Every finding on record at Waters of Covington, The

A. Based on observation, record review, and interview, the facility failed to ensure the kitchen dish machine temperature and sanitation logs, and the refrigeration temperature logs were maintained, and failed to ensure the paper towels at the kitchen handwash sink were maintained in a sanitary manner, for 1 of 3 kitchen observations. This deficient practice had the potential to affect 81 of 81 residents residing at the facility. B. Based on observation, interview, and record review, the facility failed to ensure resident hall trays were delivered in a sanitary manner for 1 of 1 meal service observation. Findings include:A. During the initial kitchen observation, on 12/9/25 at 9:55 a.m., the following was observed: 1. The November and December 2025 dish machine temperature and sanitation logs lacked documentation as follows: a. The November 2025 logs lacked documentation that the rinse temperature and sanitation readings were completed for the breakfast and lunch meals on 11/1/25, 11/6/25, 11/7/25, 11/11/25, 11/15/26, 11/16/25, 11/19/25, 11/20/25, 11/24/25, 11/25/25, 11/28/25, 11/29/25, and 11/30/25. b. The December 2025 logs, from 12/1/25 through 12/9/25, lacked documentation that the rinse temperature and sanitation readings were completed for the breakfast and lunch meals on 12/1/25, 12/4/25, 12/5/25, and 12/8/25. Both monthly logs reviewed lacked documentation of the wash temperature and all readings for all of the dinner meals for the entire month. 2. Temperature logs for the refrigeration appliances lacked documentation as follows: a. No December 2025 temperature logs were observed for the stand-up refrigerator. b. The December 2025 temperature logs for the stand-up freezer lacked documentation for the evening reading on 12/2/25, the morning reading for 12/4/25, no reading for the day of 12/5/25, the morning reading for 12/7/25, and no reading for the day of 12/8/25. c. No temperature logs were observed for the walk-in refrigerator. d. No temperature logs were observed for the walk-in freezer. During an interview, on 12/9/25 at 10:20 a.m., Dietary Aide 5 indicated she usually completed the temperature logs for the refrigerators and freezers at the end of her shift. She had not completed any of the readings yet on this date. She did not know where the logs were for the stand-up refrigerator, the walk-in refrigerator or the walk-in freezer. 3. The towel dispenser by the hand wash sink was empty. A roll of towels was sitting on table next to the hand wash sink. The roll had visible wet finger marks on towels. At the same time, [NAME] 3 indicated the towel dispenser was not working and had been out for some time. During an interview, on 12/11/25 at 1:47 p.m., the Regional Director of Operations indicated the policy was that temperatures for all refrigeration and the dish machine should be completed each shift. The logs should be kept current daily. During an interview, on 12/12/25 at 3:25 p.m., the Administrator indicated the paper towels should be inside the unit to ensure they were kept clean when not in use. The situation that was found in the kitchen would be considered an infection control risk. On 12/12/25 at 3:21 p.m., the Administrator provided an undated document, titled, Freezer/Refrigeration Temperature Record, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: Temperatures shall be monitored in aal refrigeration and freezer equipment.Procedure: .2. The internal temperature of each piece of refrigeration and freezer equipment shall be recorded twice daily at minimum. The initials of the.employee conducting the temperature checks shall also be recorded on the log.3. The Director of Food and Nutrition Services or designee shall be responsible for posting the logs in the department. On 12/12/25 at 3:21 p.m., the Administrator provided an undated policy, titled, Handwashing, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: .Hand washing facilities will be.equipped with.paper towels. On 12/11/25 at 2:32 p.m., the Regional Nurse Consultant provided a document, with a revision date of November 2022, titled, Food Preparation and Service, and indicated it was the policy currently in use by the facility. The policy indicated, .General Guidelines.3.staff shall adhere to proper hygiene and sanitary practices.Food Preparation Area.4. Appropriate measures are used to prevent cross contamination. B. During observation of meal service on,12/9/25 at 12:31 p.m., Licensed Practical Nurse (LPN) 12 was observed serving hall trays to residents. She was observed touching the outside of the tray cart and delivering and cutting up resident food. No hand sanitation was observed during the tray pass process. On 12/9/25 at 12:49 p.m., LPN 12 was observed to assist a Certified Nurse Assistant (CNA) to pull a resident up in bed. The LPN then washed her hands for less than 20 seconds before continuing to serve meal trays to residents. During an interview, on 12/11/25 at 2:23 p.m., the Director of Nursing (DON) indicated the nurse should have sanitized her hands between serving residents their meal trays. On 12/11/25 at 2:32 p.m., the Regional Nurse Consultant provided a document, with a revision date of November 2022, titled, Food Preparation and Service, and indicated it was the policy currently in use by the facility. The policy indicated, .General Guidelines.3.staff shall adhere to proper hygiene and sanitary practices.Food Distribution and Service.5. Food and Nutrition services staff, including nursing services personnel, wash their hands before serving food to residents.prior to handling food trays. 3.1-(i)(3)

Based on record review and interview, the facility failed to follow antibiotic stewardship protocol program. This deficient practice had the potential to affect 81 of 81 residents residing at the facility. Findings include:On 12/12/25 at 1:30 p.m., review of the facility infection control program with the Infection Prevention Nurse (IP) indicated, the documentation lacked evidence of antibiotic stewardship tracking and trending. The program lacked documentation of education regarding any trending infections or prevention.12/12/25 at 1:45 p.m., during an interview the IP nurse, he indicated he had been tracking antibiotic stewardship once but had not continued.Review of the Centers for Disease Control and Prevention (CDC) webpage, The Core Elements of Antibiotic Stewardship, accessed online at: https://www.cdc.gov/antibiotic-use/hcp/core-elements/ . Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance.On 12/12/25 at 2:00 p.m., the Director of Nursing (DON)provided a document, titled, Antibiotic Stewardship, dated 3/14/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Accountability.2. The Infection Preventionist monitors antibiotic utilization and discusses opportunities for improvement.Tracking.1. The Infection Preventionist/designee(s).a. Reviews culture and sensitivity reports routinely as part of the surveillance of the infection. b. Tracks how often and how many antibiotics are prescribed. C. Tracks how and why antibiotics are prescribed.

Based on record review and interview, the facility failed to ensure informed consent was obtained for the administration of psychotropic medications (drugs that affect the brain's chemical makeup to treat mental and emotional disorders), for 5 of 5 resident reviewed for unnecessary medications (Residents 53, 11, 10, 74, and 47). Findings include:1. Resident 53's record was reviewed on 12/10/25 at 1:55 p.m. The profile indicated the resident had been admitted to the facility on [DATE]. The resident was discharged from the facility on 12/10/25. The profile indicated the resident's diagnoses included, but were not limited to, major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities, significantly impacting daily life for at least two weeks) and unspecified psychosis (a diagnosis used when someone has psychotic symptoms but there's not enough information for a specific diagnosis). A quarterly Minimum Data Set (MDS) assessment, dated 10/30/25, indicated the resident had moderate cognitive deficit and received antipsychotic medication (used to treat psychosis) and antidepressant medications (used to treat depression). A physician's order, dated 3/28/25 and discontinued on 8/7/25, indicated to administer one 30 milligram (mg) capsule of duloxetine hydrochloride (HCl) (antidepressant medication) along with one 60 mg capsule, to equal 90 mg, at bedtime, related to major depressive disorder. A physician's order, dated 8/7/25 and discontinued on 8/14/25, indicated to administer one 60 mg capsule of duloxetine HCl along with one 30 mg capsule, to equal 90 mg for depression for 1 week. A physician's order, dated 8/8/25 and discontinued on 12/10/25, indicated to administer a 10 mg tablet of Lexapro (antidepressant medication), one time daily for depression. A physician's order, dated 8/15/25 and discontinued of 8/22/25, indicated to administer a 30 mg capsule of duloxetine, at bedtime for depression for 7 days. A document, dated 4/1/25 through 4/15/25, titled, Recommendation to Nursing, indicated the resident was taking psychotropic medications and no informed consent was found in the resident record for the following Psychotropic medications: duloxetine. The record lacked documentation of informed consents for the antidepressant medications when they were initiated or increased. A physician's order, dated 5/22/25 and discontinued on 6/5/25, indicated to administer one 3 milligram (mg) tablet of Invega (antipsychotic medication), at bedtime for unspecified psychosis. A physician's order, dated 6/5/25 and discontinued on 6/18/25, indicated to administer two 3 mg tablets of Invega at bedtime for psychosis. A physician's order, dated 6/18/25 and discontinued on 10/23/25, indicated to administer one 3 mg tablet of Invega, at bedtime for psychosis. A physician's order, dated 10/23/25, and discontinued on 11/6/25, indicated to administer one 2.5 mg tablet of olanzapine (antipsychotic medication), one time in the evening for psychosis. The record lacked documentation of informed consents for the antidepressant medications when they were initiated or increased. 2. Resident 11's record was reviewed on 12/11/25 at 11:27 a.m. The profile indicated the resident was admitted to the facility on [DATE]. The profile indicated the resident's diagnoses included, but were not limited to, unspecified mood disorder (a diagnosis for significant mood problems that cause distress but don't fully meet criteria for a specific disorder) and bipolar disorder (a mental health condition causing extreme mood swings, shifting between emotional highs and lows, affecting energy, activity levels, sleep, judgment, and daily functioning, with periods of normal mood in between). A quarterly Minimum Data Set (MDS) assessment, dated 11/11/25, indicated the resident had no cognitive deficit and received antipsychotic (medications used to treat symptoms of bipolar disorder) and antidepressants (medications to treat depression). A physician's order, dated 1/24/25, indicated to administer a 20 milligram (mg) tablet of fluoxetine hydrochloride (HCl) (antidepressant medication), one time daily for depression. The record lacked documentation of informed consent for the antidepressant medication. A physician's order, dated 3/28/25 and discontinued on 8/28/25, indicated to administer 100 mg tablet of quetiapine (antipsychotic medication), at bedtime related to bipolar disorder. A physician's order, dated 8/28/25 indicated to administer 150 mg of quetiapine, every evening for bipolar disorder. The record lacked documentation of informed consent for the initiation and/or increase of the antipsychotic medication. 