Every finding on record at Water's Edge Center for Health & Rehabilitation

Based on clinical record review, interviews, and facility documentation for 1 of 5 residents reviewed for abuse (Resident #22), the facility failed to protect the resident from repeated non consensual physical/sexual contact by another resident (Resident #129) despite a known history of prior sexual abuse between the same residents. The facility failed to implement required safety interventions, ensure effective 1:1 supervision, separate the residents as care planned, or follow its Abuse and Sexual Interaction policies, resulting in actual harm to Resident #22. Resident #129, who had a documented history of sexually inappropriate contact toward Resident #22, again made non consensual physical contact by grabbing the resident's chest/shirt area while under 1:1 supervision, and the facility did not complete a Reportable Event Form or document the incident in Resident #22's medical record. Despite a care plan directive to move Resident #22 to another unit for safety, the residents remained on the same unit with repeated exposure, and staff failed to immediately report the incident to the DNS, administrator, or provider as required. Inconsistent staff accounts and the lack of documentation impeded an appropriate investigation, and Resident #22 reported feeling uncomfortable, with a psychiatric provider identifying the potential for negative psychological impact from repeated exposure to the resident who previously sexually mistreated him/her. The findings include:a. Resident #22 was admitted in October 2024 with diagnoses that included anoxic brain damage and dementia.The quarterly MDS dated [DATE] identified Resident #22 had severely impaired cognition and required one person assist with locomotion with the use of a manual wheelchair.The care plan dated 1/22/25 identified Resident #22 had a behavior problem that included anxiety and aggression towards others. Interventions included monitoring behavior and administering medications as ordered. b. Resident #129 was admitted in August 2023 with diagnoses that included schizophrenia and dementia.The quarterly MDS dated [DATE] identified Resident #129 had moderately impaired cognition and was independent with ambulation.The care plan dated 1/7/25 identified Resident #129 had a mood problem related to schizophrenia and a history of elopement with wandering behaviors. Interventions include monitoring and reporting changes in mood patterns and offer diversional activities if wandering.A Reportable Event Form dated 3/19/25 identified at 10:45 AM, Resident #22 was in a wheelchair self-propelling in the hall. Staff observed Resident #129 go behind Resident #22 and place his/her open left hand on Resident #22's left breast. Staff immediately intervened and separated the residents.For Resident #129, the care plan was revised to include immediate separation, psychiatric/social worker referral and indefinite 1:1 supervision on all shifts.For Resident #22, the care plan was revised to include immediate separation, move to an alternate wing and psychiatric/social worker referral.Although Resident #22's care plan indicated to move the resident to an alternate unit, the move was not completed, and Resident #129 and Resident #22 remained on the same unit.A Medical APRN progress note (Resident #129) dated 9/26/25 at 8:30 AM identified nursing reported Resident #129 with a history of inappropriate behaviors with indefinite 1:1 supervision, recently had an incident where he/she inappropriately touched another patient's body part (Resident #22). The nursing director is requesting further medical workup. Resident #129 was unable to provide information or cooperate with instructions/boundaries regarding information or appropriate behaviors. Resident #129 was to be redirected as needed and continue 1:1 monitoring.A Psychiatric APRN progress note (Resident #129) dated 9/26/25 at 6:40 PM identified Resident #129 was evaluated for displaying sexually inappropriate behaviors per nursing. Resident #129 has a history of sexually inappropriate behaviors and under 1:1 staff supervision. Resident #129 was calm with no anxiety, denied any sexually inappropriate behaviors and was not a risk to self or others (inconsistent with documented repeated behavior). For Resident #22, a review of the clinical record identified no documentation regarding the incident and no completed reportable event form.Interview with the DNS on 3/24/26 at 1:53 PM identified she was unaware of the alleged incident and would have to further investigate the matter. Subsequently, the incident was reported.Interview with APRN #1 on 3/24/26 at 3:21 PM identified while reviewing the unit communication book on 9/26/25 she became aware of the incident involving Resident #129 who again, exhibited sexually inappropriate behaviors towards the same resident as he/she previously had in the past. APRN #1 indicated she was informed by (unidentified) nursing staff that prior to 9/26/25, Resident #22 had been sexually inappropriately touched by Resident #129 while under 1:1 staff supervision. APRN #1 indicated the incident involved Resident #129 grabbing Resident #22's left chest while passing in the hall and did not let go until 1:1 staff intervened and separated the two residents. APRN #1 spoke briefly to Resident #22 who reported while the breast was not touched, Resident #129 grabbed his/her chest causing him/her to feel uncomfortable. APRN #1 further identified Resident #129 was unusually confused during that time and received a medical workup to rule out potential underlying causes. Subsequent interview with the DNS on 3/24/26 at 3:34 PM identified she was aware of the alleged incident, but it was reported Resident #129 grabbed Resident #22's shirt, not the breast and was not threatening, therefore determined no further follow up was necessary (inconsistent staff reporting and contradicted by other accounts). Resident #129 subsequently received a medical workup and 1:1 supervision continued as ordered.Interview with NA #10 on 3/24/26 at 3:59 PM identified she was the assigned 1:1 staff during 3:00 PM to 11:00 PM on 9/25/26 and overnight 11:00 PM to 7:00 AM shift until 9/26/26. NA #10 indicated between 4:00 PM and 5:00 PM, she was walking down the hall with Resident #129. Resident #22 was approaching from the opposite direction. As they passed, with NA #10 positioned between them, Resident #129 reached out and grabbed Resident #22's shirt just above the breast holding it for approximately three seconds before NA #10 was able to separate the two. NA #10 indicated that although it did not appear Resident #129 was obviously aggressive or threatening, it was difficult to determine his/her state of mind or intent at the time of the incident. However, it was known Resident #129 had a prior history of sexual inappropriateness with Resident #22. NA #10 further identified there had been other occasions where Resident #129 had grabbed Resident #22's shirt in the past but the behavior was redirected and reported to nursing.Interview with APRN #3 (psychiatric) on 3/24/26 at 4:29 PM identified she was notified of sexually inappropriate behaviors by Resident #129 on 9/26/25 while reviewing the unit communication book used to report resident changes. The entry noted Resident #129 exhibited sexually inappropriate behaviors but did not specify it involved another resident. Resident #129 also engaged in self-stimulating sexual behaviors which at times were reported as inappropriate. APRN #3 indicated staff on duty were unable to provide details of the incident and there was no documentation in the clinical record. APRN #3 evaluated Resident #129 who had dementia and was unable to be interviewed. APRN #3 further identified no other incidents of inappropriate physical contact toward Resident #22 were reported since the initial incident (lack of nursing documentation of the event).Interview with MD #1, Medical Director on 3/25/26 at 1:29 PM identified he would expect the facility to follow policies related to abuse for any resident-to-resident incident, including those lacking the ability to consent. MD #1 indicated there was a lack of staff communication related to the incident and working with staff towards improvement.Subsequent interview with APRN #3 on 3/26/26 at 11:45 AM identified while there were no notable behavior changes requiring medication adjustments for Resident #22, repeated exposure to the same resident who sexually mistreated him/her in the past and continues to make physical contact, could have a negative psychological impact on the reasonable person over time.Review of the facility policy for Abuse directs every resident has the right to be free from abuse, including physical defined as hitting, pinching, slapping kicking, control through corporal punishment and sexual abuse defined as non-consensual contact of any type with a resident including sexual harassment, coercion, and sexual assault.Review of the facility policy for Sexual Interaction Between Residents directs for any sexual contact between residents unable to make an informed decision, attempt to separate and call for immediate assistance if unable, stay with the residents until the charge nurse/supervisor arrives to evaluate, initiate the abuse protocol, notify the administrator, DNS, health care provider, responsible parties, implement appropriate measures to keep residents safe and evaluate the residents for injury all of which will be documented.Attempts to interview RN #9, LPN #5, LPN #7, LPN #9, Resident #129 and Resident #22 were unsuccessful.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #43) reviewed for activities of daily living, the facility failed to ensure that the resident was treated in a dignified manner. The findings include:Resident #43 was admitted to the facility in October 2014 with diagnoses that included Alzheimer's disease, macular degeneration, and muscle weakness.The quarterly MDS dated [DATE] identified Resident #43 had severely impaired cognition, was always incontinent of bowel and bladder and was dependent on staff for assistance with toileting, bathing, and dressing.The care plan dated 3/18/26 identified Resident #43 had a self-care deficit due to Alzheimer's disease. Interventions included to provide the assistance of 2 staff members with showering/bathing.Observation on 3/23/26 beginning at 8:43 AM identified Resident #43 seated in a wheelchair in the hallway directly in front of the nurse's station on the 4th floor unit, with NA #2 brushing his/her hair. NA #2 was observed calling across the unit for NA #1 to look at Resident #43's hair, and NA #2 and NA #1 proceeded to move Resident #43 behind a keypad locked and unlabeled door directly behind them. At 8:45 AM upon entering the room. NA #2 was observed attempting to wet Resident #43's hair by wetting a hairbrush with water from a sink located in the room while NA #1 was observing. Resident #43 remained in his/her wheelchair and did not have any clothing protection in place. Interview with NA #2 immediately following this observation identified she observed feces in Resident #43's hair while attempting to brush it in the hallway. NA #2 identified she brought Resident #43 into the nurse aide stock room where the sink was located to use water to try to remove the feces. NA #2 identified she was unsure when Resident #43 last had a shower, and that she was not going to wash Resident #43's hair. NA #2 identified that, in her experience, there had been resident representatives on the unit who did not want the residents' hair washed due to oils in the hair but was unable to identify the specific residents. NA #2 was unable to identify if Resident #43's resident representative declined hair washing, or if Resident #43's resident representative would decline hair washing after feces was identified in Resident #43's hair.Observation at 9:00 AM identified NA #2 bringing Resident #43 out of the nurse aide stock room, positioning his/her wheelchair to the left of the room in the hallway, and leaving the area. Review of the clinical record failed to identify any documentation that the resident representative had directed staff not to wash Resident #43's hair. Interview with RN #4 (4th floor unit manager) on 3/23/26 at 9:10 AM identified that it was not acceptable for Resident #43 to not be offered or provided a shower following the identification of feces in his/her hair by NA #2. RN #4 identified that she would address the situation and provide education to NA #2 and ensure that Resident #43 was provided a shower.After surveyor inquiry, Resident #43 was provided in a shower on 3/23/26 at 11:00 AM.Review facility documentation dated 3/23/26 identified an in-servicing document for the 4th floor nursing staff. The in-service education identified that if a resident was noted to have stool, bodily fluid, or any other non-beneficial substance on their body, hair, or clothing, the resident was to be immediately offered or provided a shower unless refused. The document further identified that showers could be provided to a resident on any date or time and it did not need to be on their assigned shower day and all residents may be showered unless indicated by the nurse or care plan for a specific reason. The in-service education further identified that under no circumstances should bodily fluids be wiped away instead of washed clean. Further review of the documentation identified NA #2 signed the in-service attendance document, Interview with the DNS on 3/25/26 at 12:45 PM identified that it was not acceptable for any resident to not be provided with a shower following the identification of fecal matter in their hair. The DNS identified she was also not aware of issues on the 4th floor unit related to declining hair washing and believed that NA #2 provided this information in error. The facility policy on Resident Rights directed that all residents of the facility had the right to be treated with consideration respect and full recognition of their dignity and individuality. The policy further directed that residents had the right to receive quality care and services with reasonable accommodations of their individual needs and preferences.

