Every finding on record at The Neighborhood in Rio Rancho

Based on record review and interview, the facility failed to ensure 1 (R #1) of 4 (R #1, #2, #3, and #4) residents were free from physical and mental abuse, when: The facility failed to ensure a safe environment by not preventing a physical and verbal altercation between two staff members that occurred on the bed in R #1's room, resulting in R #1 witnessing the altercation and becoming fearful. If the facility fails to provide an environment free from abuse, then residents are at risk for physical injury and psychological harm. The findings are: A. Record review of R #1's face sheet revealed an admission date of 01/28/26 and included the following diagnoses: Displaced fracture of greater trochanter of right femur (a serious injury where the bone connecting the hip joint to the thigh bone is broken, causing the two pieces to be misaligned). Unspecified fall. Chronic obstructive pulmonary disease (COPD; lung disease). Type 2 diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin).Hypertension (HTN; high blood pressure). Pulmonary embolism with acute cor pulmonale (when an obstruction in a blood vessel in the lungs causes your right sided heart failure).Generalized muscle weakness.Cognitive communication deficit (a condition where impairments in cognitive processes disrupt a person's ability to communicate effectively). B. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 02/04/26, revealed a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 10, moderate impairment. C. Record review of the local police report involving R #1, dated 2/17/26, revealed the following:Police responded to the facility at approximately 1:06 am regarding a battery call for service (a situation where someone reports that a person has been unlawfully and intentionally touched or struck in a harmful or offensive way). Certified Nursing Assistant (CNA) #4 stated Registered Nurse (RN) #1 pushed him, and he then pushed RN #1 into a resident room where CNA #4 stated he punched RN #1 in the face one time and then restrained her to the ground to prevent her from pushing him again. RN #1 was observed by police to have multiple major injuries, her clothing was stretched out, and she was missing a shoe.RN #1 reported having ongoing issues with CNA #4 as he had gotten in her face in past incidents; this was the first time it turned physical. RN #1 reported that she heard CNA #4 yelling in a patient's room. She remained in the hallway and observed CNA #4 yelling at the Director of Nursing (DON) over the phone while in a resident's room. At that time, she advised CNA #4 to leave the facility and take the phone call elsewhere. She reported that after this request, CNA #4 approached her and punched her multiple times in the face with a closed fist, causing a broken tooth and a laceration behind her ear. CNA #4 then grabbed RN #1 by the collar of her shirt and dragged her into R #1's room, causing scratches to her upper chest. While in R #1's room, CNA #4 sat on top of RN #1 while she was on the ground and placed his knee against her chin, causing a red mark on her chin and neck and restricting her ability to move. D. On 03/12/26 at 11:20 am, during an interview, R #1's Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) stated she interviewed R #1 after the incident and R #1 did report to her that she was frightened, feeling depressed, and anxious after witnessing an incident with two staff members engaging in a verbal and physical altercation. R #1 reported to the Psychiatrist she was in her bed when she was awoken by noise and feeling her bed move. R #1's Psychiatrist stated CNA #4 was physically striking RN #1, so R #1 took her walker and left to another resident's room. R #1's Psychiatrist confirmed during the interview, she observed R #1 to be anxious, and R #1 stated she did not feel safe in the facility. E. On 03/13/26 at 10:27 am, during an interview, Certified Nursing Aide (CNA) #4 stated a verbal and physical altercation occurred between himself and RN #1 on 02/16/26 at about 12:50 am. He stated the incident began in the hallway when RN #1 asked him where he had been and why he wasn't answering the phone. He stated RN #1 then got in his face, was yelling at him, and spit on him. He stated the physical struggle moved into R #1's room, with RN #1 climbing up on the resident's bed while R #1 was still in bed and repeatedly kicked at him. He stated while they were in R #1's room, prior to RN #1 climbing onto the bed, RN #1 pushed a bedside table with a pitcher of water at him and again spit at him. He stated his main priority was to help R #1 out of the room safely, as R #1 appeared startled and to be negatively affected by the altercation. CNA #4 stated he contacted the DON via telephone and advised her that he was going to be leaving, and he had also contacted the police. He stated when the DON arrived at the facility, he was in handcuffs seated in a police car and was subsequently arrested because RN #1 was bleeding and had a chipped tooth. He stated he told the police he was only blocking RN #1's kicks and did not recall hitting her. F. On 03/13/26 at 11:38 am, during an interview, the DON stated when she arrived at the facility, staff had already moved the furniture in R #1's room back to its' original place. The DON stated R #1 was wrapped in a blanket, seated with two CNAs who were consoling her. The DON stated she calmly spoke with R #1, and they walked around the hall for about twenty minutes so the DON could observe her to ensure there were no physical injuries. R #1 was then assessed for pain and was asked if she had been hit by anyone during the altercation, to which R #1 replied no. The DON stated R #1 was very anxious and told the DON she heard loud voices and then her bed was bumped. G. On 03/13/26 at 11:42 am, during an interview, the Administrator (ADM) stated the DON called her immediately upon arriving to the facility and advised her that CNA #4 was in handcuffs and in police custody. She stated the DON advised she had immediately assessed R #1 while she was sitting with two CNAs.

Based on video observation, record review, and interview, the facility failed to prevent an employee to resident abuse for 1 (R #9) of 3 (R #9, #10 and #11) residents reviewed for abuse. This deficient practice likely resulted in psychosocial harm based upon the reasonable person concept to the resident related to fear of physical harm and mistrust of the caretaker she was dependent on for all of her care. The findings are: Past Non-ComplianceCompliance Date: 11/18/25 A. Record review of R #9's face sheet revealed she was admitted on [DATE] and had the following diagnoses: Cerebral infraction due to embolism (an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) or (stroke),Type II diabetes mellitus (DM2 is a disease in which the body cannot make or properly use insulin),Vascular Dementia (a blockage of the blood supply to the brain. It is manifested with decline of memory and cognitive functions),Parkinson's (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination),Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease).R #9 was on hospice, start date 10/15/25. B. Record review of R #9's care plan initiated on 05/29/25 and 05/30/25 revealed that R #9 had the following: initiated on 05/29/25 that R #9 is dependent on staff for all activities of daily living,initiated on 05/30/25 to use Hoyer lift (equipment used to move residents who have limited mobility) every shift related to hemiplegia (paralysis on one side of the body) affecting left non-dominant side, two persons assist when using. C. Record review of R #9's electronic medical record (EMR), vitals tab, indicated R #9 weighed 105 pounds on 11/02/25. D. Record review of the Brief Interview of Mental Status (BIMS; a screening for cognitive impairment, scores range from 00 to 15, with 15 - 13 is cognitively intact, 12 - 8 is moderately impaired, 7 - 00 is severe impairment) assessment for R #9, indicated resident was unable to complete the BIMS assessment due to R #9's cognitive impairment. E. Observation of video taken on 11/09/25 at 6:58 pm of R #9's room revealed the following: R #9 in bed lying on her back. Hoyer lift on the left side of the bed and Hoyer lift sling under the resident. Staff member, Certified Nursing Assistant (CNA) #9 was on the right side of the bed facing the resident and was changing R #9's brief. The video showed CNA #9 forcefully and aggressively grabbed R #9 on her right leg and right hand. CNA #9 pulled her onto her side, almost rolling her off the bed. R #9's brief had also been unattached and was not secured on the sides. CNA #9 then forcefully and aggressively pushed R #9 onto her back. CNA #9 pulled up the brief and threw R #9's gown up above her stomach and moved the Hoyer sling to the bottom of the bed. CNA #9 appeared very angry and frustrated and although unclear on the video, was saying something to the resident. R #9 appeared scared of CNA #9 and confused by what was happening based upon the expression on her face. CNA #9 was seen pushing and pulling R #9 in her bed and appeared strong, dominant and intimidating over R #9 who appeared frail, and weak. CNA #9 pulled up the brief and secured it. Video ends. F. Record review of R #9's nursing progress notes dated 11/09/25 at 8:26 pm, revealed the on-call nursing manager called the facility to ask about R #9 and who had placed her to bed. The note indicated it was the CNA on duty (CNA #9). CNA was asked to go home as an investigation was starting. Two nurses conducted a nursing assessment (head to toe assessment looking for bruising, scratches) on R #9. No new skin issues were detected, no redness was observed anywhere on the body and no new skin tears, lacerations (a wound produced by tearing) or abrasions (partial thickness wound caused by damage to the skin) found on the body. G. Record review of R #9's incident note dated 11/10/25 at 4:09 am, nurse from the 2nd floor was directed to perform a thorough skin assessment on R #9 with the 3rd floor nurse due to allegations of abuse. Head to toe skin assessment was performed on resident to which no findings of skin damage or impairments were found. Residents skin was clean, dry, and intact from head to toe with no discoloration found. No redness, scratches, bruises, or signs of friction or moisture associated skin damage was seen. H. On 11/17/25 at 8:50 am during an interview with the Administrator (ADM), she stated she received a text message from R #9's daughter stating she was watching the video that is in her mother's room (R #9) and watched a staff member abuse her mother. The Administrator stated she immediately had CNA #9 pulled off the floor and sent home. She had R #9 assessed by two nurses working that night shift. R #9 was assessed to be free of any physical injury. The ADM stated an investigation was started immediately although the R #9's daughter did not have administrator access to pull the video clip and send it to the administrator. The daughter stated her brother had administrator access. The ADM stated she did not see the video until the following day when R #9's son sent it to her, and CNA #9 was fired on 11/10/25 for abusing the resident. The ADM stated CNA #9 told her she did not know the video camera was back in R #9's room, and CNA #9 had worked at the facility for over three years without issue. I. On 11/17/25 at 12:15 pm, during observation and interview, R #9 was sitting in the dining room and was being assisted with her lunch meal. R #9 had on clean clothing and appeared to be content eating her lunch. R #9 did not answer any questions. J. On 11/18/25 at 11:17 am, during an interview with CNA #9, she stated she works nights on the 300 hall most of the time. She stated she was not angry that night, but she did transfer R #9 by herself due to the other CNA being busy. CNA #9 stated she used the Hoyer lift alone to put R #9 in bed and change her brief. CNA #9 stated R #9 was heavy and she (R #9) does not help you; you have to do all the work when you are assisting her, and it makes it harder to work with her. CNA #9 confirmed that R #9 was dependent on staff. CNA #9 confirmed she turned (and repositioned) R #9 with excessive force and should not have. K. Record review of CNA #9's employee file revealed CNA #9 was employed with the facility since 06/13/22 and did not have disciplinary concerns. L. On 11/18/25 at 2:42 pm, during an interview with CNA #12, she stated she had never had any issues with CNA #9. She had worked with her frequently and there was never a reason to be concerned about CNA #9. CNA #12 stated on 11/09/25 she got her report on the residents from dayshift and she started answering call lights. CNA #12 stated her and CNA #9 helped each other all the time with Hoyers. She stated CNA #9 did not ask her for help on 11/09/25 with the Hoyer lift and putting R #9 to bed. CNA #12 stated she did not know why CNA #9 would not have asked her for help with R #9 that evening. When CNA #9 was sent home she did not tell her why she only stated it had something to do with R #9. M. On 11/19/25 at 10:36 am, during an interview with the Director of Nursing (DON), she stated she received a phone call on the evening of 11/09/25 and it was reported that CNA #9 abused R #9. The DON stated she sent CNA #9 home immediately and told her she was being investigated. R #9 was assessed to be fine, and other residents were interviewed for any abuse or neglect from CNA #9. No other resident stated there was an issue and no bruising or redness was found on any of the residents. The DON stated during her interview with CNA #9, CNA #9 was very focused on the camera in the room and not knowing the camera was present even though there was a sign on the door indicating video was in use. The DON stated that CNA #9 did not feel what occurred was abuse after she watched the video and indicated it was not abuse because she had not hit R #9. The DON stated when CNA #9 wrote her statement, she did not indicate she was too rough with R #9. N. On 11/19/25 at 12:54 pm, during an interview with daughter of R #9, she stated she watched the abuse happen. She was watching the video at the time the abuse happened, and she called the ADM right away and told the ADM to not have the CNA work with her mother ever again. Evidence for Past Non-Compliance Provided by the Facility: Nursing progress notes dated 11/09/25 through 11/12/25 revealed the following: 11/09/25 at 8:26 pm: Skin assessment was completed after abuse incident. No new skin issues were identified.11/09/25 at 10:07 pm: Foot evaluation completed, no new skin issues identified.11/10/25 at 9:20 am: Foot evaluation completed, no new skin issues identified.11/11/25 at 10:35 am: Foot evaluation completed, no new skin issues identified.11/12/25 at 2:07 pm: Skin issue note- Bruising noted on resident's right hand. Family Safety Calls by Administrator (documented on notepad paper):Various resident family members called beginning on 11/10/25. Staff Calls by Administrator (documented on notepad paper):Four staff members called that worked with the CNA who committed the abuse. Calls began on 11/10/25 at 3:20 pm and ended on 11/10/25 at 3:28 pm. Each staff member called denied having concerns or observing issues with the CNA who committed the abuse. CNA statement after incident. Abuse and Neglect In-Service Sign-In Sheet dated 11/10/25:A total of 32 facility staff was documented as attending the training (Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Nursing Assistants, Certified Medication Assistants, Activity Director, Medical Records, Scheduler, Assistant Director of Nursing, and Director of Nursing).Training included: Abuse and Incident Reporting, Abuse/Neglect/Exploitation Definitions and Response, and Abuse/Neglect/Exploitation Investigation Guidelines. Root Cause Analysis (RCA) Abstract:1. Why did it happen? They know what the right thing is, but they don't do it.2. Why did it happen? The night shift has less people on it, and they feel more stressed and do things they don't normally do.3. Why did it happen? CNA got mad if she was not assigned to Memory Care previously- she did not ask for help moving this resident.4. Why did it happen? Nurses were not as aware as they could be as to what the CNAs are doing and are not willing to help aids as they could be.5. Why did it happen? Nurses don't realize that they carry responsibility for CNA actions under their license.RCA Interview Notes dated 11/18/25: CNA did not know there was a camera in the room upon being interviewed. She was removed from the site upon the allegations happening and since the abuse has been confirmed, she will be reported to the nursing registry.Fishbone analytical diagram also added with the date 11/18/25. Safe Survey Resident Interviews dated 11/11/25:12 resident interviews completed for Unit- 2. CNA Competency Checklist: CNA who committed abuse:Dated 10/08/25: Completed.Employee Termination Form dated 11/10/25:This indicated the CNA was terminated on 11/10/25.