3. Resident 10's record was reviewed on 12/10/25 at 1:35 p.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, insomnia (difficulty sleeping) and mania (abnormally elevated, extreme changes in mood). A quarterly Minimum Data Set (MDS) assessment, dated 9/26/25, indicated the resident had a moderate cognitive impairment and received an antidepressant and anticonvulsant during the look back period. A physician's order, dated 6/23/25, indicated administer trazodone (antidepressant sometimes used for insomnia) 50 milligrams (mg) daily at bedtime for insomnia. A physician's order, dated 7/31/25 and discontinued on 11/25/25, indicated administer divalproex sodium (anticonvulsant sometimes used as a mood stabilizer) extended release (ER) 500 mg by mouth twice daily for mania. The electronic record lacked documentation informed consent was obtained when the trazodone and divalproex sodium were initiated. During an interview, on 12/10/25 at 2:20 p.m., the Director of Nursing (DON) indicated some of the informed consents for psychotropic medications had not been completed. Informed consents should have been obtained when psychotropic medications were initiated or increased. 4. On 10/10/25 at 2:00 p.m., the medical record of Resident 74 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but was not limited to dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), Chronic Obstructive Pulmonary Disease, (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). The record indicated that a psychotropic medication had been ordered by the physician and a consent to administer the medication had not been obtained from the responsible party. An annual Minimum Data (MDS) assessment, dated 9/11/25, indicated the resident received anti-depressant medication. The medical record indicated the resident was administered Zoloft 25 mg (milligrams) from 1/3/25 to 3/20/25, Zoloft 50 mg from 3/20/25 to 8/7/25, and Zoloft 100 mg from 8/7/25 to 10/23/25. A physician order, dated 10/23/25, indicated to administer Cymbalta Oral Capsule Delayed Release Particles 30 mg (Duloxetine HCl) once daily at bedtime for depression. A physician order, dated 5/10/25, indicated to administer Donepezil HCl oral Tablet 10 mg (Donepezil Hydrochloride) give 1 tablet by mouth in the evening related to unspecified dementia. A pharmacy recommendation, dated 4/15/25, indicated, The resident is currently taking psychotropic medications. No informed consent found in the chart for the following medications: Sertraline. On 12/10/25 at 11:30 a.m., during an interview, the Director of Nursing (DON) indicated the resident's record did not have consents for psychotropic medications. 5. Resident 47's record was reviewed on 12/10/25 at 1:43 p.m. The profile indicated the resident's diagnoses included, but were not limited to, manic episode, severe, without psychotic symptoms (intense euphoria/irritability, high energy, racing thoughts, pressured speech, little sleep, and impulsive/reckless behavior (like spending sprees or risky sex) that significantly impairs functioning, but without hallucinations or delusions), depression (a serious mood disorder causing persistent sadness, loss of interest, and affecting how you think, feel, and live, impacting daily activities, sleep, appetite, and energy), and vascular dementia (a decline in thinking skills from reduced blood flow to the brain, often after strokes or from chronic conditions like high blood pressure, causing issues with memory, planning, judgement, and concentration). Facility census information indicated Resident 47 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 9/23/25, indicated the resident had severe cognitive impairment and received anti-psychotic medication during the look back period. A physician order, dated 7/3/25, indicated to administer Seroquel (anti-psychotic medication) 50 mg (milligram) by mouth at bedtime for manic episodes. A physician order, dated 5/29/25 and discontinued on 7/3/25, indicated to administer Seroquel 50 mg by mouth at bedtime for behavioral disturbance. A physician order, dated 1/24/25 and discontinued on 5/29/25, indicated to administer Seroquel 75 mg by mouth at bedtime for behavioral disturbance. A pharmacy recommendation to nursing, dated 4/15/25, indicated Resident 47 received a psychotropic medication and no informed consent was found in the chart for Seroquel. The electronic record lacked documentation of a psychotropic informed consent was obtained for the use of the Seroquel medication. During an interview on 12/20/25 at 2:32 p.m., the Director of Nursing (DON) indicated they had discovered that the facility had not completed all the psychotropic medication informed consents since the new regulation was initiated, and they would make sure they are completed as soon as possible. On 12/20/25 at 3:15 p.m., the Regional Nurse Consultant provided a document with a revised date of February 2025, titled, Psychotropic Medication Use, and indicated it was the policy currently being used by the facility. The policy indicated, .1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal; a. non-pharmacological alternatives; b. the indications and rationale for recommendation; c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and d. the resident's/representative right to accept or decline the treatment. 3.1-3(n)(2) 3.1-3(n)(3)

Based on record review and interviews the facility failed to offer snacks to residents in the evening for 5 of 5 residents reviewed for snacks at bedtime (Residents 27, 28, 42, 87, and 91). Findings include:On 12/11/25 at 2:00 p.m., during resident council meeting the residents indicated they did not receive bedtime snacks and indicated they had a diagnosis of diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). Review of the medical record of Residents 91, 28, 42, and 87 indicated each resident had a diagnosis of diabetes. On 12/11/25 at 2:15 p.m., during an interview the Administrator indicated the residents should be served snacks daily.On 12/11/25 at 2:23 p.m., during an interview the Director of Nursing (DON) indicated all residents should be offered a snack in the evenings especially the diabetic residents to maintain blood sugar levels through the night. On 12/11/25 during an interview Registered Nurse (RN) 11 indicated snacks were inconsistent. At times they had to go out and buy them for the residents. She indicated snacks should come out every evening. There had been times when they were told the facility did not have them.Review of the Residents medical records indicated Resident 91 had a diagnosis of diabetes. The task report (a daily record of meal and snack intake) indicated the resident had received a bedtime snack 6 times in the last 30 days.The task report of Resident 27 indicated the resident had received a bedtime snack 7 times in the last 30 days.The task report of Resident 28 indicated the resident had received a bedtime snack 5 times in the last 30 days.The task report of Resident 42 indicated the resident had received a bedtime snack 5 times in the last 30 days.The task report of Resident 87 indicated the resident had received a bedtime snack 4 times in the last 30 days.The task report of Resident 91 indicated the resident had received a bedtime snack 9 times in the last 30 days.On 12/11/25 at 2:42 p.m., the Director of Nursing (DON) provided an undated document, titled, Food and Nutrition Services, and indicated it was the policy currently being used by the facility. The policy indicated, .10. Nourishing snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns.3.1-21(e)

A. Based on observation, record review, and interview, the facility failed to ensure a catheter (tube inserted into the bladder to drain urine) bag did not come in contact with an unclean surface for 1 of 1 residents reviewed for catheters (Resident 10). B. Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed during the medication pass for 4 of 4 residents reviewed on the medication pass (Residents 92, 93, 96, and 39). Findings include: A. On 12/9/25 at 11:13 a.m., Resident 10 was observed lying in bed. The resident's catheter draining bag was hanging from the side of the bed and was resting on the bottom leg bar of the bedside table. On 12/11/25 at 9:40 a.m., Resident 10 was observed lying in bed. The resident's catheter draining bag was hanging from the side of the bed and was resting on the bottom leg bar of the bedside table. Resident 10's record was reviewed on 12/10/25 at 1:35 p.m. Diagnoses on the resident's profile included, but were not limited to, vascular dementia (a decline in thinking skills caused by conditions that damage blood vessels, restricting blood flow and oxygen to the brain, often after strokes or mini-strokes) and retention of urine. A quarterly Minimum Data Set (MDS) assessment, dated 9/26/25, indicated the resident had a moderate cognitive impairment and an indwelling urinary catheter. A care plan, initiated on 7/9/25, indicated the resident had an indwelling urinary catheter. A physician's order, dated 7/16/25, indicated the resident had a urinary catheter, and it was to be changed every 30 days and as needed. During an interview, on 12/11/25 at 1:56 p.m., the Regional Nurse Consultant indicated the resident's catheter bag should not have been in contact with the bedside table leg. Catheter bags should not have been in contact with areas not considered clean. On 12/11/25 at 2:19 p.m., the Director of Nursing (DON) provided a document titled, Catheter Care, Urinary, last revised in August 2022, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Preparation.Infection Control.2. Be sure the catheter tubing and drainage bag are kept off the floor. B. During a continuous medication pass observation, on 12/12/25 from 11:47 a.m. to 11:58 a.m., the following was observed: Registered Nurse (RN) 15 prepared and administered medication to Resident 92. The nurse pulled up his scrub pants on 2 different occasions while in the resident room along with wiping his forehead. RN 15 did not perform hand hygiene before or after administering the resident their medication. The RN returned to the medication cart and prepared medication for Resident 93. He went into the resident's room and administered the resident their medication. The nurse pulled up his scrub pants twice, wiped his forehead, and under his nose. While the RN was walking down the hallway he took hand sanitizer out of his pocket for his hands and used it. The RN returned to the medication cart and prepared medication for Resident 96. The nurse went into the resident's room to administer their medication and while waiting for the resident to take their medication he pulled up his scrub pants and wiped his mustache. RN 15 did not perform hand hygiene after administering the resident their medication. The RN returned to the medication cart and prepared medication for Resident 39, while he was obtaining the medication from the cart, he pulled up his scrub pants. RN 15 proceeded to the resident's room to administer the medication and no hand hygiene was performed before or after the administration of the resident's medication. During an interview, on 12/12/25 at 3:04 p.m., the Regional Nurse Consultant indicated that it was the expectation of the facility that staff would perform hand hygiene before and after administering medication to each individual resident. On 12/15/25 at 9:55 a.m., the Administrator provided an undated document, titled, Administering Medications, and indicated it was the policy currently being used by the facility. The policy indicated, . 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 3.1-18(a)