Based on review of the clinical record, facility documentation, facility policy, and interview for 1 of 3 residents (Resident #125) reviewed for medication administration, the facility failed to administer transdermal medication according to professional standards during a 2 week period when licensed staff applied a 12.5 mcg Fentanyl patch every 3 days despite the order directing 75 mcg be applied. The findings included:Resident #125 was admitted to the facility in July 2025 with diagnoses that included nontraumatic intracerebral hemorrhage in brain stem, chronic respiratory failure, and congestive heart failure.Review of physician's orders dated 11/5/25 through 12/31/25 directed to apply Fentanyl (opioid pain medication) 12 mcg patch, 1 patch transdermal every 72 hours for pain and remove per schedule. Review of the controlled substance disposition records dated 11/5/25 through 12/31/25 identified the pharmacy dispensed Fentanyl 12 mcg patches which were applied/removed to Resident #125 every 72 hours. The quarterly MDS dated [DATE] identified Resident #125 had severely impaired cognition and was not on oxygen. The MDS failed to identify the resident was receiving opioid medication. The care plan dated 1/28/26 identified Resident #125 had actual pain relating to disease process. Interventions included administering medication as ordered. Anticipate the need for pain relief and respond immediately to any complaint of pain. Monitor and report to the nurse any signs and symptoms of non-verbal pain. Further, Resident #125 had altered respiratory status and difficulty breathing related to chronic respiratory failure. Interventions included to administer medications as ordered, monitor for effectiveness and side effects, and elevate the head of bed 30-45 degrees to facilitate ease of breathing.Review of physician's orders dated 1/1/26 through 2/12/26 directed to administer Fentanyl 12 mcg patch, apply 1 patch transdermal every 72 hours for pain and remove per schedule. Review of the controlled substance disposition records identified the pharmacy dispensed 1 Fentanyl 12 mcg patches on 2/3/26 and 5 Fentanyl 12 mcg patches on 2/10/26, (15-day supply). Subsequent to LPN #11 removing the Fentanyl 12 mcg patch one day early in error on 2/13/26, RN #8 obtained a verbal order from APRN #4 to replace the Fentanyl patch. RN #8 transcribed the verbal order as follows; apply Fentanyl 75 mcg patch, apply one patch transdermal every 72 hours for pain. Apply new patch on 2/13/26 and next patch is due on 2/16/26, remove per schedule.Review of the controlled substance disposition records through 2/27/26 identified no Fentanyl 75 mcg patches had been delivered. Further, the controlled substance disposition records identified Fentanyl 12 mcg patches were applied to Resident #125 on 2/13/26, 2/16/26, 2/19/26, 2/22/26, and 2/25/26.Review of the February 2026 MAR dated 2/13/26 - 2/27/26 identified although Fentanyl patch 75 mcg had not been delivered, nursing staff were signing that they applied Fentanyl patch 75 mcg to Resident #125 on 2/13/26, 2/16/26, 2/19/26, 2/22/26, and 2/25/26. APRN #4 entered an order dated 2/27/26 to apply Fentanyl 75 mcg patch, one patch transdermal every 72 hours for pain and remove per schedule.Review of the controlled substance disposition record for the Fentanyl 75 mcg dated 2/28/26 identified the pharmacy dispensed 10 patches and the first 75mcg patch was applied on 2/28/26 at 1:24 PM. A written statement by LPN #10 dated 3/3/26 at 3:15 PM (who worked 2/16/26) identified she applied a 12 mcg Fentanyl patch 12 mcg but did not review the physician's order in its entirety. The physician's order at that time directed Fentanyl 75 mcg patch.A written statement by LPN #12 (agency nurse) dated 3/3/26 at 3:00 PM identified that she worked on 2/22/26, she administered Resident #125's Fentanyl 12 mcg Patch. LPN #12 indicated she did not recognize that the physician's order in the e-MAR reflected a different dosage and acknowledged she did not fully adhere to the five rights of medication administration. LPN #12 indicated Resident #125 had received a Fentanyl 12 mcg Patch. LPN #12 indicated she has since reviewed her medication verification process to ensure full adherence to the five rights of medication administration.A written statement by LPN #12 (agency nurse) dated 3/3/26 at 3:00 PM identified that she worked on 2/25/26, she administered Resident #125's Fentanyl 12 mcg patch. LPN #12 indicated she did not recognize that the physician's order in the e-MAR reflected a different dosage and acknowledged she did not fully adhere to the five rights of medication administration. LPN #12 indicated Resident #125 had received a Fentanyl 12 mcg Patch. LPN #12 indicated she has since reinforced her medication verification process to ensure full adherence to the five rights of medication administration and prevent future errors.A written statement by LPN #11 (agency) dated 3/3/26 at 5:16 PM identified that she was the assigned nurse to Resident #125 on 2/13/26 during the 7:00 AM - 3:00 PM shift. LPN #11 indicated there was an order to remove Fentanyl 12 mcg patch. LPN #11 indicated after removing the Fentanyl patch she realized there was no order to replace the patch. LPN #11 indicated she notified RN #8 (RN Supervisor). LPN #11 indicated that RN #8 notified the APRN of the 12 mcg patch removal. LPN #11 indicated the APRN approved replacement of the Fentanyl 12 mcg patch and the order to reflect the 3 days cycle. LPN #11 indicated that RN #8 entered the updated order. LPN #11 indicated she replaced the Fentanyl 12 mcg patch as instructed and documented the occurrence, including the updated schedule. LPN #11 indicated she notified the oncoming nurse of the discrepancy and informed him of the revised application and removal schedule.A written statement by RN #8 dated 3/3/26 (no time) indicated she worked on 2/13/26 during the 7:00 AM - 3:00 PM shift and LPN #11 (agency nurse) came to her with a Fentanyl patch that she took off to waste with another nurse so she could reapply today. RN #8 indicated she reviewed the MAR which directed the Fentanyl 12 mcg patch to be changed on 2/14/26, not 2/13/26. RN #8 indicated she notified the APRN and received a telephone order to change the patch on 2/13/26 and continue every 72 hours. RN #8 identified she signed onto the computer and entered a Fentanyl patch order for what she thought was a 12 mcg patch, however, she inadvertently selected and entered an order for Fentanyl 75 mcg instead of 12 mcg. RN #8 indicated she co-signed the order herself rather than obtaining a second nurse to verify the order. RN #8 indicated she was unaware at the time that the incorrect dosage had been entered.A written statement by LPN #9 (agency nurse) dated 3/4/26 at 7:31 PM identified that on the day that she worked (2/19/26), LPN #9 indicated she applied a Fentanyl patch to Resident #125 as ordered. LPN #9 indicated she was unable to recall the exact dosage that was applied. LPN #9 indicated that the previously existing Fentanyl patch was removed and destroyed with a staff witness in accordance with facility policy. The summary report dated 3/9/26 identified that on 3/1/26 a medication dose discrepancy involving a Fentanyl patch was identified for Resident #125. The patch in place was Fentanyl 75 mcg, while the intended order was for Fentanyl 12 mcg. The Fentanyl patch 75 mcg was immediately removed upon identification, and Resident #125 was promptly assessed by the RN supervisor. Resident #125 experienced a brief episode of oxygen desaturation, which was addressed with repositioning, supplemental oxygen, and ongoing monitoring. Resident #125 was stabilized and remained in the facility without the need for emergency transfer or Naloxone administration. After a thorough investigation it was determined that the discrepancy occurred during medication order entry following a provider order update, resulting in an incorrect dose being reflected in the electronic record. The facility initiated an internal review, notified the provider, conducted a root cause analysis, and implemented corrective measures, including reinforcement of medication order entry, transcription verification, and medication safety practices, additional staff education, implementation of two-nurses verification for Fentanyl patch application, and on-going medication safety audits through the facility's Quality Assurance and Performance Improvement (QAPI) process. A facility-wide review of medication records, physician's orders, and controlled substance documentation was conducted to verify that narcotic medications were accurately ordered, transcribed, and administered according to provider orders. Education was provided to the nursing staff, with reinforcement of facility policies related to medication administration, medication order entry, transcription verification, and controlled substance management. The facility implemented two-nurses verification for Fentanyl patch application and documentation to ensure the correct narcotic medication and dose are applied. Interview with the DNS on 3/22/26 at 1:00 PM identified she was not aware that the Fentanyl patch was transcribed incorrectly on 2/13/26 and the resident received a dose of 75 mcg on 2/28/26 until 3/1/26, when Resident #125 experienced a change in condition. The DNS indicated Resident #125 had a Fentanyl 75 mcg patch applied on 2/28/26, while the intended dose was Fentanyl 12 mcg. The DNS indicated upon identification of the discrepancy, the Fentanyl 75 mcg patch was immediately removed, and Resident #125 was promptly assessed by the RN supervisor. The DNS indicated the licensed nurse failed to follow the six rights of medication administration prior to administration of medication. Interview with APRN #4 on 3/26/26 at 11:16 AM identified on Friday 2/27/26 she refilled a prescription for a Fentanyl patch. APRN #4 indicated she did not recognize that the resident's Fentanyl dosage had previously been increased in error on 2/13/26 to Fentanyl 75 mcg patch. APRN #4 indicated she intended to refill Fentanyl 12 mcg patch; however, she accidentally refilled the prescription for Fentanyl 75 mcg patch. APRN #4 indicated the facility had notified her of a change in condition of Resident #125 on 3/1/26, that Resident #125 exhibited respiratory depression and mild hypoxia. APRN #4 indicated she was notified, and the Fentanyl 75 mcg patch was discontinued. APRN #4 indicated that prn narcotics were held, and Resident #125 was provided supplemental oxygen with good effects and vital signs remained stable. APRN #4 indicated per nursing Resident #125 remained alert and conversive throughout the day. APRN #4 indicated she evaluated Resident #125 the next day on 3/2/26 alert and back to baseline. APRN #4 indicated that the licensed nurse should have transcribed the medication correctly, followed the medication administration policy, and followed the six rights of medication administration.Interview with Pharmacist #1 on 3/26/26 at 11:28 AM identified the first delivery of Fentanyl 75 mcg patch to the facility occurred on 2/28/26 at 3:33 AM, following receiving an order for Fentanyl 75 mcg patch on 2/27/26. Pharmacist #1 indicated the pharmacy had only been dispensing Fentanyl 12 mcg patches prior to 2/28/26. After the Fentanyl 75 mcg was discontinued, a new order for Fentanyl 12 mcg patch was received on 3/1/26 and delivered to the facility on 3/1/26 at 9:55 PM.Interview with RN #8 on 3/27/26 at 2:21 PM identified she was the RN supervisor 2/13/26 during the 7:00 AM - 3:00 PM shift, when LPN #11 (agency nurse) presented her with a Fentanyl patch removed from Resident #125, indicating it needed to be destroyed and replaced. RN #8 indicated she could not recall all the details of the event but had previously provided a written statement. RN #8 indicated she entered a new order into the eMAR; however, she inadvertently selected and entered an order for Fentanyl 75 mcg instead of 12 mcg. RN #8 indicated she failed to read the complete order prior to entry. RN #8 indicated she co-signed the order herself rather than obtaining a second nurse to verify the order, in accordance with safe practice. RN #8 indicated she was unaware the incorrect dose had been entered at the time and she indicated she had made a mistake. RN #8 indicated the facility had conducted an investigation which identified that the incorrect Fentanyl 75 mcg order had been entered into the eMAR by her. RN #8 indicated subsequent nursing staff signed off on the incorrect eMAR order for Fentanly 75 mcg patch; however, they were administering Fentanyl 12 mcg patches on Resident #125. RN #8 indicated that the medication administered did not match the physician's order as documented in the eMAR. RN #8 indicated that nursing staff failed to fully read and verify the physician's order against the medication packaging and did not adhere to the facility's policy regarding the 6 rights of medication administration. Although attempted, an interview with MD #1, LPN #9, LPN #10, LPN #11, LPN #12, LPN #14, and LPN #15 were not obtained. Review of the facility transcription of orders policy identified the purpose is to establish requirements for accepting, transcribing, and reviewing orders. Orders can be obtained over the phone. Transcribing is the recording of orders by a RN, LPN or by clerical/non-licensed unit clerk with appropriate training and competency per state regulations. A RN or LPN must review and verify accuracy and sign off orders transcribed by a non-licensed unit clerk or Med Tech. Review of the facility handling of Fentanyl patches policy identified Fentanyl patches shall be handled in such a manner as to minimize potential for diversion or abuse. Upon applying a new patch to a resident's skin, licensed staff shall indicate date, time, and initials directly on the patch in pen or magic marker and inspect each patch every shift. Upon removal from a resident's skin, another licensed nurse signature and countersignature of disposal shall be noted on resident's MAR.Review of the facility medication pass policy identified that medications are administered safely and timely per the physician's orders. Remember the six (6) rights of medication pass: Right resident, right drug, right dose, right route, right time, and right dosage form. The policy failed to reflect documentation regarding the three (3) checks of medication administration.Review of the facility medication error policy identified that residents are to remain free from complications of medication errors. Medication errors are monitored and the facility has a process specific to medication errors that will be used for measuring inconsistencies. The policy will be used to identify opportunities for improvement in accordance with QAPI. To monitor resident outcomes related to medication errors and provide necessary following actions to correct the problem and/or avoid recurrence. Medication error is a discrepancy between what the healthcare provider ordered and what the resident received. Significant medication errors mean one that causes an adverse effect to the residents, i.e. discomfort or jeopardized his or her health and safety.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #22) reviewed for abuse, the facility failed to revise the care plan to address and prevent further occurrences of non-consensual physical/sexual contact by Resident #129. The findings include:a. Resident #22 was admitted in October 2024 with diagnoses that included anoxic brain damage and dementia.The quarterly MDS dated [DATE] identified Resident #22 had severely impaired cognition and required one person assist with locomotion with the use of a manual wheelchair.The care plan dated 1/22/25 identified Resident #22 had a behavior problem that included anxiety and aggression towards others. Interventions included monitoring behavior and administering medications as ordered.b. Resident #129 was admitted in August 2023 with diagnoses that included schizophrenia and dementia.The quarterly MDS dated [DATE] identified Resident #129 had moderately impaired cognition and was independent with ambulation.The care plan dated 1/7/25 identified Resident #129 had a mood problem related to schizophrenia and a history of elopement with wandering behaviors. Interventions include monitoring and reporting changes in mood patterns and offer diversional activities if wandering.A Medical APRN progress note (Resident #129) dated 9/26/26 at 8:30 AM identified nursing reported Resident #129 with a history of inappropriate behaviors with indefinite 1:1 supervision who recently had an incident where he/she inappropriately touched another residents body part (Resident #22). The nursing director is requesting further medical workup. Resident #129 was unable to provide information or cooperate with instructions/boundaries regarding information or appropriate behaviors. Resident #129 was to be redirected as needed and continue 1:1 monitoring.A Psychiatric APRN progress note (Resident #129) dated 9/26/25 at 6:40 PM identified Resident #129 was evaluated for displaying sexually inappropriate behaviors per nursing. Resident #129 has a history of sexually inappropriate behaviors (towards Resident #22) and under 1:1 staff supervision. Resident #129 was calm with no anxiety, denied any sexually inappropriate behaviors and was not a risk to self or others.For Resident #22, review of the care plan identified it was not revised to include interventions to reduce future risk of physical/sexual contact and Resident #129 and Resident #22 remained on the same unit.Interview with the DNS on 3/24/26 at 1:53 PM identified she was unaware of the alleged incident and would have to further investigate the matter. Subsequently, the incident was reported.Interview with APRN #1 on 3/24/26 at 3:21 PM identified while reviewing the unit communication book on 9/26/25 she became aware of an incident involving Resident #129 who again, exhibited sexually inappropriate behaviors towards the same resident as he/she previously had in the past. APRN #1 indicated she was informed by (unidentified) nursing staff that prior to 9/26/25, Resident #22 had been sexually inappropriately touched by Resident #129 while under 1:1 staff supervision. APRN #1 indicated the incident involved Resident #129 grabbing Resident #22's left chest while passing in the hall and did not want to let go until 1:1 staff intervened and separated the two residents. APRN #1 spoke briefly to Resident #22 who reported while the breast was not touched, Resident #129 grabbed his/her chest causing him/her to feel uncomfortable. APRN #1 further identified Resident #129 was unusually confused during that time and received a medical workup to rule out potential underlying causes. Subsequent interview with the DNS on 3/24/26 at 3:34 PM identified she was aware of the alleged incident, but it was reported Resident #129 grabbed Resident #22's shirt, not the breast and was not threatening, therefore determined no further follow up was necessary. Resident #129 subsequently received a medical workup and 1:1 supervision continued as ordered. The DNS further identified the facility was aware of the potential of future physical contact between Resident #129 and Resident #22, however, Resident #22's responsible party was not in agreement with moving him/her to another unit and Resident #129 required a secure unit due to a history of attempted elopement from another facility, although no documentation was provided. Interview with NA #10 on 3/24/26 at 3:59 PM identified she was the assigned 1:1 staff during 3:00 PM to 11:00 PM on 9/25/26 and overnight 11:00 PM to 7:00 AM shift until 9/26/26. NA #10 indicated between 4:00 PM and 5:00 PM, she was walking down the hall with Resident #129. Resident #22 was approaching from the opposite direction. As they passed, with NA #10 positioned between them, Resident #129 reached out and grabbed Resident #22's shirt just above the breast holding it for approximately three seconds before NA #10 was able to separate the two. NA #10 indicated that although it did not appear Resident #129 was obviously aggressive or threatening, it was difficult to determine his/her state of mind or intent at the time of the incident. However, it was known Resident #129 had a prior history of sexual inappropriateness with Resident #22. NA #10 further identified there had been other occasions where Resident #129 had grabbed Resident #22's shirt in the past but the behavior was redirected and reported to nursing.A review of the facility policy for Comprehensive Person-Centered Care Plan directed that the interdisciplinary team address resident strengths, needs and problems identified and develop a comprehensive care plan to properly care for the residents and will address preferences, goals, desired outcomes and plan for discharge. The care plan will be kept current on an ongoing basis, and disciplines will be responsible for updating the care plan when there is a new problem that requires a discipline to intervene.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #22) reviewed for abuse, the facility failed to investigate an allegation of abuse and protect the resident during the investigation. The findings include:a. Resident #22 was admitted in October 2024 with diagnoses that included anoxic brain damage and dementia.The quarterly MDS dated [DATE] identified Resident #22 had severely impaired cognition and required one person assist with locomotion with the use of a manual wheelchair.The care plan dated 1/22/25 identified Resident #22 had a behavior problem that included anxiety and aggression towards others. Interventions included monitoring behavior and administering medications as ordered.b. Resident #129 was admitted in August 2023 with diagnoses that included schizophrenia and dementia.The quarterly MDS dated [DATE] identified Resident #129 had moderately impaired cognition and was independent with ambulation.The care plan dated 1/7/25 identified Resident #129 had a mood problem related to schizophrenia and a history of elopement with wandering behaviors. Interventions include monitoring and reporting changes in mood patterns and offer diversional activities if wandering.A Medical APRN progress note (Resident #129) dated 9/26/26 at 8:30 AM identified nursing reported Resident #129 with a history of inappropriate behaviors with indefinite 1:1 supervision who recently had an incident where he/she inappropriately touched another residents body part (Resident #22). The nursing director is requesting further medical workup. Resident #129 was unable to provide information or cooperate with instructions/boundaries regarding information or appropriate behaviors. Resident #129 was to be redirected as needed and continue 1:1 monitoring.A Psychiatric APRN progress note (Resident #129) dated 9/26/25 at 6:40 PM identified Resident #129 was evaluated for displaying sexually inappropriate behaviors per nursing. Resident #129 has a history of sexually inappropriate behaviors (towards Resident #22) and under 1:1 staff supervision. Resident #129 was calm with no anxiety, denied any sexually inappropriate behaviors and was not a risk to self or others.For Resident #22, a review of the clinical record identified no documentation regarding the incident and no completed reportable event form and/or investigation.Interview with the DNS on 3/24/26 at 1:53 PM identified she was unaware of the alleged incident and would have to further investigate the matter. Subsequently, the incident was reported.Interview with APRN #1 on 3/24/26 at 3:21 PM identified while reviewing the unit communication book on 9/26/25 she became aware of an incident involving Resident #129 who again, exhibited sexually inappropriate behaviors towards the same resident as he/she previously had in the past. APRN #1 indicated she was informed by (unidentified) nursing staff that prior to 9/26/25, Resident #22 had been sexually inappropriately touched by Resident #129 while under 1:1 staff supervision. APRN #1 indicated the incident involved Resident #129 grabbing Resident #22's left chest while passing in the hall and did not want to let go until 1:1 staff intervened and separated the two residents. APRN #1 spoke briefly to Resident #22 who reported while the breast was not touched, Resident #129 grabbed his/her chest causing him/her to feel uncomfortable. APRN #1 further identified Resident #129 was unusually confused during that time and received a medical workup to rule out potential underlying causes. Subsequent interview with the DNS on 3/24/26 at 3:34 PM identified she was aware of the alleged incident, but it was reported Resident #129 grabbed Resident #22's shirt, not the breast and was not threatening, therefore determined no further follow up was necessary. Resident #129 subsequently received a medical workup and 1:1 supervision continued as ordered. The DNS further identified the facility was aware of the potential of future physical contact between Resident #129 and Resident #22, however, Resident #22's responsible party was not in agreement with moving him/her to another unit and Resident #129 required a secure unit due to a history of attempted elopement from another facility, although no documentation was provided. Interview with NA #10 on 3/24/26 at 3:59 PM identified she was the assigned 1:1 staff during 3:00 PM to 11:00 PM on 9/25/26 and overnight 11:00 PM to 7:00 AM shift until 9/26/26. NA #10 indicated between 4:00 PM and 5:00 PM, she was walking down the hall with Resident #129. Resident #22 was approaching from the opposite direction. As they passed, with NA #10 positioned between them, Resident #129 reached out and grabbed Resident #22's shirt just above the breast holding it for approximately three seconds before NA #10 was able to separate the two. NA #10 indicated that although it did not appear Resident #129 was obviously aggressive or threatening, it was difficult to determine his/her state of mind or intent at the time of the incident. However, it was known Resident #129 had a prior history of sexual inappropriateness with Resident #22. NA #10 further identified there had been other occasions where Resident #129 had grabbed Resident #22's shirt in the past but the behavior was redirected and reported to nursing.Review of the Abuse policy directs following any allegation, administrative nursing staff or nursing supervisor/charge nurse assumes responsibility for immediate notification of the Administrator/DNS by phone, notification of appropriate department head, physician to conduct a physical/mental assessment, initiate an immediate investigation of the alleged incident, interview resident/other resident witnesses with each interview dated, documented and signed by the supervisor designee, interview staff witnesses or other available witnesses. Witnesses are to document statements that are dated and signed. The facility investigation is to be completed within 5 days of the incident with findings completed in writing and reviewed by the QAA committee.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #22) reviewed for abuse, the facility failed to report an allegation of abuse to the state agency. The findings include:a. Resident #22 was admitted in October 2024 with diagnoses that included anoxic brain damage and dementia.The quarterly MDS dated [DATE] identified Resident #22 had severely impaired cognition and required one person assist with locomotion with the use of a manual wheelchair.The care plan dated 1/22/25 identified Resident #22 had a behavior problem that included anxiety and aggression towards others. Interventions included monitoring behavior and administering medications as ordered.b. Resident #129 was admitted in August 2023 with diagnoses that included schizophrenia and dementia.The quarterly MDS dated [DATE] identified Resident #129 had moderately impaired cognition and was independent with ambulation.The care plan dated 1/7/25 identified Resident #129 had a mood problem related to schizophrenia and a history of elopement with wandering behaviors. Interventions include monitoring and reporting changes in mood patterns and offer diversional activities if wandering.A Medical APRN progress note (Resident #129) dated 9/26/26 at 8:30 AM identified nursing reported Resident #129 with a history of inappropriate behaviors with indefinite 1:1 supervision who recently had an incident where he/she inappropriately touched another residents body part (Resident #22). The nursing director is requesting further medical workup. Resident #129 was unable to provide information or cooperate with instructions/boundaries regarding information or appropriate behaviors. Resident #129 was to be redirected as needed and continue 1:1 monitoring.A Psychiatric APRN progress note (Resident #129) dated 9/26/25 at 6:40 PM identified Resident #129 was evaluated for displaying sexually inappropriate behaviors per nursing. Resident #129 has a history of sexually inappropriate behaviors (towards Resident #22) and under 1:1 staff supervision. Resident #129 was calm with no anxiety, denied any sexually inappropriate behaviors and was not a risk to self or others.For Resident #22, a review of the clinical record identified no documentation regarding the incident and no completed reportable event form.Interview with the DNS on 3/24/26 at 1:53 PM identified she was unaware of the alleged incident and would have to further investigate the matter. Subsequently, the incident was reported.Interview with APRN #1 on 3/24/26 at 3:21 PM identified while reviewing the unit communication book on 9/26/25 she became aware of an incident involving Resident #129 who again, exhibited sexually inappropriate behaviors towards the same resident as he/she previously had in the past. APRN #1 indicated she was informed by (unidentified) nursing staff that prior to 9/26/25, Resident #22 had been sexually inappropriately touched by Resident #129 while under 1:1 staff supervision. APRN #1 indicated the incident involved Resident #129 grabbing Resident #22's left chest while passing in the hall and did not want to let go until 1:1 staff intervened and separated the two residents. APRN #1 spoke briefly to Resident #22 who reported while the breast was not touched, Resident #129 grabbed his/her chest causing him/her to feel uncomfortable. APRN #1 further identified Resident #129 was unusually confused during that time and received a medical workup to rule out potential underlying causes. Subsequent interview with the DNS on 3/24/26 at 3:34 PM identified she was aware of the alleged incident, but it was reported Resident #129 grabbed Resident #22's shirt, not the breast and was not threatening, therefore determined no further follow up was necessary. Resident #129 subsequently received a medical workup and 1:1 supervision continued as ordered.Interview with NA #10 on 3/24/26 at 3:59 PM identified she was the assigned 1:1 staff during 3:00 PM to 11:00 PM on 9/25/26 and overnight 11:00 PM to 7:00 AM shift until 9/26/26. NA #10 indicated between 4:00 PM and 5:00 PM, she was walking down the hall with Resident #129. Resident #22 was approaching from the opposite direction. As they passed, with NA #10 positioned between them, Resident #129 reached out and grabbed Resident #22's shirt just above the breast holding it for approximately three seconds before NA #10 was able to separate the two. NA #10 indicated that although it did not appear Resident #129 was obviously aggressive or threatening, it was difficult to determine his/her state of mind or intent at the time of the incident. However, it was known Resident #129 had a prior history of sexual inappropriateness with Resident #22. NA #10 further identified there had been other occasions where Resident #129 had grabbed Resident #22's shirt in the past but the behavior was redirected and reported to nursing.Review of the Abuse policy directs that the facility notify the Department of Public Health Immediately but no later than two hours after an allegation is made if the events that cause the allegation involve abuse or results in serious bodily harm, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Law enforcement will be notified in a reasonable time frame.

