care plan for one of four sampled residents (Resident 2) after sliding out of the wheelchair and onto the floor. This failure resulted in Resident 2, who is non-verbal and bedbound, having another fall on 06/04/2025 of sliding out of the bed and onto the floor and staff returning Resident 2 to bed without informing the charge nurse or supervisor, and without having a qualified staff assess for injuries. This failure also resulted in Resident 2 sustaining a fractured femur (a break in the femur, the long bone in the thigh, and is a serious injury), enduring hours of pain and transferring to the general acute care hospital (GACH). Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including right knee osteoarthritis (breakdown of joint cartilage, leading to pain, stiffness, and limited movement in the affected joints), hypertension (high blood pressure), and ataxia (loss of muscle coordination). During a review of Resident 2's Change of Condition (COC), dated 11/12/2024 at 5 p.m., the COC indicated Resident 2 was seen up in her wheelchair, in the hallway and was propelling self forward. The COC indicated Resident 2 reached for the hallway handrail, pulled self forward down the hallway and slowly sled out of her wheelchair and sat on the floor. During a review of Resident 2's post fall Fall Risk Assessment, dated 11/12/2024, the post Fall Risk Assessment indicated Resident 2 has a high risk/potential for falls. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 had cognitive impairment. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating, toileting hygiene and personal hygiene. During an interview on 6/16/2025 at 12 noon, with the Medical Records Director, in the Medical Records office, the Medical Records Director stated Resident 2 did not have a post fall IDT notes and post fall care plan after the 11/12/2024 fall. The Medical Records Director stated the nurses were responsible for formulating the post fall care plan and documenting in the IDT meeting notes. The Medical Records Director stated failure to conduct an IDT meeting and create the post fall care plan may jeopardize Resident 2's safety. During an interview on 6/16/2025 at 12:20 p.m., with the Director of Nursing (DON), the DON stated the Registered Nurse Supervisor was responsible for conducting an IDT meeting and documenting the IDT meeting notes and updating and documenting the fall care plan. The DON stated that failure to conduct an IDT meeting and document IDT meeting notes and update the fall care plan is a lack of documentation. The DON failed to verbalize how the lack of documentation would affect Resident 2's care and safety. During a review of the facility's P/P titled Care Plans, Comprehensive Person-Centered, revised dated March 2022, the P&P indicated care plan must include developed measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and implemented for each resident. The P&P indicated interventions should be chosen after data gathering, proper sequencing or events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The P&P indicated the interdisciplinary team review and updates the care plan when there has been a significant change in the resident's condition and when the desired outcome is not met.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2), was assessed for pain after a fall incident on 6/5/2025. This failure resulted in the delay of pain assessment and interventions and had the potential for Resident 2 to suffer severe pain. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including right knee osteoarthritis (breakdown of joint cartilage, leading to pain, stiffness, and limited movement in the affected joints), hypertension (high blood pressure), and ataxia (loss of muscle coordination). During a review of Resident 2 ' s Minimum Data Set (MDS-a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 had cognitive impairment. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating, toileting hygiene and personal hygiene. During a review of Resident 2 ' s Change of Condition (COC), dated 6/5/2025 at 2 a.m., the COC indicated Resident 1 had right leg pain when moved with facial grimacing. The COC indicated Resident 1 was unable to verbalize any pain. The COC indicated a nurse (unidentified) moved Resident 2 ' s all extremities and noted facial grimacing when right leg was moved. During an interview on 06/09/2025 at 1:10 p.m. with the Director of Nursing (DON), the DON stated the Charge Nurse did not assess Resident 2 ' s pain level after the fall because the assigned Certified Nursing Assistant (CNA 1) did not notify the Charge Nurse because the facility was having a recertification survey (an annual survey conducted to ensure compliance by healthcare facilities with the requirements for participation in Medicare and Medicaid programs). CNA 1 put Resident 2 back to bed by herself and watched for any pain and discomforts. During a telephone interview on 6/10/2025 at 2:40 p.m. with CNA 1, CNA 1 stated she was in the resident ' s bathroom preparing to provide morning care. CNA 1 stated she heard a sudden loud noise and found Resident 2 on the floor. CNA1 stated Resident 2 was nonverbal and nodded her head when asked indicating she was ok. CNA 1 stated she did not notify the Charge Nurse about the fall because she was nervous, and the facility had an ongoing recertification survey. CNA 1 stated failing to notify the Charge Nurse would have caused Resident 2 to suffer pain and delayed medical attention. During a review of the facility ' s undated policy and procedure (P&P) titled, Incidents/Accidents, the P/P indicated incidents/accidents should be reported to the charge nurse and documented on the accident/incident report as soon as they occur. The P&P indicated, the Charge nurse initiating the report will be responsible for the completeness and accuracy of the information contained in the report.

Based on interview and record review, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for three of 19 sampled residents (Residents 6, 72, and 10) by failing to: 1. Ensure Resident 6's risperidone (anti-psychotic medication used to treat several mental health conditions) was encoded as anti-psychotic medication (a type of drug used to treat symptoms of psychosis) under MDS section N (N0415 High Risk Drug Classes - Use and Indication). 2. Ensure Resident 72's significant weight loss (loss of 5 percent ([%] - out of each 100) or more in the last month or loss of 10% or more in last 6 months) was encoded under MDS Section K (K0300 Weight Loss). 3. Ensure Resident 10 had accurate documentation in the MDS to reflect her use of Dabigatran Etexilate Mesylate ([anti-coagulant]- medication used to thin the blood). These deficient practices resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and services for Resident 6, 72, and 10). Findings: 1. During a review of Resident 6's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included paranoid schizophrenia (a complex psychiatric disorder characterized by distorted thinking and awareness), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and major depressive disorder ([MDD] - a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 6's History and Physical (H&P), dated 4/17/2025, the H&P indicated, Resident 6 was able to make decisions for activities of daily living. During a review of Resident 6's MDS assessment, dated 4/23/2025, the MDS indicated, Resident 6's cognitive (ability to think and reason) skills for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated, Resident 6 was totally dependent (helper does all of the effort) from staff with toileting hygiene and upper and lower body dressing. During a review of Resident 6's Order Summary Report (a document containing active orders), dated 6/5/2025, the Order Summary Report indicated, the physician placed a telephone order on 4/16/2025 for Resident 6 to start on risperidone 2 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) to give one tablet two tines a day (9 a.m. and 5 p.m.) for paranoid schizophrenia manifested by extreme paranoid thoughts or hallucinations causing fear and stress interfering with daily living activities. During a concurrent interview and record review on 6/4/2025 at 9:17 a.m., with the Minimum Data Set Nurse (MDSN), Resident 6's MDS assessment, dated 4/23/2025, was reviewed. The MDSN stated Resident 6's MDS assessment was completed inaccurately. The MDSN stated there should be a check marked on Section N0415 under anti-psychotic drug because Resident 6 was given risperidone from 4/17/2025 to 4/23/2025. The MDSN stated risperidone was classified as anti-psychotic medication. The MDSN stated it was important to encode each sections of the MDS accurately because it could affect the delivery of care and service provided by facility to residents. During a review of the facility's policy and procedure (P&P), titled Certifying Accuracy of the Resident Assessment, dated 11/2019, the P&P indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 2. During a review of Resident 72's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 72's diagnoses included congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), anemia (a condition where the body does not have enough healthy red blood cells), and psychosis (a mental health condition characterized by a loss of touch with reality). During a review of Resident 72's History and Physical (H&P), dated 3/19/2025, the H&P indicated, Resident 72 did not have the mental capacity to understand and make medical decisions. During a review of Resident 72's Minimum Data Set ([MDS] - a resident assessment tool) assessment, dated 3/24/2025, the MDS indicated, Resident 72 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 72 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene and lower body dressing. During a review of Resident 72's Weights and Vitals Summary from 1/21/2025 to 3/18/2025, the Weights and Vitals Summary indicated the following: 1. On 1/21/2025 - 216 pounds ([lbs.] - unit of weight) 2. On 2/4/2025 - 209 lbs. 3. On 3/5/2025 - 173 lbs. (- 36 lbs./17.2 % significant weight loss in 1 month) 4. On 3/18/2025 - 169 lbs. During a concurrent interview and record review on 6/6/2025 at 9:43 a.m., with the Minimum Data Set Nurse (MDSN), Resident 72's MDS assessment, dated 3/24/2025, was reviewed. The MDSN stated Resident 72's MDS was completed inaccurately. The MDSN stated Resident 72's MDS, Section K0300 was coded 0 (No), however, it should have been coded as 1 (Yes, on physician prescribed weight-loss regimen). The MDSN stated Resident 72 had a significant weight loss of 38 lbs. (17.2%) in 1 month from 3/5/2025 to 2/4/2025. The MDSN stated by not coding the accurate information on Resident 72's MDS assessment, the facility would not be able to provide the interventions to address resident's weight loss. The MDSN stated he will modify the MDS assessment immediately. During a review of the facility's P&P, titled Resident Assessments, dated 3/2022 indicated all persons who have completed any portion of the MDS assessment form must sign the document attesting to the accuracy of such information. c. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 10's diagnoses included hypertension (HTN-high blood pressure), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and atrial fibrillation [A-Fib]- an irregular and often very rapid heart rhythm). During a review of Resident 10's History and Physical (H&P), dated 6/1/2025, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set ([MDS] - a resident assessment tool) assessment, dated 4/30/2025, the MDS indicated Resident 10 needed maximal assistance with toileting, showering, eating, and dressing. The MDS indicated Resident 10 was not taking an anti-coagulant. During a review of Resident 10's Order Summary, dated 6/1/2025, the summary indicated on 3/1/2025 the physician entered an order to give Dabigatran Etexilate Mesylate 150 mg (a unit of measure for medication) twice a day. During a review of Resident 10's care plan, dated 1/24/2025, the care plan indicated Resident 10 was at risk for adverse effects of Dabigatran Etexilate Mesylate. During a concurrent interview and record review on 6/6/2025 at 10:55 a.m. with the Minimum Data Set Nurse (MDSN), Resident 10's MDS assessment was reviewed. The MDSN stated Dabigatran Etexilate Mesylate should be coded on the assessment as an anti-coagulant. The purpose of the MDS assessment is to gather information and document the current condition of the resident. It tells CMS what kind of care the facility is providing for the resident. Since the MDS assessment was not properly completed CMS does not have an accurate description of the resident's condition. During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, dated November 2019, the P&P indicated any person who completes any portion of the MDS assessment is required to sign the assessment certifying the accuracy of that portion of that assessment.

sBased upon interview and record review, the facility failed to: 1. Ensure smoke break weren't limited for one of 5 sampled residents (Resident 55). This deficient practice resulted in violating Resident 55's rights to smoke. Findings: During a review of Resident 55's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 55 was admitted to the facility on [DATE] with diagnoses which included cellulitis of the right lower limb (a bacterial infection of the skin and underlying tissues in the right lower leg), sepsis (a life-threatening blood infection), bacteremia (bacteria in the blood) and open wound to the right thigh. During a review of Resident 55's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 55 was cognitively intact. The MDS also indicated Resident 55 required substantial assistance with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an interview, on 6/3/2025, at 11:27 a.m., with Resident 55, Resident 55 stated per the Director of Nursing (DON), she was only allowed to smoke one cigarette a day at 9:00 a.m Resident 55 stated she wanted to be able to smoke at her own preference. Resident 55 stated not being able to smoke at her leisure during smoke breaks resulted in her feeling angry. During an interview, on 6/5/2025, at 9:25 a.m., with the DON, the DON stated all residents who smoked at the facility was able to smoke during designated smoking times. The DON stated upon admission, Resident 55 was weak and had wounds. The DON stated she told Resident 55 that she was allowed to smoke 1 cigarette a day until her wounds began to heal. The DON stated the risk of limiting a resident's smoke preference could result in a restriction of resident's rights. During a review of the facility's policy and procedures (P&P), the P&P, titled Resident's Rights, revised 2/2021, indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: m. exercise his or her rights as a resident of the facility.