Based on interview and record review, the facility failed to have accurate and complete medical records for 2 (R #1 and R #11) of 3 (R #1 and R #9 and R #11) residents reviewed for showers, falls, and nutrition. This deficient practice could likely cause: - confusion on the resident's status if the history and physical was not accurately documented, -residents to go without fall interventions in place because there was no documentation of the fall, -residents could potentially suffer weight loss without appropriate interventions due to inaccurate meal intake documentation. The findings are: Inaccurate description on History and Physical: A. Record review of R #1's face sheet indicated R #1 was admitted on [DATE] with the following diagnosis: -Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), -Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), -Frontal lobe and executive function deficit from cerebral infarction (frontal lobe are responsible for higher cognitive functions including language, memory, problem solving, and judgment), -Hypertension (high blood pressure), -Cardiac pacemaker (small battery-operated device that helps regulate the heart's rhythm by sending electrical impulses to stimulate heartbeats). B. Record review of R #1's History and Physical dated 10/08/25 in the physical exam section indicated for musculoskeletal (made up of bones, muscles, tendons, ligaments, and connective tissues that provides support, stability, and movement to the body): R #1 is able to move all four extremities independently. C. Record review of R #1's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/01/24 indicated R #1 had upper and lower extremity impairment (loss of function or impairment to your limbs) on one side. R #1 required full assistance with eating, dressing, hygiene and was a moderate to partial assist for rolling from back to left side to back again when in bed. Findings for: No documentation of a fall: D. Record review of R #1's nursing progress notes dated 09/29/24 indicated R #1 was found on the floor next to her bed. No injuries noted. E. Record review R #1's assessment tab in the Electronic Medical Record (EMR) indicated there was no fall assessment completed, no neuro checks completed, no change in condition completed, no post fall assessment and no interventions in place for the fall that occurred on 09/26/24. F. Record review of R #1's care plan initiated on 09/26/24 revealed that there was not a care plan focus and intervention for the fall on 09/26/24. G. On 11/17/25 at 10:30 am, during an interview with R #1's son, he said he was notified of the fall on the morning of 09/26/24 but no interventions for this fall were put into place. H. On 11/19/25 at 10:13 am, during an interview with the Director of Nursing, she stated that no documentation around the fall occurring on 09/26/25 for R #1 is documented in the chart. The DON stated because a fall risk assessment was not completed, so no interventions were put in place for this fall. Findings for: Inaccurate or no documentation on the Activities Daily Living (ADL) Task List (documents daily on whether the task occurred, how many staff it took to perform a task, documents eating and fluid intake. R #1: I. Record review of the ADL list for R #1 from 09/25/24 to 09/30/24 indicated that no documentation was entered for any of the categories on the ADL list. J. Record review of the ADL list for R #1 from 10/01/24 to 10/31/24 indicated that no documentation was entered from 10/01/24 to the morning on 10/07/24 for any of the categories on the ADL list. K. Record review of the ADL list for R #1 indicated there was no documentation on the a.m. shift for R #1 on the following days: 10/10/24, 10/11/24, 10/13/24 10/15/24, 10/16/24, 10/22/24, 10/23/24, 10/26/24, 10/27/24, 10/30/24 and 10/31/24 for any of the categories on the ADL list. L. Record review of the ADL list for R #1 indicated there was no documentation on the p.m. shift for R #1 on the following days: 10/09/24, 10/11/24, 10/23/24, 10/31/24 for any of the categories on the ADL list. Showers for R #11 M. Record review R #11's electronic medical record (EMR) indicated R #11 went on hospice 10/10/25 and hospice is responsible for showers on Monday and Wednesday. N. Record review of R #11's ADL list for showering from 09/01/25 to 09/30/25 revealed documentation on 09/11/25 that R #11 was showered. No other documentation for showers was on the task list. O. Record review of R #11's ADL list for showering from 10/01/25 to 10/10/25 revealed documentation R #11 received a shower on 10/09/25. No other documentation for showers was on the task list. Incorrect documentation of meal percentage R #11 P. Record review of the physician orders for R #11 revealed that an order to assist with all meals for increased intake dated 09/17/25. Q. Record review of the ADL list for meal intake for R #11 dated 11/17/25 indicated that R #11 ate 75 percent to 100 percent of his meal at lunch time. R. On 11/18/25 at 12:35 pm, during an interview with Certified Nursing Assistant (CNA) # 7, she stated she was R #11's CNA yesterday on 11/17/25 and she did assist him with his meal at lunch. She stated R #11 did not eat a whole lot at lunch maybe between 0 and 25 percent. She stated sometimes the CNA's on the floor will help document for each other even if they are not caring for a resident on the day. CNA #7 stated she did not document on the ADL task list for R #11 for the lunch meal on 11/17/25, CNA #6 documented for her. S. On 11/18/25 at 12:50 pm, during an interview with CNA #6, she stated she did chart the lunch meal for R #11 on 11/17/25. She stated she must have had a misunderstanding about R #11's intake when she asked CNA #7 how much he ate at lunch on 11/17/25. T. On 11/19/25 at 10:13 am, during an interview with the DON, she stated CNAs should not be documenting for each other. If they were not caring for the resident, they should not document for the resident. The DON stated that all care areas on the ADL list should be filled in and this task is to be completed before the CNA's leave for the day. U. On 11/19/25 at 10:09 am, during an interview with Assistant Director of Nursing (ADON), she stated she had noticed during chart review the CNAs were not documenting on the ADL task list the way they are supposed to. The ADON stated by the end of day when the CNAs leave their shift there should be an indicator on the dashboard for their residents that will show green. That means documentation is complete.