Based on review of facility documentation, facility policy, and interviews for 2 of 7 nurse aide (NA #4 and #5) personnel files reviewed, the facility failed to ensure criminal background checks were completed, per the facility's screening prospective employee's policy. The findings include: a. NA #4 was hired on [DATE]. Review of NA #4's personnel file identified an undated Applicant Background Check Management System (ABCMS) Person Summary that identified NA #4's current eligibility determination was in process, and the ABCMS Final Registry Results Form dated [DATE] identified NA #4 had not been previously determined eligible for employment and must be fingerprinted. b. NA#5 was hired on [DATE].Review of NA #5's personnel file identified an undated Applicant Background Check Management System (ABCMS) Person Summary that identified NA #5's current eligibility determination noted: a new application must be submitted, and the ABCMS Final Registry Results Form dated [DATE] identified NA #4 had not been previously determined eligible for employment and must be fingerprinted. Interview with the HR Director on [DATE] at 10:10 AM indicated that on [DATE], subsequent to NA #4's personnel file being requested for review by the survey team, she identified that NA #4 had not completed the finger printing portion of the criminal background check and had not been determined eligible for employment. The HR Director indicated that NA #4 not being fingerprinted, prior to beginning her employment at the facility, was an oversight. The HR Director indicated as soon as the issue was identified, NA #4 was notified that her background check was incomplete and she was sent for fingerprinting, and would be removed from the schedule until she was determined eligible for employment. Interview with the HR Director on [DATE] at 1:00 PM indicated that, subsequent to NA #5's personnel file being requested for review by the survey team, it was identified that her ABCMS Person Summary determination directed for a new application to be submitted. The HR Director indicated that determination would be a result of 1 of 2 reasons, NA #5 never completed the fingerprinting portion of the back ground check or was greater than 3 years and had expired. The HR Director identified that she began working at the facility on [DATE] and both NA #4 and NA #5 had been hired during her time as the HR Director. In November/December of 2025 she began working with corporate on a new process for managing the fingerprinting portion of prospective employee's background checks to ensure employees did not begin orientation until the full background check, including fingerprinting, had been completed, as was identified that some employees had begun orientation prior to completing their fingerprinting. The HR Director identified that NA #5 would be removed from the schedule until her fingerprinting was completed and she was determined eligible for employment, and an audit of all personnel files to determine ABCMS eligibility would be initiated immediately. Interview with the Administrator on [DATE] at 12:06 PM identified that he would expect all state and federal guidelines to be followed, regarding screening prospective employees. The Administrator further indicated that there was a process change with the HR Director, a while ago, to ensure new employees did not begin work until they were determined eligible by ABCMS. An ABCMS Person Summary, provided on [DATE], identified NA #4's current eligibility determination was eligible. The Employment Policy directs all prospective employees must accurately complete an employment application form and arrange for a personal interview. All employment offers are subject to the receipt of satisfactory references, CNA registry, OIG, and criminal background checks. Falsification, misrepresentation, or omission of any facts on the employment application form or during the pre-employment interview may be grounds for dismissal.

Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #107) reviewed for rehabilitation, the facility failed to notify the physician that rehabilitation services were not provided according to specialty service recommendations. The findings include:Resident #107 was admitted in November 2025 with diagnoses that included nondisplaced fracture of the seventh cervical vertebra, and non-displaced fracture of the right tibia due to a motor vehicle accident.The admission MDS dated [DATE] identified Resident #A107 was cognitively intact, required two person assist with bed mobility, transfers, utilized a manual wheelchair with one assist for locomotion and was receiving occupational, physical and speech therapy.The care plan dated 11/7/25 identified Resident #107 had a fracture of the right tibia and cervical spine. Interventions included maintaining a cervical collar (neck collar) at all times, follow up with orthopedic consultations as indicated and provide occupational and physical therapy evaluation according to physician orders.Physical and Occupational Therapy Discharge Summaries dated 12/24/25 identified Resident #107 was independent bed mobility, sitting, standing and toileting with supervision/touch assist and refusing ambulation at the time. Resident #107 reached the highest functional level with continued level of function considered 'good' with consistent staff follow-through.Orthopedic consult (related to tibial fracture) dated 1/5/26 identified Resident #107 was evaluated for a tibial fracture and left hip dislocation. Recommendations included progressing to protected weight bearing status as tolerated, bilateral hip, knee and ankle range of motion (ROM) as tolerated with focus to the right knee ROM three times daily with aim of 0-90 degrees in the coming two weeks (2/9/26).An APRN progress note dated 1/5/26 identified Resident #107 returned from orthopedics with a referral for ambulatory rehabilitation services which have been reviewed and placed for scheduling. Referral indicates weight-bearing as tolerated to bilateral lower extremities, range of motion exercises bilateral hips, knees, ankles as tolerated, swelling and edema management, gait and balance exercises, and general body exercises requesting three days a week of physical therapy. Staff were to notify the provider of outpatient orthopedic consult results and any new orders for review.Physician orders dated 1/16/26, 11 days after orthopedic recommendations, directed Physical Therapy (PT) 3-5 days/week for 8 weeks.Physical Therapy evaluation dated 1/16/26 identified the continued need for services for strengthening, balance and toileting until 3/12/26.Physical Therapy Discharge summary dated [DATE] identified Resident #107 was deemed not safe to continue treatment due to non-compliance in wearing the cervical collar. Resident #107 was to continue mobility at wheelchair level until follow up appointment in February 2026 regarding any continued need for the cervical collar.Occupation Therapy Evaluation dated 1/23/26 identified therapy services were limited to evaluation only and were not continued due to non-compliance in the use of a cervical collar. Resident #107 was to follow up with orthopedics (for cervical collar) in 2/2026.Resident #107 was cleared by orthopedics for weight- bearing and was making excellent progress with physical therapy. The plan included continued OT/PT with weight bearing as cleared by orthopedics.Outpatient Rehabilitation consult dated 2/9/26 recommended OT and PT three times weekly for weight bearing, ROM and strengthening for the bilateral lower extremities.APRN progress note dated 2/10/26 at 11:31 AM identified ongoing rehabilitation after a right tibial plateau fracture. Resident #107 returned with ambulatory referral paperwork for outpatient rehabilitation services from orthopedics (for tibial fractur). Referral order reviewed and placed for scheduling today.APRN progress notes dated 2/11/26 through 2/19/26 identified Resident #107 was continuing to make progress in physical therapy and awaiting outpatient physical therapy.Orthopedic consult (for the cervical collar) dated 2/20/26 identified Resident #107's cervical collar was to be discontinued.APRN progress notes dated 2/20/26 through 3/3/26 identified Resident #107 was continuing to make progress in physical therapy and awaiting outpatient physical therapy.Neurology consult dated 3/4/26, 12 days post cervical collar discontinuation, identified Resident #107 needed rehabilitation therapy three times weekly for weight bearing and strengthening according to orthopedic recommendations.Interdisciplinary 'Secure Conversations' progress note dated 3/4/26 identified Resident #107 was recommended for physical therapy three times weekly following an orthopedic consult for weight bearing, ROM and strengthening for the bilateral lower extremities.Interdisciplinary 'Secure Conversations' progress note dated 3/5/26 identified #107 requested the physical therapy referral be sent to a community outpatient rehabilitation service and the referral was faxed.Resident #107 received the first evaluation for treatment on 3/13/26, twenty days post removal of the cervical collar.Interview with Resident #107 on 3/22/26 at 7:50 AM identified he/she was expected to begin outpatient physical therapy beginning sometime in January but was not seen until 3/13/26. Resident #107 indicated during a neurology consult on 3/4/26, providers inquired about rehabilitation services and were surprised to learn he/she had not been receiving any services.Interview and clinical record review with the Director of Rehabilitation on 3/23/26 at 8:54 AM identified on 1/16/26 a screen was requested for an evaluation and Resident #107 was subsequently seen for three sessions. However, Resident #107 still required the use of a cervical collar which he/she refused so services were not provided due to safety. Resident #107 subsequently received medical clearance 2/20/26 to discontinue the use of the collar but did not resume services with the facility as Resident #107 requested outpatient services in the community. The Director of Rehabilitation further identified Resident #107's status was discussed in morning report and nursing was responsible for any follow-up consultation, recommendations and related scheduling.Interview and clinical documentation review with the Unit Secretary on 3/23/26 at 9:37 AM identified she was responsible for the scheduling of outside appointments for the residents. Unit Secretary #1 indicated information regarding appointments was provided to her by nursing staff through messaging in the electronic medical record. The Unit Secretary further identified she was first notified of a referral for rehabilitation services on 3/5/26, spoke to Resident #107 who confirmed his/her desire to receive outpatient rehabilitation and scheduled the first appointment for 3/13/26.Interview and clinical record review with APRN #2 on 3/24/26 at 10:12 AM identified Resident #107 had recommendations for continued therapy following an orthopedic consultation on 1/5/26 and was transitioning to outside rehabilitation services. APRN #2 was aware Resident #107 was not compliant at times about wearing the cervical collar but otherwise was not notified rehabilitative services had not started from 1/5/26 and thought Resident #107 was making strides in therapy as she observed him/her ambulating in the hall with a walker. Had she been aware, she would have referred Resident #107 back to the orthopedic provider as soon as possible for clearance. APRN #2 further identified Resident #107 also had other co-occurring medical issues at the time but was unable to find any orders to hold discontinue services at any time or any documented concerns related to refusals.An interview with the DNS on 3/25/26 at 11:05 AM identified the physician should have been notified that rehabilitative services were not being provided for Resident #107.A review of the facility policy for change of condition notification directed that the facility will notify the resident, residents health care provider and legal representative when there is a change in condition and document findings in the clinical record.

Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #10) reviewed for respiratory care, the facility failed maintain infection control standards for a resident requiring specialized airway care. The findings include:Resident #10 was admitted to the facility in January 2020 with diagnoses that included traumatic subarachnoid hemorrhage with loss of consciousness and persistent vegetative state. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition, required two person assist with bed mobility, transfers and had a tracheostomy (opening in the neck to facilitate breathing). The care plan dated 2/19/26 identified Resident #10 had an ADL deficit with limitations in mobility and altered respiratory status related to the presence of a tracheostomy. Interventions included one to two staff for ADL care, deep suction as needed and administer medication according to physician orders. Physician orders dated 3/4/26 directed to change the inner cannula Shiley #6.5mm every shift for tracheostomy care and suction with a #10 French suction catheter every shift and as needed.Observation on 3/24/26 at 11:06 AM identified LPN #6 washed her hands, put on clean gloves and removed the tracheostomy inner cannula using her right hand and discarded it in garbage at the bedside. LPN #6 then removed her gloves and proceeded to open the sterile tracheostomy care kit without first performing hand hygiene. LPN #6 preceded to place the pop-up basin to the side of the bedside table using the same right hand, don sterile gloves and set up a sterile drape on the bedside table. LPN #6 continued with the task of removing soiled bandages and cleansing around the tracheostomy using the left hand. Using the same right hand when removing the inner cannula, LPN #6 opened the sterile inner cannula, held on to the end with the opening and attempted to advance the inner cannula. The task was interrupted.Interview with LPN #6 on 3/24/26 at 11:06 AM identified she thought she maintained sterile technique during the procedure.Interview with RN #5, Regional Nurse Consultant on 3/25/2026at 1:38 PM identified that while sterile technique was not required for the procedure, LPN #6 should have performed hand hygiene after the removal of the inner cannula and before opening the sterile kit and donning sterile gloves.A review of the facility policy for Tracheostomy Care directed Tracheostomy care to be completed when an inner cannula is changed or cleaned. The procedure directs to wash hands once the inner cannula is removed from the trach tube and apply clean gloves before proceeding.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #107) reviewed for rehabilitation, the facility failed to implement specialty service recommendations in a timely manner for a resident requiring rehabilitative services. The findings include:Resident #107 was admitted in November 2025 with diagnoses that included nondisplaced fracture of the seventh cervical vertebra, and non-displaced fracture of the right tibia (leg bone) secondary to a motor vehicle accident.The admission MDS dated [DATE] identified Resident #107 was cognitively intact, required two person assist with bed mobility, transfers, utilized a manual wheelchair with one assist for locomotion and was receiving occupational, physical and speech therapy.The care plan dated 11/21/25 identified Resident #107 had a fracture of the right tibia and cervical spine. Interventions included maintaining a cervical collar (neck collar) at all times, follow up with orthopedic consultations as indicated and provide occupational and physical therapy evaluation according to physician orders.Physical and Occupational Therapy Discharge Summaries dated 12/24/25 identified Resident #107 was independent bed mobility, sitting, standing and toileting with supervision/touch assist and refusing ambulation at the time. Resident #107 reached the highest functional level with continued level of function considered 'good' with consistent staff follow-through.Orthopedic consult (related to tibial fracture) dated 1/5/26 identified Resident #107 was evaluated for a tibial fracture and left hip dislocation. Recommendations included progressing to protected weight bearing status as tolerated, bilateral hip, knee and ankle range of motion (ROM) as tolerated with focus to the right knee ROM three times daily with aim of 0-90 degrees in the coming two weeks (2/9/26).APRN progress note dated 1/5/26 identified Resident #107 returned from orthopedics with a referral for ambulatory referral to rehabilitation services which have been reviewed and placed for scheduling. Referral indicates weight-bearing as tolerated to bilateral lower extremities, range of motion exercises bilateral hips, knees, ankles as tolerated, swelling and edema management, gait and balance exercises, and general body exercises requesting three days a week of physical therapy. Staff were to notify the provider of outpatient orthopedic consult results and any new orders for review.Physician orders dated 1/16/26, 11 days after orthopedic recommendations, directed PT 3-5 days/week for 8 weeks.Physical Therapy evaluation dated 1/16/26 identified the continued need for services for strengthening, balance and toileting until 3/12/26.Physical Therapy Discharge summary dated [DATE] identified Resident #107 was deemed not safe to continue treatment due to non-compliance in wearing the cervical collar. Resident #107 was to continue mobility at wheelchair level until follow up appointment in 2/2026 regarding any continued need for the cervical collar.Occupational Therapy Evaluation dated 1/23/26 identified therapy services were limited to evaluation only and were not continued due to non-compliance in the use of a cervical collar. Resident #107 was to follow up with orthopedics (for the continued use of the cervical collar) in 2/2026.Nurse's note dated 1/27/26 at 3:09 PM identified per orthopedics (for the cervical collar), Resident #107 was to continue to wear the cervical collar until his/her follow up appointment in 2/2026.APRN progress note dated 1/29/26 at 9:30 AM identified Resident #107 was cleared by orthopedics for weight bearing and was making excellent progress with physical therapy. The plan included continued OT/PT with weight bearing as cleared by orthopedics.Outpatient Rehabilitation consult dated 2/9/26 recommended OT and PT three times weekly for weight bearing, ROM and strengthening for the bilateral lower extremities.APRN progress note dated 2/10/26 at 11:31 AM identified ongoing rehabilitation after a right tibial plateau fracture. Resident #107 returned with ambulatory referral paperwork for outpatient rehabilitation services from orthopedics (for tibial fractur). Referral order reviewed and placed for scheduling today.APRN progress notes dated 2/11/26 through 2/19/26 identified Resident #107 was continuing to make progress in physical therapy and awaiting outpatient physical therapy.Orthopedic consult (for the cervical collar) dated 2/20/26 recommended Resident #107's cervical collar to be discontinued.APRN progress notes dated 2/20/26 through 3/3/26 identified Resident #107 was continuing to make progress in physical therapy and awaiting outpatient physical therapy.Review of nursing progress notes dated 1/6/26 through 3/3/26 did not include documentation related to Resident #107 not receiving rehabilitation services.Neurology consult dated 3/4/26, 12 days post cervical collar discontinuation, identified Resident #107 needed rehabilitation therapy three times weekly for weight bearing and strengthening according to orthopedic recommendations.Interdisciplinary 'Secure Conversations' progress note dated 3/4/26 identified #107 was recommended physical therapy three times weekly following an orthopedic consult for weight bearing, ROM and strengthening for the bilateral lower extremities.Interdisciplinary 'Secure Conversations' progress note dated 3/5/26 identified #107 requested the physical therapy referral be sent to a community outpatient rehabilitation service and the referral was faxed.Resident #107 received the first evaluation for treatment on 3/13/26, twenty days post removal of the cervical collar.Interview with Resident #107 on 3/22/26 at 7:50 AM identified he/she was expected to begin outpatient physical therapy beginning sometime in January but was not seen until 3/13/26. Resident #107 indicated during a neurology consult on 3/4/26, providers inquired about rehabilitation services and were surprised to learn he/she had not been receiving any services.Interview and clinical record review with the Director of Rehabilitation on 3/23/26 at 8:54 AM identified Resident #107 was provided OT, PT and speech services from 11/3/25 to 12/24/25 for strengthening and cognition. Resident #107 was subsequently discharged after meeting his/her goals given orthopedic restrictions during that time. On 1/16/26 a screen was requested for an evaluation and Resident #107 was subsequently seen for three sessions. However, Resident #107 still required the use of a cervical collar which he/she refused so services were not provided due to safety. Resident #107 subsequently received medical clearance 2/20/26 to discontinue the use of the collar but did not resume services with the facility as Resident #107 requested outpatient services in the community. The Director of Rehabilitation further identified Resident #107's status was discussed during morning report and nursing was responsible for any follow-up consultation, recommendations and related scheduling.Interview with RN #6 on 3/23/26 at 9:17 AM identified she was the assigned unit manager for the floor where Resident #107 resided. RN #6 indicated the charge nurse; nursing supervisor and herself share the responsibility for reviewing and referring specialty consultation recommendations to the APRN and responding appropriately. Consult recommendations were addressed depending on who received the information first and RN #6 was not responsible for ensuring the completeness of the task by another nurse. RN #6 further identified she was not aware of any lapse in implementing rehabilitation services for Resident #107 adding the unit secretary was responsible for the scheduling of outside appointments.Interview with the Unit Secretary on 3/23/26 at 9:37 AM identified she was responsible for the scheduling of outside appointments for the residents. Unit Secretary #1 indicated information regarding appointments was provided to her by nursing staff through messaging in the electronic medical record. The Unit Secretary further identified she was first notified of a referral for rehabilitation services on 3/5/26, spoke to Resident #107 who confirmed his/her desire to receive outpatient rehabilitation and scheduled the first appointment for 3/13/26.Interview and clinical record review with the DNS on 3/24/2026 at 7:32 AM identified the charge nurses, unit manager and nursing supervisor were responsible for reviewing specialty consultations, referring to the APRN and any address any required follow up. The DNS indicated Resident#107 had recommendations from orthopedics, however the facility rehabilitation staff were unable to provide services safely due to his/her noncompliance with wearing the cervical collar. The DNS was unable to explain the lapse in implementing rehabilitation services between the time of the orthopedic consult dated 1/5/26 until 1/16/26 when an evaluation took place and again from 2/20/26 when the cervical collar was discontinued until the time rehabilitation services began on 3/13/26 but indicated refusals or issues related to scheduling would have been documented. The DNS further identified Resident #107 should have been referred to physical therapy as soon as possible once the collar was discontinued and in accordance with his/her preference.Subsequent interview with RN #6 on 3/24/26 at 9:08 AM identified he contacted orthopedics at Resident #107's request to determine if he/she was still required to wear the cervical collar but was unaware of any issues related to non-compliance with its use. RN #6 further identified she did not follow up with the outpatient physical therapy referral once the cervical collar was discontinued again noting the Unit Secretary was responsible for scheduling outside appointments.Interview and clinical record review with APRN #2 on 3/24/26 at 10:12 AM identified Resident #107 had recommendations for continued therapy following an orthopedic consultation on 1/5/26 and was transitioning to outside rehabilitation services. APRN #2 was aware Resident #107 was non complaint at times about wearing the cervical collar but otherwise, was not aware rehabilitative services had not started from 1/5/26 at and thought Resident #107 was making strides in therapy as she observed him/her ambulating in the hall with a walker. Had she been aware, she would have referred Resident #107 back to the orthopedic provider as soon as possible for clearance. APRN #2 further identified Resident also had other co-occurring medical issues at the time but was unable to find any orders to hold discontinue services at any time or any documented concerns related to refusals.Although requested, a policy for responding to special service recommendations was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interview for 1 of 3 residents (Resident #125) reviewed for medication administration, the facility failed to ensure the resident was free from a significant medication error. The findings included:Resident #125 was admitted to the facility in July 2025 with diagnoses that included nontraumatic intracerebral hemorrhage in brain stem, chronic respiratory failure, and congestive heart failure.Review of physician's orders dated 11/5/25 through 12/31/25 directed to apply Fentanyl (opioid pain medication) 12 mcg patch, 1 patch transdermal every 72 hours for pain and remove per schedule. Review of the controlled substance disposition records dated 11/5/25 through 12/31/25 identified the pharmacy dispensed Fentanyl 12 mcg patches which were applied/removed to Resident #125 every 72 hours. The quarterly MDS dated [DATE] identified Resident #125 had severely impaired cognition and was not on oxygen. The MDS failed to identify the resident was receiving opioid medication. The care plan dated 1/28/26 identified Resident #125 had actual pain relating to disease process. Interventions included administering medication as ordered. Anticipate the need for pain relief and respond immediately to any complaint of pain. Monitor and report to the nurse any signs and symptoms of non-verbal pain. Further, Resident #125 had altered respiratory status and difficulty breathing related to chronic respiratory failure. Interventions included to administer medications as ordered, monitor for effectiveness and side effects, and elevate the head of bed 30-45 degrees to facilitate ease of breathing.Review of physician's orders dated 1/1/26 through 2/12/26 directed to administer Fentanyl 12 mcg patch, apply 1 patch transdermal every 72 hours for pain and remove per schedule. Review of the controlled substance disposition records identified the pharmacy dispensed 1 Fentanyl 12 mcg patches on 2/3/26.Review of the controlled substance disposition record identified the pharmacy dispensed 5 Fentanyl 12 mcg patches on 2/10/26, (15-day supply). Subsequent to LPN #11 removing the Fentanyl 12 mcg patch one day early in error on 2/13/26, RN #8 obtained a verbal order from APRN #4 to replace the Fentanyl patch. RN #8 transcribed the verbal order as follows; apply Fentanyl 75 mcg patch, apply one patch transdermal every 72 hours for pain. Apply new patch on 2/13/26 and next patch is due on 2/16/26, remove per schedule.Review of the controlled substance disposition records through 2/27/26 identified no Fentanyl 75 mcg patches had been delivered. Further, the controlled substance disposition records identified Fentanyl 12 mcg patches were applied to Resident #125 on 2/13/26, 2/16/26, 2/19/26, 2/22/26, and 2/25/26.Review of the February 2026 MAR dated 2/13/26 - 2/27/26 identified although Fentanyl patch 75 mcg had not been delivered, nursing staff were signing that they applied Fentanyl patch 75 mcg to Resident #125 on 2/13/26, 2/16/26, 2/19/26, 2/22/26, and 2/25/26. APRN #4 entered an order dated 2/27/26 to apply Fentanyl 75 mcg patch, one patch transdermal every 72 hours for pain and remove per schedule.Review of the controlled substance disposition record for the Fentanyl 75 mcg dated 2/28/26 identified the pharmacy dispensed 10 patches and the first 75mcg patch was applied on 2/28/26 at 1:24 PM. Review of the February 2026 MAR identified Fentanyl 75 mcg patch was applied on 2/28/26 at 1:24 PM. The SBAR (Situation, Background, Assessment, Recommendation; a crucial communication technique in healthcare that helps health professionals communicate clear elements of a patient's condition) dated 3/1/26 at 12:32 PM identified the following. Resident #125 experienced a change in condition, including a decrease respiratory rate of 9 breaths per minute (normal respiratory rate is 12 - 20 breaths per minute), oxygen saturation 86% on room air (normal is 95 - 100%), which improved to 96% following elevation of head of bed, repositioning, and administration of oxygen via nasal cannula. Subsequently, Resident #125 was alert, with no change in mental status, and responded appropriately to questions and directions. The reportable event form dated 3/1/26 at 1:30 PM identified Resident #125 received Fentanyl 75 mcg patch, an error of clinical significance, due to a transcription error. The Fentanyl patch was removed and Resident #125 was assessed and monitored, with vital signs obtained. Resident #125 was alert with confusion. Physician's orders included to hold Oxycodone and Xanax for 24 hours. The nurse's note dated 3/1/26 at 2:51 PM identified Person #1 approached LPN #15 expressing concern about Resident #125's respiratory status. LPN #15 immediately assessed Resident #125 and observed a respiratory rate of 9 breaths per minute and oxygen saturation 86% on room air. Resident #125 was repositioned with the head of the bed elevated, and supplemental oxygen was administered at 3 liters via nasal cannula. APRN #4 was notified and ordered the removal of the Fentanyl patch and a hold on Xanax and Oxycodone for 24 hours. Monitor vital signs every 15 minutes for the first hour, then every 30 minutes for the following 4 hours. Resident #125 remained alert and verbally responsive. MD #1 (Medical Director) was notified. Reported vital signs 116/80, 73, respiration rate 10. MD #1 ordered the resident to continue oxygen via nasal cannula and obtain vital signs every 30 minutes until 6:00 PM, with updates to be reported to MD #1.A written statement by APRN #4 dated 3/2/26 at 4:33 PM indicated that on Friday 2/27/26 she refilled a prescription for a Fentanyl patch. APRN #4 indicated she did not recognize that the resident's Fentanyl dosage had been increased in error to Fentanyl 75 mcg. APRN #4 indicated she intended to refill Fentanyl 12 mcg patch; however, she accidentally refilled the prescription for Fentanyl 75 mcg. APRN #4 indicated record review identified Resident #125 received Fentanyl 75 mcg Patch on 2/28/26, and subsequently on Sunday 3/1/26, Resident #125 exhibited respiratory depression and mild hypoxia. APRN #4 indicated she was notified, and the Fentanyl 75 mcg patch was discontinued, the prn narcotics were held, and Resident #125 was provided supplemental oxygen. Resident #125 was monitored for 24 hours without further adverse effects. APRN #4 indicated she evaluated Resident #125 the next day on 3/2/26 and the resident had returned to baseline and no longer required supplemental oxygen. A plan to restart his/her usual Fentanyl 12 mcg patch on 3/3/26.A written statement by LPN #11 (agency) dated 3/3/26 at 5:16 PM identified that she was the assigned nurse to Resident #125 on 2/13/26 during the 7:00 AM - 3:00 PM shift. LPN #11 indicated there was an order to remove Fentanyl 12 mcg patch. LPN #11 indicated after removing the Fentanyl patch (mcg strength not noted), she realized there was no order to replace the patch. LPN #11 indicated she notified RN #8 (RN Supervisor). LPN #11 indicated that RN #8 notified the APRN of the 12 mcg patch removal. LPN #11 indicated the APRN approved replacement of the Fentanyl 12 mcg patch and the order to reflect the 3 days cycle. LPN #11 indicated that RN #8 entered the updated order. LPN #11 indicated she replaced the Fentanyl 12 mcg patch as instructed and documented the occurrence, including the updated schedule. LPN #11 indicated she notified the oncoming nurse of the discrepancy and informed him of the revised application and removal schedule.A written statement by RN #8 dated 3/3/26 (no time) indicated she worked on 2/13/26 during the 7:00 AM - 3:00 PM shift and LPN #11 (agency nurse) came to her with a Fentanyl patch that she took off to waste with another nurse so she could reapply today. RN #8 indicated she reviewed the MAR which directed the Fentanyl 12 mcg patch to be changed on 2/14/26, not 2/13/26. RN #8 indicated she notified the APRN and received a telephone order to change the patch on 2/13/26 and continue every 72 hours. RN #8 identified she signed onto the computer and entered a Fentanyl patch order for what she thought was a 12 mcg patch, however, she inadvertently selected and entered an order for Fentanyl 75 mcg instead of 12 mcg. RN #8 indicated she co-signed the order herself rather than obtaining a second nurse to verify the order. RN #8 indicated she was unaware at the time that the incorrect dosage had been entered.The summary report dated 3/9/26 identified that on 3/1/26 a medication dose discrepancy involving a Fentanyl patch was identified for Resident #125. The patch in place was Fentanyl 75 mcg, while the intended order was for Fentanyl 12 mcg. The Fentanyl patch 75 mcg was immediately removed upon identification, and Resident #125 was promptly assessed by the RN supervisor. Resident #125 experienced a brief episode of oxygen desaturation, which was addressed with repositioning, supplemental oxygen, and ongoing monitoring. Resident #125 was stabilized and remained in the facility without the need for emergency transfer or Naloxone administration. After a thorough investigation it was determined that the discrepancy occurred during medication order entry following a provider order update, resulting in an incorrect dose being reflected in the electronic record. The facility initiated an internal review, notified the provider, conducted a root cause analysis, and implemented corrective measures, including reinforcement of medication order entry, transcription verification, and medication safety practices, additional staff education, implementation of two-nurses verification for Fentanyl patch application, and on-going medication safety audits through the facility's Quality Assurance and Performance Improvement (QAPI) process. A facility-wide review of medication records, physician's orders, and controlled substance documentation was conducted to verify that narcotic medications were accurately ordered, transcribed, and administered according to provider orders. Education was provided to the nursing staff, with reinforcement of facility policies related to medication administration, medication order entry, transcription verification, and controlled substance management. The facility implemented two-nurses verification for Fentanyl patch application and documentation to ensure the correct narcotic medication and dose are applied. Interview with the DNS on 3/22/26 at 1:00 PM identified she was not aware that the Fentanyl patch was transcribed incorrectly on 2/13/26 and the resident received a dose of 75 mcg on 2/28/26 until 3/1/26, when Resident #125 experienced a change in condition. The DNS indicated Resident #125 had a Fentanyl 75 mcg patch applied on 2/28/26, while the intended dose was Fentanyl 12 mcg. The DNS indicated upon identification of the discrepancy, the Fentanyl 75 mcg patch was immediately removed, and Resident #125 was promptly assessed by the RN supervisor. The DNS indicated the licensed nurse failed to follow the six rights of medication administration prior to administration of medication. Interview with APRN #4 on 3/26/26 at 11:16 AM identified on Friday 2/27/26 she refilled a prescription for a Fentanyl patch. APRN #4 indicated she did not recognize that the resident's Fentanyl dosage had previously been increased in error on 2/13/26 to Fentanyl 75 mcg patch. APRN #4 indicated she intended to refill Fentanyl 12 mcg patch; however, she accidentally refilled the prescription for Fentanyl 75 mcg patch. APRN #4 indicated the facility had notified her of a change in condition of Resident #125 on 3/1/26, that Resident #125 exhibited respiratory depression and mild hypoxia. APRN #4 indicated she was notified, and the Fentanyl 75 mcg patch was discontinued. APRN #4 indicated that prn narcotics were held, and Resident #125 was provided supplemental oxygen with good effects and vital signs remained stable. APRN #4 indicated per nursing Resident #125 remained alert and conversive throughout the day. APRN #4 indicated she evaluated Resident #125 the next day on 3/2/26 alert and back to baseline. APRN #4 indicated that the licensed nurse should have transcribed the medication correctly, followed the medication administration policy, and followed the six rights of medication administration.Interview with Pharmacist #1 on 3/26/26 at 11:28 AM identified the first delivery of Fentanyl 75 mcg patch to the facility occurred on 2/28/26 at 3:33 AM, following receiving an order for Fentanyl 75 mcg patch on 2/27/26. Pharmacist #1 indicated the pharmacy had only been dispensing Fentanyl 12 mcg patches prior to 2/28/26. After the Fentanyl 75 mcg was discontinued, a new order for Fentanyl 12 mcg patch was received on 3/1/26 and delivered to the facility on 3/1/26 at 9:55 PM.Interview with RN #8 on 3/27/26 at 2:21 PM identified she was the RN supervisor 2/13/26 during the 7:00 AM - 3:00 PM shift, when LPN #11 (agency nurse) presented her with a Fentanyl patch removed from Resident #125, indicating it needed to be destroyed and replaced. RN #8 indicated she could not recall all the details of the event but had previously provided a written statement. RN #8 indicated she entered a new order into the eMAR; however, she inadvertently selected and entered an order for Fentanyl 75 mcg instead of 12 mcg. RN #8 indicated she failed to read the complete order prior to entry. RN #8 indicated she co-signed the order herself rather than obtaining a second nurse to verify the order, in accordance with safe practice. RN #8 indicated she was unaware the incorrect dose had been entered at the time and she indicated she had made a mistake. RN #8 indicated the facility had conducted an investigation which identified that the incorrect Fentanyl 75 mcg order had been entered into the eMAR by her. RN #8 indicated subsequent nursing staff signed off on the incorrect eMAR order for Fentanly 75 mcg patch; however, they were administering Fentanyl 12 mcg patches on Resident #125. RN #8 indicated that the medication administered did not match the physician's order as documented in the eMAR. RN #8 indicated that nursing staff failed to fully read and verify the physician's order against the medication packaging and did not adhere to the facility's policy regarding the 6 rights of medication administration. Although attempted, an interview with MD #1, LPN #9, LPN #10, LPN #11, LPN #12, LPN #14, and LPN #15 were not obtained. Review of the facility transcription of orders policy identified the purpose is to establish requirements for accepting, transcribing, and reviewing orders. Orders can be obtained over the phone. Transcribing is the recording of orders by a RN, LPN or by clerical/non-licensed unit clerk with appropriate training and competency per state regulations. A RN or LPN must review and verify accuracy and sign off orders transcribed by a non-licensed unit clerk or Med Tech. Review of the facility handling of Fentanyl patches policy identified Fentanyl patches shall be handled in such a manner as to minimize potential for diversion or abuse. Upon applying a new patch to a resident's skin, licensed staff shall indicate date, time, and initials directly on the patch in pen or magic marker and inspect each patch every shift. Upon removal from a resident's skin, another licensed nurse signature and countersignature of disposal shall be noted on resident's MAR.Review of the facility medication pass policy identified that medications are administered safely and timely per the physician's orders. Remember the six (6) rights of medication pass: Right resident, right drug, right dose, right route, right time, and right dosage form. The policy failed to reflect documentation regarding the three (3) checks of medication administration.Review of the facility medication error policy identified that residents are to remain free from complications of medication errors. Medication errors are monitored and the facility has a process specific to medication errors that will be used for measuring inconsistencies. The policy will be used to identify opportunities for improvement in accordance with QAPI. To monitor resident outcomes related to medication errors and provide necessary following actions to correct the problem and/or avoid recurrence. Medication error is a discrepancy between what the healthcare provider ordered and what the resident received. Significant medication errors mean one that causes an adverse effect to the residents, i.e. discomfort or jeopardized his or her health and safety.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #103) reviewed for accidents, the facility failed to ensure a safe transfer of the resident with a mechanical lift per the physician's order. The findings include:Resident #103 was admitted to the facility in May 2020 with diagnoses that included Alzheimer's disease, colostomy and muscle weakness.A physician's order dated 6/26/23 directed to transfer the resident with the assistance of 2 staff using a mechanical lift.The quarterly MDS dated [DATE] identified Resident #103 had severely impaired cognition, had an ostomy, was always incontinent of bladder and was dependent on staff to assist with toileting, bathing, and transfers.The care plan dated 2/28/25 identified Resident #103 had a self-care deficit due to dementia. Interventions included to provide assistance of 2 staff using a mechanical lift.A nurse aide care card dated 5/11/25 identified Resident #103 required an assist x 2 using a mechanical lift for transfers at wheelchair level.Review of a Reportable Event Form dated 5/11/25 at 7:30 PM identified Resident #103 had a witnessed fall while being transferred in a mechanical lift. Review of the report included a written statement from NA #3 (agency nurse aide), who identified she was transferring the resident alone at the time of the fall. NA #3 indicated she did not realize the mechanical lift pad was not under the resident properly and during the transfer with the mechanical lift, Resident #103 slid out of the pad. A change of condition nursing assessment note dated 5/11/25 at 9:48 PM identified Resident #103 slipped out of the mechanical lift sling while NA #3 was attempting to transfer the resident on her own. The note identified that Resident #103 was unable to relay what occurred. The note further identified Resident #103's neuros were within normal limits, he/she was able to move all extremities without difficulty and no signs/symptoms of pain or discomfort were noted. The note also identified that Resident #103 was assisted back to bed with use of the mechanical lift without difficulty.Interview with NA #3 on 3/23/26 at 11:25 AM identified that she was the nurse aide assigned to Resident #103 on 5/11/25 when the fall occurred. NA #3 identified she was preparing Resident #103 for bed, and that she was attempting to transfer Resident #103 from the wheelchair to the bed using a mechanical lift by herself. NA #3 identified that during the transfer she identified the pad was not situated under Resident #103 properly and that Resident #103 began to slip out of the lift and ultimately fell. NA #3 identified that Resident #103 did not fall far but did hit his/her bottom on the floor. NA #3 identified that she attempted to catch Resident #103 prior to the fall but was not able to in time. NA #3 identified she attempted the transfer by herself because she had attempted to try and find another staff member to help her but was unable find someone. NA #3 identified she did not review the nurse aide care card and relied on information that she received in report, however she was aware, due to the need for a mechanical lift, that Resident #103 would require 2 staff members for the transfer. NA #3 identified there was no urgency to transfer Resident #103, but that she had other residents to attend to and wanted to finish care with Resident #103. NA #3 failed to identify why she was not able to wait until another staff member was available to assist with Resident #103's transfer instead of attempting it on her own. NA #3 identified that she called for help following the fall and stayed with Resident #103 when a nurse arrived. NA #3 identified that following incident, she was sent home and did not return to the facility. Interview with the Nurse Scheduler on 3/23/26 at 12:30 PM identified NA #3 was an agency nurse aide who worked at the facility for 2 shifts on 5/10/25 - 5/11/25. The Nurse Scheduler identified that NA #3 did not work a full shift on 5/11/25 and was sent home following the incident with Resident #103, and that the facility placed her on 'do not return' status at the facility. Interview with the DNS on 3/25/26 at 12:45 PM identified that Resident #103 was always to be transferred with 2 staff members and a mechanical lift in and out of bed, and that immediately following the fall on 5/11/25, NA #3 was sent home, and the staffing agency was notified she was not to return to the facility. The DNS further identified that all nursing staff also were in serviced following the incident that any resident who required a mechanical lift were always to have 2 staff present. Although requested, a policy on use of a mechanical lift was not provided.The facility policy on safe patient/resident handling and movement directed it was the duty of employees to take reasonable care of their own health and safety as well as that of their residents during handling activities by following the policy. Noncompliance would indicate a need for retraining/discipline. The policy also directed that staff were to avoid hazardous patient handling and movement tasks whenever possible. The policy further directed that use of mechanical lifting devices or other approved patient handling aids should be used with instructions and training.