Based on interview and record review, the facility failed to: 1. Obtain a written informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) and conduct an interdisciplinary team (([IDT] - team members from different disciplines who come together to discuss resident care) meeting before initiation of a psychotropic drug (Any drug that affects brain activities associated with mental process and behavior) for resident with diagnosis of dementia (a progressive state of decline in mental abilities) for one of six sampled residents (Resident 35). This deficient practice had the potential for Resident 35 to receive unnecessary medications. Findings: During a review of Resident 35's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 35's diagnoses included dementia, bipolar disorder (sometimes called manic-depressive disorder, mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 35's History and Physical (H&P), dated 4/19/2025, the H&P indicated, Resident 35 did not have the capacity to understand and make decisions. During a review of Resident 35's Minimum Data Assessment ([MDS] - a resident assessment tool), dated 4/28/2025, the MDS indicated, Resident 35's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated, Resident 35 was totally dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 35's Order Summary Report (a document containing active orders), dated 6/1/2025, the Order Summary Report indicated, the physician placed a telephone order on 5/20/2025 for Resident 35 to start on Depakote sprinkles (drug used to treat seizure and mood disorder) 125 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) to give two capsules once a day ( 9 a.m.) for bipolar disorder manifested by uncontrollable extreme mood swings causing anger interfering with daily activities. The Order Summary Report indicated, the physician placed a telephone order on 4/17/2025 for Resident 35 to start on risperidone (anti-psychotic medication used to treat several mental health conditions) 1 mg to give twice a day (9 a.m., and 5 p.m.) for schizophrenia manifested by uncontrollable anger causing to strike out. During a review of Resident 35's medication administration records ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 4/18/2025 to 6/3/2025, the MAR indicated, Resident 35 was given Depakote and risperidone. During a concurrent interview and record review on 6/4/2025 at 1:40 p.m., with the Director of Nursing (DON), Resident 35's clinical records were reviewed. The DON stated, Resident 35's Informed Consent for Depakote and risperidone were not signed by the IDT. The DON stated, Resident 35 lacks capacity to give informed consent because he had a diagnosis of dementia. The DON stated there was no IDT meeting minutes that was completed before the initiation of Resident 35's psychotropic drug. The DON stated the IDT together with the psychiatrist (a medical doctor who specializes in the diagnosis, treatment, and prevention of mental health disorders), and physician should meet and discuss prior to administration of the proposed treatment for the psychotropic drug making sure that the medications were used appropriately and safely to residents with dementia. The DON stated long term use of psychotropic drugs can cause unwanted side-effects such as slow heart rate, dizziness, headache and could affect or alter residents behavior. During a review of the facility's undated, policy and procedure (P&P) titled, Lack of Capacity when Medical Interventions Requires Informed Consent, the P&P indicated, The facility shall conduct an interdisciplinary team review of the prescribed medical interventions prior to the administration of the medical intervention, except in the case of emergency. The P&P indicated when the resident lacks capacity for informed consent and a psychoactive medication are ordered by the physician, a bioethics meeting will be held. It will include the resident's physician, another physician along with the facility interdisciplinary team member.

Based upon observation and interview, the facility failed to: 1. Ensure the room's curtains and curtain rod was not broken for one of 5 sampled residents (Resident 79). This deficient practice resulted in a violation of Resident 79's right to privacy and a potential to result in a safety hazard. Findings: During a review of Resident 79's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 79 was admitted to the facility on [DATE] with diagnoses which included cerebral ischemia (insufficient blood flow to the brain), gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) and adult failure to thrive (an inability to sustain weight due to poor nutrition, leading to progressive decline). During a review of Resident 79's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/13/2025, the MDS indicated Resident 79's cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 79 required substantial assistance with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview, on 6/3/2025, at 10:10 a.m., with Resident 79, Resident 79's curtains were observed hanging from a bent curtain rod. Resident 79 stated the curtains and curtain rod had been in that condition for a while now. Resident 79 stated it caused him to feel violated as pedestrians on the street could see through his window. During an interview, on 6/5/2025, at 9:15 a.m., with the Maintenance Supervisor (MS), the MS stated he was responsible for repairing equipment and furnishings in the facility. The MS stated the curtain and curtain railing in Resident 79's room was not in good condition and did not promote a homelike environment. The MS stated he had fixed Resident 79's curtain and curtain rod. The MS stated the risk of not having Resident 79's curtain and curtain rod in good condition could result in a safety issue if the curtains and curtain rod fell on a resident. During a review of the facility's policy and procedures (P&P), titled Homelike Environment, revised 2/2021, the P&P indicated the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.

Based on observation, interview, and record review, the facility failed to provide appropriate services to prevent a decline in joint range of motion ([ROM] - full movement potential of a joint) for two out of two sampled residents (Resident 24 and 76) who had limited ROM by failing to: 1. Ensure 24 received timely quarterly (every three months) Joint Mobility Screening/Assessment to monitor changes in joint range of motion. 2. Ensure one of seven sampled residents (Resident 76) received passive range of motion ([PROM]- movement of a joint through its full range of motion without any effort from the individual) exercises seven days a week by the Restorative Nurse Assistant ([RNA]- a healthcare worker who helps residents improve and maintain function in physical abilities) as ordered by the physician. These deficient practices had the potential to cause further decline in Resident 24 and Resident 76's ROM and overall quality of life. Findings: 1. During a review of Resident 24's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 24 was admitted to the facility on [DATE]. Resident 24's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and other abnormalities of gait and mobility. During a review of Resident 24's History and Physical (H&P), dated 9/27/2024, the H&P indicated, Resident 24 did not have the mental capacity to understand and make decisions. During a review of Resident 24's Minimum Data Set ([MDS] - a resident assessment tool), dated 4/4/2025, the MDS indicated, Resident 24's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated, Resident 24 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene and upper and lower body dressing, and personal hygiene. The MDS indicated, Resident 24 had functional limitation in ROM on one side of upper extremity (shoulder, elbow, wrist, hand). During an observation on 6/3/2025 at 10:19 a.m., in the activity room, observed Resident 24 sitting in wheelchair, unable to fully extend her right upper extremity particularly the elbow. During a concurrent interview and record review on 6/4/2025 at 9:37 a.m., with the Minimum Data Set Nurse (MDSN), Resident 24's clinical records, were reviewed. The MDSN stated Joint Mobility Screening/Assessment should be completed quarterly based on the MDS scheduled assessment, yearly and as needed. The MDSN stated Resident 24's last Joint Mobility Screening was completed on 9/26/2024 and another quarterly screening should have been completed on December 2024 and March 2025. The MDSN stated the purpose of completing the Joint Mobility Screening in a timely manner was to monitor resident's range of motion and if there was a decline then the resident could be a good candidate for active therapy services. During an interview on 6/4/2025 at 9:55 a.m., with the Director of Rehab (DOR), the DOR stated the quarterly Joint Mobility Screening for Resident 24 was not completed as scheduled. The DOR stated the rehabilitation staff was responsible in completing the Joint Mobility Screening to monitor contracture (stiffening/shortening at any joint, that reduces the joint's range of motion) and keep track of residents change in range of motion so the facility could provide interventions to prevent further contractures. During a review of the facility's undated policy and procedure (P&P) titled, Screening, the P&P indicated, Quarterly and Annual screens (both Rehabilitation and/or Joint Mobility Screening forms) may be done as per facility policy and in conjunction with the MDS assessment schedule. During a review of the facility's P&P titled Resident Mobility and Range of Motion. Dated 7/2017, indicated documentation of the resident's progress towards the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. During a review of the facility's P&P titled Functional Impairment - Clinical Protocol, dated 3/2018, indicated upon admission to the facility, whenever a significant change of condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident's function along with their physical condition. b. During a review of Resident 76's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 76 was initially admitted to the facility on [DATE], with a readmission on [DATE]. Resident 76's diagnoses included dysphagia (difficulty swallowing), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 76's History and Physical (H&P), dated 1/28/2025, the H&P indicated Resident 76 was able to make decisions for activities of daily living. During a review of Resident 76's Minimum Data Set ([MDS]- a resident assessment tool), dated 6/2/2025, the MDS indicated Resident 76's cognition (ability to understand and reason) was intact. The MDS indicated Resident 76 needed supervision bathing and dressing the upper body. During a review of Resident 76's Order Summary Report, dated 6/1/2025, the report indicated on 4/11/2025 the physician entered an order for the RNA to perform left upper extremity PROM every day seven times a week. During a review of Resident 76's care plan, dated 5/27/2024, the care plan indicated the facility would provide the RNA program as ordered to minimize decline in joint mobility. During a review of Resident 76's RNA task form for left upper extremity PROM every day seven times a week, dated 5/8/2025 through 6/5/2025, the task indicated PROM was provided on the following dates: 5/8/2025 5/9/2025 5/12/2025 5/13/2025 5/14/2025 5/15/2025 5/16/2025 5/20/2025 5/21/2025 5/22/2025 5/23/2025 5/26/2025 5/27/2025 5/28/2025 5/30/2025 6/2/2025 6/3/2025 6/4/2025 6/5/2025 During an interview on 6/6/2025 at 11:19 a.m. with Licensed Vocational Nurse (LVN) 1, LVN1 stated RNA services are provided to keep the resident at their highest level of functioning. Providing PROM exercises prevents contractures. If PROM is not provided as ordered, the resident may become contracted. During a concurrent interview and record review on 6/6/2025 at 11:32 a.m. with RNA1, Resident 76's RNA task form for PROM was reviewed. RNA1 stated when a resident has an order for PROM seven times a week, it must be done every day. RNA1 stated Resident 76 did not receive PROM every day. RNA1 stated the purpose of RNA services are to help the resident move their bodies when they can't do it themselves or need assistance. Not completing the PROM as ordered put the resident at risk for decline. The resident can become contracted. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion dated July 2017, the P&P indicated residents with limited range of motion will receive treatment and services to prevent a further decrease in range of motion. Residents with limited mobility will receive appropriate services to maintain or improve mobility. During a review of the Restorative Nurse Assistant job description, the job description indicated the RNA's duties and responsibilities are to assist the resident with range of motion exercises per physician's orders to improve or maintain mobility and independence in the resident.