Based on interview, and record review, the facility failed to capture an accurate and consistent weight for 1 (R #1) of (R #1) residents reviewed for weight loss. This deficient practice potentially created a delay in R #1 receiving a nutritional supplement due to missing and inaccurate weights, which likely contributed to weight loss. The findings are: A. Record review of R #1's Electronic Medical Record (EMR) revealed she had dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), frontal lobe and executive function deficit from cerebral infarction (is responsible for higher cognitive functions including language, memory, problem solving, and judgment), hypertension (high blood pressure), cardiac pacemaker ) small, battery-operated device that helps regulate the heart's rhythm by sending electrical impulses to stimulate heartbeats). R #1 was admitted to the facility on [DATE]. B. Record review of R #1's physician orders indicated the following: weigh on admission then weekly X (times) 4 weeks every day shift every Thursday for routine monitoring for 5 weeks. Start date 09/26/25. C. Record review of R #1's care plan dated 09/26/24 indicated the following: eating assistance level: assist of 1, she can refuse to open her mouth start date 09/25/24. D. Record review of R #1's weight log revealed the following: - 09/25/24 125.0 pounds (Lbs) - 10/08/24 125.0 Lbs - 10/17/24 150.5 Lbs a note next to the weight documented that the weight was documented incorrectly -10/25/24 113.0 Lbs -10/30/24 111.4 Lbs E. Record review of the electronic medical record for R #1 did not reveal a weight for 10/02/25 that was missed and there was no order for a re-weight on the inaccurate weight on 10/17/25. F. Record review of R #1's mini nutrition progress note revealed on 10/08/24 resident weighed 125 lbs. Resident has mild dementia. Resident Body Mass Index is greater than 21 and less than 23. R #1's Mini Nutrition Score is: 6.0 12 - 14 points: Normal nutritional status 8 - 11 points: At risk of malnutrition 0 - 7 points: Malnourished G. Record review of R #1's physician orders indicated the following: give Ensure drink at each mealtime, three times a day for insufficient nutrition. Start date 10/25/24. H. On 11/17/25 at 12:15 pm, during an interview with the Nutritional Services Director (NSD), she stated she works closely with the Registered Dietician (RD). She stated weights have been an issue because the weights don't get done according to the physician order which is usually once per week for five weeks and monthly after that. Getting reweighs done has also been an issue and they are almost impossible to get. She remembers R #1 was not eating and refusing most of her meals. R #1 was ordered a protein shake and was to be in the dining room for meals because she required assistance with eating. She stated that she was very malnourished. She stated most of the meal percentage documentation was not accurate. She stated she would see documentation of R #1 eating 50 to 75% of her meal but her plate would come back totally full. I. On 11/19/25 at 10:09 am, during an interview with Assistant Director of Nursing (ADON), she stated getting weights done has been a problem. When new residents come into the facility on admission they will usually get weighed the first three days and then for four weeks after that. Getting a re-weigh for a weight that is inaccurate can also be a challenge. The staff view weights as a vital sign and need to be completed and accurate. J. On 11/19/25 at 10:13 am, during an interview with the Director of Nursing (DON), she stated that weights have not always been consistent and because they have not always been consistent and getting reweighs has also been challenging. K. On 11/19/25 at 12:25 pm, during an interview with the Registered Dietician (RD), she stated she is in contact with the NSD all the time. The RD stated she is notified of weight loss through call, text or email. The electronic medical record (EMR) also notifies of weight loss and it will be on the EMR dashboard for the resident who has weight loss or abnormal vitals. The RD stated there had been issues with getting weights and re-weighs and stated they had not been done consistently. The RD stated it is impossible to know if they weight loss or gain is a true weight loss or gain if a reweigh isn't done. The RD stated for R #1 if her weight on 10/17/24 was inaccurate, she was not reweighed, and her next weight was 10/25/24 and showed a 9-pound weight loss. The RD confirmed there was a delay in getting R #1 a weight loss supplement and addressing R #1's weight loss.

Based on record review and interview, the facility failed to: - Complete necessary assessments, -Open a risk management report, -Create interventions for a fall, and-Use two staff when using the Hoyer lift (equipment used to move residents who have limited mobility). for 2 (R #1 and R #9) of 2 (R #1 and R #9) residents reviewed for falls. Failure to provide fall prevention interventions and facility staff using the Hoyer lift with only one person are likely to cause accidents, injuring the resident. The findings are: Findings for Fall Assessment R #1: A. Record review of the face sheet for R #1 indicated she was admitted on [DATE] and had the following diagnoses: -Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), -Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), -Frontal lobe and executive function deficit from cerebral infarction (responsible for higher cognitive functions including language, memory, problem solving, and judgment), -Hypertension (high blood pressure), -Cardiac pacemaker) small battery operated device that helps regulate the heart's rhythm by sending electrical impulses to stimulate heartbeats). B. Record review of R #1's nursing progress notes dated 09/29/24 revealed the following: -R #1 was found on the floor next to her bed. She was awake and alert, denied pain. No obvious injury. Vital signs were within normal limits (standard or typical). -R #1's son requested R #1 be sent to the hospital. R #1 was sent to the hospital. -R #1 had no injury from the fall, but it was discovered R #1 had a urinary tract infection (UTI) and was treated with antibiotics. C. Record review of R #1's assessment tab in the Electronic Medical Record (EMR) revealed there was no fall assessment completed, no neuro checks (a brief neurological assessment performed by staff repeatedly to monitor a resident's neurological status) completed, no change in condition completed, no post fall assessment and no interventions in place for the fall that occurred on 09/26/24. D. Record review of R #1's care plan initiated on 09/26/24 revealed that there was not a care plan focus or intervention for the fall on 09/26/24. The first care plan item for falls was dated 10/26/24 after the second fall occurred. E. Record review of R #1's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/01/24 revealed R #1 had upper and lower extremity impairment (loss of use) on one side. R #1 required full assistance with eating, dressing, hygiene and was a moderate to partial assist for rolling from back to left side to back again when in bed. F. On 11/17/25 at 10:30 am, during an interview with R #1's son, he stated he was notified of the fall on the morning of 09/26/24. R #1's son also stated when he spoke to the Nurse Practitioner (NP) (not sure of the exact date) about fall mats being placed on the side of the bed, the NP stated they don't use fall mats because they are a restraint to residents. He was told he could buy a sensor for the bed if he wanted to. He stated no interventions were done for the fall on 09/26/24. G. On 11/18/25 at 12:45 pm, during an interview with Licensed Practical Nurse (LPN) #5, she stated when a resident has a fall she would be notified right away, and she would go down and assess the resident. She would check vitals, including neuro checks, pain, bruising, if the resident was bleeding, and if they hit their head. She would send the resident to the hospital if needed or requested from family and physician. Notification of everyone who is notified of a fall. H. On 11/19/25 at 10:13 am, during an interview with Director of Nursing (DON), she stated when a resident has a fall, a nursing assessment for falls is completed whether it was witnessed or not witnessed. The nurse would look for injuries, if the resident hit their head. Neuro checks are done for every fall, and a post fall assessment is completed the next day. They would open a risk management for the fall and then interventions would be discussed once they have determined the cause of the fall. The DON stated fall mats are used in this building and the resident would be assessed if they are appropriate or not. The DON confirmed none of this was completed for the fall on 09/26/24 for R #1. Findings for Hoyer lift R #9: I. Record review of R #9's face sheet revealed she was admitted on [DATE] and had the following diagnoses: Cerebral infraction due to embolism (an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) or (stroke), Type II diabetes mellitus (DM2 is a disease in which the body cannot make or properly use insulin), Vascular Dementia (a blockage of the blood supply to the brain. It is manifested with decline of memory and cognitive functions), Parkinson's (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination), Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease). J. Record review of R #9's care plan revealed the following: -initiated on 05/29/25, R #9 is dependent on staff for all activities of daily living, -initiated on 05/30/25 to use Hoyer lift every shift related to hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) affecting left non-dominant side, two persons assist when using. K. Record review of R #9's physician orders 08/05/25 revealed the following: may use Hoyer lift for transfers every shift related to hemiplegia affecting left non-dominant side, two persons to assist when using. L. On 11/18/25 at 11:17 am, during an interview Certified Nursing Assistant (CNA) #9, she stated she used the Hoyer lift by herself to transfer R #9 because the CNA she was working with the evening of 11/09/25 was busy helping other residents. M. On 11/18/25 at 12:35 pm, during an interview with CNA #10, she stated R #9 is a two person assist for everything including changing the resident. R #9 is a Hoyer lift, and you have to use two staff to use the Hoyer lift. N. On 11/18/25 at 2:42 pm, during an interview with CNA #8, she stated on 11/09/25 she and CNA #9 were working night shift with each other. She stated when they (CNAs) come on shift, they will answer any call lights that maybe going off. CNA #8 stated CNA #9 did not ask her for help with transferring R #9. She stated she did not know why CNA #9 did not ask her for help with the Hoyer lift for R #9, and she could only guess CNA #9 was busy answering call lights and she wanted to get R #9 to bed. O. On 11/19/25 at 10:36 am, during an interview with the Director of Nursing (DON), she stated R #9 is a two person assist, and R #9 requires two people when changing her, dressing her, and transferring her with the Hoyer lift. The DON confirmed CNA #9 did not use a second staff for the Hoyer lift and transferred R #9 alone.

Based on record review and interview, the facility failed to notify the guardian of a change in condition for 1 (R #3) of 2 (R #3 and R #9) residents reviewed for weight loss. This deficient practice is likely to cause residents to go without needed interventions, if the guardian of the resident is unaware of the change in condition. The findings are: A. Record review of R #3's face sheet revealed she was admitted into the facility on [DATE] with the following diagnoses: -Osteoarthritis (chronic degeneration of the joint cartilage), -Bi-polar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), -Type II diabetes (a disease in which the body cannot make or properly use insulin), - Atherosclerosis of native arteries (hardening of your arteries from plaque building up gradually inside them, plaque buildup limits blood flow causing complications like a heart attack or stroke), - Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). B. Record review of R #3's face sheet revealed the guardian for R #3 was listed as emergency contact #1, guardian, responsible party and responsible for statement (financial). There is an address listed along with a cell phone number and an office number. C. Record review of R #3's physician's orders revealed the following: -On 09/17/25 R #3 was on regular diet, soft and bite sized texture, thin consistency. -On 09/18/25 R #3 needs assistance with meals for expected decline due to disease process. -On 10/03/25 R #3's diet changed to a regular diet, puree texture and thin consistency. D. On 11/26/25 at 9:10 am, during an interview with the Director of Nursing (DON), she stated R #3's guardian was upset about a few things. He was upset about not being notified of the diet change and R #3's decline due to disease process. The DON stated the guardian had not been around at all and none of the nurses knew him. She stated when she spoke to the nurse about not notifying the Guardian, the nurse stated she did not know who the Guardian was and notified the grandson instead. E. On 11/26/25 at 9:21 am, during an interview with Social Services Director (SSD), she stated R #3's guardian had a few issues with the notification process. She stated she called to speak with him (she could not recall the date) and the guardian told her that he was unaware R #3 had a decline and diet change, and he was not notified of these changes. The SSD stated she was unclear on whether or not he was notified of the diet change and the decline. F. On 11/26/25 at 10:00 am during an interview with R #3's guardian, he stated he was not notified of R #3's change in condition and her diet change. The guardian stated he was not notified of her overall condition and he should have been notified of all of these changes. G. Record review of R #3's electronic medical record (EMR) revealed the medical record did not contain any documentation of the guardian being notified of R #3's change in condition or diet change after R #3 returned from the hospital on [DATE].