Based on record review and interview, the facility failed to ensure the physician signed and dated a pharmacy recommendation for psychotropic medications, failed to ensure behavior documentation was available to justify an increase in psychotropic medication dosage, and failed to ensure documentation to justify the declination of psychotropic medication dosage reductions for 3 of 5 residents reviewed for unnecessary medications (Residents 53, 11, and 10). Findings include:1. Resident 53's record was reviewed on 12/10/25 at 1:55 p.m. The profile indicated the resident's diagnoses included, but were not limited to, major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities, significantly impacting daily life for at least two weeks). A quarterly Minimum Data Set (MDS) assessment, dated 10/30/25, indicated the resident had moderate cognitive deficit and received antidepressant medications (used to treat depression). A pharmacy recommendation, with a printed date of 3/21/25, indicated to consider a dose reduction of the resident's duloxetine (antidepressant medication) from the current administered dose of 60 milligrams (mg) at bedtime to 40 mg at bedtime, for major depressive disorder. The document indicated the recommendation had been marked as declined. A handwritten note on the document, signed by the psychologist, indicated the resident was actively depressed and hurting and recommended the duloxetine be increased to 90 mg at bedtime. A physician's order, dated 3/28/25, indicated to administer one 30 milligram (mg) capsule of duloxetine hydrochloride (HCl) (antidepressant medication) along with one 60 mg capsule, to equal 90 mg, at bedtime, related to major depressive disorder. The pharmacy recommendation lacked a signature and date of review by the attending physician. 2. Resident 11's record was reviewed on 12/11/25 at 11:27 a.m. The profile indicated the resident's diagnoses included, but were not limited to, bipolar disorder (a mental health condition causing extreme mood swings, shifting between emotional highs and lows, affecting energy, activity levels, sleep, judgment, and daily functioning, with periods of normal mood in between). A quarterly Minimum Data Set (MDS) assessment, dated 11/11/25, indicated the resident had no cognitive deficit and received antipsychotic medication (used to treat symptoms of bipolar disorder). A pharmacy recommendation, with a printed date of 8/25/25, indicated the resident was due for a trail dose reduction of her order for Seroquel (antipsychotic medication) 100 milligrams (mg) at bedtime for bipolar disorder. The document indicated the physician had marked the recommendation had been declined. A handwritten note on the document, signed by the psychologist, indicated the resident's mood was not great and to increase the Seroquel to 150 mg at bedtime. The recommendation was signed and dated by the physician on 8/28/25. A physician's order, dated 8/28/25, indicated to administer 150 mg of quetiapine, every evening for bipolar disorder. A Medication Administration Record (MAR), dated July and August 2025, indicated the resident was monitored every shift for behaviors including, but not limited to, depression and withdrawal, insomnia, refusal of care, and falsely accusing staff. Each shift indicated the resident had no behavior documented. The record lacked any psychologist visit notes from 3/27/25 to 10/2/25, or any other documentation of behavior concerns by the resident. During an interview, on 12/12/25 at 11:46 a.m., the Regional Nurse Consultant indicated they had reached out to the psychologist for any notes to justify the increase in the resident's Seroquel. He had indicated he could not provide any further documentation. 3. Resident 10's record was reviewed on 12/10/25 at 1:35 p.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, insomnia (difficulty sleeping) and mania (abnormally elevated, extreme changes in mood). A quarterly Minimum Data Set (MDS) assessment, dated 9/26/25, indicated the resident had a moderate cognitive impairment and received an antidepressant and anticonvulsant during the look back period. A physician's order, dated 6/23/25, indicated administer trazodone (antidepressant sometimes used for insomnia) 50 milligrams (mg) daily at bedtime for insomnia. A physician's order, dated 7/31/25 and discontinued on 11/25/25, indicated administer divalproex sodium (anticonvulsant sometimes used as a mood stabilizer) extended release (ER) 500 mg by mouth twice daily for mania. A gradual dose reduction (GDR) request from the pharmacist was dated 10/27/25. The request indicated the resident received divalproex sodium 500 mg twice daily and requested the medication be decreased to 375 mg twice daily. The psychologist wrote on the form not to reduce the medication. A nurse wrote on the form, Declined per [physician's name] as recommended by [psychologist's name]. The physician did not document a justification for the GDR declination or sign the form. A Medication Administration Record (MAR), dated November 2025, indicated the resident was monitored every shift for behaviors including physical aggression, agitation, mania, anxiety, resisting care, refusing to change clothes, refusing treatments, and sleeplessness. Each shift indicated the resident had no behaviors. A document titled, Behavior Meeting, was dated 11/21/25. The document indicated the resident was reviewed and increase Depakote [divalproex sodium] 500 mg TID [three times daily]. The behavior meeting lacked documentation of why the divalproex sodium was increased, including what behaviors the resident exhibited. A physician's order, dated 11/25/25, indicated administer divalproex sodium delayed release 500 mg by mouth three times daily for mania. A progress note, dated 11/25/25, indicated the resident was reviewed in the behavior meeting with a recommendation to increase the divalproex sodium to three times daily for mania. The note lacked documentation of why the divalproex sodium was increased, including what behaviors the resident exhibited. A MAR, dated December 2025, indicated the resident was monitored every shift for behaviors including physical aggression, agitation, mania, anxiety, resisting care, refusing to change clothes, refusing treatments, and sleeplessness. Each shift indicated the resident had no behaviors. During an interview, on 12/11/25 at 10:36 a.m., the Regional Nurse Consultant indicated the resident's physician normally agreed with the psychologist regarding GDR requests, but the physician did not always document or sign the forms. During an interview, on 12/11/25 at 11:12 a.m., the Regional Nurse Consultant indicated the resident was reviewed in the behavior meeting, and the medication was increased. She was unable to find any documentation of the resident's behaviors. Behaviors should have been monitored and documented on the MAR. During an interview, on 12/11/25 at 11:34 a.m., Psychologist 14 indicated the resident's medication was increased because his mood was becoming accelerated and falls had increased. The behaviors should have been documented by the facility staff, but sometimes there were issues with documentation. On 12/11/25 at 11:12 a.m., the Regional Nurse Consultant provided a document titled, Tapering Medications and Gradual Dose Reduction, last revised April 2025, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement.2 Residents who use psychotropic medications received gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these medications. Policy Interpretation and Implementation: 1. Gradual Dose Reduction (GDR) refers to the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed at a lower dose or if a medication can be discontinued.Documentation – Gradual Dose Reduction: 1. Gradual dose reduction attempts are documented in the medical record. The documentation includes.2. Physician documentation contains the rationale for why GDR attempts are clinically contraindicated for the resident. On 12/11/25 at 11:29 a.m., the Regional Nurse Consultant provided a document titled, Psychotropic Medication Use, last revised February 2025, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement: Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Policy Interpretation and Implementation: 1. Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior.Behavioral and Other Non-Pharmacological Interventions: 1. Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction.Adequate Indications for Psychotropic Medication Use.3. The clinical rationale for the use of psychotropic medication, or a change from one type of psychotropic to another, is documented in the medical record. a. Documentation must include that behavioral (non-pharmacological) interventions were attempted but not successful, and these interventions were deemed clinically contraindicated. b. Alternatively, documentation from a physician must describe that alternative treatments are clinically contraindicated and the rationale for this conclusion. 3.1-48(b)(2)

Based on record review and interview, the facility failed to ensure a notice of transfer or discharge and bed hold policy was provided to the resident who was transferred to the hospital for 1 of 2 residents reviewed for hospitalization (Resident 12). Findings include:Resident 12's record was reviewed on 12/12/25 at 10:21 a.m. Census information indicated the resident was hospitalized from [DATE] to 10/10/25. A significant change Minimum Data Set (MDS) assessment, dated 9/3/25, indicated the resident was cognitively intact. A progress note, dated 10/6/25 at 3:40 a.m., indicated the resident was found sitting on the floor in his room. The resident denied pain and was assisted back to the chair. A progress note, dated 10/6/25 at 3:13 p.m., indicated the resident complained of pain to the right hip, and an x-ray was ordered by the physician. A progress note, dated 10/6/25 at 9:02 p.m., indicated the facility received the x-ray results and, and an order was received to send the resident to the emergency room (ER). A report was called to the ER. A progress note, dated 10:19 p.m., indicated the resident left in an ambulance for the treatment of a fractured right hip related to a fall. A progress note, dated 10/10/25, indicated the resident returned to the facility. Progress notes lacked documentation a notice of transfer or discharge and a bed hold policy was provided when the resident was transferred to the hospital. The electronic record lacked documentation a notice of transfer or discharge or bed hold policy was provided with the hospitalization on 10/6/25. During an interview, on 12/12/25 at 1:33 p.m., the Regional Nurse Consultant indicated when a resident was transferred to the hospital a packet should have been sent with them which included the notice of transfer or discharge and the bed hold policy. On 12/12/25 at 1:30 p.m., the Regional Nurse Consultant provided a document titled, Transfer or Discharge, Emergency Acute Care, last revised in April 2025, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement: Residents transferred to an acute care setting for emergency treatment are provided with a notice of transfer and are permitted to return to the facility. Policy Interpretation and Implementation.2. When a resident is temporarily transferred to an acute care facility, a notice of transfer is provided to the resident and resident representative as soon as practicable before the transfer.