Based on observation, interview, and record review, the facility failed to: 1. Ensure a peripheral catheter ([IV] - a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) was removed after IV antibiotic (a drug used to treat infections caused by bacteria) was completed for one of one sampled resident (Resident 57). This deficient practice had the potential for the IV insertion site to develop infection and/or hospitalization for Resident 57. Findings: During a review of Resident 57's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 57 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 57's diagnoses included urinary tract infection ([UTI] - an infection in the bladder/urinary tract), dementia (a progressive state of decline in mental abilities), and type 2 Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar and poor wound healing). During a review of Resident 57's Minimum Data Assessment ([MDS] - a resident assessment tool), dated 4/14/2025, the MDS indicated, Resident 57's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated, Resident 57 was totally dependent (helper does all of the effort) from staff with oral hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 57's Order Summary Report (a document containing active orders), dated 6/1/2025, the Order Summary Report indicated, the physician placed a telephone order on 5/29/2025 for Resident 57 to start on ceftriaxone (drug used to treat bacterial infection) 1 gram ([gm] - metric unit of measurement, used for medication dosage and/or amount) IV one time a day for UTI for 4 days. During a review of Resident 57's IV medication administration records ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), the IV MAR indicated, Resident 57's last dose of ceftriaxone 1 gm IV was given on 6/1/2025 at 4:30 p.m. During a concurrent observation and interview on 6/3/2025 at 2:28 p.m., with the Minimum Data Set Nurse (MDSN), in Resident 57's room, Resident 57 had an IV line on left hand. The MDSN stated, Resident 57's IV antibiotic was completed two days ago. The MDSN stated the licensed nurse who administered the last dose of IV antibiotic should have removed the IV peripheral catheter immediately to minimize discomfort and prevent infection. During a review of the facility's policy and procedure (P&P) titled, Peripheral Catheter Removal, dated 5/2023, the P&P indicated, Peripheral catheters are removed at the time completion of therapy.

Based on observation, interview, and record review, the facility failed to: 1. Ensure accurate accounting/documentation of a controlled drug ([Lyrica]- medication used for nerve pain) for one out of seven sampled residents (Resident 21). This deficient practice had the potential to result in drug diversion. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE]. Resident 21's diagnoses included hypertension (HTN-high blood pressure), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 21's History and Physical (H&P), dated 6/20/2025, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set ([MDS]- a resident assessment tool), dated 6/4/2025, the MDS indicated Resident 21 needed moderate assistance with toileting, showering, eating, and dressing. During a concurrent interview and record review on 6/6/2025 at 10:59 a.m. with the Director of Nursing (DON), the facility's Controlled Medication Destruction Log was reviewed for Resident 21's Lyrica. The DON stated when a resident is discharged or a drug is discontinued, the nurse brings it to her and fills in the log indicating it was turned in. The DON then signs indicating the drug was received. The DON stated the purpose of signing the form is to keep track of where the medication is. The log indicated on 6/4/2025 the nurse turned in 28 Lyrica pills for destruction. There is no signature indicating who received the Lyrica. The DON stated she did not sign the form because the drug count was incorrect. Review of the medication bubble pack indicated there are 28 Lyrica pills remaining. Review of the Antibiotic or Controlled Drug Record form indicated there are 30 pills remaining. The DON stated the nurse gave the doses and did not document it upon administration. Both nurses should count the drugs during hand off at shift change. The hand off was not done correctly. During a concurrent interview and record review on 6/6/2025 at 12:07 p.m. with Licensed Vocational Nurse (LVN) 2, the facility's Controlled Medication Destruction Log was reviewed for Resident 21's Lyrica. LVN2 stated looking at the documentation you would not know where the drug is. It looks like the medication was displaced. This is not okay for a controlled drug. During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, dated April 2008, the P&P indicated in no case should the individual who administered the medication report off-duty without first recording the administration of any medication. During a review of the facility's P&P titled, Controlled Substances, dated April 2019, the P&P indicated controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. The P&P indicated the nurse administering the medication is responsible for recording the tine of administration, quantity of the medication remaining, and signature of the nurse administering the medication. The P&P indicated disposal of controlled medications are done in the presence of the nurse and a witness who also signs the disposition sheet. During a review of the Licensed Vocational Nurse job description, the job description indicated the nurse will ensure medications are documented in a timely fashion and in accordance with the company's policies and procedures.

Based on interview and record review, the facility failed to: 1. Ensure a pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendation to consider ordering valproic acid level (test that measures the concentration of valproic acid, an anticonvulsant medication, in the blood) and ammonia level (test that measures the amount of ammonia level in the blood) was acknowledged and acted upon for one of five sampled residents (Resident 72). This deficient practice had the potential for Resident 72 to experience a delay in treatment. Findings: During a review of Resident 72's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 72's diagnoses included congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), anemia (a condition where the body does not have enough healthy red blood cells), and psychosis (a mental health condition characterized by a loss of touch with reality). During a review of Resident 72's History and Physical (H&P), dated 3/19/2025, the H&P indicated, Resident 72 did not have the mental capacity to understand and make medical decisions. During a review of Resident 72's Minimum Data Set (a resident assessment tool), dated 3/24/2025, the MDS indicated, Resident 72 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 72 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene and lower body dressing. During a review of Resident 72's Order Summary Report (a document containing active orders), dated 6/1/2025, the Order Summary Report indicated, the physician placed a telephone order on 3/18/2025 for Resident 72 to start on Depakote Delayed Release (drug used to treat seizure and mood disorder) 250 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) to give one tablet twice a day (9 a.m. and 5 p.m.) for mood disorder manifested by episodes of hallucination hearing someone is out to get him to do surgery on him. During a concurrent interview and record review on 6/5/2025 at 1:31 p.m., with the Director of Nursing (DON), Resident 72's Consultant Pharmacist Medication Regimen Review (MRR), dated 4/24/2025, was reviewed. The MRR indicated, Please follow-up with doctor to consider ordering valproic acid and ammonia level. The DON stated the timeline to follow-up pharmacy consultant recommendation to physician is within 14 days after receiving the MRR report. The DON stated the facility failed to take any action on the consultant pharmacist recommendation by not informing Resident 72's physician. The DON stated there was no previous and current order to check valproic acid and ammonia level. The DON stated it is the facility's policy to address MRR by the pharmacy consultant for the welfare of the resident. The DON stated the purpose of checking valproic acid and ammonia level of Resident 72's was to check the therapeutic blood level (amount of a specific medicine or drug present in the blood stream at a particular time) in order to determine if the medication was safe to administer. The DON stated if Resident 72's valproic acid and ammonia level was not within the therapeutic range then his behavior would escalate (certain pattern of behavior that can get worse over time). During a review of the facility's policy and procedure (P&P), titled Consultant Pharmacist Reports, dated 12/2016, the P&P indicated, Recommendations are acted upon and documented by the facility staff and or the prescriber. The P&P indicated the physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing.

Based on interview and record review, the facility failed to: 1. Ensure laboratory test (a medical procedure that analyzes a sample of blood, urine, or other bodily fluid or tissue) to check ammonia level (test that measures the amount of ammonia level in the blood) was completed monthly as ordered by the physician for one of 19 sampled residents (Resident 24). This deficient practice had the potential for Resident 24 not receiving necessary medical treatment. Findings: During a review of Resident 24's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 24 was admitted to the facility on [DATE]. Resident 24's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and other abnormalities of gait and mobility. During a review of Resident 24's History and Physical (H&P), dated 9/27/2024, the H&P indicated, Resident 24 did not have the mental capacity to understand and make decisions. During a review of Resident 24's Minimum Data Set (a resident assessment tool), dated 4/4/2025, the MDS indicated, Resident 24's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated, Resident 24 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene and upper and lower body dressing, and personal hygiene. During a review of Resident 24's Order Summary Report (a document containing active orders), dated 6/1/2025, the Order Summary Report indicated, the physician placed a telephone order on 1/30/2025 for Resident 24 to check ammonia level monthly. During a concurrent interview and record review on 6/4/2025 at 9:27 a.m., with the Minimum Data Set Nurse (MDSN), Resident 24's clinical records were reviewed. The MDSN stated Resident 24's laboratory tests as ordered by the physician on 1/30/2025 to check for ammonia level was not completed and results were not available. The MDSN stated there was no documentation indicating that the ammonia level for the month of March, April, and May 2025 were drawn. The MDSN stated elevated ammonia level could cause confusion and loss of consciousness. The MDSN stated it was important for Resident 24's ammonia level to be drawn to keep track of the therapeutic level (amount of a specific medicine or drug present in the blood stream at a particular time) so the physician could implement medical interventions. During a review of the facility's policy and procedure (P&P), titled Lab and Diagnostic Test Results - Clinical Protocol, dated 3/2023, the P&P indicated, The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs and the staff will process test requisitions and arrange for tests.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 31) had enhanced barrier precautions ([EBP]- infection control strategy aimed at reducing the transmission of bacteria resistant to antibiotics) was implemented when care was provided to his feeding tube (a flexible plastic tube placed into the stomach to help you get nutrition when you're unable to eat). This deficient practice put Resident 31 at risk for infection. Findings: During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was initially admitted to the facility on [DATE], with a readmission on [DATE]. Resident 31's diagnoses included hypertension (HTN-high blood pressure), dysphagia (difficulty swallowing), and malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients). During a review of Resident 31's History and Physical (H&P), dated 9/19/2024, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a review of Resident 31's Minimum Data Set ([MDS]- a resident assessment tool), dated 3/15/2025, the MDS indicated Resident 31 was dependent on staff for toileting, showering, dressing, and hygiene. During a review of Resident 31's care plan, dated 9/16/2024, the care plan indicated Resident 31 was at moderate risk for infection related to his feeding tube. The care plan indicated the facility would provide enhanced barrier precautions Gloves, Gowns, Masks. During an observation on 6/5/2025 at 9:25 a.m., there was an Enhanced Barrier Precautions sign located at the doorway of Resident 31's room and over his bed. The sign indicated staff must wear gloves and a gown when providing care or using a feeding tube. During an observation on 6/5/2025 at 9:26 a.m., Licensed Vocational Nurse (LVN) 1 was observed applying gloves, then injecting air into the feeding tube to check placement. LVN1 then aspirated fluid to check the feeding tube residual. LVN1 was not wearing a gown. During an interview on 6/5/2025 at 9:39 a.m. with LVN1, LVN1 stated EBP should be practiced when you are using a device such as a feeding tube. EBP includes performing hand hygiene and applying a gown and gloves. LVN1 stated she was not wearing a gown when she checked the G-tube residual because she forgot. LVN1 stated EBP prevents infection. LVN1 stated the resident is now at risk for infection because she did not wear a gown. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated June 2024, the P&P indicated device care or use of a feeding tube is a high contact resident care activity requiring the use of gown and gloves for enhanced barrier precautions.

Based upon observation and interview, the facility failed to: 1. Ensure 1 of 2 trash dumpster lids were closed. This deficient practice had the potential to result in unwanted pests and vermin. Findings: During a concurrent observation and interview, on 6/3/2025, at 9:25 a.m., with the Dietary Supervisor (DS), one trash dumpster lid was observed filled with trash and the lid was open. The DS stated all dumpsters were to remain closed. The DS stated the risk of having an open trash dumpster lid could result in a potential infestation for pests and vermin. During a review of the facility's undated policy and procedures (P&P), titled Waste Control and Disposal, the P&P indicated Trash bins should be covered at all times.