The facility failed to provide adequate supervision and implement effective fall prevention interventions for a cognitively impaired resident with incontinence and a known fall risk, resulting in two (2) unwitnessed falls with major injuries (right and left humerus fractures). The findings include:Resident #1 was admitted to the facility with diagnoses that included osteoarthritis of the knee, anxiety and Alzheimer's dementia. Resident #1 had a conservator of person and estate.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had impaired cognition (Brief Interview for Mental Status (BIMS) score of 5), was frequently incontinent of bowel and bladder and was not currently on a toileting program.The Resident Care Plan (RCP) dated 12/2/25 identified Resident #1 had a deficit in self-care function related to weakness and deconditioning. Interventions included toileting with a straight point cane with a supervise/touching assist of one (1) staff (helper gives verbal cues or touch assist) and personal hygiene with a supervise/touching assist of one (1) staff. The RCP identified Resident #1 had Dementia with interventions that included to anticipate and meet needs. The RCP further identified Resident #1 had a potential for fall due to unsteady gait with interventions that included non-skid socks at all times and in bed, note any changes in gait and report as needed and offer diversional activities such as music, snack, toileting and ambulating.Review of the clinical record failed to identify a scheduled toileting or prompted voiding program to address incontinence and toileting needs.The Reportable Event form dated 1/25/26 at 10:30 AM identified Resident #1 had an unwitnessed fall with a head strike that caused a hematoma of Resident #1's frontal head and a painful right forearm. Resident #1 was sent to the emergency department (ED) for an evaluation.A statement by NA #1 dated 1/25/26 identified he opened the bathroom door for Resident #1 and Resident #1 put his/her cane in the sink. NA #1 turned away slightly and closed the door a little to give Resident #1 privacy. NA #1 heard a sound, turned around, and saw Resident #1 on the floor lying on his/her back.Review of the ED visit dated 1/25/26 identified Resident #1 was diagnosed with a bicondylar intra-articular fracture of the distal humerus. Resident #1 had new orders to maintain a sling and follow up in one (1) to two (2) weeks.Physician's orders dated 1/26/26 directed non-weight baring to the right upper extremity, ensure right arm sling is in place and arm elevated and Tylenol 325 mg two tablets every eight hours as needed for pain.The RCP was updated on 1/26/26 with an intervention to keep hands on Resident #1 at all times when assisting Resident #1 with bathroom needs until further notice and cleared by therapy team.A nursing note dated 1/29/26 at 2:40 PM identified Resident #1 was noncompliant with transfers. Resident #1 was noted in the bathroom after asking to lay down.The RCP was updated on 1/30/26 with the interventions to attempt to keep Resident #1 entertained in the common area as tolerated for monitoring, CBC/CMP, orthostatic blood pressure monitoring and every fifteen (15) minute checks when Resident #1 was in the bathroom.A nursing note dated 1/31/26 at 2:33 PM identified Resident #1 continued with every fifteen (15) minute checks while in the room.A nursing note dated 2/10//26 at 9:09 PM identified Resident #1 was observed multiple times ambulating without assistance and not using the call light.The nursing note dated 2/14/26 at 12:45 AM identified Resident #1 was observed lying on the bathroom floor on his/her left side at 12:45 AM. Resident #1 stated he/she was using the bathroom. Resident #1 complained of severe pain to the left upper extremity, was unable to move the left upper arm due to pain and 911 was called for hospital transfer.Review of the ED visit dated 2/14/26 identified Resident #1 was diagnosed with a left displaced comminuted fracture of the distal humerus.Interview with NA #1 on 3/5/26 at 12:15 PM identified on 1/25/26 at 10:30 AM he assisted Resident #1 to the bathroom to wash his/her hands. He identified Resident #1 ambulated with a cane and once in the bathroom, Resident #1 put the cane on the sink. He identified Resident #1 liked privacy when in the bathroom, so he closed the door but left it slightly open and turned around in the other direction. He identified he then heard a sound, turned around, and saw Resident #1 on the floor.Interview with the DNS on 3/5/36 at 1:45 PM identified at the time of the first fall, Resident #1 was a supervised assist of one with personal hygiene and toileting. She identified a supervised assist meant staff were to supervise Resident #1 with the Activity of Daily Living (ADL) to allow for queuing and assistance if needed. She identified the NA did not have constant supervision because his back was turned.Review of the ADL policy identified that ADL's are essential tasks that each person needs to perform, on a regular basis, to sustain basic survival and well-being. Staff are to provide assistance to complete ADL activities per the person-centered evaluation and care plan.Review of the Fall Prevention Program directed for resident review of risk factors and develop interventions and incorporate them into the Resident Care Plan. The facility presented a corrective action plan for past non compliance dated 1/30/26 which included:A facility wide audit to identify cognitively impaired residents.Staff education for following the plan of care and what was required for supervision with ADLs.Care observation audits to ensure plans of care were implemented.The corrective action plan was reviewed during QAPI on 2/26/26 The corrective action plan was accepted by the state agency during an onsite visit on 3/5/26.

Based on review of the clinical record, facility documentation, and staff interviews for one (1) of two (2) residents (Resident #1) reviewed for accidents, the facility failed to develop a comprehensive, person-centered care plan to address a cognitively impaired resident's toileting needs and fall risk, including the absence of a scheduled toileting or prompted voiding program. The findings include:Resident #1 was admitted to the facility with diagnoses that included osteoarthritis of the knee, anxiety and Alzheimer's dementia. Resident #1 had a conservator of person and estate.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had impaired cognition (Brief Interview for Mental Status (BIMS) score of 5), was frequently incontinent of bowel and bladder and was not currently on a toileting program.The Resident Care Plan (RCP) dated 12/2/25 identified Resident #1 had a deficit in self-care function related to weakness and deconditioning. Interventions included toileting with a straight point cane with a supervise/touching assist of one (1) staff (helper gives verbal cues or touch assist) and personal hygiene with a supervise/touching assist of one (1) staff. The RCP identified Resident #1 had Dementia with interventions that included to anticipate and meet needs. The RCP further identified Resident #1 had a potential for fall due to unsteady gait with interventions that included non-skid socks at all times and in bed, note any changes in gait and report as needed and offer diversional activities such as music, snack, toileting and ambulating.Review of the RCP failed to identify a scheduled toileting or prompted voiding program to address incontinence and toileting needs.The Reportable Event form dated 1/25/26 at 10:30 AM identified Resident #1 had an unwitnessed fall with a head strike that caused a hematoma of Resident #1's frontal head and a painful right forearm. Resident #1 was sent to the emergency department (ED) for an evaluation.A statement by NA #1 dated 1/25/26 identified he opened the bathroom door for Resident #1 and Resident #1 put his/her cane in the sink. NA #1 turned away slightly and closed the door a little to give Resident #1 privacy. NA #1 heard a sound, turned around, and saw Resident #1 on the floor lying on his/her back.Review of the ED visit dated 1/25/26 identified Resident #1 was diagnosed with a bicondylar intra-articular fracture of the distal humerus. Resident #1 had new orders to maintain a sling and follow up in one (1) to two (2) weeks.The RCP was updated on 1/26/26 with an intervention to keep hands on Resident #1 at all times when assisting Resident #1 with bathroom needs until further notice and cleared by therapy team.A nursing note dated 1/29/26 at 2:40 PM identified Resident #1 was noncompliant with transfers. Resident #1 was noted in the bathroom after asking to lay down.The RCP was updated on 1/30/26 with the interventions to attempt to keep Resident #1 entertained in the common area as tolerated for monitoring, CBC/CMP, orthostatic blood pressure monitoring and every fifteen (15) minute checks when Resident #1 was in the bathroom.A nursing note dated 1/31/26 at 2:33 PM identified Resident #1 continued with every fifteen (15) minute checks while in the room.A nursing note dated 2/10//26 at 9:09 PM identified Resident #1 was observed multiple times ambulating without assistance and not using the call light.The nursing note dated 2/14/26 at 12:45 AM identified Resident #1 was observed lying on the bathroom floor on his/her left side at 12:45 AM. Resident #1 stated he/she was using the bathroom. Resident #1 complained of severe pain to the left upper extremity, was unable to move the left upper arm due to pain and 911 was called for hospital transfer.Review of the ED visit dated 2/14/26 identified Resident #1 was diagnosed with a left displaced comminuted fracture of the distal humerus.Interview with NA #1 on 3/5/26 at 12:15 PM identified on 1/25/26 at 10:30 AM he assisted Resident #1 to the bathroom to wash his/her hands. He identified Resident #1 ambulated with a cane and once in the bathroom, Resident #1 put the cane on the sink. He identified Resident #1 liked privacy when in the bathroom, so he closed the door but left it slightly open and turned around in the other direction. He identified he then heard a sound, turned around, and saw Resident #1 on the floor.Interview with the DNS on 3/5/36 at 1:45 PM identified at the time of the first fall, Resident #1 was a supervised assist of one with personal hygiene and toileting. She identified a supervised assist meant staff were to supervise Resident #1 with the Activity of Daily Living (ADL) to allow for queuing and assistance if needed. She identified the NA did not have constant supervision because his back was turned.Review of the ADL policy identified that ADL's are essential tasks that each person needs to perform, on a regular basis, to sustain basic survival and well-being. Staff are to provide assistance to complete ADL activities per the person-centered evaluation and care plan.Review of the Fall Prevention Program directed for resident review of risk factors and develop interventions and incorporate them into the Resident Care Plan.

Based on clinical record review, facility documentation review, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure care was provided in accordance with the plan of care. The failure resulted in a fall with injury. The findings include: Resident #1‘s diagnoses included cerebral infarction (stroke) and morbid obesity. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of three (3) indicative of severely impaired cognition and was dependent on staff for bed mobility and transfers. The Resident Care Plan (RCP) dated 4/16/2025 identified that Resident #1 a deficit related to deconditioning and weakness. Interventions directed side-rails to assist with bed mobility, and two (2) staff for assistance personal hygiene, and turning and repositioning in bed. Facility reportable event dated 6/27/2025 at 8:15 AM identified Resident #1 had severe cognitive impairment, and required assist of two (2) for activities of daily living (ADLs) and bed level rolling. The report identified Nurse Aide (NA) #1 witnessed Resident #1 roll out of bed. Right knee pain and swelling were noted, the provider was notified and new orders obtained for x-rays, with positive results for a right femur fracture and Resident #1 was sent to the hospital. The facility incident summary dated 7/3/2025 identified NA #1 reported that Resident #1 rolled out of bed to his/her left side after feeling confused when the aide instructed him/her to roll towards me. Instead, Resident #1 rolled the opposite way with the use of the partial bed rails, and fell out of the bed. A nurse's note dated 6/27/2025 at 9:13 AM identified while NA #1 was giving personal care and attempted to change the bed linens, NA #1 asked Resident #1 to turn onto his/her left side. Resident #1 rolled too far and subsequently fell out of the bed. APRN note dated 6/27/2025 at 10:00 AM identified Resident #1 was seen after a fall with right knee pain. Resident #1 complained of significant right knee pain, had swelling with tenderness and an abrasion (scrape) and decreased range of motion. A STAT (immediate) x-ray was ordered to rule out a fracture. X-ray results dated 6/27/2025 identified a displaced fracture of the distal femur (fractured ends of the thigh bone near the knee that have shifted out of alignment). Nursing change in condition note dated 6/28/2025 at 5:40 AM identified x-ray results indicated a right distal femur fracture (just above the knee joint). The provider was notified, and Resident #1 was transferred to the hospital for evaluation. Review of hospital documentation identified that Resident #1 was admitted for a fracture of the right distal femur. Resident #1 had a right femur Open Reduction and Interval Fixation (ORIF - surgical procedure to stabilize the femur near the knee joint) on 6/28/2025. Record review identified Resident #1 was readmitted to the facility on [DATE] with orders for touch-down-weight bearing right leg, with a knee immobilizer, and orthopedic follow up in two (2) weeks. Orthopedic visit note dated 7/14/2025 identified staples were removed, directed start Physical Therapy (PT) for range of motion and follow up in two (2) to four (4) weeks. Interview with NA #1 on 7/28/2025 at 11:11 AM identified on 6/27/2025 when she provided incontinent care for Resident #1, she requested Resident #1 turn towards her onto his/her right side and grab onto the side-rail. NA #1 stated that instead of turning to the right side as requested, Resident #1 grabbed onto the left side-rail and turned to the left and slid off the bed onto the floor landing on his/her right side. NA #1 stated she was unsure how the fall actually happened, or which leg went over the side of the bed first because it happened so quickly. NA #1 stated she had provided care for Resident #1 for the past two (2) years, but she never looked at the resident's Kardex/NA Care Card and she did not know Resident #1 required two (2) staff for bed-level care and turning and repositioning in bed. Although NA #1 indicated she should have checked the NA Care Card for directions, she was unable to explain why she did not look at the NA Care Card prior to providing care. Interview with PT #1 and Speech Therapist (ST) #1 on 7/28/2025 at 11:59 AM identified that Resident #1 was discharged from PT services on 6/19/2025 (8 days prior to the fall), and required two (2) staff for ADLs and bed mobility for safety. Interview with the DNS on 7/28/2025 at 10:10 AM identified the Kardex/NA Care Card directed two (2) staff for assistance with bed-level care and bed mobility, and NA #1 provided the care without a second staff member to assist. The DNS stated NA #1 did not request assistance from other staff when she provided care and when she asked Resident #1 to turn in the bed. The DNS indicated NA #1 should have had another staff member to assist with the care and she expected all staff to review the Kardex/NA Care Card for a resident prior to providing care. Although requested, the Kardex/NA Care Card for Resident #1 prior to the fall was not provided during the survey. Facility documentation review identified staff education was initiated on 6/27/2025 and included NAs must check the Kardex (NA Care Card) before providing care to a resident, and residents that require assistance of two (2) staff MUST have two (2) staff present for care. A QAPI meeting was held on 6/27/2025 and audits were initiated on 6/27/2025. Based on review of facility documentation, past non-compliance was identified.