Based on observations, interviews, and record review, the facility failed to ensure:- Staff entering the second-floor kitchen during meal service wore required hair restraints, which had the potential to affect 19 out of 19 residents on the second floor.This deficient practice increased the risk of food contamination which could lead to foodborne illness.The findings are: A. Record review of Facility Uniform Dining Services Policy, last revised November 2024, revealed hair must be pulled up and contained in a hair net, visor, and/or cap if it is long. B. On 08/11/2025 at 12:24 PM, observation revealed an Activities Staff member entered the kitchen without a hairnet to grab a wash rag. The staff member exited kitchen to clean a table and then re-entered kitchen without hairnet at 12:25pm to return the wash rag. Further observation revealed the Activities Staff member walked past the food that staff was serving to the residents. C. On 08/13/2025 at 10:00 AM, during an interview, the Activities staff member stated she did not wear a hairnet either time she entered the kitchen. Activities staff member stated she should wear a hairnet when entering the kitchen. D. On 08/13/2025 at 12:45 PM, during an interview, the Nutritional Services Manager (NSM) stated all staff should wear hairnets when entering kitchen for any amount of time.

Based on record reviews and interviews, the facility failed to ensure resident records were complete when staff failed to document resident weights into the residents' medical record for 2 (R #45 and #46) of 2 (R #45 and #46) residents. If staff do not document necessary resident information into the medical records, then the resident may not receive the services needed to maintain or achieve optimum health. The findings are: R #45A. Record review of R #45's face sheet revealed an admission date of 08/07/25 with the following diagnoses:- Fracture (break) of the left lower leg,-Chronic Obstructive Pulmonary Disease (COPD; lung disease),- Hypertension (high blood pressure).B. Record review of R #45's physician orders, dated 08/08/25, indicated an order for daily weights, starting on admission for 3 days and then weekly for 4 weeks. C. Record review of R #45's weights revealed staff documented one weight for R #45 on 08/10/25. R #46D. Record review of R #46's face sheet revealed an admission date of 08/08/25 with the following diagnoses:-Fracture of the right femur (break in the long bone that connects the hip to the knee)-Type II diabetes (DM; a disease in which the body cannot make or properly use insulin),-Acute kidney failure (impaired kidney function). E. Record review of R #46's physician orders, dated 08/08/25, indicated an order for daily weights, starting on admission for 3 days and then weekly for 4 weeks. F. Record review of R #46's weights revealed staff documented one weight for R #45 on 08/08/25.G. On 08/14/25 at 9:03 am, during an interview, Nurse #8 stated the physician liked to monitor resident weights, so every new admit had an order to weigh daily for three days. Nurse #8 stated they documented the weights on a piece of paper and checked it for consistency before it was entered into the system. Nurse #8 stated the Certified Nursing Assistants (CNA) were delegated to do the weights. Nurse #8 stated the Nurse, Assistant Director of Nursing (ADON), or the Dietician would enter the weights into the system. H. On 08/14/25 at 9:13 am, during an interview, CNA #6 stated the Nurse told her which residents needed to be weighed. She stated they documented the weights on a piece of paper and gave them to the Nurse when completed. She stated the Nurse reviewed the weights and entered the weights into the system. CNA #6 stated she thought she weighed R #46 and R #45 three days in a row.I. On 08/14/25 at 12:20 pm, during an interview, the ADON stated all weights should be completed as ordered and put into the system. The ADON stated the weights went to the Dietician to make sure the weights are accurate. She stated the Dietician or the Nurse entered the weights into the system after they were verified.

Based on record review, interview, and observation the facility failed to ensure professional standards of care for (R #19 and #46) of 2 (R #19 and #46) residents when staff failed to:- Obtain and enter wound care orders for the resident's wounds.- Put away a resident's fall mat after the resident got out of bed. If the facility fails to obtain and enter orders for wound care, then residents may not receive the care needed to improve their wounds. If staff fail to put away a resident's fall mat after they get out of bed, then the resident may not be able to access their bed or other areas of their room. The findings are: R #46A. Record review of R #46's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 08/14/25, indicated the resident was admitted to the facility on [DATE] with the following diagnoses:- Major joint replacement,-Fracture of the right femur (long bone that connects the hip to the knee),-Type II diabetes (DM2; a disease in which the body cannot make or properly use insulin) B. Record review of R #46's wound assessments revealed the resident had the following wounds on admission: -Right lateral thigh surgical wound with staples dated 08/08/25,-Surgical wound with staples front right knee dated 08/08/25,-Surgical front right trochanter (hip) with staples dated 08/08/25,-Skin tear/laceration to the right lower elbow dated 08/12/25,-Skin tear right upper arm laceration, dated 08/12/25. C. Record review of R #46's physician orders, dated 08/08/25, revealed there were not any orders for wound care. D. Record review of R #46's Treatment Administration Record (TAR), dated 08/08/25 to 08/11/25, revealed staff did not document they provided any wound care to the resident. E. On 08/11/25 at 2:50 pm, during an observation and interview, R #46 had a bandage on her left arm. The bandage was slightly soiled and dirty. The bandage did not have a date on it. R #46 stated she fell before coming to the facility. R #46 stated she had surgery and was bruised all over from the fall. She stated her bandage on her left arm was changed yesterday on 08/10/25 by the nurse. F. On 08/11/25 at 3:11 pm, during an interview, Nurse #3 stated she was aware of R #46's wounds, because she provided wound care for R #46. Nurse #3 stated she did not see any wound care orders in the resident's physician orders on admission. She stated the admitting nurse should enter the orders into the electronic medical record on admission. She stated staff should call the provider or on-call provider if there were not any orders on admission. Nurse #3 stated she brought up that R #46 did not have any wound orders to the Assistant Director of Nursing (ADON). Nurse #3 stated if she provided wound care to the resident, then there should be wound care orders in the resident's record. G. On 08/11/25 at 3:30 pm, during an interview, the ADON stated she did not review R #46's medical record, but she was aware R #46 did not have wound care orders in the electronic medical record. She stated Nurse #3 asked her about the resident's wound care orders. The ADON stated it was the responsibility of the admitting nurse to enter orders into the electronic medical record on admission. She stated if a nurse provided wound care, then there should be orders for wound care. H. On 08/12/25 at 3:04 pm, during an interview, the Director of Nursing (DON) stated she expected a new resident to receive a full skin check. She stated staff should take pictures of any wound and measure them. She stated staff should enter wound orders into the electronic medical record. She stated if there were not any wound orders from the hospital discharge paperwork, then staff should call the physician or on-call physician to get some orders. She stated she assumed wound care was completed because the resident had a wound dressing on. The DON stated wound care should not be provided without physician orders. R #19I. Record review of R #19's medical record revealed an admission date of 07/18/25 with the following diagnoses:-Hypertension (high blood pressure),-Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),-Atrial fibrillation (A-fib; irregular heart rhythm),-Metabolic encephalopathy (a brain dysfunction caused by an underlying condition that affects your metabolism). J. Record review of R #19's physician orders, dated 07/18/25, revealed an order for fall precautions/restrictions. K. Record review of R #19's care plan, 07/19/25 revealed the following:- R #19 was a fall risk.- The resident had six falls since admission.- Interventions: floor mats on floor next to the bed. L. On 08/12/25 at 9:30 am, an observation revealed fall mats on the floor in R #19's room, and R #19 was not in bed. M. On 08/12/25 at 9:45 am, during interview, Certified Nurse Assistant (CNA) #5 stated the resident's fall mats were always on the floor. She stated she did not remove them when the resident was out of bed. N. On 08/14/25 at 12:20 pm, during an interview, ADON stated fall mats should not be on the floor when the resident was not in bed.

Based on observation, record reviews, and interviews, the facility failed to ensure a call light was within reach for 1 (R #4) of 1 (R #4) resident. If the facility is not ensuring the call light is within residents' reach, then residents may be unable to request immediate assistance when needed.The findings are: A. Record review of the facility's Call Lights Policy, dated October 2024, revealed staff were instructed to place the call light within easy reach of the resident while in bed or a chair. B. On 08/11/25 at 11:27 am, observation revealed R #4's call light hung out of R #4's reach while the resident lay in bed watching TV. C. On 08/13/25 at 9:39 am, during an interview, Certified Nurse Assistant (CNA) #1 stated call lights should be within residents' reach. She stated R #4 needed the call light to request assistance when needed. D. On 08/13/25 at 11:50 am, during an interview, the Director of Nursing (DON) stated he expected all staff to check R #4's call light when they went into the resident's room. The DON stated if a call light hung off R #4's bed, then staff should pick it up and place it by the resident. The DON stated staff should use a clip to ensure the call light stayed attached to R #4's bed and within the resident's reach. E. On 08/14/25 at 9:21 am, during an interview, Nurse #1 stated call lights should be within the resident's reach. He stated Nurses and CNAs should have noticed R #4's call light was out of reach and should have clipped to R #4's bed.