Based on interview and record review, the facility failed to: 1. Implement its policy and procedure (P&P) titled, Identifying Abuse which indicated the facility did not condone any form of resident abuse or neglect for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 2 physically assaulting Resident 1, causing serious injuries such as a swelling to the right side of Resident 1's forehead, and a zygomatic arch fracture (a break in the cheekbone). Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hypertension (high blood pressure), bilateral hearing loss (hearing loss in both ears), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypercalcemia (a condition in which the calcium level in the blood becomes too high). During a review of Resident 1's Minimum Date Set (MDS- a resident assessment tool), the MDS indicated Resident 1's cognitive (thinking) skills for daily decision making were intact. The MDS indicated Resident 1 required setup and clean up assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Change of Condition (COC- a communication tool used to communicate a resident's change of condition), dated 4/19/2025, the COC indicated on 4/19/2025, a staff member reported hearing a loud noise coming from the hallway. The COC indicated the staff member went to investigate the noise and saw Resident 1 lying on the floor. The COC stated the staff member saw Resident 2 physically assaulting Resident 1 with his hands and feet. During a review of Resident 1's General Acute Care Hospital (GACH) records, dated 4/19/2025, the GACH records indicated Resident 1 was diagnosed with a traumatic injury to the right ear and temple area (side of the head behind the eyes, located between the forehead and ear), temporary unconsciousness (the state of not being awake) possibly due to head trauma, a suspected zygomatic arch fracture (break in the cheekbone), and hearing loss in the right ear. The GACH records indicated Resident 1 was ordered Hydrocodone-Acetaminophen (Norco, used to treat moderate to severe pain) 5/325 milligrams (mg, unit of measurement) 1 tablet by mouth every 4 hours for pain. The GACH records indicated Resident 1 was admitted to the GACH on 4/19/2025 and discharged on 4/24/2025. During a review of Resident 1's facility readmission Progress Note dated 4/24/2025 at 4:40 p.m., the progress note indicated Resident 1 was readmitted to the facility from the GACH where he was treated for status post (s/p) right temple and ear subarachnoid (the space between the brain and the thin tissues covering it) and subdural (collection of blood in the brain) hemorrhages (bleeding from a broken vessel either inside or outside of the body). b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paranoid schizophrenia (a mental health condition characterized by delusions that others are persecuting, tracking, or otherwise monitoring a person), mood affective disorder (a mental health condition that primarily affects your emotional state), hypertension, and type 2 diabetes. During a review of Resident 2's MDS, the MDS indicated Resident 2's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 2 was independent with ADLs. During a review of Resident 2's care plan titled, Resident non-compliance manifested by: Resident at risk for not being treated related to refusing medication, dated 3/23/2025, the care plan indicated Resident 1 will comply with the facility's policy/protocols, physician orders daily. The interventions indicated an interdisciplinary team (IDT, group of different disciplines working together towards a common goal of a resident) meeting to be held address non-compliant behavior. During a review of Resident 2's physician's order, dated 4/3/2025, the physician's order indicated Haldol (a typical antipsychotic [medication used to treat mental disorders] medication used to treat certain types of mental disorders) 10 mg intramuscularly (an injection administered into a muscle) twice a day starting 4/3/2025. During a review of Resident 2's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of April 2025, the MAR indicated Resident 2 refused Haldol daily from 4/3/2025 to 4/19/2025. During a review of Resident 2's Psychiatric Initial Evaluation dated 4/50/2025, the evaluation indicated Resident 2 appeared visibly anxious, suspicious, and mildly disoriented. The evaluation indicated over the past month the resident had exhibited increasing paranoia (unjustified suspicion and mistrust of other people or their actions) and was now expressing fixed delusions (having false or unrealistic beliefs) that others were attempting to harm him. During an interview on 4/25/2025 at 10:01 a.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated on 4/19/2025 around 8:30 a.m., she heard loud noises coming from the patio hallway. CNA 1 stated she ran over and saw Resident 2 standing over Resident 1, kicking and stomping (to put a foot down on the ground hard and quickly, making a loud noise, often to show anger) on Resident 1's head. CNA 1 stated Resident 1 was on the floor and appeared unconscious. CNA 1 stated staff immediately separated the residents. During an interview, on 4/25/2025 at 10:58 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he heard a bunch of commotion at the patio hallway. LVN 1 stated he saw CNA 1 run to the patio hallway and began screaming. LVN 1 stated he ran over and saw Resident 1 on the floor. LVN 2 stated Resident 2 was kicking and stomping on Resident 1's head. LVN 1 stated Resident 1 was unconscious for 2 minutes. LVN 1 stated Resident 2 began walking towards him stating, I'm waiting to get you next. LVN 1 stated once Resident 1 regained consciousness, Resident 1 was observed with swelling to the forehead, and stumbled upon standing. LVN 1 stated Resident 1 was transferred to the GACH immediately, while Resident 2 was taken into police custody. LVN 1 stated Resident 2 had been refusing Haldol. LVN 1 stated the risk of resident refusing antipsychotic medications could result in aggressive residents and a possibility of a resident to abuse/assault other residents and staff. During an interview, on 4/25/2025 at 11:58 a.m., LVN 2, LVN 2 stated, on 4/19/2025 around 8:34 a.m., she observed a staff member rushing a crash cart over to Resident 1. LVN 2 stated as she ran to the patio hallway, she observed Resident 1 on the floor, unconscious. LVN 2 stated when Resident 1 regained consciousness, he began bleeding from his nose. LVN 2 stated the ambulance arrived at the facility within 2 minutes after 911 was called and was transferred to the GACH due to the injuries he sustained from Resident 2. During an interview on 4/25/2025 at 12:58 p.m., with the Registered Nurse Supervisor (RNS), the RNS stated Resident 2's refusal of Haldol resulted in sudden aggression and a physical altercation towards Resident 1. During a review of the facility's policy and procedures (P&P), titled Identifying Abuse, revised 9/2022, the P&P indicated, Abuse of any kind against residents is strictly prohibited. The P&P indicated Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking.

Based on interview and record review, the facility failed to implement 1 of 3 sampled residents ' , (Resident 1) care plan titled, Resident non-compliant manifested by refusing medications, history of refusing to take medications for 2 months, which indicated to hold an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) to address non-compliant behavior. This failure resulted in Resident 1 ' s continued refusal of medications not addressed, and had the potential to affect in maintaining the resident ' s highest practicable physical, mental and psychosocial well-being. Findings: During a review of Resident 1 ' s Admission Record, dated 2/3/2025, the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of schizophrenia (a chronic mental health condition characterized by profound disruptions in thought processes, perceptions, emotions, and behaviors), suicidal ideations (occurs when you think about or consider death or suicide), and restlessness and agitation. During a review of Resident 1 ' s Order Summary Report dated 12/1/2024, the order summary report indicated a physician order, dated 11/16/2024 for Lithium Carbonate Oral Capsule 300 milligrams (mg.- a unit of measurement), one (1) capsule by mouth three times a day for paranoid schizophrenia. During a review of a Resident 1 ' s care plan titled Resident non-compliant manifested by refusing medications, history of refusing to take medications for 2 months; at risk for not being treated related to refusing medication, dated 11/19/2024, the interventions indicated an IDT should be held as needed to address non-compliant behavior, document Resident 1 ' s response to specific non-compliance as needed, notify any risks/ consequences as a result of non-compliance, involve resident/ significant others in care to gain cooperation. During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/22/2024, the MDS indicated Resident 1 had clear speech and had the ability to express ideas and wants and understands. The MDS indicated Resident 1 was independent with daily task of eating, toileting hygiene, and personal hygiene. During a review of Resident 1 ' s January 2025 Medication Administration Record (MAR), the MAR indicated Resident 1 had refused Lithium Carbonate Oral Capsule 300 mg on 1/13/2025 at 1 p.m. and on 1/19/2025 at 9 a.m. and 1 p.m. During a review of Resident 1 ' s progress notes dated 1/13/2025 at 12: 25 p.m., the progress notes indicated on 1/13/2025 during the morning shift (time not specified), Resident 1 had episodes of distress, anger, verbalization of the F . word, threatening nurses, and was unable to control her thinking. The progress notes indicated Resident 1 refused some of the morning medications and had refused noon medications. The progress notes did not indicate physician was notified of Resident 1 ' s refusal. During a review of Resident 1 ' s progress notes dated 1/13/2025 at 9:42 p.m., the progress notes indicated Registered Nurse (RN) had documented Resident 1 was yelling the F . word after being informed she will be transferred to a general acute care hospital (GACH). The progress notes indicated Resident 1 yelled and stated she was not going to a psyche hospital. The progress notes indicated Resident 1 started to pace around the facility and yelled the F . word when asked to go back to her room. The progress notes indicated Resident 1 stated, she will not follow anything the RN said and will not take any psyche medications. During a review of Resident 1 ' s progress notes dated 1/19/2025, the progress notes did not indicate the physician was notified on 1/19/2025 at 9 a.m. and 1 p.m. when Resident 1 refused the Lithium Carbonate. During a telephone interview on 2/4/2025 at 3:44 p.m. with the Director of Nursing (DON), the DON stated since Resident 1 was admitted with a diagnosis of non-compliance, an IDT meeting should have been conducted to discuss Resident 1 ' s refusal of medications. During a review of the facility ' s policy and procedure (P&P) titled, Requesting, Refusing and/or Discontinuing Care or Treatment, dated 2/2021, the P&P indicated if a resident refuse care or treatment, an appropriate member of IDT should meet with the resident/resident representative to determine why he or she is refusing, try to address his or her concerns and discuss alternative options and discuss the potential outcomes or consequences (positive and negative) of the decision.