Based on review of the clinical record and facility documentation, and interviews for one (1) of two (2) residents (Resident #2) reviewed for medication errors, the facility failed to ensure a physician order was transcribed correctly, and failed to ensure the resident was free from a medication error. The findings include: Resident #2‘s diagnoses included atrial fibrillation (fast irregular heart rate). Hospital Discharge summary dated [DATE] directed Resident #2 was to receive Aspirin 81 milligrams (mg) by mouth two times a week. The Nursing admission Evaluation dated 4/19/2025 identified Resident #2 was alert and oriented, and was on anticoagulant medication (a blood thinner preventing blood clots). The Resident Care Plan (RCP) dated 4/19/2025 identified a potential for adverse effects due to anticoagulant therapy. Interventions administer medications as ordered. Nursing note dated 4/19/2025 at 6:07 PM written by RN #3 identified the physician was upadted and orders were verified. A physician order dated 4/19/2025 directed to administer Aspirin oral tablet 81 mg once daily for antiplatelet therapy (prevent blood clots) starting on 4/21/2025. Additional reivew identified the order was transcribed and entered into the electronic medical record (EMR) by RN #2. Review of the April 2025 Medication Administration Record (MAR) identified Aspirin 81 mg was administered daily at 9:00 AM from 4/21 through 4/25/2025 (5 days). Record review identified Resident #2 was discharged from the facility on 4/25/2025. Facility Medication Incident Report dated 5/7/2025 identified a medication error for Resident #2 was discovered at 9 AM. Resident #2 was given Aspirin once a day, and the order was for the Aspirin to be given twice a week. The form indicated the error was a transcription error. Interview with RN #2 on 7/28/2025 at 2:18 PM identified she transcribed the physician order for Aspirin from the hospital discharge summary on 4/20/2025, and stated she must have read the order wrong, and she did not re-check the order before confirming it in the EMR. RN #2 identified she when the error occurred and she thought her preceptor/RN #3 would have checked her work. Interview with RN #3 on 7/28/2025 at 2:41 PM identified on 4/19/2025 she was orienting RN #2 and she did not check the physician orders for accuracy when they were transcribed by RN #2. RN #3 stated that when RN #2 entered (acknowledged) the physician order, she also confirmed the order in the EMR, and it did not display for RN #3 to review the order to ensure it was accurate. RN #3 stated that since she was orienting RN #2, she should have checked RN #2's work and verified the orders. Interview with the DNS on 7/28/2025 at 2:56 PM identified nurses are expected to reconcile hospital orders with the physician, transcribe the orders into the EMR and then acknowledge that the orders are correct. She reported that once the orders are acknowledged in the EMR the orders show as pending confirmation and a second nurse is responsible to review them for accuracy. The second nurse would then confirm the orders in the EMR and they would then be listed in the MAR. The DNS stated a second check was not completed, resulting in the medication error. Facility documentation review identified staff education was initiated on 5/12/2025 and included review of transcription of physician orders and medication reconciliation. A a QAPI meeting was held on 5/13/2025 and audits were initiated on 5/30/2025. Based on review of facility documentation, past non-compliance was identified.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse timely. The findings include: Resident #1's diagnoses included dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicative of severe cognitive impairment, was dependent for ADLs, and was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 9/10/2024 identified Resident #1 had deficit in self-care function related to impaired mobility, limited functional ability, cognitive deficit and incontinence. Interventions directed assist of two (2) for bed mobility, bed level rolling, turned, repositioned slowly assisted by two (2) staff members while reassuring the resident he/she is safe bathing, dressing, transfers, and mechanical lift for transfers. Nursing note written by RN #1 on 1/4/2025 at 9:31 AM identified Resident #1 sustained a left eye bruise and cut from Hoyer lift sling attachment. Resident #1 reportedly had been agitated and banged his/her head on the pillow and then the device. The area was cleansed, and one steri-strip was applied. The MD and responsible party notified were notified, and the plan of care was updated to direct the sling was not to be attached until the resident was ready for immediate transfer. The facility reportable event dated 1/9/2025 at 6:35 PM identified NA #1 alleged that NA #2 could have struck Resident #1 in the face during care. NA #1 alleged she heard Resident #1 yell out and say, she punched me in my eye, while NA #2 was providing care. The facility summary report dated 1/13/2025 identified that on 1/9/2025 NA #1 reported to the supervisor that on 1/4/2025 she heard Resident #1 yell out and say, she punched me in my eye, while NA #2 was providing care. Following this, NA #1 entered Resident #1's room and observed a discoloration and an open area to his/her left lower eye. NA #2 who was caring for Resident #1 stated that she wasn't sure how the resident sustained the discoloration, but noted that Resident #1 was very combative during care and she denied inflicting the injury. Both NAs were suspended pending the investigation. Interview, facility documentation review on 1/30/2025 at 11:19 AM with NA #1 identified on 1/4/2025 she heard Resident #1 say that NA #2 hit him/her, and she reported the incident on 1/9/2025 to RN #1. NA #1 stated she should have reported the allegation to her supervisor right away on 1/4/2025 instead of waiting another five (5) days to notify a supervisor. Review of State Agency Reportable Events website identified the allegation was reported to the State Agency on 1/9/2025, five (5) days after the incident occurred. Interview with RN #1 was not obtained during the survey. Interview with the DON on 1/30/2025 at 1:45 PM identified that on 1/9/2025 she received a call from the supervisor indicating NA #1 had expressed concerns about Resident #1 yelling out, she punched me in the face, and during the investigation NA #1 identified that this occurred on 1/4/2025 (five days prior). The DON stated the incident should have been reported on 1/4/2025 when it occurred. Review of facility Abuse Policy & Procedure Policy directed in part, abuse allegations require immediate reporting to the supervisor. Facility documentation review identified staff education was initiated on 1/10/2025 regarding Abuse and Resident Rights policies and reporting of abuse timely. A QAPI meeting was held on 1/24/2025 and audits were initiated 12/1/2024. Based on review of facility documentation, past non-compliance was identified as of 1/24/2025.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure care was provided in accordance with the resident plan of care. The findings include: Resident #1's diagnoses included dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicative of severe cognitive impairment, was dependent for ADLs, and was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 9/10/2024 identified Resident #1 had deficit in self-care function related to impaired mobility, limited functional ability, cognitive deficit and incontinence. Interventions directed assist of two (2) for bed mobility, bed level rolling, turned, repositioned slowly assisted by two (2) staff members while reassuring the resident he/she is safe bathing, dressing, transfers, and mechanical lift for transfers. Nurse aide care card directed two (2) staff for care. Nursing note written by RN #1 on 1/4/2025 at 9:31 AM identified Resident #1 sustained a left eye bruise and cut from Hoyer lift sling attachment. Resident #1 reportedly had been agitated and banged his/her head on the pillow and then the device. The area was cleansed, and one steri-strip was applied. The MD and responsible party notified were notified, and the plan of care was updated to direct the sling was not to be attached until Resident #1 was ready for immediate transfer. Interview, review of facility documentation on 1/30/2025 at 11:08 AM with NA #1 identified that when on 1/4/2025 she heard the resident yell, NA #2 was the only aide in the room at the time. NA #1 indicated that the Hoyer lift was not yet in the room and once she returned with the Hoyer, they got the resident up using the Hoyer lift and when Resident #1 was out of bed, NA #1 saw the discoloration to the resident's eye. Interview and record review with NA #2 on 1/30/2025 at 11:19 AM identified on 1/4/2025 Resident #1 was agitated, and when she returned to provide care, Resident #1 stated ow, my eye. NA #2 stated she could not recall what position the resident was in while in the bed and indicated that she was providing care alone as she typically does prior to calling for help with the Hoyer transfer. NA #2 stated the resident care card directed the assistance of two (2) staff with care, and it takes too long sometimes to get help, so she provided the care by herself. Then she asked for help with the transfer. NA #2 stated she should not have provided care alone and she should not have provided care while the resident was yelling. Interview with the DON on 1/30/2025 at 1:45 PM identified Resident #1 had a history of combative behaviors and was care planned for two (2) staff assist with care, and NA #2 should not have provided care alone. The DON further stated, if Resident #1 was agitated when NA #2 approached the resident for care, NA #2 should not have provided care at that time. Facility documentation review identified staff education was initiated on 1/10/2025 regarding providing the correct level of assistance per the [NAME] (plan of care). Audits were initiated 1/10/2025 and a QAPI meeting was held on 1/24/2025. Based on review of facility documentation, past non-compliance was identified as of 1/24/2025.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for accidents, the facility failed to provide ensure the medical record was complete and accurate to include documentation of neurological monitoring per facility policy. The findings include: Resident #2's diagnoses included dementia. The Admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #2 was severely cognitively impaired, and dependent with transfers, walking, and ADLs. The Resident Care Plan (RCP) dated 8/1/2022 identified Resident #2 had a history of a fall due to poor balance. Interventions directed therapy consult for strength and mobility, and offer to go to bed with first rounds on 3 to 11 PM shift. A physician's order dated 9/19/2022 directed Aspirin AC (blood thinner)tablet delayed release 81 milligrams (mg) give one (1) tablet by mouth in the morning for prophylaxis. Review of Reportable Event form dated 9/30/2022 at 4:00 PM indicated resident was observed on the floor Resident #2 had a minor contusion to left parietal (top rear of) head after an unwitnessed event. Resident #2's mental status was alert and confused, the APRN and responsible party were notified, and Resident #2 was assessed. A nursing progress note dated 9/30/2024 at 5:48 PM identified about 4:00 PM resident was observed on floor; resident rolled out of bed while trying to transfer and sustained a minor contusion to left parietal head, was alert with stable vital signs. Neurological assessment was at baseline with facility protocol in place, upper and lower extremities strength and range of motion at baseline. A nurse progress note dated 10/1/2022 at 12:44 PM indicated resident status post fall day one (1), vital signs stable, continued on neurological (neuro) check every shift, and will continue to monitor. Record review failed to identify neurological assessments were completed. Interview and record review on 12/27/2024 with the DNS identified that neuro monitoring was done after Resident #2 was found on floor on 9/30/2022, however she was unable to provide a copy of assessments completed. The DNS stated neuro assessments were completed on paper at the time of the fall and was unable to explain why the documentation was missing. The DNS further indicated that the facility should maintain a copy and have access to the neuro monitoring in the medical record. Review of the facility Neurological Assessment/Evaluation Policy directed in part the licensed nurse performs neurological evaluations whenever there is a possibility of a head injury, change in mentation, or an unwitnessed fall. Any resident who has had an unwitnessed or witnessed fall and is on an anticoagulant/antiplatelet therapy, will have an initial neurological evaluation by the LPN or RN per state regulation follow by neurological monitoring per policy, after the initial evaluation, the neurological exam is repeated every 15 minutes x 4 (1 hour), every 30 minutes x 4 (2 hours), every 2 hours x 4 (8 hours), then every shift x 8 (64 hours). If neurological check sheet is stopped before it is completed the reason will be documented in the electronic health record. Review of the Documentation Guidelines policy directed in part, services provided to residents are documented by the individual providing the service within the electronic medical record (EMR). Should an omission of documentation occur, a late note may be added within the EMR.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of two (2) sampled residents (Resident #2) who were reviewed for an allegation of staff to resident verbal abuse, the facility failed to ensure the resident's dignity was maintained when the resident attended a staff assisted outpatient appointment. The findings include: Resident #2's diagnoses included stroke. The nursing admission/readmission evaluation dated 7/9/24 identified Resident #2 was alert and oriented to person, place, time and situation. A physician's order dated 7/11/24 directed assistance of one (1) staff at bed level for activities of daily living (ADL's) and assistance of two staff at wheelchair level for toileting. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable and consistent decisions regarding tasks of daily life, was occasionally incontinent of bladder, frequently incontinent of bowel and had no behavioral symptoms. The care plan dated 7/17/24 identified Resident #2 had functional bladder incontinence related to impaired mobility. Interventions directed to establish voiding patterns and clean peri-area with each incontinence episode and assistance of two (2) staff for toilet use. The Facility Reported Incident form dated 7/18/24 identified Resident #2 alleged on 7/16/24 the nurse aide, Nurse Aide (NA) #1, who accompanied Resident #2 to their doctor's appointment, was abusive and neglectful. Resident #2's statement dated 7/18/24 identified on 7/16/24 Resident #2 needed to use the bathroom before leaving the facility for his/her appointment and NA #1 originally declined but did end up bringing Resident #2 to the commode. Resident #2 stated NA #1 told him/her to hurry up and who do you think you are wanting to give orders. Resident #2 identified in the hospital, where the doctor's office was located, Resident #2 asked NA #1 to move him/her away from the busy area and NA #1 stated shut your mouth. Resident #2 indicated in the cab on the way back to the facility, NA #1 told him/her to shut your mouth, you don't know what you are talking about. NA #1's statement dated 7/23/24 identified on 7/16/24 Resident #2's ride was running late and Resident #2 asked to use the bathroom. NA #1 indicated she stated to Resident #2 he/she may miss their ride but did not decline or refuse and assisted Resident #2 back up to the unit. NA #1 identified at no point did she tell Resident #2 to hurry up. NA #1 explained once they arrived to the appointment around 10:30 AM, Resident #2 missed his/her appointment but was able to be seen at 3:00 PM. NA #1 identified she assisted Resident #2 once to the bathroom while waiting, Resident #2 was not incontinent and assisted with wiping Resident #2. NA #1 stated at no point did she ever tell Resident #2 to shut his/her mouth or you don't know what you are talking about. The psychiatric exam dated 7/18/24 identified Resident #2 was seen for initial evaluation and allegation of verbal abuse and neglect. Resident #2's cognitive function was intact and age appropriate. The Director of Nursing's progress note dated 7/18/24 at 5:13 PM identified Resident #2 alleged the nurse aide that accompanied him/her to his/her appointment on Tuesday 7/16/24 was abusive and neglectful. Interview with Resident #2 on 8/7/24 at 10:30 AM identified on 7/16/24 he/she had to have a bowel movement before the doctor's appointment and NA #1 was rushing him/her. Resident #2 identified when he/she and NA #1 got into the transportation van, it was hot and muggy and he/she asked for all the windows to be down, to which NA #1 told the driver to roll the windows up and told him/her to shut his/her mouth. Resident #2 identified although he/she ended up missing the appointment that was for 10:00 AM because they arrived at 10:30 AM, the doctor's office had an appointment at 3:00 PM and NA #1 and he/she agreed to stay until that appointment. Resident #2 identified he/she had to go to the bathroom, his/her brief was wet, but NA #1 did not have a replacement brief or wipes, therefore Resident #2 did not have a new brief placed after going to the bathroom. Resident #2 identified NA #1 told him/her several times to shut his/her mouth. Resident #2 identified when he/she returned to the facility, he/she was wet and had to change. Interview with NA #1 on 8/7/24 at 2:45 PM identified she was the nurse aide who assisted Resident #2 to the doctor's appointment on 7/16/24. NA #1 indicated Resident #2 appeared happy all day and did not have any concerns. NA #1 identified she did not tell Resident #2 to shut his/her mouth. NA #1 identified Resident #2's appointment scheduled for 10:00 AM was missed and Resident #2 was ok with staying until the next available appointment at 3:00 PM. NA #1 identified she brought a brief with her but did not need to use it because when she brought Resident #2 to the bathroom, the brief was dry. Interview with the Director of Nursing (DON) on 8/7/24 at 3:02 PM identified the facility became aware of Resident #2's allegations of abuse on 7/18/24 and completed a full investigation, the event on 7/16/24 appeared to be a customer service issue and NA #1 was re-educated. Review of the urinary management policy directed to check the resident at regular intervals to determine if they are wet or dry. It further directed to provide perineal care and change absorbent product if wet. Review of the residents' bill of rights policy directed that residents have the right to be treated with consideration, respect and full recognition of your dignity and individuality. It further directed residents have the right to receive quality care and services.