Based on record reviews and interviews, the facility failed to schedule an annual appointment for dental services for one (R #6) of one (R #6) residents. This deficient practice could likely result in an increased risk of developing serious dental issues like tooth loss and infection, which can require extensive treatment. The findings are:A. Record review of the facility's Dental Services & Oral Screening Policy, dated February 2023, revealed the following:- Each resident will be offered the opportunity to receive an annual oral screening by the contracted facility dentist.- Residents will be assisted, when necessary or if requested, in making routine and annual appointments and with arranging transportation to and from dental location.- The resident will have the right to select the dental care provider of their choice. The facility will inform the resident as to how the dental care provider can be contacted.- Facility staff will track when resident annual exam is due and notify family and/or the facility dentist. B. Record review of R #6's Face Sheet revealed R #6 was admitted to the facility on [DATE]. C. Record review of R #6's Electronic Health Record (EHR), undated, revealed R #6 did not have a scheduled dental appointment or a dental service visit during the past 12 months. D. Record review of a written statement provided by the administrator, dated 08/13/25, revealed the Medical Records Director (MRD) stated R #6 used a geriatric wheelchair and the facility's transportation could not transport geriatric chairs. The MRD stated she attempted to schedule R #6 for dental services with a mobile dental company, but those attempts were unsuccessful due to dental company phone number was unreachable. E. On 08/11/25 at 12:46 pm, during an interview, R #6 stated he did not recall the last time he went to a dentist for routine dental exam. He stated he was interested in having his teeth and mouth checked. He stated staff did not offer him a dental appointment. F. On 08/13/25 at 09:50 am, during an interview, the Director of Social Services (DSS) stated R #6 went over a year without having a dental appointment. She stated she should have scheduled R #6 for a dental appointment within the past 12 months. G. On 08/13/25 at 11:50 am, during an interview, the Director of Nursing (DON) stated she expected the DSS to schedule R #6 for his annual dental exam.

Based on record review and interviews, the facility failed to complete an annual performance/competency review for 1 (Certified Nurse Assistants - CNA #5) of 5 (CNAs #2, #3, #4, #5 and #10) CNAs. If staff do not receive 12 performance/competency reviews annually, then they may not maintain the competencies necessary to perform daily tasks of providing care and services to meet the needs of all residents. The findings are:A. Record review of the facility's staffing competencies from August 2024 to August 2025 revealed the facility did not perform staffing competencies on a yearly basis for CNA #5. The facility conducted staffing competency on hire only. B. On 08/11/25 at 10:30 am, during an interview, the Administrator stated they did not currently have a Nurse Educator, and the Assistant Director of Nursing (ADON) was in charge of the CNA competencies. C. On 08/13/25 11:30 am, during an interview, CNA #5 stated she did not have competencies completed, and she could not remember doing them when she was hired. D. On 08/14/25 at 12:20 pm, during an interview, the Assistant Director of Nursing (ADON) stated competencies were completed for new hires, but the facility did not complete yearly competencies with the staff.

Based on interview and record review, the facility failed to ensure nursing staff were competent to provide nursing and related services. This deficient practice could affect all 53 residents in the facility (residents were identified by Resident Matrix provided by the Administrator on [DATE]). This deficient practice could likely result in CNA's (Certified Nurse Assistant) and RN's (registered nurses) working with residents without adequate knowledge to do so; likely resulting in injury or inappropriate care being provided to the residents. The findings are: A. Record review of the facility's Agency Use Policy (policy and procedures for using nursing staff who are contracted through a third-party agency) revised on ,d+[DATE], revealed the facility will ask the agency to fax to the facility the completed LN (Licensed Nurse) competency evaluation on each individual. In addition, the verification of licensure and/or certification and background check results for all agency staff must be given/faxed to the facility. The facility must provide the necessary orientation to enable the registry personnel to carry out their responsibilities. B. On [DATE] at 3:17 pm during an interview with Certified Nurse Aid (CNA) #3, he confirmed he is a contracted agency staff. He stated he did not receive any training's or orientation from the facility prior to working at the facility. C. On [DATE] at 3:41 pm during an interview with CNA #5, she confirmed she is a contracted agency staff. She stated she did not receive any trainings or orientation from the facility prior to working at the facility. D. On [DATE] at 12:30 pm during an interview with Registered Nurse (RN) #3, he confirmed he is a contracted agency nurse. RN #3 confirmed he was working his first shift since 6:30 am [[DATE]]. He reported that he did not have any training or orientation with the facility prior to starting his shift and was only given a brief tour when he arrived. RN #3 stated he was given a code to sign into a tablet, but did not have access to the residents' electronic health records until approximately 12:30 pm [[DATE]]. RN #3 confirmed he was working on the floor as the only nurse with a Certified Medication Aide (CMA) and he was dependent upon the CMA to access resident medical records for him due to not having access. E. On [DATE] at 1:00 pm during an interview with the administrator (ADM), she confirmed the facility does not complete any training or orientation for agency staff prior to working their first shift. The ADM stated the expectation is that the contracting agency completes all required verifications and trainings. The agency staff should arrive at the facility ready to work. The Administrator confirmed that she did not have any record of staff training or background checks for agency staff. F. On [DATE] at 2:25 pm during an interview with the scheduler and central supply (S/CS), she confirmed the facility does not provide any training or orientation to agency contracted staff. G. [DATE] at 2:23 pm during interview with Human Resources (HR), she confirmed that the facility did not have to keep records for agency staff. Findings for R #2: H. Record review of R #2's admission record revealed R #2 was originally admitted to the facility on [DATE], and readmitted on [DATE] after a hospital stay with the following diagnoses: 1. Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (weakness or paralysis on one side of the body) following cerbral (brain) infarction (condition where blood flow to the brain is interrupted, causing brain tissue damage) affecting left non-dominant side. 2. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]). 3. Altered mental status, unspecified. 4. Strange and inexplicable behavior. 5. Cardiac (heart) Arrythmia (irregular heartbeat). I. Record review of R #2's care plan dated [DATE] revealed R #2 was at risk for falls due to generalized weakness. Interventions include staff to assist as needed with transfers and ADLs (activities of daily living). J. Record review of Minimum Data Set (MDS) assessment dated [DATE], revealed that R #2 has upper and lower extremity impairment on one side. Assessment also indicated that R #2 needed substantial/maximal assistance (helper does more than half the effort) for upper body dressing and dependent (helper does all the effort) for lower body dressing. K. Record review of a written statement by CNA #6, acquired by facility during an investigation conducted on [DATE], revealed CNA #6 was not aware that R #2 had left-sided weakness and had told R #2 to put her arms in the sleeves of her shirt by herself. R #2 began to cry an stated that she couldn't [dress herself] and that's why she needed help. R #2 began to swing at the CNA. CNA #6 wrote in her statement that she didn't know the resident wasn't able to dress herself. L. Record review of the employee record for CNA #6 confirmed that she was agency staff. The record also identified that training for abuse, neglect and misappropriation had not been completed, dementia care assessment 1 was expired, enhanced barrier precautions training not started, long term care essential clinical assessment was not started, CNA acute care training was expired, psychiatric and mental health nursing was expired. Findings related to R #3: M. Record review of R #3's admission record revealed R #3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: 1. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]). 2. Chronic atrial fibrillation (heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly that last for more than a week). 3. Acute congestive heart failure (a sudden, life-threatening condition where the heart struggles to pump enough blood to meet the body's needs, leading to fluid buildup and symptoms like shortness of breath and swelling). 4. Chronic Kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products from the blood). 5. Type 2 Diabetes Mellitus (a chronic condition characterized by high blood sugar levels due to the body's inability to use insulin effectively or produce enough insulin). 6. Benign prostatic Hyperplasia (a non-cancerous condition where the prostate gland grows larger than normal, potentially causing urinary problems) N. Record review of R #3's hospice admission order form (a form completed by a hospice nurse to identify diagnosis, activity, diet, allergies and medication orders) revealed resident was admitted to hospice on [DATE]. O. Record review of the nurse progress note dated [DATE], revealed Sent patient to hospital this morning, Was acting aggressive, confused and lethargic. He did slap one of the techs and refused a blood sugar and medication. Ambulance took patient to [Name of hospital]. Note was written by RN #1. P. On [DATE] at 2:59 pm during interview with the Administrator, she confirmed that the nurse that sent R #3 to the hospital was unaware that he was on hospice and he should not have been sent out. The Administrator confirmed that RN #1 was an agency nurse. 51616

Based on interview and record review, the facility failed to ensure that they did not impose a charge against the personal funds for items or services already being billed for (R #1 and R #3) of 3 (R #1, R #3 and R #4) residents reviewed when staff billed the residents instead of billing the hospice agency for supplies and medications. This deficient practice is likely to cause undue financial strain for the residents. The findings are: A. Record review of R #1's Admission Record revealed R #1 was admitted to the facility on [DATE]. B. Record review of R #1's medical orders revealed an order dated 10/08/23 to admit R #1 to hospice effective 10/08/23. C. Record review of R #1's billing statements from the facility revealed the following: 1. A charge dated 06/01/24 for an oxygen concentrator (a medical device that delivers concentrated oxygen to a person via cannula (a medical device/plastic tube that delivers oxygen to a person through their nostrils) for $75.00, 2. A charge dated 07/01/24 for an oxygen concentrator for $75.00, 3. Charges dated 07/28/24 for a cannula for $1.25 and a humidifier for $4.73, 4. A charge dated 08/05/24 for a cannula for $1.25, 5. A charge dated 08/11/24 for a cannula for $1.25, 6. A charge dated 08/18/24 for a cannula for $1.25, 7. A charge dated 09/01/24 for an oxygen concentrator for $75.00, 8. A charge dated 10/01/24 for an oxygen concentrator for $75.00, 9. A charge dated 12/01/24 for an oxygen concentrator for $75.00, 10. Charges dated 12/31/24 for three medications for a total amount of $19.56. D. On 03/19/25 at 1:22 pm, during an interview with [NAME] Specialist (BS), she confirmed she billed R #1 for the oxygen concentrator, canula and medications. She further stated she was waiting for a list of items that are covered by hospice. E. On 03/18/25 at 4:25 pm, during an interview with the Hospice Agency Clinical Services Director (HACSD), she confirmed hospice does cover oxygen concentrators, cannulas, humidifiers, and the medications that were charged to R #1 was because these items were relate to R #1's terminal diagnosis. R #3 F. Record review of R #3's Admission Record revealed R #3 was admitted to the facility on [DATE]. G. Record review of the hospice agency's admission form dated 10/22/24, revealed R #3 started hospice on 10/22/24. H. Record review of R #3's billing statements from the facility revealed the following: 1. A charge dated 12/08/24 for wipes for $9.61, 2. A charge dated 12/16/24 for adult briefs for $23.04, 3. A charge dated 12/22/24 for a medication of $0.54. I. On 03/19/25 at 1:22 pm, during an interview with [NAME] Specialist (BS), she confirmed she billed R #3 for wipes, adult briefs and medication. BS further stated she was waiting for a list of items that are covered by hospice.