Based on interview and record review, the facility failed to immediately inform and consult with the resident ' s physician when a resident experienced a significant change of condition ([COC] a clinical deviation from a resident's baseline) for one of three sample residents (Resident 1). Resident 1 experienced a decline with vital signs (clinical measurements, specifically heart rate, temperature, respiration rate [breathing rate], and blood pressure [BP- the amount of pressure in the arteries during contraction of the heart], that indicated the state of a person's essential body functions) that were not within normal limit. Resident 1 ' s BP was at ,d+[DATE] millimeter of mercury (mmHg-unit of measurement) below Resident 1 ' s baseline (104 to148 systolic [when the heart muscle contracts) and 56 to 86 diastolic [when the heart muscle relaxes]) heart rate 117 beats per minute (bpm) normal reference range (NRR) was between 60 to 100 bpm, oxygen (O2-a colorless, odorless reactive gas, and the life-supporting component of the air) saturation ([O2 sat] a measure of how much oxygen the blood is carrying with NRR being ,d+[DATE] percent [%]) was 90% on room air and had an increased need for O2 and the physician was not notified. This failure resulted in a delay of evaluation, care, and treatment for Resident 1. Resident 1 was exhibiting a COC for over four (4) hours before Resident 1 was transferred to a general acute care hospital (GACH) by 911 (any situation that requires immediate assistance from the police, fire department or ambulance). Resident 1 was admitted with acute hypoxic respiratory failure (blood does not have enough oxygen) due to mucus plugging (a buildup of mucus in your airways) and likely aspiration pneumonia (lung infection caused by inhaled oral or gastric contents). Resident 1 eventually was placed on hospice (medical care for people with an anticipated life expectancy of six (6) months or less, when cure is not an option, and the focus shifts to symptom management and quality of life) and passed away on [DATE] due to hypoxic respiratory failure and pneumonia. Findings: A review of Resident 1 ' s admission record (Face Sheet), dated [DATE] the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses that included dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), bipolar disorder (a mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), hyperlipidemia (an elevated level of lipids), anemia (a condition in which the body does not have enough healthy red blood cells), gastro-esophageal reflux disease (a condition in which the stomach contents leak backward from the stomach into the esophagus), atherosclerotic heart disease of native coronary artery (thickening or hardening of the arteries), history of transient ischemic attack (TIA- there is a temporary disruption in the blood supply to part of the brain) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessels that supply it) without residual deficits. A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool) dated [DATE], the MDS indicated the cognitive (the ability to think and process information), skills for daily decisions making was severely impaired and required limited assistance of one-person physical assist for activities of daily living (ADL). The MDS indicated Resident 1 did not have pulmonary (pertaining to the lungs) concerns and did not have shortness of breath. A review of Resident 1 ' s History and Physical (H&P), dated [DATE], the H&P indicated, Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s vital signs from [DATE] to [DATE] indicated the following: [DATE] at 08:41 a.m., BP was ,d+[DATE] mmHg. [DATE] at 08:35 a.m., BP was ,d+[DATE] mmHg. [DATE] at 09:02 a.m., BP was ,d+[DATE] mmHg. [DATE] at 08:52 a.m., BP was ,d+[DATE] mmHg. [DATE] at 08:38 a.m., BP was ,d+[DATE] mmHg. [DATE] at 10:32 a.m., BP was ,d+[DATE] mmHg. [DATE] at10:49 a.m., BP was ,d+[DATE] mmHg. [DATE] at 08:30 a.m., BP was ,d+[DATE] mmHg. [DATE] at 08:33 a.m., BP was ,d+[DATE] mmHg. [DATE] at 10:42 a.m., BP was ,d+[DATE] mmHg. [DATE] at 0846 a.m., BP was ,d+[DATE] mmHg. [DATE] at 10:59 a.m., BP was ,d+[DATE] mmHg. A review of Resident 1 ' s COC form dated [DATE], the COC form indicated on [DATE] at 08:30 a.m., Resident 1 ' s BP was ,d+[DATE] mmHg, Pulse 117 bpm, Respiration 16 and O2 sat was 90% at room air. Resident 1 ' s lower extremities were elevated and two (2) liters per minute (lpm) of oxygen was administered via nasal cannula (a device used to deliver supplemental oxygen into the nose). The COC form indicated on [DATE] at 12:00 p.m., Resident 1 ' s BP was ,d+[DATE], Pulse 124 bpm and oxygen was fluctuating between 78 to 85% on five (5) lpm and head of the bed (HOB) was elevated. The COC form indicated Resident 1 was difficult to arouse and only responsive to painful stimuli, 911 was called and Resident 1 was transferred to GACH at 12:33 p.m., the physician and family were made aware. A review of Resident 1 ' s Nurses Notes (NN), dated [DATE] at 14:28 p.m., the NN indicated LVN 2 documented Resident 1 was in bed, respirations labored, resident vital signs were assessed stable, but was unable to arouse Resident 1. LVN 2 raised Resident 1 ' s head of bed and continued to monitor Resident 1. The NN indicated O2 sat decreased to 85% and still unable to arouse Resident 1. Physician 1 was notified and 911 was called. During a concurrent interview and record review on [DATE] at 9:57 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 1 ' s COC form dated [DATE] and Resident 1 ' s nurses note date [DATE] at 14:28 p.m. were reviewed and clarified with LVN 2. LVN 2 stated on [DATE] at 8:30 a.m., Resident 1 ' s vital signs were BP ,d+[DATE] mmHg, and O2 sat was 90%. LVN 2 stated she elevated Resident 1 ' s feet and gave him two (2) lpm of oxygen. Then she (LVN 2) notified Resident 1 ' s physician (Physician 1) by sending Physician 1 a text message about Resident 1 ' s low blood pressure and low oxygen saturation. LVN 2 stated she did not get a response from Physician 1 and continued to monitor Resident 1 every 15 minutes, but the blood pressure and oxygen saturation did not go up until 10:30 a.m. LVN 2 stated Resident 1 ' s blood pressure went up to ,d+[DATE] mmHg, O2 sat of 98% on 2 liters oxygen via nasal cannula. LVN 2 stated she did not document Resident 1 ' s monitoring for vital signs. LVN 2 stated she waited for Physician 1 to call back to get an order to transfer Resident 1 to the hospital by regular ambulance and not by 911. LVN 2 stated on [DATE] at 12:00 p.m., Resident 1 became unresponsive, O2 saturation dropped between 78% to 85% on five (5) liters of oxygen. LVN 2 stated she called 911 at 12:00 p.m. when Resident 2 became unresponsive. During an interview on [DATE] at 1:30 p.m., with LVN 2. LVN 2 stated she was not sure what to do if the physician does not call back. LVN 2 stated there was no protocol or policy when to call 911. She (LVN 2) and Registered Nurse Supervisor (RN 1-Resident 1 ' s primary nurse on [DATE]) would use nursing assessment to make the decision when to call 911. LVN 2 stated she was not aware she should call the medical director and did not know who the on-call physician was. During an interview on [DATE] at 10:30 a.m., with RN 1, RN 1 stated she does not remember the incidence on [DATE] about Resident 1 and unable to recall what interventions were done when Resident 1 had COC. RN 1 was unable to say if any nurses were able to speak to the primary physician when Resident 1 was having COC. RN 1 stated if she was informed about Resident 1 ' s COC she should call the primary physician, if unable to reach the primary physician, she would call the house doctor (medical director). RN 1 stated if Resident 1 was unresponsive she would have called 911 immediately and then inform the physician. During an interview on [DATE] at 12:01 p.m., with the Director of Nursing (DON), the DON stated if the physician does not respond when nurses were trying to reach Physician 1, the nurses should have called the medical director. The DON stated the nurses should know when to check the resident and when to call 911. The nurses do not have to wait for the physician to call and should have called 911 right away when Resident 1 had a COC. The DON stated the COC and monitoring should have been documented. During an interview on [DATE] at 4:05 p.m. with the Administrator (ADM), the ADM stated there was a policy for emergency physician care, if the nurse cannot reach the physician, the nurses should call medical director and 911. The ADM stated if a resident had a change in condition, it should be documented in the COC form. During an interview on [DATE] at 12:25 p.m., with Physician 1. Physician 1 stated if he was not available the nurses should have called 911 when there was a medical emergency. Physician 1 stated the nurses should have not waited to send Resident 1 to the hospital. A review of Resident 1 ' s General Acute Care Hospital Record (GACH), GACH record indicated Resident 1 was seen on [DATE] at 12:56 p.m., in the Emergency Department (ED), Resident 1 ' s O2 sat was 93%, pulse 108 bpm, respiratory rate 40 breaths per minute. The GACH record indicated Resident 1 ' s general condition indicated moderate distress, on a nonrebreather mask (a non-invasive oxygen supplementation device that is used to provide continuous oxygen flow), and not alert. The ED notes indicated Resident 1 had dried blood in his mouth, mildly tachycardic (elevated heart rate) with hypotension (low BP). Resident 1 was started on 30 cubic centimeter per kilogram (cc/kg) of intravenous (IV, within a vein) fluids to treat dehydration (caused by not drinking enough fluid or by losing more fluid than you take in) and electrolyte imbalances (occurs when you have too much or not enough of certain minerals in your body). A review of Resident 1 ' s GACH Discharge Summary dated [DATE], the GACH record indicated Resident 1 was admitted to GACH on [DATE]. Resident 1 ' s Chest Computed tomography (CT-used to enhance certain anatomic views) noted bilateral pneumonia and mucous plugging. Resident 1 was admitted for treatment of respiratory failure due to pneumonia likely aspiration, severe dehydration, acute kidney injury (a condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days) and hypernatremia (having too much sodium in the blood, a mineral that helps regulate fluid balance and nerve signals in the body). Resident 1 was started on antibiotics remained encephalopathic (altered mental state). The GACH record indicated Resident 1 was placed on GIP (general inpatient) hospice. A review of Resident 1 ' s CT scan of the chest, dated [DATE] taken 6:44 p.m., CT scan impression indicated a significant mucous plugging. Finding could represent pneumonia and or aspiration pneumonitis (a general term that refers to inflammation of lung tissue), left atelectasis (a condition where lungs collapse partially or completely,) .and left pleural effusion (the build-up of excess fluid between the layers of the pleura outside the lungs). A review of Resident 1 ' s Death Certificate, dated [DATE], the Death Certificate indicated Resident 1 died on [DATE] at 9:45 a.m., immediate cause of death (final disease or condition resulting in death) was hypoxic respiratory failure and pneumonia, time interval between onset and death was weeks. Resident 1 ' s Death Certificate indicated other significant condition included acute renal failure (when the kidneys are suddenly unable to filter wastes from the blood), dehydration, and dementia, but not resulting in the underlying cause. A review of the facility ' s policy and procedures (P&P) titled, Emergency Physician Care dated ,d+[DATE], the P&P indicated, Emergency physician care is available to all resident when their attending physician are unavailable. Should the resident ' s attending physician be unavailable, the nurse supervisor/charge nurse must first attempt to contact the physician ' s designated referral physician or practitioner. Should the designated referral physician be unavailable to assist in the emergency, the on-call physician or medical director shall be contacted. A review of the facility ' s P&P titled Change in a Resident ' s Condition or Status dated ,d+[DATE], indicated the facility will promptly notifies the resident, his or her attending physician, and the representative of changes in the resident ' s medical/mental condition and/or status. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the interact SBAR ([situation-background-assessment-recommendation]-a form of communication between members of the health care team). A review of the facility ' s P&P titled Acute Condition Changes - Clinical Protocol, dated ,d+[DATE], indicated the nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a response (within approximately one-half hour or less).