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) (screening assessment to determine if a resident has a serious mental illness) was completed accurately for 1 of 2 residents reviewed for PASRR (Resident 2). Findings include:Resident 2's record was reviewed on 12/11/25 at 10:47 a.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, unspecified dementia (general term for a decline in cognitive function severe enough to interfere with daily life, affecting memory, thinking, and social abilities) of unspecified severity with other behavioral disturbance and unspecified psychosis (disconnection from reality with false beliefs and experiencing things that are not real) not due to a substance or known physiological condition. A Notice of PASRR Level I (screening required for all residents entering a long-term care facility to determine if there is a serious mental illness present) Screen Outcome, dated 12/14/24, indicated the resident did not require a level II PASRR (a comprehensive evaluation process for individuals identified as having serious mental illness or intellectual disabilities when applying for admission to a long-term care facility) assessment because there was no serious mental illness found on the level I PASRR assessment. The attached assessment lacked documentation of the resident's diagnosis of psychosis. A comprehensive Minimum Data Set (MDS) assessment, dated 9/42/25, indicated the resident was not considered by the state to be a level II PASRR but had a diagnosis of psychotic disorder other than schizophrenia (a serious mental health disorder that affects how a person thinks, feels, and behaves, often leading to a distorted perception of reality). During an interview, the Social Services Director (SSD) indicated she was not sure why the psychosis diagnosis was not included on the resident's Level I PASRR. On 12/11/25 at 1:23 p.m., the SSD provided a document titled, PASRR Completion Policy, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement: The Center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. Practice Guidelines: 1. Center Administrator will designate either the Admissions Director or Social Worker to make sure that the PASSRR [sic] and/or Level of Care (LOC) is done on all potential residents. If the referral indicates anything which might constitute an SMI [serious mental illness] or ID [intellectual disability], the PASRR must be completed prior to admission. If the resident is deemed 'hospital exempted' that must be clearly documented in the transfer documents prior to admission from the acute care facility. 3.1-16(d)(1)(A)

Based on observation, record review, and interview, the facility failed to ensure residents were provided assistance with activities of daily living (ADLs) to ensure good hygiene for 3 of 4 residents reviewed for ADLs (Residents 10, 2, and 90). Findings include: 1. On 12/9/25 at 11:12 a.m., Resident 10 was observed lying in bed with untrimmed facial hair and long untrimmed fingernails with dark debris underneath them. On 12/9/25 at 9:40 a.m., Resident 10 was observed lying in bed with untrimmed facial hair and long untrimmed fingernails with dark debris underneath them. Resident 10's record was reviewed on 12/10/25 at 1:35 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 9/26/25, indicated the resident had a moderate cognitive impairment, required substantial/maximal assistance from staff with personal hygiene, had a diagnosis of moderate vascular dementia (a type of dementia caused by reduced blood flow to the brain, leading to cognitive impairment and memory loss), and indicated the resident had no behaviors including rejection of care. A care plan, initiated on 6/24/25, indicated the resident required staff assistance with ADLs related to impaired cognition and poor activity endurance. The shower/bathing task document in the electronic record indicated the resident had not refused showering or bathing in the last 30 days. Progress notes, dated November and December 2025, lacked documentation the resident was offered or refused shaving and nail care. Shower sheets indicated the resident received a shower on 11/8/25, 11/12/25, 11/19/25, 11/22/25, and 12/7/25. The documents lacked documentation the nail care or shaving was offered or refused with the showers. During an interview, on 12/11/25 at 10:55 a.m., the Regional Nurse Consultant indicated nail care and shaving should have been provided with showers and as needed. 2. On 12/9/25 at 11:26 a.m., Resident 2 was observed with untrimmed facial hair growth. At the same time, he indicated he wanted to have a mustache but wanted the rest of the facial hair shaved every day. The resident indicated he was shaved last about a week ago. On 12/11/25 at 1:30 p.m., Resident 2 was observed lying in bed with untrimmed facial hair growth on his face. At the same time, the resident indicated he had not been shaved for six days. The resident indicated he wanted to keep the mustache but wanted the rest of his face shaved at least every other day. Resident 2's record was reviewed on 12/11/25 at 10:47 a.m. A comprehensive Minimum Data Set (MDS) assessment, dated 9/4/25, indicated the resident was cognitively intact, had a diagnosis of unspecified dementia (a decline in cognitive function severe enough to interfere with daily life, affecting memory, thinking, and social abilities), and had no behaviors including rejection of care. A care plan, last revised on 10/15/25, indicated the resident required assistance with ADLs related to weakness. Progress notes, dated 11/11/25 to current, lacked documentation the resident was offered or refused shaving. The shower/bathing task document in the electronic record indicated the resident had not refused showering or bathing in the last 30 days. Shower sheets indicated the resident received a shower on 11/18/25 and 12/2/25. The documents lacked documentation the resident was offered or refused shaving with the showers. During an interview, on 12/11/25 at 10:55 a.m., the Regional Nurse Consultant indicated shaving should have been provided with showers and as needed. On 12/11/25 at 1:54 p.m., the Regional Nurse Consultant provided a document titled, Shaving the Resident, last revised in February 2018, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: The purpose of this procedure is to promote cleanliness and to provide skin care.Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed.4. Any problems or complaints made by the resident related to the procedure. 5. If the resident refused the treatment, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the procedure. 3. On 12/10/2025 9:13 a.m., during initial observation noted Resident 90 had brown debris caked under fingernails. On 12/11/25 at 11:28 a.m., the medical record of Resident 90 was reviewed. The resident was admitted to the facility on [DATE], admission diagnosis included but were not limited to, chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat. It can be a normal reaction to stress), and congestive heart failure (CHF) (a condition that develops when your heart doesn't pump enough blood for your body's needs). An admission Minimum Data Set (MDS) assessment, dated 10/31/25, indicated the resident had limited cognition and she was dependent for upper body assistance and showers. A care plan, dated 10/27/25, indicated the resident required staff to assist with activities of daily living due to poor activity endurance. Interventions included but were not limited to, bathe per resident preference 2 times week and as needed, set up and assist with shower 2 times week and as needed. On 12/11/25 at 10:30 a.m., during general observation and interview noted the resident still had caked on debris under her nails. She indicated she did receive showers sometimes and she guessed she should clean her nails. On 12/11/25 at 10:35 a.m., during an interview Certified Nurse Aide (CNA) 8 indicated the residents were provided a shower two three times per week and indicated the staff should clean the residents nails when providing showers. On 12/11/25 at 10:45 a.m., during an interview Registered Nurse (RN) 6 indicated the residents should have nails cleaned on shower days and as needed. Shower records reviewed and indicated the resident was provided 4 showers from 11/1/25 to 11/30/25 and no showers were provided from 12/1/25 to 12/11/25. On 12/15/25 at 12:34 p.m., the Director of Nursing (DON) provided an undated document, titled, Bath, Shower, Tub, and indicated it was the policy currently being used by the facility. The policy indicated, .Documentation 1. The date and time the shower/tub bath was performed.5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. On 12/11/25 at 11:16 a.m., the Director of Nursing (DON) provided an undated document, titled, Fingernails/Toenails, Care of, and indicated it was the policy currently being used by the facility. The policy indicated, .General guidelines.1. Nail care includes daily cleaning and regular trimming. 3.1-38(a)(3)

Based on record review and interview, the facility failed to ensure a pharmacy recommendation was implemented as requested and approved by physician for 1 of 5 residents reviewed for unnecessary medications (Resident 47). Findings include: Resident 47's record was reviewed on 12/10/25 at 1:43 p.m. The profile indicated the resident's diagnoses included, but were not limited to, manic episode, severe, without psychotic symptoms (intense euphoria/irritability, high energy, racing thoughts, pressured speech, little sleep, and impulsive/reckless behavior (like spending sprees or risky sex) that significantly impairs functioning, but without hallucinations or delusions), depression (a serious mood disorder causing persistent sadness, loss of interest, and affecting how you think, feel, and live, impacting daily activities, sleep, appetite, and energy), and vascular dementia (a decline in thinking skills from reduced blood flow to the brain, often after strokes or from chronic conditions like high blood pressure, causing issues with memory, planning, judgement, and concentration). Facility census information indicated Resident 47 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 9/23/25, indicated the resident had severe cognitive impairment and received anti-psychotic and diuretic medication during the look back period. Review of pharmacy recommendation, dated 6/24/25, indicated Resident 47 received medications that should have routine laboratory monitoring. Please indicate one or [NAME] of the following: CBC (complete blood count), Vitamin D and CMP (complete metabolic panel) now and every 6 months. TSH (thyroid stimulating hormone), LFT's (liver function test), A1C (measures average blood sugar levels), Lipid Panel (test that measures lipid (fats) in your blood) now and every 6 months, Ferritin (protein that stores iron), Total Iron now and every 6 months. The physician marked the form as agree and signed and dated the form on 7/3/25. The electronic health record lacked documentation of the labs being drawn and lacked a physician order for repeat labs in 6 months. During an interview on 12/11/25 at 11:03 a.m., the Regional Nurse Consultant indicated she was unable to find where Resident 47's labs had been drawn as recommended and agreed upon by the physician and there was no order to repeat the labs in 6 months. The facility did not follow the pharmacy recommendation that the physician agreed upon. On 12/11/25 at 11:23 a.m., the Regional Nurse Consultant provided a undated document, titled, Medication Regimen Reviews, and indicated it was the current policy being used by the facility. The policy indicated, .1. The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication.4. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.d. inadequate monitoring for adverse consequences.12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it.15. Copies of medication regimen review reports, including physician responses, are maintained as a part of the permanent medical record.b. Staff performance in complying with regulatory requirements related to medication utilization and monitoring.3.1-25(i)

Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of for 1 of 1 medication storage rooms reviewed and 1 of 5 medication carts reviewed for medication storage (Residents 23 and 10). Findings include: 1. On 12/12/25 at 10:00 a.m., the rehab unit medication storage room refrigerator contained an opened Humalog (insulin medication) pen with an open date of 10/5/25 and a use by date of 11/3/25. The insulin pen contained a label that indicated it was for Resident 23. The cart also contained an opened Lantus (insulin mediation) pen with an open date of 11/2/25 and a use by date of 12/2/25. The insulin pen contained a label that indicated it was for Resident 23. During an interview, on 12/12/25 at 10:02 a.m., the Regional Nurse Consultant indicated she was not aware of who or why the insulins pens were placed in the medication storage room refrigerator. She indicated the insulin pens were expired and should have been disposed of properly. Resident 23's record was reviewed on 12/12/25 at 10:29 a.m. The profile indicated the resident's diagnosis included, but were not limited to, type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A physician order, dated 4/27/25 with a discontinued date of 12/8/25, indicated to administer Humalog Kwik Pen subcutaneous (under the skin) solution pen injector 100 unit/ml (milliliter). Inject subcutaneously per sliding scale four times a day. A physician order, dated 12/8/25, indicated to administer Lantus Solostar subcutaneous solution pen injector 100 unit/ml. Inject 30 units subcutaneously two times a day. 2. On 12/12/25 at 10:15 a.m., the ICF (intermediate care facility) insulin medication cart contained an opened bottle of irrigation solution. The bottle had an open date of 10/31/25. The bottle contained a label that indicated it was for Resident 10. During an interview, on 12/12/25 at 10:18 a.m., the Regional Nurse Consultant indicated she irrigation solution was expired and should have been disposed of. The solution was good for 30 days once opened. Resident 10's record was reviewed on 12/12/25 at 10:35 a.m. The profile indicated the resident's diagnosis included, but were not limited to obstructive and reflux uropathy (blocks urine flow, causing backup and potential kidney damage). A physician order, dated 10/12/25, indicated to administer Sodium Chloride Irrigation solution 0.9%; use 120 ml(milliliter) irrigation every shift for Foley (indwelling catheter) cath irrigation. On 12/12/25 at 10:42 a.m., the Regional Nurse Consultant provided a document, dated March 2023, titled, Medication Storage in the Facility, and indicated it was the policy currently being used by the facility. The policy indicated, .14. Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled, or without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures, and reordered form the pharmacy if a current order exists.On 12/15/25 at 9:55 a.m., the Administrator provided an undated document, titled, Administering Medications, and indicated it was the policy currently used by the facility. The policy indicated, .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container 3.1-25(0)

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect when staff ignored a resident's continued reports of acute pain and his request to be sent to the hospital which resulted in prolonged pain and a delay of treatment for 1 of 3 residents reviewed for neglect (Resident B). The immediate jeopardy began on 9/24/25 at 10:00 p.m., when Certified Nursing Aide (CNA) 3 observed Resident B to be sweaty and he complained of acute pain. CNA 3 reported his concerns to Licensed Practical Nurse (LPN) 4. CNA 3 and CNA 8 reported to LPN 4 around 1 or 2 a.m., that Resident B was still in pain and wanted to see the nurse. LPN 4 failed to assess the resident or report the resident's change of condition to a physician. CNA 3 reported Resident B's pain to the incoming dayshift nurse, Registered Nurse (RN) 5. On 9/25/25 around 7:40 a.m., CNA 6 heard Resident B screaming out and informed RN 5. Housekeeper (HK) 10 and two CNAs reported Resident B's pain and discomfort to RN 5. RN 5 refused requests to go see Resident B. Resident B told CNA 6 he wanted to go to the hospital, and CNA 6 reported the request to RN 5. On 9/25/25 Resident B's family member was on the phone with him for over 45 minutes before they called the facility directly and told management they wanted Resident B sent to the hospital immediately. Resident B was finally sent to the hospital on 9/25/25 at 9:45 a.m., where he required operative intervention under anesthesia for a bowel obstruction, and was diagnosed with gallbladder cancer. The Administrator, Director of Nursing (DON), and Regional Clinical Support (RCS) were notified of the immediate jeopardy on 10/16/25 at 3:15 p.m. The immediate jeopardy was removed on 10/17/25, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During a confidential interview on 9/15/25 at 10:00 a.m., it was indicated, Resident B called a family member and was on the phone for more than 45 minutes complaining of pain without getting help from a nurse. The family member finally hung up with the resident and called the facility directly. The family member spoke to the Business Office Manager (BOM) and indicated Resident B needed to go to the hospital immediately. The BOM interrupted morning meeting to notify the DON and Assistant Director of Nursing (ADON) that the family was demanding the resident be sent to the hospital. The family member was very upset over Resident B's treatment and indicated he was not taken seriously and was neglected by both the night shift and morning shift nurses. During an interview on 10/15/25 at 1:40 p.m., with the DON present, CNA 6 indicated on 9/25/25 she heard Resident B screaming for help around 7:00 a.m. She went to see what was wrong. Resident B told her he was in pain and wanted the nurse. CNA 6 assured him she would let the nurse know. CNA 6 immediately went to RN 5 who indicated, he's going to have to wait. CNA 6 went to help with breakfast in the dining room. A little while later, HK 10 came to ask CNA 6 if the nurse ever went to check on Resident B because he was still screaming out for help. CNA 6 went to RN 5 a second time to ask if she had been to see Resident B, to which RN 5 indicated, oh my F------ God. CNA 6 told RN 5 that Resident B may need some pain medication and Qualified Medication Aide (QMA) 11, was standing there too. CNA 6 indicated CNA 7 came to her and told her that she had also told RN 5 that Resident B was in pain and RN 5 did not care. Later that morning, CNA 6 and CNA 7 checked on Resident B together, while RN 5 and QMA 11 stood in the hallway, and found that he was on the phone with his family member who was really upset. The resident's family wanted the resident to be sent to the hospital. CNA 6 indicated she told RN 5 that Resident B's family member was upset and wanted him to go to the hospital, but RN 5 said no. CNA 6 indicated most everyone in the building knew about Resident B being in pain because of how loudly and repeatedly he was yelling for help. After RN 5 told CNA 6 she would not send Resident B out, CNA 6 and 7 went to the ADON and told him their concerns. CNA 6 indicated it was neglectful in her opinion, but she was just the CNA, so she couldn't do anything but keep telling the nurse. The DON indicated the Business Office Manager (BOM) got involved after Resident B's family member called the facility and talked to the BOM. When the DON arrived at the facility the BOM stuck her head in at morning meeting and said, Resident B's family wanted Resident B sent out to the hospital now. The DON indicated she did not receive any calls the previous night, so this was the first time she had heard about it. The DON told RN 5 to start the process of sending Resident B to the hospital. RN 5 said, I have pills to pass. The DON indicated she told RN 5 no, he needs to be sent out now. CNA 6 indicated RN 5 made a comment after Resident B was sent to the hospital, saying I hope they keep him. During an interview on 10/16/25 at 11:09 a.m. RN 5 indicated she came in and got report from LPN 4 who said Resident B had been in pain overnight. RN 5 indicated she was setting up her medications for morning medication pass when CNA 6 told her that Resident B wanted a nurse. She told CNA 6 she would be there soon and went back to setting up her medications. RN 5 indicated she did forget to go check on Resident B so CNA 6 had to come back a second time to remind her. RN 5 indicated Resident B was screaming out for help and saying his back was hurting him. RN 5 indicated she didn't have the keys to the medication cart which held Resident Bs medications, so she asked QMA 11 to get him something for pain. RN 5 indicated she told Resident B every resident was important not just him. RN 5 indicated she then went back to passing medications. RN 5 indicated a while later the DON told her Resident B wanted to go to the hospital and the BOM told her that the resident's family member called and wanted him to go to the hospital. RN 5 indicated she was told Resident B was in a lot of pain. During an interview on 10/16/25 at 11:27 a.m., the ADON indicated he did not become aware of Resident B's acute pain until the BOM interrupted morning meeting to let the staff know Resident B's family was on the phone and demanding to have him sent to the hospital. The ADON indicated it was his expectation that staff would immediately notify the on-call doctor if the resident had a change of condition. The ADON spoke with the family member later, who indicated they were very upset about the manner of his treatment and that they had been on the phone over 40 minutes before he was able to see the nurse. During an interview on 10/16/25 at 12:15 p.m., the DON indicated she was extremely upset to learn about how Resident B had been treated and that she had not been called or notified of his change of condition. The treatment he received was neglectful and would rise to the level of abuse. The DON indicated they followed protocol and suspended both nurses and eventually terminated them due to the results of the investigation. During an interview on 10/17/25 at 10:27 a.m., the BOM indicated she came into the facility on 9/25/25 around 7:00 a.m. Resident B's family member called and said they had been trying to reach the BOM for several hours because Resident B was in excruciating pain and she wanted him sent to the hospital immediately. The BOM went to RN 5 and explained the family member's wishes to send him out. The BOM did not know if RN 5 went to check on Resident B at that time, or how long it took before he was sent to the hospital. The BOM indicated Resident B acted sometimes like, the boy who cried wolf,. He was on his light all the time and if he didn't get what he wanted as soon as he thought he should have it he would start screaming. During an interview on 10/17/25 at 10:38 a.m., HK 10 indicated she heard Resident B screaming for help as soon as she walked into the facility for her shift on 9/25/25. She went to tell a CNA and continued onto her shift. She did not know if the incident was resolved or reported. During an interview on 10/17/25 at 11:45 a.m., the Administrator indicated it was his expectation that all staff should immediately report all witnessed or suspected allegations of abuse. The incident with Resident B was unacceptable and rose to the level of neglect and abuse. Upon finding out about what happened to Resident B, the Administrator fired both nurses involved. The Administrator indicated only one of the CNAs had reported the neglect to the Administrator the day after the incident by slipping a folded note under his door. Although the staff had received education and in-service retraining for bowel protocol and pain management, no additional training had been provided for staff related to abuse/neglect. Additionally, no other residents had been interviewed to determine if they had received similar treatment from the fired nurses, or any other staff. On 10/16/25 at 1:11 p.m., the Administrator provided copies of the facilities investigation and corrective actions taken which included, but were not limited to the following: A witness statement from CNA 3 indicated, arrived at 10:00 p.m. on 9/24/25. [Resident B] was constantly on his light. I went in, he was sweaty at 10:00 p.m. to 11:00 p.m. I went to go get the nurse. The nurse [LPN 4] said, 'there is nothing I can do.' I said he specifically asked for a nurse. between 1-2 a.m. we were doing another round, he said he was hurting. I told [LPN 4], she shrugged her shoulders. He began crying, 'my light has been on. I can't take it, I'm hurting.' LPN 4 was right at the door, I walked out and told the nurse. She still didn't go in. I finally told the day shift nurse. A witness statement from LPN 4 indicated, .at 11:00 p.m. I asked what he needed and he said I need to talk to the nurse. He did say something about pain. After 5-10 minutes he had pain. Right hip pain. Checked catheter. It was fine. He showed me where pain was. Told him I could get a Tylenol. He said it was so bad he couldn't turn. Would not let me reposition him or put pillow under his hip. He put call light on again at about 2:00 a.m. -2:30 a.m. wanting more medication. Did give Tylenol 1 hour early. I did not use pad to notify [name of physician on-call company]. I thought it might be muscles spasm, I went in again after the last time and he was sleeping. A CNA during report stated he wanted to talk to a nurse. I did not check his vitals. I did look at his right hip. I felt along his hip. Stated it hurt up to his back. A witness statement from RN 5 indicated, .7:30 a.m., trying to get meds ready. CNA stated he wanted me. I was preparing my meds to pass. 7:45 a.m. - 8:00 a.m., I went in. What he need [sic]. Yelling for help. Stated back was hurt. Told him I would have to check on when pain meds due. Kept yelling for help. Can't keep yelling for help. Told him I couldn't do anything if he kept yelling for help, I had to keep going in there. 