Based on record review and interview, the facility failed to notify the Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, and/or medical care) for 1 (R #1) of 3 (R #1, R #2, and R #5) residents when injuries or incidents occurred. If the facility is not notifying the resident's POA when the resident has an injuries or incident occur, then the POA is not able to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of R #1's Admission Record revealed R #1 was admitted to the facility on [DATE], with the following diagnoses: 1. Chronic heart failure, 2. Anxiety (feelings of fear or apprehension) disorder due to known physiological condition, 3. Insomnia (disorder where a person has persistent difficulty falling asleep, staying asleep, or quality of sleep), unspecified, 4. Adjustment disorder (emotional or behavioral reaction to a stressful event or change in a person's lift) with depressed mood (feelings of sadness, loss of interest, and difficulty with thinking, memory, eating, and sleeping). B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/25/25 revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 00, severe impairment. C. On 03/18/25 at 10:33 am, during an interview with R #1's POA and daughter, she stated she went to the facility on [DATE] to visit R #1 when she noticed a bandage on R #1's wrist that went from her wrist to her elbow. She stated R #1 also had a bandaid on her face. R #1's POA stated that she was not informed of any new injuries, and she wanted to know the cause, so she asked the staff that were working that day, but nobody knew what happened. She said one staff member looked through the electronic medical record but could only tell her that a staff member documented that she bandaged R #1 on 01/31/25. R #1's POA stated the facility's communication used to be better, she said the staff at the facility would inform her of everything that happened, but since the new management company took over, things have gone downhill and she is not informed about anything anymore. D. Record review of R #1's electronic health record (EHR) revealed the following: 1. A Change of Condition form dated 01/31/25 that listed a skin wound or ulcer as the change of condition, but no cause of injury is stated. 2. A Total Body Skin assessment dated [DATE] revealed R #1 has two new wounds. E. On 03/19/25 at 3:00 pm, during an interview with the Director of Nursing (DON), she confirmed R #1's POA was not notified of the injuries that R #1 incurred on 01/31/25. The DON stated that the nurse on duty should notify POAs when residents are injured. 51616

Based on record review and interview, the facility failed to ensure staff revised the care plan for 3 (R #2, R #3 and R #5 ) of 4 (R #1, R #2, R #3, and R #5) residents reviewed when staff failed to update care plans to include hospice care or fall protocol . This deficient practice is likely to result in residents' care and needs not being addressed. The findings are: R #2 A. Record review of R #2's admission record revealed R #2 was originally admitted to the facility on [DATE], and readmitted on [DATE] after a hospital stay with the following diagnoses: 1. Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (weakness or paralysis on one side of the body) following cerbral (brain) infarction (condition where blood flow to the brain is interrupted, causing brain tissue damage) affecting left non-dominant side. 2. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]). 3. Altered mental status, unspecified. 4. Strange and inexplicable behavior. 5. Cardiac (heart) Arrythmia (irregular heartbeat). B. Record review of R#2's facility Nursing progress note revealed the following: 1. dated 02/25/25, revealed R #2 had a fall with injuries. 2. Dated 03/03/25 revealed R #2 returned from hospital after fall resulting in right hip fracture and surgical repair. C. Record review of R #2's Care Plan dated 07/16/24 revealed .at risk for falls due to: Generalized Weakness. Care Plan did not include date of fall on 02/25/25 which resulted in hip fracture. There were no additional updates or interventions added. D. On 03/19/25 at 3:15 pm, during an interview with the Director of Nursing (DON), she confirmed R #2's care plan was not revised to include the fall R #2 had sustained that caused R #2 to break her hip or added new interventions for the 02/25/25 fall, she confirmed after R #2's fall the care plan should have been updated to include a fall protocol with interventions and prevention. R #3 E. Record Review of R #3's admission record revealed R #3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: 1. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]). 2. Chronic atrial fibrillation (heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly that last for more than a week). 3. Acute congestive heart failure (a sudden, life-threatening condition where the heart struggles to pump enough blood to meet the body's needs, leading to fluid buildup and symptoms like shortness of breath and swelling). 4. Chronic Kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products from the blood). 5. Type 2 Diabetes Mellitus (a chronic condition characterized by high blood sugar levels due to the body's inability to use insulin effectively or produce enough insulin). 6. Benign prostatic Hyperplasia (a non-cancerous condition where the prostate gland grows larger than normal, potentially causing urinary problems) F. Record review of R #3's hospice admission order form (a form completed by a hospice nurse to identify diagnosis, activity, diet, allergies and medication orders) revealed resident was admitted to hospice on 10/22/24. G. Record review of R #3 significant change Minimum Data Set (MDS) assessment dated [DATE] revealed R #3 receives hospice in the facility. H. Record review of R #3's care plan dated 07/09/24 and revised on 01/02/25 revealed the care plan was not revised to reflect hospice care. I. On 03/19/25 at 12:59 pm during an interview with the Director of Nursing (DON), she confirmed the following: 1. R #3 is currently receiving hospice services 2. R #3's care plan was not updated prior to 01/02/25 to include hospice services which originally began on 10/22/24. 3. R #3's care plan revised on 01/02/05 does not meet her expectations for interventions regarding R #3's care for hospice needs. R #5 J. Record review of R #5's admission record revealed R #5 was admitted to the facility on [DATE] with the following diagnoses: 1. Alzheimer's disease, 2. Depression and anxiety disorders, 3. Generalized epilepsy and epileptic syndromes (seizure disorder), 4. Disorientation, unspecified, 5. Unspecified psychosis (mental disorder), not due to a substance or known condition. K. Record review of R #5's electronic health record (EHR) revealed a Long Term Care Form dated 02/20/25 completed by the hospice agency stated routine hospice care to start on 02/20/25. L. Record review of R #5's MDS assessment dated [DATE] revealed R #5 was receiving hospice care in the facility. M. Record review of R #5's care plan dated last revised on 07/19//24 did not identify that R #5 was receiving hospice services. N. On 03/19/25 at 3:00 pm, during an interview with the DON, she confirmed R #5's care plan did not contain any information regarding R #5 being on hospice. She stated her expectation is for all residents that are on hospice to have a comprehensive care plan that includes interventions for hospice. 50207

Based on record review and interview, the facility failed to ensure hospice services met professional standards for 2 (R #3 and R #5) of 3 (R #1, R #3, and R #5) residents reviewed for hospice services by: 1. Not having an order for hospice services for R #5 2. Not having a qualifying diagnosis for R #3. 3. Not having hospice plans of care for R #3 and R #5. 4. Not communicating with hospice regarding a change in condition for R #3. These deficient practices are likely to result in the resident not receiving the services that she needs. The findings are: R #3 A. Record review of R #3's admission record revealed R #3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: 1. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]). 2. Chronic atrial fibrillation (heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly that last for more than a week). 3. Acute congestive heart failure (a sudden, life-threatening condition where the heart struggles to pump enough blood to meet the body's needs, leading to fluid buildup and symptoms like shortness of breath and swelling). 4. Chronic Kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products from the blood). 5. Type 2 Diabetes Mellitus (a chronic condition characterized by high blood sugar levels due to the body's inability to use insulin effectively or produce enough insulin). 6. Benign prostatic Hyperplasia (a non-cancerous condition where the prostate gland grows larger than normal, potentially causing urinary problems) B. Record review of R #3's hospice admission order form (a form completed by a hospice nurse to identify diagnosis, activity, diet, allergies and medication orders), revealed: 1. R #3 was admitted to hospice on 10/22/24. 2. R #3 was admitted to hospice care with a diagnosis listed as unspecified illness. C. Record review of R #3's Electronic Health Record (EHR) revealed the hospice plan of care was not available. D. Record review of nurse progress notes dated 12/29/24 revealed registered nurse (RN) #1 sent R #3 to the emergency room (ER) for unusual behavior and that RN #1 was unaware R #3 was on hospice. E. On 03/18/25 at 11:07 am during an interview with R #3's family member, he confirmed RN #1 was not aware R #3 was on hospice and that the family member informed RN #1 of R #3's hospice care when he asked why hospice was not notified. F. On 03/18/25 at 12:38 pm during an interview with R #3's hospice nurse, she stated the facility did not notify the hospice agency about R #3 condition prior to transporting him to the hospital on 12/29/24 and was notified from the family member. G. Record review of R #3's Medical Record revealed R #3 returned to the facility on [DATE] with COVID as his hospice qualifying diagnoses. H. Record review of R #3 EHR revealed a diagnosis of COVID dated 12/23/24 and resolved on 02/10/25. I. Record review of the facility's End of life Guidelines revised 05/2023 revealed the following: 1 When hospice services are involved, the facility and hospice are jointly responsible for developing a coordinated plan of care (POC) for the residents that guides both providers and is based upon their assessments and the resident's needs and goals. The coordinated POC must identify which provider (hospice or facility) is responsible for various aspects of care. The facility is required to update its POC just as Hospices need to update their POC. 2. The hospice and the facility should have a process by which they can exchange information from their respective plans of care reviews, assessment updates, and patient and family conferences, when updating the plan of care (POC) and evaluating outcomes of care. 3 The facility's services must be consistent with the plan of care (POC) developed in coordination with the hospice. The facility continues responsibility for providing the residents' overall care and comfort. 4. The care plan incorporates the hospice philosophy of care. The care plan includes interventions and orders to manage pain and other uncomfortable symptoms. Procedures exist to ensure that the resident receives timely, pertinent nonpharmacologic and pharmacological interventions for optimal palliation. The hospice and facility need to collaborate to train facility staff in managing the residents' symptoms and utilizing any special equipment. 5. The facility should notify the hospice when the resident experiences a significant change in physical, mental, social, or emotional status, or needs to be transferred from the facility. 6. In order to ensure that each provider meets its responsibilities, it is essential the facility and hospice have a means to communicate how all needed services, professionals, medical supplies, Durable medical equipment (DME) drugs and biologicals will be made available to the resident 24 hours a day, seven days a week, including who may receive and/or write orders for care, in accordance with State/Federal requirements. J. Record review of R #3 hospice agreement 1. Section 3.1.2 Hospice shall assess the resident in accordance with hospice's criteria for admission to the hospice program and shall notify the resident and facility whether the resident meets such criteria. a. Exhibit E hospice criteria for admission is the terminal prognosis of six months or less if the disease follows its normal course. 2. Section 3.2.13 The facility shall immediately notify hospice when a significant change in a patients physical, mental, social or emotional status occurs, a life threatening condition has appeared, a need to transfer the patient from the facility arises, or the patient dies. 3. Section 3.31 Hospice and facility shall jointly develop and agree upon the patient's Plan of Care (POC). Hospice and facility each shall maintain a copy of each patients' POC in the respective clinical records maintained by each party. Hospice and facility shall designate a registered nurse responsible for coordinating the implementation of the POC for each patient. K. On 03/19/25 at 12:59 pm during an interview with the Director of Nursing (DON), she confirmed the following: 1. R #3 is currently receiving hospice services 2. R #3's current hospice admission order form dated 01/02/24, COVID diagnoses does not meet her expectations as a qualifying diagnosis for hospice care. 3. The facility does not have a record of R #3's hospice POC. 4. R #3's care plan was not updated prior to 01/02/25 to include hospice services which originally began on 10/22/24. 5. R #3's care plan revised on 01/02/05 does not meet her expectations for interventions regarding R #3's care for hospice needs. R #5 L. Record review of R #5's admission record revealed R #5 was admitted to the facility on [DATE] with the following diagnoses: 1. Alzheimer's disease, 2. Depression and anxiety disorders, 3. Generalized epilepsy and epileptic syndromes, (seizures-uncontrolled jerking and loss of consciousness) 4. Disorientation, unspecified, 5. Unspecified psychosis, not due to a substance or known condition. M. Record review of R #5's electronic health record (EHR) revealed a Long Term Care Form dated 02/20/25 completed by the hospice agency stated routine hospice care to start on 02/20/25. N. Record review of R #5's Electronic Health Record (EHR) revealed there was no hospice plan of care. O. Record review of R #5's current medical orders revealed there is no order for hospice services. P. On 03/19/25 at 3:00 pm, during an interview with the DON, she confirmed R #5's EHR did not contain any information regarding R #5 being on hospice. She stated that her expectation is for all residents that are on hospice to have an order for hospice, a pertinent diagnosis, a coordinated care plan, and it should be included in the agency's care plan and confirmed none of that is in place for R #5. 51616