Based on observation, interviews and record review, the facility failed to implement a resident's plan of care and its policies titled, Care of the Wandering Resident, Elopement Risk /Prevention and Wanderguard, which indicated that the staff would follow protocol for conducting visual checks, checking residents at risk for elopement (leaving unsupervised, undetected and without authorization or permission) on a regular means, monitor the resident's location and provide one to one (1:1) monitoring as needed, and the facility failed to monitor all doors and ensure alarms were operable on all doors for two of four sampled residents (Residents 1 and 2). Residents 1 and 2, who were assessed as a risk for elopement had a history of [REDACTED]. and the staff did not have any knowledge of Resident 1 and 2's whereabouts. Resident 1, who had eloped three times, was not being supervised by the nightshift staff, after attempting to exit from an unalarmed back door of the facility several times within 24 hours prior to him eloping. A review of the facility's surveillance camera video indicated on [DATE] at 5:06 a.m., Resident 1 exited from the back door of the facility and entered into a utility van located in the facility's parking lot. Resident 2, who had a history of [REDACTED]. These deficient practices resulted in Resident 1, who required close supervision, went missing and was found 36 hours ([DATE] at 11:30 a.m.) in a utility van located in the facility's parking lot by the facility's staff after they reviewed the video surveillance. The staff discovered Resident 1 was in the van breathless and without movement. The staff determined Resident 1 was deceased . These deficient practices had the potential to result in harm, injury, or death to the other 12 high risk elopement residents. A pattern of the facility's system failure to implement its policies to ensure residents who were at risk for elopement and required supervision and/or monitoring was not being supervised and had more than two elopement attempts without the staff's knowledge, and unsafe environment, inadequate monitoring and supervision was identified. On [DATE] at 5:40 p.m., an Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared for F689. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened. On [DATE] at 10:23 p.m., the ADM and DON provided an acceptable plan of action (POA) for correction of the I[NAME] The POA included the following: 1. An alarm installed to emergency exit door, from smoking patio to the west side parking lot on [DATE]. 2. An alarm installed on the back of the building to the east side emergency exit by the kitchen as of [DATE]. 3. An alarm installed to exit door employee lunch room to the west side parking lot. 4. The west side parking lot emergency exit had an alarm system installed. 5. The east side parking lot emergency exit had an alarm system installed. 6. The emergency exit alarm system will be loud enough that the staff will respond quickly. 7. In-service provided by the administrator/designee to all shifts staff and contracted vendors in regards to elopement risk behavior including policy/procedure, intervention and the alarm system. 8. Current residents will be assessed for elopement risk factors to ensure intervention will be implemented based on findings. 9. Residents with risk of elopement will have personal safety alarm device, identification bracelet and pictures on the elopement risk list. 10. The DON/Registered Nurse (RN) Supervisor will monitor residents every two hours, during medication pass and activities of daily living ((ADL) routine activities that people do every day without needing assistance, such as: eating, bathing, dressing, toileting, transferring and walking) care for 30 days and findings will be presented to the Quality Assurance (QA) committee in 90 days. 11. The Minimum Data Set (MDS) nurse will ensure physician's orders [REDACTED]. 12. Wanderguard (a device that alarms when residents attempt to elope or wander from a safe environment) checks will be in place on a weekly basis for activity and admission coordinator to ensure the Wanderguard system is effective. 13. A binder per Station, will be placed for elopement risk residents with name and picture. 14. The shift supervisor/charge nurse will discuss with the Certified Nursing Assistant (CNAs), on every shift, re: residents with risk of elopement, monitoring system and supervision. 15. A door person will be assigned by the front door to monitor, redirect and prevent elopement of residents from exiting the building. 16. Reporting within 24 hours of an unusual occurrence/missing resident to the Department of Public Health. On [DATE] at 5:08 p.m., after the team verified that the Plan of Action (POA) was implemented, both the DON and the ADM were notified the IJ was lifted. Findings: a. A review of Resident 1's records indicated the following: An Admission Record, indicated the resident was initially admitted to the facility on [DATE] and most recently re-admitted on [DATE]. [DIAGNOSES REDACTED]. An Admission Assessment, dated [DATE], indicated the resident's cognition (ability to think and reason) was marked only as alert. A history and physical (H/P), dated [DATE], [DATE] and [DATE], indicated the resident did not have the capacity to understand and make decisions. A Care Plan, dated [DATE], last revised on [DATE], and titled Elopement Risk, resident may sometimes leave the facility without authorization/permission because of [DIAGNOSES REDACTED]. A Care Plan, dated [DATE] and titled, Language Barrier, indicated the resident was at risk for having communication difficulties due to non-English speaking. The staff's interventions included for the staff to use non-verbal ways of communicating, such as gestures, signals/sounds and facial expressions. An Interdisciplinary Team Conference ((IDT) a group of healthcare professionals developing care needs that meets the resident's needs and goals) record, dated [DATE], with a note entry dated [DATE], by the Social Service Designee (SSD) that indicated the SSD was informed by the Director of Nursing (DON) of Resident 1's attempts to leave out of the back door of the facility leading to the back parking lot. There was no documented evidence in Resident 1's nurses' notes of the resident's attempted elopement on [DATE]. A physician's orders [REDACTED]. A nurses' note, dated [DATE] and timed at 8 a.m., indicated Resident 1 was observed walking fast towards the direction of the front lobby, main door of the facility, but was observed and escorted back to his room. The note indicated on the same day at 9 a.m., an hour after the first attempt, Resident 1 attempted to leave the facility again from the main door of the lobby and was escorted back to his room. The nurses' note indicated on the same day at 9:05 a.m., Resident's family member (FM 1) was notified of the resident's two elopement attempts ([DATE] and [DATE]) and FM 1 stated Resident 1 displayed the same behavior while at home. According to the nurses' note, FM 1 indicated Resident 1 had escaped from home because he wanted to find his girlfriend and the police was called to search for him. FM 1 asked for the staff to notify Resident 1's physician to transfer the resident to the hospital. A Psychiatric Emergency Teams ((PET) mobile response teams made up of licensed mental health clinicians that evaluate and assess individuals during a psychiatric crisis) note, dated [DATE] indicated According to a charge nurse, the resident (Resident 1) eloped from the facility and walked onto a busy traffic street, for which the cars had to stop to prevent hitting the resident. The note indicated the staff returned Resident 1 to the facility and Resident 1's behavior had been out of control for the past 24 hours. A discharge summary indicated the Resident 1 was transferred to the GACH on [DATE] for delusions and agitation (feeling or appearing troubled or nervous). A GACH Psychiatrist's (a physician who specializes in the [DIAGNOSES REDACTED]. The Psychiatrist's evaluation indicated Resident 1 had eloped from the facility and walked onto the busy street in the middle of oncoming traffic, where cars had to stop to prevent Resident 1 from being hit. A re-Admission Assessment, dated [DATE], after seven days at the GACH, indicated Resident 1 was reluctant to answer questions, had slow comprehension and was alert, but only oriented to time and place. A Physical Restraint Assessment, dated [DATE], indicated Resident 1 required a Wander guard at all times due to risk of elopement related to disorientation (confusion) and cognitive communication. A review of Resident 1's plan of care, dated [DATE] titled, Wanderguard, resident to wear because of a history of leaving or attempting to leave the facility which compromises his safety due to a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Re-Admission Assessment, dated [DATE], indicated Resident 1 was combative (ready or eager to fight), and disoriented to time, place and person. A nurses' note, dated [DATE] and timed at 6:30 a.m., indicated Resident 1 was observed playing with the facility's back door, next to the kitchen. According to the nurses' note, Resident 1 was escorted back to his room (Sic). A nurses' note, dated [DATE] and timed at 7 a.m., indicated a Certified Nursing Assistant (CNA 2) reported that Resident 1 was not in his room and was unable to be located. The note indicated the staff began searching for Resident 1. A nurses' notes, dated [DATE] and timed at 8 a.m., 8:10 a.m., 8:20 a.m., and 8:30 a.m., indicated FM 1, the physician and the local police department were notified that Resident 1 went missing and had not been located within the facility. The note indicated on [DATE] at 8:20 a.m., two local police officers arrived to the facility and took a report. The note indicated at 8:30 a.m., on the same day the Administrator (ADM) and the DON were notified that Resident 1 was missing from the facility. A nurses' note, dated [DATE] and timed at 10 a.m., indicated the local police officers arrived to the facility with a sniff and search dog (trained dogs that are sensitive to smells and can identify suspicious objects more easily than humans) attempting to locate Resident 1. A nurses' note, dated [DATE] and timed at 10:40 a.m., 4 p.m., and 10:45 p.m. indicated the facility received a telephone call from the local police department inquiring if Resident 1 had been located and they would continue to call for an update about Resident 1. A nurses' note, dated [DATE] and timed from 8 a.m. through 11 a.m., indicated various hospitals in the surrounding area were called to check if Resident 1 was possibly admitted , but Resident 1 was not located. A nurses' note, dated [DATE] and timed at 11:30 a.m., (over 30 hours after going missing) indicated two nurses and the ADM reviewed the facility's surveillance camera (used for observing an area) and observed Resident 1 leaving out of his room, and walking towards the kitchen door going towards the back parking lot, located on the west side of the facility. The note indicated Resident 1 walked in the corner of the parking lot and opened the door of the utility van and sat in the driver's seat. The note indicated after Resident 1 sat in the van, he was observed getting out of the van for three to five seconds, before returning to the driver's seat of the van. The note indicated on the same day, Licensed Vocational Nurse 1 (LVN 1) and the Maintenance Supervisor (MS) approached the van parked in the parking lot and observed Resident 1 sitting in the passenger's seat of the van. The note indicated Resident 1 was pale, not breathing, with no chest movement and appeared to be deceased . The note indicated 911(emergency services) and the local police department was called. A nurses' note, dated [DATE] and timed at 3:16 p.m., indicated the coroner (an official who investigates violent, sudden, or suspicious deaths) arrived to the facility for Resident 1. A nurses' note, dated [DATE] and timed at 5 p.m., indicated Resident 1's physician was called and was notified that Resident 1 was located in a van in the facility's parking lot deceased . On [DATE] at 2:37 p.m., upon entrance to the facility, local police officers and detectives, were observed in the ADM's office, when one of the police officers' indicated there was an unfortunate incident. On [DATE] at 2:40 p.m., during an interview, the DON stated Resident 1 went out of the back door of the facility, into the parking lot and entered into one of the facility's corporate vans and was found deceased by the staff. On [DATE] at 2:50 p.m., during a concurrent observation of the facility's back door and interview with the DON and the MS, they stated the alarm attached to the back door was not working and the MS stated that the door leads to the parking lot. On [DATE] at 3:08 p.m., during an interview, CNA 3 started crying and stated, This really hurts me. CNA 3 stated she worked in the facility on Sunday [DATE] and Monday [DATE] from 7 a.m. to 3 p.m., and was assigned to Resident 1. CNA 3 stated Resident 1 had a routine of sitting in the non-smoking patio for long hours and would eat his breakfast, lunch and dinner in that patio area. CNA 3 stated Resident 1 would only come inside from the patio to use the bathroom. CNA 3 stated back in (MONTH) (YEAR), Resident 1 was not in his room and was not in the facility, and the staff did not know that Resident 1 went missing. CNA 3 stated Resident 1 had eloped from the facility and was found outside of the facility, standing under a tree shivering, because it was very cold that day. CNA 3 stated two weeks prior to Resident 1's (MONTH) (YEAR) elopement, Resident 1 was found outside of the facility in the east parking lot by the large gate. CNA 3 stated on [DATE] at 7:14 a.m., and she entered the facility at 7:15 a.m., went to Resident 1's room, but he was not there and she began passing breakfast trays. CNA 3 stated on the same day she did not see Resident 1's breakfast tray and went to the non-smoking patio, but Resident 1 was not there. CNA 3 stated on the same day she asked LVN 3 if Resident 1 was sent out to the hospital or discharged from the facility and LVN 3 replied, No, the resident was probably in the patio. CNA 3 stated she informed LVN 3 that Resident 1 was not in the patio, CNA 3 stated the facility then began searching for Resident 1. CNA 3 stated Resident 1 wore an alarm bracelet on his ankle. CNA 3 stated on [DATE], the same day, she asked LVN 1 to review the facility's surveillance video and camera, but LVN 1 stated the surveillance camera and video were locked in the Administrator's office and the staff does not have a key. On [DATE] at 3:05 p.m., during a concurrent observation of the facility's back door and the east parking lot and an interview, LVN 1 stated Resident 1 was alert and oriented, but a quiet person and cognition (thought process) was impaired and did not communicate well due to a language barrier. LVN 1 stated Resident 1 was at risk for eloping and attempted to elope from the front door of the facility six months prior. LVN 1 stated Resident 1 made an attempt to elope, but never got out of the building and was re-directed (sic). LVN 1 stated on [DATE] at approximately at 7:15 a.m., CNA 3 indicated Resident 1 was unable to be located within the facility. LVN 1 stated she searched the middle patio (non-smoking patio) for Resident 1 because he loved sitting in that patio and the bathrooms, but Resident 1 was not located. LVN 1 stated a Code Green (an emergency code used denote the activation of an emergency plan; missing resident) was announced and initiated between the time of 7:15 a.m. to 7:30 a.m. On [DATE] at 3:25 p.m., during a subsequent interview, LVN 1 stated on [DATE] at 7:30 a.m., LVN 1 stated she and the staff drove around the surrounding area in an attempt to locate Resident 1. LVN 1 stated on [DATE], the same day at 8 a.m., she placed a telephone call to the Adm. and the DON and informed them that Resident 1 was missing. LVN 1 stated she was instructed by the ADM to follow the facility's protocol for a missing resident. LVN 1 stated on [DATE] between the hour of 7 a.m. and 8 a.m., she began calling the hospitals in search of Resident 1. LVN 1 stated when the ADM arrived to the facility, they were able to view the facility's surveillance video and she and the ADM observed Resident 1 exiting the facility, entering into a van parked in the facility's parking lot and did not make an exit from the van. LVN 1 stated on [DATE], the same day at 12 p.m., she and the MS went out to the east parking lot, opened the door of the van and observed Resident 1 sitting upright and slightly slumped over, with his head down and eyes closed. LVN 1 stated Resident 1 appeared to be deceased and 911 was called. On [DATE] at 6 p.m., during an observation of the facility's surveillance video with the ADM and the DON of the day of the incident, Resident 1 was observed walking rapidly in the facility's east parking lot, towards a large gate on [DATE] at 5:06 a.m., towards two large white vans parked in the parking lot. At 5:09 a.m., Resident 1 was observed standing between both vans and opened the driver's side door and entered the van closest to the large gate. Resident 1 was observed sitting in the van with the door ajar (slightly open) until 5:12 a.m., then exited the van, at 5:13 a.m., and at 5:14 a.m., Resident 1 returned to the van, closed the door and did not exit the van again. On [DATE] at 7:24 p.m., during an interview, CNA 1 stated he was assigned to Resident 1 on [DATE] and [DATE]. CNA 1 stated Resident 1 did not talk much and always sat in the middle patio across from his room. During the interview, CNA 1 was unaware why Resident 1 wore an alarm bracelet and was unaware Resident 1 was a high elopement risk. On [DATE] at 8:33 p.m., during a concurrent interview and a review of Resident 1's medical records assessments, the DON stated Resident 1 did not have an elopement risk assessment completed on [DATE] and [DATE], during two separate re-admissions to the facility. The DON stated she could not provide a reason and the facility just missed completing the elopement risk assessment on Resident 1. On [DATE] at 8:49 p.m., during a telephone interview, LVN 3 stated she worked in the facility on Sunday [DATE] and Monday [DATE] from 11 p.m. to 7 a.m. LVN 3 stated on Sunday, [DATE] at 6:30 a.m., she observed Resident 1 at the facility's back door. (Sic) LVN 3 stated the back door did not open and it was locked, however, LVN3 stated she did not check to ensure that the back door was locked. LVN 3 stated she observed Resident 1 pushing on the door handles attempting to open the door and she escorted the resident back to his room. LVN 3 stated approximately three months' prior, Resident 1 attempted to elope from the facility by exiting from the front door. b. A review of Resident 2's records indicated the following: An Admission Record indicated Resident 2 was admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. An H/P, dated [DATE], indicated Resident 2 did not have the capacity to understand and make decisions. An Elopement Risk Assessment, dated [DATE], indicated the resident had a score of 10. According to the Elopement Risk Assessment, a score of eight (8) or more indicated a risk for elopement. A physician's orders [REDACTED]. A Care Plan, dated [DATE] and titled, Wander guard, Resident 2 was at risk for Elopement, indicated for the staff to frequently conduct visual supervision. A Care Plan, dated [DATE] and titled, Elopement Risk, Resident 2 was at risk for leaving safe area without authorization, indicated the interventions included for the staff to monitor the resident at frequent intervals, redirect and other alternatives such as, 1:1 monitoring if indicated to redirect the behavior. A nurses' notes, dated [DATE] and timed from 3 p.m. through 11:30 p.m., indicated Resident 2 was wandering around the facility, searching for an exit door and had to be redirected to return to his room. The note indicated on [DATE] at 5 p.m., Resident 2 made three attempts to exit the facility through the front door and was redirected to return to his room, but continued to wander around the facility. The note indicated on the same day, at 6:15 p.m., Resident 2 made another attempt to leave out of the facility and was placed at the nurses' station for 1:1 monitoring. The note indicated at 7:30 p.m., the licensed nurse reported that she was not able to locate Resident 2 and the staff began searching for Resident 2 and 911 was called. The note indicated on the same day, at 8:30 p.m., two police officers arrived to the facility. The note indicated on 10 p.m., on [DATE], the local police officers, including a helicopter searched the surrounding area was conducted for Resident 2, but the resident was not located. The note indicated at 11:30 p.m., on [DATE], the facility was waiting for the police officers with the blood hounds (a dog with the ability to detect human scent over great distances, even days later) to arrive at the facility. A Change of Condition (C[NAME]) Assessment, dated [DATE], indicated at 1:30 a.m., Resident 2 was escorted by local police officers back to the facility. The note indicated Resident 2 was found 1.4 miles (an estimated 34-minute walk, equivalent to over 3,000 steps) from the facility. The note indicated upon Resident 2's return to the facility, the resident had an elevated blood glucose (sugar) level of 472 milligrams per deciliter ((mg/dL; unit of measurement) the normal reference range (NRR) is 70 and 130 mg/dL), 911 was called and Resident 2 was sent to the GACH for evaluation and treatment. A C[NAME] Assessment, dated [DATE], indicated at 7:30 a.m., on [DATE], Resident 2 was found outside of the facility and had exited from the Physical Therapy (PT) room. The note indicated security should be put in place, because this was the second time Resident 2 had eloped from the facility from the PT room, four CNAs had to run after him and the staff and resident was locked out of the facility due to no access to open the door or the gate at 2 a.m. A C[NAME] Assessment, dated [DATE], indicated at 1:30 p.m., the nursing staff made rounds when the front door alarmed and observed Resident 2 walking towards the east direction of the facility. The note indicated the nursing staff yelled and ran towards Resident 2 and returned the resident back to the facility. On [DATE] at 4:11 p.m., during an interview, LVN 2 stated Resident 1 was known for wandering and going into other residents' rooms. LVN 2 stated she was told that Resident 1 made an attempt to elope from the facility and would normally sit in the non-smoking patio. LVN 2 stated Resident 2 made an attempt to elope from the facility, however, Resident 2 is no longer in the facility. LVN 2 stated Resident 2 attempted to exit from the west parking lot gate. On [DATE] at 4:24 p.m., during a concurrent observation of the smoking patio emergency exit door leading to the west parking lot of the facility and interview, the emergency exit door was opened with no sound of an alarm ringing, the DON stated there was no alarm at this door and the front door was the only door in the facility with a sensor alarm to activate the alarm bracelets. The DON was asked for a log of residents in the facility who were an elopement risk and residents who required the use of alarm bracelets, which was 14 residents. On [DATE] at 4:45 p.m., a review of the facility's list of residents at risk for elopement with alarm bracelets from [DATE] to [DATE], indicated Residents 1 and 2 were on the list. On [DATE] at 5 p.m., during an interview, the DON was asked how did the facility ensure residents who were at risk for eloping from leaving out the facility's back door when there was no alarm on the exit doors. The DON stated the residents could not get out of the facility's parking lot without a remote control to open the gate. The DON was asked when visitors and staff are entering and exiting the facility, how did the facility ensure a resident who was already in the parking lot awaiting for the gate to open since there was no alarm on the back door, the DON could not provide an answer. The DON was asked how did the facility ensure residents with alarm bracelets were being monitored. The DON stated the residents with alarm bracelets cannot go out the front door of the facility without the alarm sounding off. A review of the facility's undated policy titled, Elopement, indicated the facility will monitor and manage residents at risk for elopement to minimize the risk of residents leaving a safe area without authorization. A review of the facility's undated policy titled, Care of Wandering Residents, indicated the purpose was to protect wandering residents from injury. The policy indicated residents who wander shall have their picture taken and placed in the medical record and a plan of care should address the wandering. The policy indicated all staff must continuously reorient wandering residents to their room and belongings. The policy indicated the nursing staff must monitor the wandering resident's location with visual checks as needed.