8:30 a.m. [Resident was] on phone with [family member] when I went back. DON told me he needed to go out. I think staff asked me to go in. I didn't do any interventions. Did not give number for pain. Vital signs were [within normal limits] no other assessment done. A witness statement from CNA 6 indicated, .7:40 a.m., [Resident B] screaming for help. He was in pain and needed nurse and pills. Got [RN 5], but [RN 5] did not go in. She was not nice. [HK 10] heard [Resident B] scream again. [HK 10] came and got me. He [Resident B] said nurse never came. I told [RN 5], and [QMA 11] was there as well. [RN 5] .was negative and did not go. [CNA 7] told [RN 5] he wanted to go to the hospital, [RN 5] said no. CNA 7 said she would wait for the [ADON]. A witness statement from CNA 7 indicated, .8:30 a.m., [Resident B] told me he was hurting, told RN 5, told her he needed pain medicine, she said, 'no, he's just doing this.' I will get there when I can get in there. He is not due for anything. It sounds like he is hurting. She said he is not due. Answered call light again. He said he needed to go to the hospital. Told RN 5, she said, no, pointed to [QMA 11] and said she is getting his meds now. He is in pain, HK 10 down there. Sounds like he's in real pain. Answered again, let BOM know, BOM said to reach out to ADON. CNA 6 came to me and said help [Resident B] the ambulance is coming. On 10/16/25 at 11:10 a.m. CNA 3 was called, and a voicemail was left. She did not return the call at the time of exit. On 10/16/25 at 11:10 a.m. LPN 4 was called, and a voicemail was left. She did not return the call at the time of exit. On 10/15/25 at 10:30 a.m., Resident B's record was reviewed. Resident B's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated his Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating he was cognitively intact. He was totally dependent on staff to roll him from side to side while he was laying in bed and transfer him to and from the toilet. He was always incontinent. Resident B's last recorded bowel movement (BM) occurred on 9/19/25 at 11:17 a.m. His record lacked documentation of any interventions attempted related to lack of bowel movement for several days. On 9/23/25 a Kidney, Ureter, Bladder scan (KUB) was ordered to evaluate the gastrointestinal systems. The results were received on 9/23/25 at 2:14 p.m., and the results confirmed constipation. The record lacked documentation of any new orders or interventions to address the KUB results. The September 2025 Medication Administration Record (MAR) indicated Resident B received one as needed (PRN) docusate (stool softener) on 9/23/25 at 2:07 p.m. but it was recorded as ineffective. On 9/23/25 at 5:31 p.m., the resident received a dose of Miralax (laxative), which was also recorded as ineffective. Resident B's September 2025 MAR indicated he received Naloxegol Oxalate (treats opioid induced constipation) 25 mg every morning for constipation. He received Amitiza (treats certain types of chronic constipation) 24 microgram (mcg) two times a day for constipation. Resident B's September MAR indicated he received Tramadol (opioid pain medication) 50 mg three times a day for pain. Resident B's corresponding hospital records, dated 9/25/25, were reviewed and indicated Resident B arrived at the hospital on 9/25/25 at 10:21 a.m. He presented with ongoing abdominal pain for 4 days associated with decreased bowel movements, mild nausea and 7 out of 10 pain. When Resident B arrived at the hospital he was in Atrial Fibrillation (AFib) (an irregular and often rapid heart rhythm that occurs when the heart's upper chambers beat chaotically due to electrical signal problems.) with Rapid Ventricular Response (RVR) (a fast and irregular heartbeat often associated with atrial fibrillation.) with heart rates in the 140s. A computed topography (CT) scan indicated there was a large stool burden with wall thickening (The bowel wall has become thicker than normal, which can be a sign of inflammation, infection, or a tumor) and pericolonic stranding (this refers to increased density in the fat around the colon, visible on a CT scan. It is caused by inflammatory fluid and cellular changes in the fat tissue.). This CT scan indicated Resident B was severely impacted with stool. The resident underwent manual disimpaction (a medical procedure used to treat fecal impaction by manually breaking up and removing hardened stool from the rectum with a gloved and lubricated finger) under monitored anesthesia care. Approximately 2 liters of fecal matter was removed. Resident B was transferred from the local hospital to a larger hospital for continued care and reported in route to the EMS crew 0 out of 10 pain after his disimpaction. An NP progress note, dated 10/2/25, indicated Resident B was being seen for readmission to the facility for malignant neoplasm of the gallbladder (gallbladder cancer). Cross reference F684. On 10/16/25 at 1:34 p.m., the ADM provided a copy of current facility policy titled, Abuse Prevention Program, dated 10/22/22. The policy indicated, .It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property. Each resident received care and services in a person-centered environment in which all individuals are treated as human beings. The following procedures shall be implemented when an employee or agent become aware of abuse or neglect of a resident or of an allegation of suspected abuse or neglect of a resident by a 3rd party. employees are required to report any incident, allegation, or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator. The Administrator is the Abuse Coordinator. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. Any incident or allegation involving abuse or mistreatment will result in an abuse investigation. For any incident involving suspicion of abuse, neglect, or mistreatment, the Administrator or person appointed by the Administrator will gather further facts prior to making a determination to conduct an abuse investigation. The immediate jeopardy that began on 9/24/25 was removed on 10/17/25, when the facility ensured a systemic plan to include education and monitoring of staff to ensure staff provided supervision and required care to all residents residing at the facility. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Intake 2633270. 3.1-27(a)

Based on interview and record review, the facility failed to ensure a resident with constipation, no recent bowel movements (BM), and reporting pain was monitored and treated timely resulting in the resident having a delay in treatment and requiring interventions under anesthesia for a severe fecal impaction for 1 of 5 residents reviewed for quality of care related to their bowel management program (Resident B), and the facility failed to ensure an effective protocol was put in place for the ongoing monitoring of 5 of 5 residents reviewed for quality of care related to the bowel management program (Residents B, E, F, G, and H). The Immediate Jeopardy (IJ) began on 9/24/25 when Resident B began to experience and complain of acute pain. His last recorded BM was 9/19/25 at 11:17 a.m. A Kidney, Ureter and Bladder (KUB) scan (a diagnostic scan of the abdominal area) was completed 9/23/25 and confirmed constipation. No orders or treatment were obtained after the results of the KUB. On 9/23/25 two doses of PRN medications were given for constipation and documented as ineffective. No additional treatment or notification of the physician were documented. During night shift on 9/24/25, Resident B began to experience acute pain and reported his pain to two night shift Certified Nursing Aides (CNAs). The CNAs reported the resident's pain to Licensed Practical Nurse (LPN) 4. No additional treatment or notification of the physician about the resident's change of condition was documented. Resident B's pain continued and on 9/25/25 CNAs 6 and 7 reported Resident B's pain to RN 5 multiple times and reported Resident B's request to go to the hospital. RN 5 did not assess the resident, call the physician, or send the resident to the hospital. On 9/25/25 Resident B's family member got in contact with the Business Office Manager (BOM) demanded that the resident be sent to the hospital. Resident B was sent out emergently on 9/25/25 at 9:45 a.m. At the hospital, Resident B required operative intervention under anesthesia for a bowel obstruction and was diagnosed with gallbladder cancer. The Administrator, Director of Nursing (DON), and Regional Clinical Support (RCS) were notified of the immediate jeopardy on 10/16/25 at 3:15 p.m. The immediate jeopardy was removed on 10/17/25, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 10/15/25 at 10:30 a.m. Resident Bs medical record was reviewed. He was a long-term care resident whose diagnoses included but were not limited to a history of constipation. Resident B's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated his Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating he was cognitively intact. He was totally dependent on staff to roll him from side to side while he was laying in bed and transfer him to and from the toilet. He was always incontinent. A Nurse Practitioner (NP) progress note, dated 9/3/25, indicated Resident B was at risk for opioid versus immobility induced constipation. Resident B had a comprehensive care plan, initiated on 9/9/24, which indicated he was at risk for bowel irregularity related to his diagnoses, decreased bowel mobility, and medications with a target goal to have a BM every 2 to 3 days. Interventions for this plan of care included, but were not limited to, record BMs, assess resident, and if no BMs notify the MD. Prior to being sent to the hospital on 9/25/25, the last recorded BM was recorded on 9/19/25 at 11:17 a.m. The record lacked documentation of a bowel movement between 9/19/25 and 9/25/25. A progress note, dated 9/23/25 at 1:45 p.m., indicated Resident B complained of abdominal discomfort. He had active bowel sounds and a firm, but non-tender abdomen. On 9/23/25 a Kidney, Ureter, Bladder scan (KUB) was ordered to evaluate the gastrointestinal systems. The results were received on 9/23/25 at 2:14 p.m., and the results confirmed constipation. The record lacked documentation the physician was notified of the KUB results or of any new orders or interventions to address the KUB results. Resident B's September 2025 MAR indicated he received Naloxegol Oxalate (treats opioid induced constipation) 25 mg every morning for constipation. He received Amitiza (treats certain types of chronic constipation) 24 microgram (mcg) two times a day for constipation. Resident B's September MAR indicated he received Tramadol (opioid pain medication) 50 mg three times a day for pain. The September 2025 