Based on observation, record review and interviews for 1 of 4 residents (Resident #78) who was on a secured locked unit and wore a wander guard, the facility failed to ensure the residents wander guard was changed when it expired, failed to investigate and implement interventions after Resident #78 was able to exit the secured locked unit on [DATE]; and failed to provide adequate supervision and devices to prevent the resident from exiting the secured locked unit on [DATE] when the resident accessed the elevator on the 4th floor, (secured locked unit), took the elevator to the 1st floor, and walked out the front door unsupervised. These failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #78 was admitted to the facility in [DATE] with diagnoses that included dementia and traumatic brain injury. A fall risk evaluation, done upon admission in ,d+[DATE], identified Resident #78 was at high risk to fall due to a history of multiple falls prior to admission and use of multiple sedative, cathartic, and psychotropic medications. An elopement evaluation on admission, dated ,d+[DATE], identified Resident #78 was at high risk for elopement due to a physical ability to leave the facility, cognitive impairment, inability to make informed decisions about leaving the facility, and disorientation. Resident #78 had a wander guard device placed. The care plan dated [DATE] identified Resident #78 had impaired cognitive thought processes due to dementia that included inattention and disorganized thinking and was at risk for elopement and wandering. Interventions included to keep the resident's routine as consistent as possible to decrease confusion and the use of a wander guard device. Further, the care plan indicated the resident was at risk to fall. The care card, not dated, identified that Resident #78 was to have appropriate footwear on including non-skid socks and non-skid soles on shoes/sneakers while ambulating and non-skid socks on at bedtime. A psychiatric note dated [DATE] identified that staff had reported Resident #78 had periods of exit seeking behaviors and difficulty with redirection, the resident was cognitively impaired, was confused, was alert to person only, had confabulatory speech, had delusions that included confabulatory false fixed ideations, had poor insight, poor judgement, and impaired short-term memory and poor long term memory. A psychiatric note dated [DATE] identified Resident #78 had poor insight and judgement. The physician's orders dated [DATE] directed behavior monitoring for elopement every shift, and the use of a wander guard, check for expiration date every 7 days and check for function every 11:00 PM - 7:00 AM shift and as needed. Review of facility documentation identified Resident #78 resided on the 4th floor, a secured locked unit. Review of the March, April and [DATE] MARs identified Resident #78's wander guard had been checked for expiration by licensed staff weekly, however, documented on the MARs was an expiration date of [DATE] for the wander guard. The quarterly MDS assessment dated [DATE] identified Resident #78 had severely impaired cognition. Review of the [DATE] MAR identified Resident #78's wander guard had been checked for expiration by licensed staff on [DATE], [DATE], [DATE], and [DATE], however, documented on the MAR was an expiration date of [DATE] for the wander guard (8 months expired). The nurse's note dated [DATE] at 12:36 PM, written by the RN Supervisor (RN #3), entered as a late entry on [DATE] identified that Resident #78 wandered off the unit and was found on the 1st floor near the kitchen area. (This is in conflict with security camera footage that identified Resident #78 left the 4th floor via a stairwell to the 1st floor unsupervised from 8:11 PM - 8:26 PM, not 12:36 PM.) Although Resident #78 eloped the 4th floor secured unit during the 3:00 PM - 11:00 PM shift on [DATE], LPN #7 documented no elopement behaviors during the 3:00 PM - 11:00 PM shift on the MAR. Review of the clinical record failed to identify documentation regarding how Resident #78 was able to leave the secured unit or new interventions to monitor the resident's location on or following the [DATE] elopement from the secured locked unit on the 4th floor to the 1st floor on [DATE]. The nurse's note dated [DATE] by LPN #12 identified Resident #78 had been placed on every 15-minute checks for the 3:00 PM - 11:00 PM shift only however the clinical record failed to identify any documentation related to 15-minute checks being completed. In a 2nd elopment in 3 days, the nurse's note dated [DATE] at 2:00 PM by LPN #3 identified Resident #78 had been observed in the lobby (1st floor) by staff. The note further identified that Resident #78's wander guard was replaced, and Resident #78 was placed on 1:1 observation from 7:00 AM - 11:00 PM and every 15-minute checks from 11:00 PM - 7:00 AM. Interview with RN #3 on [DATE] at 9:11 AM identified he was the RN Supervisor on [DATE] during the 3:00 PM - 11:00 PM shift. RN #3 identified that Resident #78 was found on the 1st floor near the kitchen on [DATE] at approximately 9:00 PM by NA #5 but could not identify how Resident #78 was able to leave the secured unit. RN #3 identified he was notified of the incident by LPN #7, who was assigned to Resident #78. RN #3 identified the wander guard should have been changed at time it expired on [DATE], and that it should have been changed following the 1st elopement attempt on [DATE] as the wander guard can malfunction or lose battery function if not changed timely. Interview with LPN #7 on [DATE] at 12:54 PM identified she was the nurse assigned to Resident #78 on [DATE] during the 3:00 PM - 11:00 PM shift. LPN #7 identified that she was in another resident's room administering medications when she was notified by NA #5 that Resident #78 was found on the 1st floor near the kitchen around 9:00 PM. LPN #7 identified that Resident #78 had not been exit seeking during her shift, and that she spoke with Resident #78 and asked Resident #78 if he/she knew the code to leave the secured unit, which the resident did not. LPN #7 brought Resident #78 to the exit doors by the elevators, checked the function of the wander guard by entering the 4th floor elevator with Resident #78, and the alarm box for the wander guard did beep, however, the elevator did not lock and allowed LPN #7 and Resident #78 to operate the elevator to the 1st floor and then back up to the unit. LPN #7 identified that while the elevators did not lock, since the alarm beeped, LPN #7 did not check further into the actual wander guard Resident #78 was wearing to see if there were any issues with the it, including the expiration date, since the beep would mean the wander guard was functioning, even if the elevators did not lock. LPN #7 identified she notified RN #3 of the situation and was told by RN #3 he contacted the DNS that Resident #78 was to be placed on 1:1 monitoring. LPN #7 identified she did not complete 1:1 monitoring of Resident #78's location during her shift and was unable to identify who was assigned to complete the 1:1 monitoring. LPN #7 identified she did not notify any other facility staff, including maintenance staff, of the issue with Resident #78's wander guard, since she felt notification to RN #3 was sufficient. LPN #7 identified she did not document the residents elopement behaviors or the attempted elopement incident on [DATE] as she also felt this was addressed by her notification to RN #3. Interview with LPN #3 on [DATE] at 11:55 AM identified she was the charge nurse assigned to Resident #78's secured unit on [DATE] when the resident exited the unit unsupervised. Resident #78 was able to get off of the secured unit by following visitors to the elevator, which should have locked once Resident #78 attempted to use it, but Resident #78's wander guard was not working properly, and did not lock down the elevator, allowing the resident to leave the secured unit. LPN #3 identified that Resident #78's wander guard worked in some areas of the facility and not others, based on the investigation by LPN #3 and the DNS, but LPN #3 did not identify the specific areas that the wander guard failed to work. LPN #3 identified that the wander guard did not work to lock down the elevator on the secured locked unit, and Resident #78 was able to leave the unit. Further, LPN #3 identified the wander guard had expired in [DATE] and she changed it after the incident on [DATE]. LPN #3 identified that wander guards should be changed upon expiration. Interview with the Receptionist on [DATE] at 10:00 AM identified she was assigned to work the reception desk on [DATE] and was also assisting with admissions. The Receptionist identified she witnessed RN #1 walking a resident back into the building and that she was told the resident had a wander guard on, but it did not alarm or lock the exit doors. Interview with the Administrator on [DATE] at 10:12 AM identified he was aware Resident #78 had 2 incidents involving leaving the secured unit on the 4th floor to the 1st floor on [DATE] and [DATE]. The Administrator identified he had reviewed the security footage following the [DATE] attempt when he was made aware of an additional attempt on [DATE], 3 days prior. The Administrator identified that with both attempts, Resident #78 remained in the building and did not leave the lobby area (This is in conflict with the surveillance video that showed Resident #78 exiting the front door and being [NAME] back into the facility by RN #1). A request was made by this surveyor to review the security footage of the [DATE] and [DATE] incidents. The footage was observed with the Administrator identified the following: Observation of the security camera footage on [DATE] identified the following:. -At 8:10 PM Resident #78 walking toward the end of the 4th floor secured unit. At 8:13 PM Resident #78 walking down a flight of stairs located in the 1st floor stairwell. Resident #78 turns around to walk back up the stairs. At 8:16 PM Resident #78 is walking down the flight of stairs in the stairwell and exits the stairwell walking through a hallway on the 1st floor and towards to the main elevators. -At 8:18 PM Resident #78 pressed the up button and entered the elevator. At 8:24 PM Resident #78 walked out of the elevator on the 1st floor and through a set of double doors where the facility laundry and kitchen areas are located. -From 8:24 PM - 8:26 PM Resident #78 remained out of camera view in the laundry and kitchen areas. -At 8:26 PM NA #5 was seen entering the double doors in the laundry and kitchen areas and escorted Resident #78 towards the elevator and back to the 4th floor at 8:27 PM. Based on review of this security camera footage, Resident #78 was able to leave the 4th floor and was unsupervised in the facility from 8:11 PM - 8:26 PM, a total of 15 minutes. Observation of the security camera footage on [DATE] identified the following:. At 10:39 AM Resident #78 was seen standing at the 4th floor doors that give access to the elevator. A visitor exited the elevator to the 4th floor unit. -At 10:40 AM Resident #78 pressed the down button for the elevator and entered the elevator after the doors opened. -At 10:41 AM Resident #78 was observed exiting the 1st floor elevator and walked towards the lobby. -At 10:41 AM the Receptionist is seated at the reception desk, within direct eyesight of the exit door (approximately 6 feet) and the HR Director and Administrator are standing to the side of the reception desk facing the area of the front entrance. -At 10:41AM Resident #78 was seen walking towards the front entrance, directly passing the Receptionist, Administrator, and HR Director, through the initial exit door which did not appear to lock or alarm, and into the vestibule. -At 10:42 AM RN #1 was seen entering the facility with Resident #78. Interview with the Administrator immediately following the security camera footage identified that on [DATE], Resident #78 was able to access a back stairwell outside of camera view, descend 4 flights of stairs, and accessed the 1st floor. The Administrator identified that the 4th floor unit has 3 access stair wells, all secured by the wander guard system. The Administrator also identified while he reviewed the camera footage at the time of the [DATE] incident, he did not realize that that Resident #78 had gotten outside the building. The Administrator further identified that Resident #78's wander guard failed, which allowed him/her to be able to access the stairwell on the 4th floor on [DATE] as well as leave the building on [DATE]. Areas that Resident #78 had access to when the resident eloped the 4th floor on [DATE] and when he/she eloped the facility on [DATE] included the following. On the 1st floor, the resident had access to the kitchen area, oxygen storage area, maintenance area, and nursing supply storage and equipment storage areas. The kitchen area included a large walk-in refrigerator and freezer, large industrial gas burner stove/ovens and dishwasher areas with sanitizing chemicals. The 1st floor also included the location of the maintenance office with equipment. In addition, the 1st floor has a total of 8 separate exit doors. The 1st floor also had 3 additional access points to the facility basement, which include the facility boiler room, the laundry room, the electrical room, and main mechanical room. When the resident eloped the facility on [DATE], the resident had access to the facility parking lot which provided direct access to 2 city roads, and the main access road was visible from the parking lot. The facility is also located in close proximity to a large parking lot used for medical offices, a private school, and a church. Interview with RN #1 (IP Nurse) on [DATE] at 11:23 AM identified that he was leaving the facility for an appointment sometime between 10:30 AM - 11:00 AM on [DATE] and although he did not see the resident exit the facility, he saw Resident #78 outside of the facility. RN #1 identified he had observed Resident #78 standing approximately 5 feet from the outside exit doors of the facility on a sidewalk. Interview with the Maintenance Technician on [DATE] at 11:27 AM identified he was outside the facility working in the parking lot approximately 15 feet from the outside entrance doors on [DATE] when he saw RN #1 pull his vehicle up to the sidewalk near the entrance and saw a resident standing in the walkway. The Maintenance Technician identified he saw the resident there prior to RN #1 pulling up. The Maintenance Technician identified he saw RN #1 park his vehicle, get out, and walk Resident #78 back into the building. The Maintenance Technician identified he did not know Resident #78 was able to exit the building with a wander guard, or that the resident was able to leave the secured unit, until he was notified later that day. Review of the clinical record failed to reflect that every 15-minute checks or 1:1 monitoring had been initiated after Resident #78 was able to exit the 4th floor secured locked unit on [DATE]. Review of the user manual for the Advantage 1000DE system, the wander guard system used by the facility, directed that the transmitter should have an annual battery change, and that once the expiration date of the transmitter had been reached, they would not be repaired or have the warranty extended. The manual also directed that the advanced security mode feature allowed for doors attached to the system to remain locked when a monitored resident with a transmitter approached. The manual directed that when a resident with a transmitter was in range of the system, any doors connected to the system would lock and be accompanied by a beep. The facility policy on the Wander Guard Secure Care Alarm directed that residents identified as an elopement risk would have a wander guard applied to ensure their safety and directed that the device would be checked for placement every shift, function once daily and expiration and/or battery life weekly and these would be documented in the TAR. The policy further directed that any device that had expired or malfunctioned would be discarded or replaced. The facility policy on elopement directed that residents of the facility would be accounted for at all times, and any resident identified as missing would require protocol that would include to announce a designated code alert for a missing person and initiate a missing person report; assign staff to begin an organized search of the facility and grounds, and notify the DNS, Administrator, provider, and resident representative. The facility policy on environment of care related to the Alzheimer's Special Care Unit (located on the 4th floor) directed that the facility Wander Guard system was worn by residents who were determined to be high risk of elopement from the unit, and that the system would not allow exit from the facility's entrances and exits. The facility policy on 1:1 monitoring directed that a licensed nurse, the DNS, and/or the Administrator was responsible to place a resident on 1:1 observation if the safety of the resident was at risk. The policy further directed that facility guidelines for 1:1 observation included unsafe wandering or exit seeking behavior on or off the unit. The policy further directed that staff members were responsible to report any resident behaviors that posed a potential for harm to the resident, and the person who becomes aware of the situation was to stay with the resident and call for assistance, and that the licensed nurse was to evaluate the resident and ensure that the resident was not left alone and assign a designated person to monitor the resident 1:1. The policy also directed the DNS/Administrator, attending physician, and resident representative would be notified and that staff responsible for the resident would be educated by the licensed nurse on 1:1 observation.

Based on review of the clinical record, review of facility documentation, and staff interviews, for one of three residents (Resident #66) reviewed for accidents, the facility failed to provide adequate supervision and/or provide care according to the care plan to prevent a fall with an injury. The findings include: Resident #66 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#66 with assistance of two staff using a Hoyer lift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #66 was cognitively intact, required extensive assistance of 2 staff for bed mobility and toilet use, and was totally dependent on 2 staff members for transfers. Additionally, Resident #66 required extensive assistance of 1 staff for personal hygiene, dressing, and bathing and did not walk. The care plan dated 4/25/19 identified Resident #66 had a self-care performance deficit secondary to weakness and [MEDICAL CONDITION]. Additionally, the care plan interventions included to turn, reposition, and toilet Resident #66 in bed with the assistance of two staff. Review of a physical therapy progress note dated 5/8/19 identified Resident #66 was instructed on bed mobility from supine to sitting in bed and required assistance of one person due to the air mattress on Resident #66's bed. Additionally, Resident #66 required minimal assistance of two persons for slide board transfers due to Resident #66 had the tendency to shift weight too far forward due to the air mattress on the bed. Review of the physical therapy discharge summary dated 6/5/19 identified Resident #66 would perform bed mobility tasks with set up assistance, supervision and occasional verbal cues for proper positioning in order to decrease the risk for skin breakdown. Review of a facility reportable event form dated 6/6/19 identified Resident #66 was found lying on floor on his/her left side next to his/her bed and Resident #66 stated he/she had rolled out of bed. Additionally, interventions were revised to provide assistance of two staff with (activities of daily living) ADL's, although the care plan dated 4/25/19 already identified Resident #66 required assistance of two persons for bed mobility (turning and repositioning) and toileting. The clinical services summary of investigations form dated 6/6/19 identified Resident #66 rolled out of bed onto the floor when Resident #66 was on his/her side pulling onto the side rail during care. Review of the statement provided by Nurse Aide (NA) #4 on 6/6/19 identified he/she was changing Resident #66's bed sheet and giving care to Resident #66. Additionally, the statement identified NA #4 rolled Resident #66 onto the right side, and then to the left side and while Resident #66 held the rail NA #4 went to the other side of the bed to finish cleaning Resident #66 and that is when Resident #66 fell out of the bed. Further NA #4 identified Resident #66 told NA #4 that his/her leg gives out. A nurses note dated 6/6/19 identified Resident #66 stated he/she rolled out of bed when NA #4 was turning him/her in bed. The X-ray report dated 6/8/19 identified an acute, slightly angled [MEDICAL CONDITION] distal femoral shaft and at supracondylar region with diffuse osteopenia. The orthopedic consult report dated 6/10/19 identified Resident #66 rolled to the left, grabbed handrail to have sheets changed and lost his/her [MEDICATION NAME] and fell to the left onto the floor. Additionally, the consult identified Resident #66 had severe osteopenia and an acute [MEDICATION NAME] distal femur. Interview with NA #4 on 08/28/19 10:27 AM identified NA #4 was changing Resident #66's brief in bed on the air mattress. Additionally, after NA #4 rolled Resident #66 to the opposite side, he/she went around to the other side of the bed to finish care. Additionally, Resident #66 was holding the bed rail and NA #4 indicated that when he/she pulled the draw sheet using both of his/her hands by him/herself to pull Resident #66 closer to the middle of the bed, Resident #66's leg went over the other leg and pulled Resident #66's body over and he/she rolled onto the floor from the air matress. Further, NA #4 identified that Resident #66 had no sensation or control of his/her legs. Interview with Occupational Therapist (OT) #2 and Physical Therapist (PT) #1 on 08/29/19 at 9:53 AM identified Resident #66 required supervision with bed mobility at the time of the fall. Additionally, PT #1 identified Resident # 66 could turn on his/her side by him/herself with verbal cues. Further, PT #1 identified NA #4 should have had Resident #66 participate in the bed repositioning and had Resident #66 lay on his/her back, hold the bed rail and push to the middle of the bed, rather than NA #4 pull the bed sheet and Resident #66 toward the middle of the bed by him/herself. Additionally, OT #2 identified staff did not receive in-service training on bed mobility or how to reposition Resident #66 in bed because it was in their scope of practice to know and Resident #66 was alert and oriented and participated in his/ her care. Review of the facility fall prevention program policy identified each resident will have an individual evaluation and care plan which will address specific needs related to fall risk. Additionally, interventions included to provide staff supervision of ADL's, assist with ADL's to the extent required. Further the policy indicated to refer to the PT/OT evaluation for transfer techniques.