Based on observation, interview and record review, the facility failed to develop and implement a discharge plan that addressed the resident's discharge needs upon resident's readmission to the facility, reduced a resident's and family's anxiety (feeling of unease; excessive worry), and include a post-discharge plan of care with the participation of the resident and/or the resident's family for one of three sampled residents (Resident 1). Resident 1, who was alert and self-responsible, had been requesting upon re-admission on 5/20/19 (30 days after), to be discharged home with family and the facility failed to address her request. These deficient practices resulted in Resident 1 expressing feeling like a hostage (holding someone against their own will), depressed (state of general unhappiness), sad, and not participating in activities of daily living ((ADLs) grooming, tooth/hair brushing, and eating) due to her inability to go home with her family. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. According to the Face Sheet, Resident 1 was self-responsible and her own decision maker. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/16/19, indicated Resident 1 had a Brief Interview for Mental Status ((BIMS) a mental test) score of 15 (13 to 15 indicates an intact cognition (thought process)). The MDS indicated Resident 1 was totally dependent of a one-person physical assist for ADLs. The MDS indicated there was no discharge plan initiated for Resident 1 to return to the community. A review of Resident 1's undated Baseline Care Plan indicated that the staff would initiate discharge planning process. The problem indicated an uncertain discharge plan and the goal was for Resident 1 to received ancillary services (wide range of healthcare services provided to support the care of a resident) within the next three (3) months. A review of Resident 1's untimed Multidisciplinary Progress Note, dated 5/21/19 and signed by the Social Services Director (SSD), indicated that Resident 1's family wanted to take the resident home. A review of Resident 1's Interdisciplinary Team's ((IDT) a group of disciplines that work together towards a common goal for a resident) note, dated 5/28/19 and titled, Resident's Discharge Planning, indicated that Resident 1's family member (FM 1) wanted Resident 1 to be discharged home. The IDT indicated that neither Resident 1 or FM 1 attended the discharge planning meeting. A review of Resident 1's IDT note, dated 6/5/19, indicated that Resident 1 had family to assist with her care at home. The IDT note indicated the SSD informed another family member, FM 2, that Resident 1's physician (Physician 1) refused to discharge Resident 1 home because she is a total care and its unsafe. The IDT indicated that Resident 1 required reinforcement to participate in rehabilitation. The IDT indicated that FM 2 stated having sufficient help at home or have Resident 1 move to a facility closer to them. A review of the Resident 1's psychologist ((Physician 2) a physician dedicated to the study of the human behavior) consultation notes indicated the following: On 5/23/19 and timed at 12:52 p.m., Resident 1 demonstrated improved alertness and conversation. The psychologist's consult indicated that Resident 1 reported wanting to go home to reunite with her family. On 5/30/19 and timed at 11:27 a.m., Resident 1 expressed her desire to be discharged from the facility and asked the family to assist in the process of discharge planning. On 6/4/19 and timed at 10:46 a.m., Resident 1 reported being frustrated due to being separated from her family. On 6/11/19, and timed at 12:34 p.m., Physician 2 informed the facility's staff of Resident 1's decline in health because of her depression and adjustment to the nursing home. On 6/19/19 at 4:09 p.m., during a telephone interview, FM 1 stated that on 5/18/19 he communicated to the facility SSD his wishes to discharge Resident 1 home, but was informed that they had to hold Resident 1 in the facility for 24 hours for billing purposes. FM 1 stated that the facility was not acknowledging Resident 1's wishes to go home and She (Resident 1) was being held hostage by the facility. On 6/19/19 at 4:35 p.m., during a concurrent observation and interview, Resident 1 was observed in her wheelchair with her head down looking towards the floor. Resident 1's eyes were observed watery and stated that she felt sad and unhappy because she was unaware why she was not allowed to go home to be with her family. Resident 1 stated that she had family to take care of her at home and she did not want to die in a place it was not her home. On 6/19/19 at 4:56 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated that Physician 1 was not discharging Resident 1 home because she required total assistance from staff in her ADLs. The DON was not able to provide documentation of the phone conversation with Physician 1. On 6/19/19 at 5:05 p.m., during an interview, FM 2 stated that the facility staff was notified of Resident 1's strong family support and that Resident 1 had someone at home to care for her. On 6/19/19 at 5:20 p.m., during a concurrent interview and record review (Nursing notes 5/2019 through 6/2019), the DON stated that according to the facility's policy (Resident's Rights), Resident 1 had the right to go home, but the physician (Physician 1) was not approving Resident 1's discharge. The DON stated that there was no documentation of the conversations between Physician 1 and the facility's staff regarding Resident 1's wishes to be discharged home with her family. On 6/19/19 at 5:25 p.m., during a telephone interview, the SSD stated that Resident 1 was self-responsible and able to make decisions. The SSD stated that she initiated Resident 1's discharge in 5/2019 (didn't remember the date) but discontinued it when the doctor (Physician 1) indicated that a discharge was unsafe. The SSD stated that she did not speak with Physician 1 regarding the resident's wishes to be discharged home. The SSD stated that the resident had the right to be discharged and not held against her will. On 6/19/19 at 5:31 p.m., during a concurrent interview and record review (Nursing notes 5/2019 through 6/2019), Licensed Vocational Nurse 1 (LVN 1) stated there was no documentation of the conversation she had with Physician 1 regarding Resident 1's wishes to be discharged home. LVN 1 stated that none of the staff followed-up or acknowledged the residents' wishes to be discharged home. LVN 1 stated that she was aware of Resident 1's decline in her emotional state, as was indicated in Physician 2's consultation notes. LVN 1 indicated that Physician 2 informed the staff of Resident 1's frustration of not being able to be discharged home to her family. On 6/19/19 at 6:13 p.m., during a telephone interview, Physician 1 stated he mentioned to the staff to start planning Resident 1's discharge (did not remember the fate) with the appropriate home health assistance. Physician 1 stated that Resident 1 was declining ad becoming depressed and sad because she wanted to go home, but couldn't discharge her until the facility provided the resident and family with teach back education regarding her care at home. Physician 1 stated he was aware he could not hold Resident 1 against her will and he would write a discharge order to go home when education and medical equipment was provided by the facility. On 6/19/19 at 6:35 p.m., during a concurrent observation and interview, Resident 1 was observed to be excited and smiling after she was notified that Physician 1 would write a discharge order after discharge education and medical equipment was provided. FM 1 stated that the reason why Resident 1 did not leave Against Medical Advice (AMA) was because they were informed by the staff that no home equipment was going to be provided if she (Resident 1) left AMA (such as a wheelchair, hospital bed and transfer lift). On 6/27/19 at 2:30 p.m., during a telephone interview, Physician 2 stated that Resident 1 was emotionally distressed due to her separation from her family. Physician 2 stated that the facility's staff was made aware over a month prior of Resident 1's wishes to go home with her family. A review of the facility's undated policy, Resident's Right, indicated that the purpose of the facility was to respect and encourage patient self-determination and encourage participation in decision making regarding their care through education and inquiry. A review of the undated policy, Transfer and Discharge Policy & Procedure, indicated that the transfer and discharge is ideally planned event. The facility's staff should handle the transfer/discharge of the residents in a way that minimizes the resident's and family's anxiety.