Medication Administration Record (MAR) indicated Resident B received one as needed (PRN) docusate (stool softener) on 9/23/25 at 2:07 p.m. which was recorded as ineffective. On 9/23/25 at 5:31 p.m., Resident B received a PRN dose of Miralax (laxative), which was recorded as ineffective. The record lacked documentation of a physical assessment of the Resident B on 9/23/25, 9/24/25, and 9/25/25. The record lacked documentation of physician notification of the resident's continued constipation and ineffective PRN medications. Resident B had an active order for Tylenol PRN every 4 hours for mild pain of 1-3 on a scale of 1-10. One dose of Tylenol was administered on 9/24/25 at 11:23 p.m. for a pain level of 4 and it was recorded as ineffective. The medical record lacked documentation of a physical assessment of the Resident and lacked physician notification of the resident's continued pain. On 9/25/25 at 8:47 a.m. A change of condition summary was documented at the DON's instruction, and Resident B was sent to the hospital on 9/25/25 at 9:45 a.m. A progress note, dated 9/25/25 at 9:45 a.m., indicated at 7:00 a.m. Resident B had been screaming out for help repeatedly. RN 5 asked the resident what he needed help with, and the resident indicated his back hurt. RN 5 informed Resident B that it was not time for another pain pill, but he would receive one when it was time. At 8:45 a.m. RN 5 indicated Resident B had continued to scream for help and asked to go to the hospital. Resident B was on the phone with his family member when RN 5 entered the resident's room. RN 5 indicated the resident's family member began to yell at her indicating Resident B had been yelling out for help for hours with no help. The medical record lacked documentation of a physical assessment of the resident and lacked physician notification of the resident's continued pain and requests to go to the hospital. Resident B's corresponding hospital records, dated 9/25/25, were reviewed and indicated Resident B arrived at the hospital on 9/25/25 at 10:21 a.m. He presented with ongoing abdominal pain for 4 days associated with decreased bowel movements, mild nausea and 7 out of 10 pain. When Resident B arrived at the hospital he was in Atrial Fibrillation (AFib) (an irregular and often rapid heart rhythm that occurs when the heart's upper chambers beat chaotically due to electrical signal problems.) with Rapid Ventricular Response (RVR) (a fast and irregular heartbeat often associated with atrial fibrillation.) with heart rates in the 140s. A computed topography (CT) scan indicated there was a large stool burden with wall thickening (The bowel wall has become thicker than normal, which can be a sign of inflammation, infection, or a tumor) and pericolonic stranding (this refers to increased density in the fat around the colon, visible on a CT scan. It is caused by inflammatory fluid and cellular changes in the fat tissue.). This CT scan indicated Resident B was severely impacted with stool. The resident underwent manual disimpaction (a medical procedure used to treat fecal impaction by manually breaking up and removing hardened stool from the rectum with a gloved and lubricated finger) under monitored anesthesia care. Approximately 2 liters of fecal matter was removed. Resident B was transferred from the local hospital to a larger hospital for continued care and reported in route to the EMS crew 0 out of 10 pain after his disimpaction. An NP progress note, dated 10/2/25, indicated Resident B was being seen for readmission to the facility for malignant neoplasm of the gallbladder (gallbladder cancer). An NP progress note, dated 10/6/25, indicated Resident B had returned from the hospital on [DATE] after having operative disimpaction for significant constipation and stercoral colitis (an inflammation of the colon caused by a hardened mass of stool that puts pressure on the bowel wall). During an interview on 10/15/25 at 1:40 p.m., with the DON present, CNA 6 indicated on 9/25/25 she heard Resident B screaming for help around 7:00 a.m. She went to see what was wrong. Resident B told her he was in pain and wanted the nurse. CNA 6 assured him she would let the nurse know. CNA 6 immediately went to RN 5 who indicated, he's going to have to wait. CNA 6 went to help with breakfast in the dining room. A little while later, HK 10 came to ask CNA 6 if the nurse ever went to check on Resident B because he was still screaming out for help. CNA 6 went to RN 5 a second time to ask if she had been to see Resident B, to which RN 5 indicated, oh my F------ God. CNA 6 told RN 5 that Resident B may need some pain medication and Qualified Medication Aide (QMA) 11, was standing there too. CNA 6 indicated CNA 7 came to her and told her that she had also told RN 5 that Resident B was in pain and RN 5 did not care. Later that morning, CNA 6 and CNA 7 checked on Resident B together, while RN 5 and QMA 11 stood in the hallway, and found that he was on the phone with his family member who was really upset. The resident's family wanted the resident to be sent to the hospital. CNA 6 indicated she told RN 5 that Resident B's family member was upset and wanted him to go to the hospital, but RN 5 said no. CNA 6 indicated most everyone in the building knew about Resident B being in pain because of how loudly and repeatedly he was yelling for help. After RN 5 told CNA 6 she would not send Resident B out CNA 6 and 7 went to the ADON and told him their concerns. CNA 6 indicated it was neglectful in her opinion, but she was just the CNA, so she couldn't do anything but keep telling the nurse. The DON indicated the Business Office Manager (BOM) got involved after Resident B's family member called the facility and talked to the BOM. When the DON arrived at the facility the BOM stuck her head in at morning meeting and said, Resident B's family member wanted Resident B sent out to the hospital now. The DON indicated she did not receive any calls the previous night, so this was the first time she had heard about it. The DON told RN 5 to start the process of sending Resident B to the hospital. RN 5 said, I have pills to pass. The DON indicated she told RN 5 no, he needs to be sent out now. CNA 6 indicated RN 5 made a comment after Resident B was sent to the hospital, saying I hope they keep him. During an interview on 10/15/25 at 1:45 p.m. the DON indicated everything went wrong the day Resident B was sent to the hospital. She indicated she should have gotten a call from the night shift nurse, and the night shift nurse should have called the on-call physician company immediately to notify the physician. She indicated Resident B should have been sent out on nightshift, it should never have been a dayshift issue. The DON indicated the CNAs chart bowel movements under the bowel management tab of the task section and nowhere else. She indicated if a medication was ineffective the nurse should notify the physician and make sure the documentation supported that the medication was ineffective. During an interview on 10/16/25 at 11:09 a.m. RN 5 indicated she came in and got report from LPN 4 who said Resident B had been in pain overnight. RN 5 indicated she was setting up her medications for morning medication pass when CNA 6 told her that Resident B wanted a nurse. She told CNA 6 she would be there soon and went back to setting up her medications. RN 5 indicated she did forget to go check on Resident B, so CNA 6 had to come back a second time to remind her. RN 5 indicated Resident B was screaming out for help and saying his back was hurting him. RN 5 indicated she didn't have the keys to the medication cart which held Resident Bs medications, so she asked QMA 11 to get him something for pain. RN 5 indicated she told Resident B every resident was important not just him. RN 5 indicated she then went back to passing medications. RN 5 indicated a while later the DON told her Resident B wanted to go to the hospital and the BOM told her that the resident's family member called and wanted him to go to the hospital. RN 5 indicated she was told Resident B was in a lot of pain. During an interview on 10/16/25 at 11:27 a.m. the ADON indicated he was in morning meeting on 9/25/25 when someone came in and said Resident B's family member was on the phone demanding that the Resident be sent to the hospital. The ADON and the DON went to talk to RN 5. The ADON indicated RN 5 did not give them any indication of how long Resident B had been in pain. The ADON indicated he and the DON told RN 5 that Resident B needed to be sent to the hospital as soon as possible, RN 5 indicated she had a few more medications to pass. The ADON indicated he and the DON told RN 5 to stop what she was doing and go assess Resident B immediately The ADON and DON got the necessary paperwork together for transfer and Resident B was sent out to the hospital. The ADON indicated he was not aware of anything until that morning, he did not receive any calls overnight. On 10/16/25 at 11:10 a.m. CNA 3 was called, and a voicemail was left. She did not return the call at the time of exit. A witness statement from CNA 3, provided by the Administrator on 10/16/25 at 1:11 p.m., indicated, arrived at 10:00 p.m. on 9/24/25. [Resident B] was constantly on his light. I went in, he was sweaty at 10:00 p.m. to 11:00 p.m. I went to go get the nurse. The nurse [LPN 4] said, 'there is nothing I can do.' I said he specifically asked for a nurse. between 1-2 a.m. we were doing another round, he said he was hurting. I told [LPN 4], she shrugged her shoulders. He began crying, 'my light has been on. I can't take it, I'm hurting.' LPN 4 was right at the door, I walked out and told the nurse. She still didn't go in. I finally told the day shift nurse. On 10/16/25 at 11:10 a.m. LPN 4 was called, and a voicemail was left. She did not return the call at the time of exit. A witness statement from LPN 4, provided by the Administrator on 10/16/25 at 1:11 p.m., indicated, .at 11:00 p.m. I asked what he needed and he said I need to talk to the nurse. He did say something about pain. After 5-10 minutes he had pain. Right hip pain. Checked catheter. It was fine. He showed me where pain was. Told him I could get a Tylenol. He said it was so bad he couldn't turn. Would not let me reposition him or put pillow under his hip. He put call light on again at about 2:00 a.m. -2:30 a.m. wanting more medication. Did give Tylenol 1 hour early. I did not use pad to notify [name of physician on-call company]. I thought it might be muscles spasm, I went in again after the last time and he was sleeping. A CNA during report stated he wanted to talk to a nurse. I did not check his vitals. I did look at his right hip. I felt along his hip. Stated it hurt up to his back. During an interview on 10/16/25 at 11:22 a.m. CNA 7 indicated Resident B was screaming out in pain and that he needed some type of medication. She indicated she told RN 5 that Resident B needed help but she said no she was helping other residents right now. She indicated many of her co-workers heard him screaming and you could hear him down in the dining room. CNA 7 indicated she told RN 5 Resident B wanted to go to the hospital and RN 5 said no again. CNA 7 indicated she was helping a different resident with a shower when staff came to her to help get him ready to go to the hospital. When she got to the room Resident B was on the phone talking to his family. No nurse came in to check on him during that time. During an interview on 10/17/25 at 10:27 a.m. the BOM indicated on 9/25/25 Resident B's family member called the facility and said she had been trying to get ahold of the BOM for a couple hours. The BOM did not get to the facility until 7 a.m. and she answered the phone around 8:00 a.m. Resident B's family member indicated to the BOM that he had been in a lot of pain for a while now and requested they get an order to get him sent out to the hospital. The resident's family member indicated to the BOM that she had been on the phone with Resident B and could hear him yelling. The BOM indicated Resident B was one of those residents like the boy who cried wolf, if he needed something he would be on his call light and scream. Cross reference F600. A progress note, dated 10/7/25 at 4:43 p.m., indicated Resident B was complaining of stomach pain. The writer