Based on record review and interview, the facility failed to ensure the assessment was accurate for 1 (R #2) of 1 (R #2) resident reviewed. This deficient practice could likely result in the residents' preferences and care needs not being met accurately. The findings are: A. Record review of R #2's admission record revealed R #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] after a hospital stay with the following diagnoses: 1. Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (weakness or paralysis on one side of the body) following cerbral (brain) infarction (condition where blood flow to the brain is interrupted, causing brain tissue damage) affecting left non-dominant side. 2. Atherosclerotic heart disease (a condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]). 3. Altered mental status, unspecified. 4. Strange and inexplicable behavior. 5. Cardiac (heart) Arrythmia (irregular heartbeat). 6. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). 7. Vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), unspecified severity with other behavioral disturbances. B. Record review of local police report dated 12/15/24 revealed that staff heard a loud scream and entered R #2's room to observe R #2 going after another staff member. C. Record review of R #2's annual MDS assessment dated [DATE], section E0200 Behaviors, revealed R #2 had not exhibited any physical and verbal behavioral symptoms directed towards others. D. On 03/19/25 at 1:00 pm during an interview with Minimum Data Set (MDS) Coordinator, she confirmed that any alteration in behavior should have be brought to her attention. She confirmed that the Annual MDS for R #2 dated 12/19/24 should have contain information on behaviors and that the MDS was not accurate.

Based on record review and interview, the facility failed to prevent an accident for 1 (R #1) of 1 (R #1) residents reviewed for falls when the facility failed to ensure proper use of mechanical lift (a device designed to help staff move a resident from one place to another within a room or from one position to another) which resulted in R #1 falling and sustaining injuries that required treatment at the hospital. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: 1. Acute kidney failure, 2. Inclusion body myositis (a progressive muscle disease that causes muscle inflammation, weakness, and atrophy), 3. Permanent atrial fibrillation (abnormal heartbeat despite previous attempts to restore normal heart rhythm), 4. Muscle weakness, generalized. 5. Other reduced mobility. B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/18/24, revealed the following: 1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. 2. R #1 was dependent and required the assistance of two or more staff to complete transfer activities. C. Record review of R #1's Change of Condition Note, dated 10/23/24, revealed the resident was transferred to the emergency room by Emergency Medical Services (EMS) for an evaluation related to a fall from a Hoyer sling. D. Record review of the facility's Initial Incident Report, dated 10/23/24, revealed staff used a Hoyer lift to transfer R #1, and the hoyer sling broke which caused R #1 to fall. E. Record review of R #1's Post Fall Evaluation, dated 10/25/24, revealed the following: 1. On 10/23/24 at 7:50 am, R #1 had a witnessed fall in his room while being transferred by staff. 2. R #1 suffered a skin tear and bruising from the fall. F. Record review of the facility's Follow-Up Report, dated 10/24/24, revealed the conclusion that the Certified Nurses Aides (CNAs) should have used two staff members while using the Hoyer lift to transfer R #1. Staff also documented there was some negligence (failure to take proper care in doing something). G. On 01/02/25 at 2:15 pm during an interview with R #1, he stated he remembered falling from the Hoyer sling, and he was glad he wasn't really hurt. H. On 01/03/25 at 11:45 am during an interview with the Administrator (ADM), she stated she was the only staff member that would remember the incident. She stated the Hoyer sling was not visibly worn at the time of the incident, but there was only one CNA operating the lift when R #1 fell on [DATE]. The ADM stated there should always be two staff members operating the mechanical lift.

Based on record review and interview, the facility failed to ensure patient care equipment was in safe operating condition for 1 (R #1) of 1 (R #1) residents reviewed. This deficient practice likely resulted in a Hoyer sling (a specialized fabric that connects onto the mechanical lift and supports a person's weight when transferring from one position to another using a mechanical lift) breaking and causing R #1 to fall and sustain injuries. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: 1. Acute kidney failure, 2. Inclusion body myositis (a progressive muscle disease that causes muscle inflammation, weakness, and atrophy), 3. Permanent atrial fibrillation (abnormal heartbeat despite previous attempts to restore normal heart rhythm), 4. Muscle weakness, generalized. 5. Other reduced mobility. B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 10/18/24, revealed the following: 1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. 2. R #1 was dependent and required the assistance of two or more staff to complete transfer activities. C. Record review of R #1's Change of Condition Note, dated 10/23/24, revealed the resident was transferred to the emergency room by Emergency Medical Services (EMS) for an evaluation related to a fall from a Hoyer sling. D. Record review of the facility's Initial Incident Report, dated 10/23/24, revealed staff used a Hoyer lift to transfer R #1, and the Hoyer sling broke which caused R #1 to fall. E. Record review of the facility's policy and procedure for Patient Care-Related Electrical Equipment, revised October 2024, revealed the Maintenance Manager was to develop a maintenance schedule based on manufacturer and regulatory requirements, as well as, perform regular inspections and testing. F. On 01/03/25 at 11:45 am during an interview with the Administrator (ADM), she stated the Hoyer sling was not visibly worn at the time of the incident on 10/23/24. She confirmed that the Hoyer sling did break which caused R #1's fall on 10/23/24. The Administrator confirmed that Maintenance staff was suppose to be checking the condition of equipment but was not able to indicate when the hoyers were last checked prior to this incident.