Based on observation, interview and record review, the facility failed to ensure the Invacare lift (a manual lift) sling was inspected prior to use for wear and/or frayed areas as indicated in the facility's policy and procedure to prevent an accident for one of one residents (1). On May 26, 2013, at 10 a.m., Resident 1 was being transferred from the bed into the wheelchair. When the Invacare lift sling broke Resident 1 was dropped into the wheelchair, sustaining a left hip fracture that required surgery. Findings: On June 12, 2013, at 9 a.m., the sling that was used during the incident was provided by the director of nurses (DON). The tan colored sling was observed to be clean. The upper portion of the two straps that held the resident was broken off completely and the bottom portion of the straps were frayed. A photo of the sling was taken on the same date of observation. On June 12, 2013 at 12:30 p.m., Resident 1 was interviewed and stated this was the first time the staff had used this sling on her. She stated the nurses usually use the big blue sling for her but they could not find it that morning. She stated she was strapped in and over the chair when she heard two snaps, and then dropped a few inches in to the wheelchair. She stated she was scared and in pain. According to the admission record Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) a standardized assessment and care screening tool, dated March 18, 2013, indicated Resident 1 had good short and long term memory with no impairment in her cognitive skills for daily decision-making, able to understand or be understood. The resident was totally dependent on staff with two plus person physical assistance during transfers. The Fall Risk assessment dated [DATE], indicated Resident 1 was at risk for falls. The Monthly Record of Vital Signs and Weight dated May 10, 2013, indicated Resident 1 weighed 344 pounds. The Multidisciplinary Progress Note dated May 26, 2013 at 10 a.m., indicated Resident 1 requested to be transferred from the bed into the wheelchair. The note indicated "the resident was being transferred from the bed using a Invacare lift assisted by four certified nursing assistants (CNAs). While the resident was hanging over the wheelchair approximately 2 inches from the wheelchair the front strap of the Invacare lift sling snapped and the resident dropped into the wheelchair. The Multidisciplinary Progress Record dated May 27, 2013, at 3:30 p.m., indicated Resident 1 complained of severe pain on the left hip rated 8 out of 10 (ten being the worst pain a person could experience) and was medicated with Tylenol 500 milligrams (mg). The note indicated the pain decreased to 4 out of 10, the physician was notified and ordered X-Rays of both hips. The X-Ray results dated May 27, 2013 at 6:07 p.m., indicated Resident 1 sustained a displaced (not aligned) intertrochanteric (space between the greater and lesser trochanters (bony prominences toward the near end of the thighbone)) fracture of the proximal (next to) left femur, and severe degenerative changes of the hips. The physician was notified of the X-ray result dated May 27, 2013, and ordered to transfer Resident 1 to a general acute care hospital (GACH). The resident was transferred to GACH at 8:30 p.m. On June 12, 2013, at 11 a.m., during an interview with CNA 1, she stated she was one of the CNAs helping to transfer Resident 1. She stated during the transfer the sling broke, Resident 1 dropped in a wheelchair 1 1/2 to 2 inches. She further stated Resident 1 has two designated slings that they use just for her, which they checked for the weight capacity and size of the sling before using it. At 11:15 a.m., CNA 2 was interviewed. She stated there were three CNAs transferring Resident 1 when the sling straps broke. She stated the sling, hook and joint were checked prior to using it At 11:45 a.m., CNA 3 was interviewed. He stated he helped to transfer Resident 1 because she was heavy. He further stated the resident needed 2-3 people for transfer to hold the Invacare lift sling over the wheelchair. He stated the sling straps broke, resident went forward and he had to hold the resident back. During an interview on June 12, 2013, at 4:30 p.m., housekeeping staff 1 stated he was not sure of what the facility policy for mechanical lift slings stated, but when he checks, he checks for the cleanliness and if the sling is broken. He stated he checked the slings two weeks ago and there was no problem with the slings, but did not write anything down in his log book. He stated he does not know specifically which slings belong to which resident; he just checks all slings that come to the laundry after the slings are washed. He was unable to provide documented evidence that any slings were inspected. The undated facility's Housekeeping policy and procedure (P&P) on Mechanical Lift Slings: disinfection and monitoring indicated mechanical lift slings will be inspected prior to use to identify frayed spots or other evidence of wear: Slings will be replaced as needed if evidence of wear and/or frayed areas were identified. Charge nurse will be notified of any sling wear and/or frays. Prior to lifting resident with slings the attachments (hooks of the sling) will be inspected to ensure they are properly attached to ensure safe resident transfers. Mechanical lift slings will be inspected for frayed spots and sent to the laundry weekly for disinfection. On June 12, 2013, at 10 a.m., the director of nurses (DON) stated each heavy care resident has his/her own Invacare lift sling and the maintenance staff should be checking to make sure the Invacare lift sling is in proper working order. The DON stated that it is the responsibilities of the CNAs/nurses to check for wear/frayed areas before using the sling. A review of the in-service dated January 10, 2013, titled "Proper use of Lift " included a review of the facility's P&P on Mechanical Lifts/Slings; Monitoring function will be inspected daily by CNA prior to use to verify function of sling - no frayed areas, seat, straps, feet and legs of lift. Further review of the in-service sign in sheets indicated three of the CNAs involved during the incident (May 26, 2013) attended the in-service. During telephone interviews with the administrator on August 22, 2013, at 11:50 a.m., and September 9, 2013, at 4:10 p.m., she stated the blue color with mesh Invacare lift sling is used for showers, and the tan color Invacare lift sling that the resident used when the incident happened is used for regular transfers. She stated each sling can lift a maximum of 450 to 500 pounds. She was unable to provide the invoice as to when the sling that was used during the incident was purchased; she stated the facility uses different vendors. The administrator was unable to verify the age of the sling and stated she had been working in the facility for more than three years and had not purchased slings.