Based on clinical record reviews, review of facility documentation and interviews for one of four sampled residents (Resident #1) who required the assistance of two for bed mobility and/or transfers, the facility failed to utilize the appropriate number of staff during care to prevent an injury. The findings include: Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1's vision was highly impaired, short and long term memory deficits, severe cognitive impairments, difficulty focusing attention, was easily distracted, had difficulty following what was said, exhibited no behavioral symptoms, required total two person assistance for bed mobility, toilet use, and transfers in and out of the bed and/or chair, was non-ambulatory, had no history of falls, received an antianxiety medication daily and had functional limitation in range of motion on both sides of the upper extremities. The Resident Care Plan dated [DATE] identified Resident #1 had an alteration in bed mobility. Interventions directed for two person assistance with turning, positioning and pulling up in the bed. The nurse aide care card identified that Resident #1 was an extensive assist of two for bed mobility and was non-ambulatory. The Reportable Event Form dated [DATE] identified that Resident #1 fell from the bed while the nurse aide was rendering care. The report indicated that when the nurse aide turned Resident #1 on to his/her side, the resident reached for the privacy curtain and fell from the bed to the floor. Resident #1 sustained a laceration to the forehead that measured approximately eight (8) centimeters (cm), bruising to the left and right eyes and bruising to the left hand. The investigation dated [DATE] identified that the siderails were not up. The report indicated the Registered Nurse (RN) Supervisor upon responding to a call from the staff, found Resident #1 lying on the floor face down between the beds with a large amount of bleeding around the resident's head. The emergency personnel were called and Resident #1 was transferred to the hospital. The hospital record dated [DATE] identified Resident #1 sustained an acute cervical two spine fracture with left maxillary sinus fracture and left orbital fracture. Resident #1 was admitted to the Hospice Unit after it was determined that the best course of action was to stabilize and control the pain. Interview with the Director of Nursing (DON) on [DATE] at 2:00 PM identified the facility was informed that Resident #1 had expired and subsequent to the incident Nurse Aide (NA) #1 was terminated for not following the care plan. Interview with Registered Nurse (RN) #1 on [DATE] at 11:10 AM identified she responded when there was a call for supervisors to the unit. RN #1 indicated that Resident #1 was observed on the floor lying face down between the two beds and was bleeding from the face, emergency response was called and the resident was transferred to the hospital. RN #1 identified that the bed was observed at the time of the incident to be in the high position. Interview with NA #1 on [DATE] at 12:00 PM identified that on [DATE] while providing incontinent care Resident #1 grabbed for the curtain and fell off the bed. NA #1 stated that she was aware Resident #1 required two person assistance for a Hoyer lift transfer but was not aware that the resident required a two person assist with bed mobility. NA #1 identified that it the responsibility of the nurse aides to check the communication book to review and note if the care plan had changed for their assigned residents. NA #1 stated that there was no difficulty getting assistance from staff when needed. Interview with NA #2 on [DATE] at 1:15 PM identified that on a normal day there was no problem with getting the necessary assistance for care. Review of the nurse aide job description identified that the duty of the nurse aide was to perform duties as instructed by written assignment which will include resident care, activities of daily living, grooming and hygiene and transferring.

Based on review of the clinical records, a review of facility documentation, facility policies/ procedures and interviews for one of three sampled residents, (Resident #6 ), reviewed for mistreatment, the facility failed to ensure that the residents were free from physical abuse. The findings include: 1. Resident #6 [DIAGNOSES REDACTED]. The care plan dated 5/28/13 identified cognitive loss related to dementia, anxiety and rejection of care. Interventions included re-approaching if needed and anticipating the resident ' s needs. The facility accident incident report dated 6/5/13 identified NA # 4 and NA#5 reported NA#3 was observed "slapping " Resident#6's hand during care on the 3PM to the 11PM shift. The nursing assessment on 6/5/13 revealed a faint small bruise to the right elbow, the right forearm as well as redness to the right and left knees and shin. The alleged NA was immediately removed from the facility and the police were notified. Further assessment on 6/6/13 during the 7AM to the 3PM shift noted two additional bruises to the left forearm, and the bruise on the right elbow and forearm had increased in size and were darker in appearance. The facility investigative statement dated 6/5/13 at 8PM identified NA#4 and NA #5 reported to RN#1 that they had observed NA#3 slapping Resident #6 during the provision of care. The documentation also identified NA#3 was overheard to say " stop it, stop it ". Interview with NA#5 on 6/26/13 at 9:32PM identified he/ she was in a room with a peer assisting Resident#6 ' s roommate when he/she heard and observed NA#3 slap Resident#6 and covered the resident ' s head with his/her hand. Resident#6 yelled out during the incident. Interview with NA#3 on 6/27/13 at 12PM identified on 6/5/13 NA#4 and NA #5 assisted him/ her to transfer Resident #6 to bed for care. Resident #6 was combative during the transfer at which time NA#3 held onto Resident #6's hands so he/she would not get injured on the mechanical lift. NA #3 further identified Resident#6 remained combative while care was being provided in bed therefore he/she held Resident#6's hands across his/her chest when he/she was providing care. Interview with the DNS on 6/27/13 at 12:15 PM identified NA#3 employment was terminated as he/ she admitted to holding Resident#6's hands during care and the expectation would be for the nurse aide to stop care, report the behavior to the charge nurse and reapproach the resident at a later time.

Based on review of the clinical record, review of facility policy and procedures and interviews for one of eleven residents reviewed for unnecessary medications (Resident #161), the facility failed to ensure the resident was free of a significant medication error.The findings included: Resident #161 ' s was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of physician orders [REDACTED].M., 11:30 A.M. 4:30 P.M. and at hs (bedtime and/or 9:00 P.M.). The orders further directed to administer [MEDICATION NAME]/insulin sliding scale coverage for the following blood sugar results: BS 180-200 mg/dl give (=) 1 unit of insulin; BS 201-220 mg/dl = 2 units of insulin; BS 221-240 mg/dl = 3 units of insulin; BS 241-260 mg/dl = 4 units; BS 261-280 mg/dl = 5 units; BS 281-350 mg/dl = 6 units. Notify MD if BS is less than 60 and/or greater than 300. A review of facility documentation dated 1/19/13 at 2:00 A.M. identified Resident #161 was noted as having [MEDICAL CONDITION] -like activity, lethargy and decrease in his/her oxygen (O2) saturation (sat) level. Upon further review of the facility ' s investigation it was identified on 1/18/13 at 9:00 P.M. Resident #161 ' s BS was noted at 62 mg/dl. He/she was given a snack by LPN #1 (a new hire on orientation). After receiving the snack, LPN #1 went back to the resident to check his/her BS and it was noted at 201 mg/dl. After review of the physician sliding scale orders for [MEDICATION NAME]/insulin, LPN #1 determined the resident required 6 units of insulin when in fact, Resident #161 was to have been given only 2 units of insulin. At 12:15 A.M. the resident was observed exhibiting [MEDICAL CONDITION] activity and when his/her blood sugar was rechecked it was noted at 32 mg/dl, the resident O2 sat was down to 74% (normal range is 90 to 100%). The physician was notified and directed to administer emergency glucose, oxygen to support the resident ' s breathing and to transfer the resident to the ER for an evaluation. Resident #161 returned to the facility on [DATE] with no new orders. On 6/26/13 at 11:17 A.M. interview and review of the clinical record with LPN #2 identified LPN #1 was a new hire and that he/she was the new nurse ' s preceptor. He/ She further identified he/she left LPN #1 alone to complete the medication pass because he/she was busy doing other duties in the facility and felt comfortable with LPN #1 managing the medication pass because LPN #1 has performed this duty with him/ her in recent days without a problem. On 6/26/13 at 1:20 P.M. an interview and review of the clinical record with the DNS identified that the expectation that LPN#2 remain with LPN#1 during medication administration as LPN#1 was on orientation. According to the facility's policy and/or procedures for Safe Medication Administration, which identified the Nurse will demonstrate the ability to accurately identify the correct drug and dosage by utilizing necessary resources: pharmacy, supervisor and/or MD for clarification.

Based on clinical record review, review of facility documentation and staff interview for four of six sampled residents Residents #11, #20, #48, and #88, reviewed for accidents, the facility failed to ensure that a safe environment was provided the provision of incontinent care and/or transfer and/or that the brakes on the wheelchair of one resident, Resident #28, were repaired/replaced timely and/or that the device for one resident's electronic wheelchair, Resident #164, was recharged in a safe environment. The findings include: 1. Resident #11 (R #11) was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified R #11's Brief Mental Status (BIMs) score was seven which indicated moderate cognitive impairment. The assessment further identified that R #11 was totally dependent on staff for all Activities of Daily Living (ADLs) and required two persons for assistance with bed mobility and transfers. The resident care plan dated 1/12/12, identified R #11's alteration in bed mobility with interventions that included two nursing assistants to provide bed mobility and transfers and the use of a Hoyer lift. Review of a nursing note dated 3/12/12 at 11:00 AM identified that R #11 complained of left lower leg discomfort. The documentation dated 3/12/12 identified that R #11 reported that during a transfer the evening before, his/her leg "twisted the wrong way". Physician orders [REDACTED]. Written statements dated 3/14/12 by staff who performed R #11's transfer on the evening of 3/11/12, Nursing Assistant #7 (NA #7) and NA #8, were reviewed. NA #7's statement identified that R #11 cautioned the NAs not to touch his/her legs but denied that there were any obstacles in the way or that the resident made contact with the bed during the transfer. NA #8's written statement identified that R #11 told the NAs not to touch his/her legs as soon as the Hoyer lift was brought into the room, denied that the resident's legs bumped into anything, and indicated that R #11 did not complain of leg pain when NA #8 returned later in the evening. Review of the radiology report dated 3/13/12 identified that R #11 had sustained a slightly impacted fracture of the left distal femoral metaphysis. R #11 was subsequently transferred to the acute care hospital for further evaluation and returned to the facility on [DATE] with a left lower extremity immobilizer in place. Interview with the orthopedic physician, MD #1 on 8/9/12 at 1:00 PM identified that the type of fracture sustained by R #11 would not be caused by lowering the resident onto the bed during a Hoyer transfer. MD #1 stated that although the resident had very weak bones, R #11's leg would have had to been forcefully rotated, somehow twisted, and pulled hard while being moved and indicated that the resident's leg may have been caught during the move. 2. Resident #88 (R #88) had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified that R #88 had severe cognitive impairment and was totally dependent on facility staff for all Activities of Daily Living (ADLs) including bed mobility and transfers. Review of the care dated 7/7/11 identified that R #88 was for at risk for falls with interventions that included to keep the resident's bed in a low position and to apply bolsters to the air mattress. In addition, the care plan identified R #88's need for assistance with bed mobility with interventions that included to provide two people for turning and repositioning the resident in bed. The facility's ADL flow sheets dated 9/1/11 to 9/18/11 identified that R #88 required two people for bed mobility. Review of the nursing notes dated 9/18/11 at 5:30 AM identified that Nursing Assistant #3 (NA #3) reported that R #88 was sitting on the floor by the bed. The documentation identified that no injuries were noted at that time. A subsequent nursing note dated 9/18/11 recorded on the 7:00 AM to 3:00 PM shift identified that R #88's right shoulder/axilla and breast area was swollen and bruised, that the physician was notified, and that an order for [REDACTED]. Review of the radiology report dated 9/18/11 identified that the resident had a healing fracture at the greater tuberosity of the right humerus. Physician orders [REDACTED]. Review of a written statement by NA #3 dated 9/18/11 identified that on that date, NA #3 reported that as he/she changed the bottom sheet on R #88's bed, the resident slid to the opposite side and out of the bed. NA #3 documented that he/she tried to catch the resident but was unable to get to him/her in time and the resident slid down next to the bed. NA #3 documented that he/she then lifted the resident up and yelled for help. Interview with NA # 3 on 8/8/12 at 3:45 PM identified that he/she could not recall the incident but that he/she had documented what had occurred. Review of a written statement by LPN #3 dated 9/18/111 identified that upon hearing NA #3 call for help, he/she entered R #88's room, observed that the resident was "almost kneeling," and that NA #3 was holding the resident up. The documentation identified that LPN #3 instructed NA #3 to hold the resident's head and ease him/her to the floor. Review of a written statement dated 9/18/12 by the night supervisor, RN #1, identified that on 9/18/11, NA #3 reported that as R #88 started to slide out of the bed, NA #3 grabbed the resident's right arm to prevent further slipping while calling for help. Interview with RN #1 on 8/9/12 at 10:00 AM identified that on 9/18/11, NA #3 independently attempted to tuck in Resident #88's linen and that resident slid out of the bed and rolled onto the floor. Review of the orthopedic consult conducted at the acute care hospital dated 9/19/11 identified that R #88 had sustained a new fracture of the greater trochanter with a subacute appearing fracture in the humeral head. 3. Resident #20 (R #20) had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] identified that R #20 was alert and oriented though required extensive assistance with bed mobility and personal hygiene. The assessment further identified that R #48 was non-ambulatory, and totally dependent for transfers. Physician orders [REDACTED]. A nursing note dated 7/29/11 at 10:45 PM by LPN #4 identified that R #20 had rolled out of bed. Review of facility documentation dated 7/31/11 identified that R #20 reported that he/she rolled out of bed when he/she attempted to turn over in the bed. The resident denied pain upon initial evaluation by LPN #4. The nursing note dated 8/1/11 at an illegible time identified that a bruise was noted on R #20's the left shin. A late entry nursing note dated 8/2/11 identified that the left shin bruise was eight inches long on 8/1/11 and that R #20 was complaining of pain upon lifting the left leg. A subsequent nursing note dated 8/1/11 at 11:00 PM identified that the bruise to the lower left extremity persisted and that an x-ray was obtained. Interview with Nursing Assistant #10 on 8/8/12 at 2:30 PM identified that he/she was called to R #20's room on 7/29/11 to find R #20 sitting on the floor next to the bed. NA #10 stated that the resident's half side rails were in the up position when he/she entered the room. NA #10 identified that a new air mattress had been applied to R #20's bed that day and questioned if the air mattress could have caused the fall. Review of the radiology report dated 8/1/11 identified that R #20 had sustained a non-displaced incomplete fracture of the proximal fibula. Review of the manufacturer's warnings related to the use of the air mattress identified the potential for falls related to the soft edges of the air mattress that could collapse when patients (residents) roll to that edge. Subsequently to R #20's fall from the bed on 7/29/11, the air mattress was removed. 4. Resident #48 (R #48) had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] identified that R #48 was cognitively impaired, unable to make his/her needs known, was total totally dependent on staff for all Activities of Daily Living (ADLs) including bed mobility and transfer, and was non ambulatory. physician's orders [REDACTED]. A nursing note dated 12/31/11 at 2:00 PM identified that R #48 had a 10.0 by 13.0 centimeter (cm.) raised bruise on the right inner thigh. A subsequent nursing note dated 12/31/11 at 10:25 PM identified that upon the resident's return to bed after supper, R #48's right thigh was observed to also be swollen. The supervisor was notified, assessed the resident, and notified the physician. Physician orders [REDACTED]. A nurse's note dated 1/1/12 at 8:20 AM identified a late entry note for 12/30/11 which identified that a large bruise measuring 10 x 13 CM was noted during resident care. Interview on 8/8/12 at 1:10 PM with NA #6 identified that R #48's transfer from bed to chair on the morning of 12/31/11 was completed in accordance with the resident's plan of care and was without incident. NA #6 identified that the bruising/swelling of the resident's right thigh and swelling was not noted until R #48 was returned to bed after lunch. Review of the radiology report dated 12/31/11 identified that R #48 had sustained a comminuted proximal femur fracture. R #48 was subsequently transferred to the acute care hospital and underwent an Open Reduction/Internal Fixation (ORIF) of the right hip. Interview with the orthopedic surgeon, MD #1, on 8/8/12 at 1:40 PM identified that the type of fracture sustained by R #48 was due to trauma and could have occurred from falling out of bed with a twisting, pivoting force. MD #1 stated that a routine stand/pivot transfer would not have caused this type of fracture. 5. Resident #28 (R#28) had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified that R #28's Brief Interview for Mental Status (BIMS) score was fifteen, indicating no cognitive impairment. Current physician's orders [REDACTED]. During tour of the Unit 3 on 8/7/2012 at 9:20 AM, interview with R#28 identified that his/her wheelchair brakes were not functional. R#28 stated that he/she had notified Maintenance Worker #1 on numerous occasions over the prior several weeks and that the wheelchair brakes were still not functional. R #28 also indicated he/she transferred from the bed/chair/toilet independently to the wheelchair, and had to be "extra careful" since the wheelchair would roll backwards during transfer. Inspection of the wheelchair brakes with the Unit Supervisor, RN #5, on 8/7/2012 at 9:30 AM identified that the brakes on R#28's wheelchair were not functioning properly on both the left and right side of the wheelchair. Interview with the Director of Maintenance on 8/9/2012 at 11:45 AM indicated that if an equipment maintenance complaint is made directly to a the maintenance worker, the problem is usually resolved at that time, or if the maintenance worker is busy with another task, it would be resolved soon thereafter. The Director of Maintenance was unable to identify why the brakes on R #28's wheelchair had not been repaired. Maintenance Worker #1 was unavailable for interview during the duration of the survey. 6. Resident #164's [DIAGNOSES REDACTED]. The care plan dated 8/2/12 directed assist of two staff for transfers out of bed to a motorized wheelchair. Observation on 8/6/12 at 11:00AM identified that a twenty four (24) volt battery maximizer was plugged into the wall outlet of the resident's room. Observation on 8/7/12 at 9:36 AM identified the battery maximizer was noted to be plugged into the wall outlet and charging the electric wheelchair while two residents were in the room. Interview with the Unit Manager, RN #2, on 8/7/12 at 9:39 AM identified that the wheelchair should be charged downstairs, not in residents' rooms. Although a facility policy for safety measures when charging electric wheelchair batteries/maximizers was requested, the facility did not provide the information by the conclusion of the survey.