Based on observation, record review, and interview, the facility failed to prevent neglect for 1 (R #50) of 1 (R #50) residents by: 1. Not providing R #50 with proper access to a call light/ability to request assistance from staff while in his room. 2. Failing to recognize and treat a significant decline experienced by R #50 which likely resulted in resident's inability to use the call light. This deficient practice likely resulted in R #50 feeling mental anguish (a feeling of hurt and anger) and emotional distress, which also affected the dignity and health of the resident. The findings are A. On [DATE] at 1:02 pm during an interview with R #50 and observation of R #50's room, R #50 stated, Sometimes I'm not treated like I'm welcome [in the facility]. R #50 is observed to have a gray call light pad on his bed. R #50 is observed not being able to use gray call light pad R #50 stated that since he had COVID-19 ([DATE]) (acute respiratory illness in humans) which had been a couple weeks he had lost his ability to use his arms and the call light does require the use of his hands or arm. R #50 stated he knows he has declined. R #50 further stated that he would like to eat in his room because he is weak and feels like he is more comfortable in his room and is only allowed to eat in his room if his wife comes in to assist him. I have begged staff to let me stay in my room to eat and I am told there is not enough staff to assist me with dining in my room. Recently the staff was asking wife to assist with feeding him in his room with dining, otherwise he was going to have to go to the dining room. Resident also stated that he call several times using [NAME] or yelling to get staff to go re-position him because of the pain due to his [CONDITION(S)]. Many times they do not come or [NAME] is not working, I yell out for help sometimes they hear me and come. B. Record review of R #50's care plan dated [DATE] revealed, Problem- Category: Behavioral Symptoms: [Name of R #50] is having behaviors: He is using his call light or calling the nurses station approximately every ,d+[DATE] minutes an hour and at times 15 - 20 times an hour and becomes verbally abusive with the staff such as yelling and cursing at them. Refusing to come out to DR [Dining Room] for meals due to being dependent with this ADL [Activities of Daily Living] as agreed before coming to HC [Health Care]. Goal- [Name of R #50] will understand about the schedule on the floor such as meal times and understand that he can not be placed in or out of bed at these times. That he will come out to DR for meals. Approach- [Name of R #50] has agreed to get OOB [out of bed] at 0730 [am] and with the understanding that 2 staff members are needed for hoyer (device used to transfer residents between a bed and a chair or other similar resting places) transfers. [Name of R #50] will come out to DR for meals due to other Residents being dependent with meal intake. It has been explained that the staff may be busy with other Residents and he may have to wait for his wants to be addressed. C. Record review of R #50's progress notes dated [DATE] revealed, Resident [NAME] [Name of R #50's electronic assistive device] charge come off the wall and resident unable to reach the nurse station or his call light. Heard resident calling out for help. Plug [Name of R #50's electronic assistive device] back on the wall and he was able to communicate with [Name of R #50's electronic assistive device]. Resident continue having issue communicating with nurse station, the phone at the nurse station was not working. Resident contact his wife and she called the nurse station. Resident request to be check on his [sic} every 30 minutes. CNA [Certified Nursing Assistant] continue checking on resident and reposition him in bed as resident request. Call security and had the phone fix at the nurses station. Informed resident the phone is back on and he should able to contact the nurses. Resident also has difficulty using the call button. D. On [DATE] at 9:54 am during an interview with R #50's Wife, she stated, Staff only came to his room when I was in the room or when he yelled out for help or when he called through [NAME] them to check on him as much as they could. He [R #50] could use it [call light] up until like last Thursday [[DATE], when R #50 began to lose the ability to use his call light] his MS ([CONDITION(S)]- chronic disease affecting the central nervous system) when he gets tired in the evening he has to use [Name of R #50's electronic assistive device]. He [R #50] has gone downhill really fast in the past three weeks. I could tell he was slowing down and he wasn't feeling well. On Monday and Tuesday [[DATE] and [DATE]], he [R #50] was calling me at home and he was saying he couldn't move and he was in so much pain. I called the nurse station and they would say he's not calling us. He would call again and say he can't get a hold of the nurses. One of the nurses said the battery in the phone died . One time he [R #50] said I'm tired of trying. They refuse to take him to the toilet. They refuse to do it. He [R #50] can't project his voice right now. He [R #50] told me that he doesn't feel welcome here. He [R #50] says he feels like he's a bother here and they act like I'm a bother too and I understand. I came in one time and he [R #50] was crying because they wouldn't help him. E. On [DATE] at 10:42 am during an interview with Registered Nurse (RN) #1, she stated, I hadn't been on this floor this week and he [R #50] was using it [call light] last time. RN #1 confirmed she was not aware of R #50's decline and thought R #50 could still use his call light. F. On [DATE] at 10:42 am during an interview with Certified Nursing Assistant (CNA) #1, she stated it has been approximately ,d+[DATE] days since R #50 could use his call light. CNA #1 also confirmed this decline began on R #50 returned from the hospital. CNA confirmed she had reported the decline to the nurse. G. On [DATE] at 11:47 am during an interview with the Director of Nursing (DON), she stated, I didn't know he [R #50] could no longer use it [call light]. The nurse should have notified me and maintenance to see if we could get him another call light if he needed it. We would have approached it if I would have known that. The nurses know they can call me or text me. DON confirmed she was unaware of R #50's decline. H. On [DATE] at 12:35 pm during an interview with the Social Services Director (SSD), he stated, Our expectation is to give him [R #50] the service he needs. The customer is always right is the expectation we have here (facility). Nobody should feel that way [unwanted in the facility]. It [R #50's care plan] should be re-addressed or re-worded because it shouldn't read like that (that resident is a burden to the facility or staff. SSD confirmed no resident should feel unwanted in the facility. SSD also confirmed R #50's care plan should be written so it doesn't make R #50 seem like a burden to the facility.

Based on observation, record review, and interview, the facility failed to ensure residents had adequate (satisfactory or acceptable) access to request staff assistance from the resident room for 1 (R #50) of 1 (R #50) residents reviewed for call light access. This deficient practice likely resulted in the resident feeling as if he were a burden to the staff and was not able to notify staff of his needs or alert staff during emergent (calling for prompt action, emergency) situations because he felt as if staff did not care about his well-being. The findings are: A. Record review of R #50's face sheet revealed R #50 was admitted into the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [CONDITION(S)] (MS) (a disease in which the immune system eats away at the protective covering of nerves resulting in nerve damage that disrupts communication between the brain and body) 2. Other muscle spasm 3. Urinary Tract Infection,(an infection in any part of the urinary system, kidneys, bladder or urethra) site not specified 4. 2019-nCoV acute respiratory disease (COVID-19, acute respiratory illness caused by a coronavirus) 5. Major depressive disorder, single episode, unspecified 6. Irritant contact [CONDITION(S)], unspecified cause (condition where the skin becomes red, swollen, and sore) 7. Encounter for testing for latent [CONDITION(S)] infection (condition where bacteria is in active) 8. Hordeolum externum left upper eyelid (a red painful lump near the edge of the eyelid) 9. Pain, unspecified 10. Personal history of other diseases of the nervous system and sense organs 11. Dependence on wheelchair 12. Difficulty in walking, not elsewhere classified 13. Neuromuscular dysfunction of bladder,(lack of bladder control) unspecified 14. Essential (primary) hypertension (high blood pressure) 15. Unspecified mood [affective] disorder 16. [CONDITION(S)], unspecified (paralysis of all four limbs) 17. Constipation, unspecified B. Record review of R #50's Care Plan dated 01/15/22 revealed, Problem Start Date: 01/15/2022, Category: ADL [Activities of Daily Living] Functional/Rehabilitation Potential: [Name of R #50] has potential for deterioration (become progressively worse) in ADLs (transfer, walk in room, walk in corridor, dress, eat, toilet, maintain personal hygiene, bathing) related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approach: Provide 1 person assistance in ADLS such as feeding, dressing, grooming and 2 person hoyer lift (assistive device that allows residents to be transferred between surfaces) for transfers. C. Record review of R #50's progress notes dated 02/14/22 revealed, [NAME] [Name of R #50's electronic assistive device] charger come off the wall and resident unable to reach the nurse station or his call light. Heard resident calling out for help. Plug [NAME] back on the wall and he was able to communicate with [NAME]. Resident continue [sic] having issue communicating with nurse station, the phone at the nurse station was not working. Resident contact his wife and she called the nurse station. Resident request to be check on his [sic] every 30 minutes (requested that staff check on resident every 30 minutes). CNA [Certified Nursing Assistant] continue checking on resident and reposition him in bed as resident request. Call security and had the phone fix at the nurses station. Informed resident the phone is back on and he should able to contact the nurses. Resident also has difficulty using the call button. D. On 02/14/22 at 1:02 pm during an interview with R #50 and observation of R #50's room, R #50 stated, Sometimes I'm not treated like I'm welcome [in the facility]. They treat me like I am a burden to the facility and staff. R #50 is observed to have a gray call light pad on his bed (resident is unable to use the gray call light pad because he has lost his strength to be able to trigger the light). R #50 confirmed that he is no longer able to use the call light and he has not been able to use it for approximately one week. E. On 02/16/22 at 11:41 am during an interview with R #50 and R #50's wife, she stated, he [R #50] can't lift his arms to use his call light and I don't think they [facility] check on him enough. He [R #50] said he was in pain last night [02/15/22], but he [R #50] couldn't get anyone to assist him.R #50 confirmed he was in pain and could not get assistance because he was unable to use the call light. and stated he used his [NAME], but could not get assistance. ([NAME] communicates with facility phone) F. On 02/16/22 at 1:54 pm during a random observation, R #50 is heard shouting [NAME] HELP from his room. R #50 is observed stating, [NAME], help! R #50's call light is not activated and no staff is present near R #50's room. R #50's electronic assistive device did not call the nursing station. R #50 is observed to be frustrated and telling his device Never mind then. Staff was not observed entering R #50's room after this. Staff was observed entering R #50's room approximately 10 minutes later. G. On 02/16/22 at 6:04 pm during an interview and observation with R #50, R #50 is observed telling [NAME] call [Name of Licensed Practical Nurse (LPN) #1. R #50's electronic assistive device replied, That name [LPN #1] is not in number in your contacts. R #50 then stated, [NAME] call nurse. [NAME] is observed not calling LPN #1. R #50 stated, I don't know why [NAME] didn't call [Name of LPN #1]. [NAME] wasn't working the other day because her [LPN #1] phone didn't have power. Now [NAME] is not working, unless she [LPN #1] doesn't have her phone on her. I can't get a hold of anybody [nursing staff]. R #50 is observed to be visibly distressed due to his electronic assistive device not being able to contact staff. H. On 02/16/22 at 6:08 pm during an interview with Temporary Nursing Aide (TNA) #1, he stated, If he [R #50] calls [Name of LPN #1], [NAME] will call her [LPN #1] phone. She [LPN #1] works the memory unit [first floor] and this floor [second floor] tonight. I will call IT [Information Technology] in the morning and let them know [NAME] is not working]. He [R #50] needs to call the front because [NAME] might not have went to [Name of LPN #1's phone] because there's spots [in the facility] with bad [cell phone] service. TNA #1 further stated, [NAME] call [Name of LPN #1]. [NAME] replied, I cannot find that contact. TNA #1 confirmed [NAME] was not working. LPN #1's phone is one of the phone numbers that is connected to R #50's. I. On 02/16/22 at 6:19 pm during an interview with Certified Nursing Assistant (CNA) #1, she stated, He [R #50] doesn't have her [LPN #1] contact, but I'll add it now. CNA #1 confirmed R #50 did not have the correct contact information for LPN #1. J. On 02/16/22 at 6:36 pm during an interview with CNA #1, she stated, I check on him [R #50] every hour to 1.5 hours because he calls the front so often. K. On 02/16/22 at 6:32 pm during an interview with LPN #1, she stated, This is not the first time [R #50's] [NAME] has gone out. It [R #50 not being able to use his electronic assistive device] happened a few days ago as well. LPN #1 confirmed that R #50's [NAME] does not work sometimes due to poor service in the facility and the nurses cell phone was not charged before. L. On 02/17/22 at 4:31 pm during an interview with R #50, he stated, They [nursing staff] pull me over to adjust me. It's [R #50's pain] usually an 8 out of 10 [10 being the worst amount of pain]. I haven't been in this situation in the past. R #50 confirmed he uses his call light and electronic assistive device because he is in constant pain. M. On 02/18/22 at 11:46 am during an interview with the Director of Nursing (DON) she stated, He's [R #50] had [NAME] since he came over from AL [Assisted Living]. I've seen him use it [gray call light pad] and I saw him use it [gray call light pad] maybe 10 days ago. He uses his [NAME] a lot. The nurse should have notified me and maintenance to see if we could get him [R #50] another call light if he needed it. I didn't know he [R #50] couldn't use that call light anymore or I would have fixed it. DON confirmed R #50 should have access to a call light at all times.