of the progress note indicated they gave him PRN Miralax and PRN Tylenol. Upon assessment the Resident had no bowel sounds, and the stomach was distended. The NP was notified and the writer indicated they gave milk of magnesia (MOM) (a liquid laxative) and a warm cup of coffee to try to help move Resident B's bowels. The October 2025 MAR lacked documentation of PRN Tylenol, PRN Miralax, and PRN MOM being administered on 10/7/25. A progress note, dated 10/7/25 at 9:35 p.m., indicated Resident B still had not had a bowel movement after MOM and Miralax, and upon assessment the Resident still had no bowel sounds and his stomach was still distended so the writer indicated they gave Resident B a suppository. The record lacked documentation of the physician being notified of continued constipation. During an interview on 10/15/25 at 1:45 p.m. the DON indicated, since the incident with Resident B, the facility had reviewed and revised, a new bowel procedure/protocol, it was created in collaboration with the Medical Director, all nursing staff had been educated on the new policy. The new protocol became effective 10/1/25. The DON indicated the new protocol included a complete audit of residents' records for the need and/or continued use of Milk of Magnesia (M.O.M.) and other bowel management medications. Orders were confirmed with the Medical Director and the new protocol followed as: If a resident flagged on the EMAR (Electronic Medication Administration Record) dashboard as not having had a BM after 72 hours, they should have received a dose of MOM. if they had not had a BM by the end of that nurse's shift, they would notify the physician and give report to the oncoming nurse. Additional residents were reviewed for the new bowel procedure/protocol. a. On 10/16/25 at 1:00 p.m., Resident E's record was reviewed. She was a long-term care resident with diagnoses which included but were not limited to: muscle wasting and atrophy and lower abdominal pain. Resident E's quarterly MDS, dated [DATE], indicated she was severely cognitively impaired, had no recorded behaviors, was always incontinent of urine and stool, and required total assistance with all activities of daily living (ADLs). A new comprehensive care plan was initiated on 10/5/25 which indicated Resident E was at risk for episodes of constipation secondary to decreased mobility with a goal to have formed stools on a regular basis. Interventions for this plan of care included, encourage fluids, medications per MD orders, monitor bowel movements (BM), provide diet per MD orders, and report changes to MD. Resident E had a documented BM on 10/2/25 at 1:41 a.m. 72 hours later, on 10/5/25 at 1:41 a.m., Resident E had not had another recorded BM. A nursing progress note, dated 10/6/25 at 11:45 a.m., (4 days and 10 hours after last recorded BM) indicated, Bowel sounds are normoactive in four quadrants. QMA aware resident may be given Milk of Magnesia at this time, related to constipation. According to the new facility protocol, Resident E's MOM intervention was more than 1 day and 10 hours late. Resident E was administered a dose of MOM on 10/6/25 at 12:05 p.m., which produced a BM by 11:47 p.m. that evening. According to the facilities proactive audit reviews, Resident E flagged on the dashboard for review on 10/6/25. The audit indicated a bowel assessment was completed, documented and the PRN was ineffective, therefore hospice was notified. Resident E's record lacked documentation of a complete bowel assessment as indicated. As a result, RN 12 received a write up for not following facility protocol, but she refused to sign the form. A nursing progress note, dated 10/7/25 at 6:41 p.m., indicated, Hospice nurse in today and gave verbal orders to start milk of mag, every other day routinely for constipation. Resident E had a documented BM on 10/9/25 at 5:59 a.m. 72 hours later, on 10/12/25 at 5:59 a.m., Resident E had not had another recorded BM. A nursing progress note, dated 10/13/25 at 4:59 p.m., (4 days and 11 hours after last recorded BM) indicated, Resident has not had a BM for 3 days. Assessed with hypoactive bowel sounds, Abdomen is firm, denies discomfort, PRN Milk of mag given, Hospice and family are aware. Resident E received a dose of M.O.M. on 10/13/25 at 5:04 p.m., which was ineffective. A nursing progress note, dated 10/14/25 at 3:07 p.m., indicated, PRN enema effective this shift. Resident had a large, formed BM. Bowel sounds are hypoactive in bilateral lower quads. Hospice nurse in and gave new orders to change milk of mag. to daily. Resident E received her PRN enema on 10/14/25 at 10:00 a.m. Resident E went more than 5 days and 7 hours in between recorded BMs. According to the facilities proactive audit reviews, Resident E did not flag on the EMAR dashboard after no recorded BM from 10/9/25 until 10/14/25, more than 5 days. b. On 10/16/25 at 1:10 p.m., Resident F's record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, adult failure to thrive, low back pain and anxiety. Resident F had a significant change MDS dated [DATE]. It indicated she was moderately cognitively impaired with a BIMS score of 8/15, had no recorded behaviors, was occasionally incontinent of urine and stool, and required substantial/maximum assistance with toileting. Resident F had a comprehensive care plan initiated on 8/6/25 which indicated she was at risk for adverse effects from opioid use with a goal to have no preventable complications from opioid use. Interventions included but were not limited to; Encourage an adequate fluid and fiber intake to facilitate regular bowel movements. Report and observe adverse effects of opioid use to MD, including but not limited to: lethargy, dizziness, confusion, constipation, nausea and vomiting, respiratory depression/distress. A new comprehensive care plan was initiated on 10/16/25 which indicated Resident F had the potential for bowel irregularity related to diagnoses of decreased mobility and medications with a target goal to have a BM every 2-3 days. Interventions for this plan of care included but were not limited to; assess resident if no BM [but did not specify for how long], meds per order, and record BMs. Resident F had a recorded BM on 9/30/25 at 5:59 a.m., 72 hours later, on 10/3/25 at 5:59 a.m., Resident F had not had another recorded BM. A nursing progress note, dated 10/3/25 at 6:56 p.m., indicated Resident F received a PRN dose of M.O.M. Resident F's Medication Administration Record (MAR) lacked documentation for the administration of PRN M.O.M. on 10/3/25. Resident F's MAR indicated, she received a dose of M.O.M. on 10/5/25 at 9:47 a.m., which was ineffective, and another dose on 10/6/25 at 1:28 p.m. which was effective, but the record lacked documentation of a recorded BM on 10/6/25. A nursing progress note, dated 10/7/25 at 3:15 p.m., (7 days and 9 hours since last recorded BM) indicated Resident F still had not had a BM and the writer of the note notified Hospice. A new one-time order was obtained to administer a bisacodyl suppository and the Medical Director requested to be notified if the resident did not have a BM by morning for additional orders. Resident F's MAR documented the administration of the suppository on 10/7/25 at 8:01 p.m. On 10/8/25 Resident F had two recorded BMs at 5:59 a.m. and 12:40 p.m. According to the facilities proactive audit reviews, Resident F triggered for no BMs on 10/3/25 and that a bowel assessment was completed and documented, and a PRN medication was administered but was not effective and the MD was not notified that the PRN was not effective. Resident F triggered again for no BMs on 10/6/25, but the audit was left blank for bowel assessment completed and documented and/or physician notification. Resident F triggered for a third time for no BMs on 10/7/25, with a bowel assessment completed and documented and that the PRN was ineffective and Hospice was notified. c. During an interview on 10/16/25 at 2:45 p.m., Resident G indicated, sometimes she did get constipated, and it seemed like it would take a while before the nurses would take her seriously. Sometimes if she was in pain she would be told she would have to wait her turn for the nurse to get to her during the med pass. It often made her feel like she wasn't important. On 10/16/25 at 1:20 p.m., Resident G's record was reviewed. He was a long-term care resident with diagnoses which include, but were not limited to, dementia, reduced mobility, and muscle weakness. Resident G's quarterly MDS, dated [DATE], indicated he was moderately cognitively impaired with a BIMS score of 10/15, had no recorded behaviors, was occasionally incontinent of urine and stool, and required substantial/maximum assistance with toileting. He had a comprehensive care plan, initiated on 5/9/22, which indicated he was at risk for episodes of constipation secondary to decreased mobility with a target goal to have formed stools on a regular basis. Interventions for the plan of care included, but were not limited to; Encourage fluids, medications per MD orders, monitor BMs, provide diet per MD orders and report changes to MD. Resident G had a recorded BM on 10/6/25 at 5:59 a.m. 72 hours later, on 10/9/25 at 5:59 a.m., resident G had not had another recorded BM. Resident G's MAR indicated, he received a PRN suppository on 10/9/25 at 1:31 p.m., (6 hours after the triggered 72-hour mark) which was recorded as effective, but the record lacked documentation of a recorded BM. Resident G had a recorded BM on 10/12/25 at 5:59 a.m. 72 hours later, on 10/15/25 at 5:59 a.m. Resident G did not have another recorded BM. A nursing progress note, dated 10/16/25 at 10:18 a.m., indicated Resident G had not had a bowel movement and was assessed and found to have hypoactive bowel sounds and a firm abdomen. He did not complain of pain at that time, was administered M.O.M. at 10:10 a.m. and the physician was notified. According to the facilities proactive audit reviews, Resident G triggered for no BMs on 10/9/25 and 10/10/25 with Hospice being notified on 10/10/25. d. On 10/16/25 at 1:28 p.m., a record review was completed for Resident H. He had the following diagnoses which included but were not limited to major depressive disorder, heart transplant, hypertension, muscle weakness, and unsteadiness on feet. His brief interview mental status (BIMS) score on 9/28/25 was 15, indicating his mental status was intact. His MDS, dated [DATE], indicated he was continent of bowel and not receiving a bowel management program. Resident H was prescribed Miralax 17 grams (gm) daily in a large glass of water for bowel health dated 8/30/25. He was prescribed Milk of Magnesia (MOM) 30 milliliters (ml) daily as needed for constipation dated 9/30/25. He had no bowel movement from 9/30/25 through 10/3/25. On 10/4/25 at 21:59 he had a medium sized bowel movement. Resident's care plan lacked any mention of the potential for constipation. During an interview on 10/16/25 at 11:50 a.m., the DON indicated some of the time discrepancies may be due to a technological date/time recording error for some new tables that had been used by the aides to chart. Some of the tablets were several hours behind the actual time zone, and had not been fixed yet. During an interview on 10/17/25 at 11:45 a.m., the Administrator indicated it was his expectation for nursing staff to immediately respond to Resident B's complaints of pain and take appropriate measures to assist him or send him to the emergency room. Further, it was his expectation that nursing staff should be charting accurately, and following the new facility protocol as implemented by the DON and MD. On 10/16/25 at 10:25 a.m., the Administrator provided a copy of facility policy titled, Bowel Protocol, dated 10/1/25. At this time the ADM indicated, there had been a bowel regimen in place at the time Resident B experienced his obstruction and hospitalization, but it was evidently not being implemented or monitored effectively, so the DON and MD with the clinical team got together to create a revised protocol, which he provided at that time. The new protocol indicated, .use stepwise approach: A. no BM for 3 days [give] M.O.M. 30 ml by mouth once daily. B. If no BM for 4 days, notify the physician or NP. 5. Documentation: record all bowel movements (date, time, consistency, amount), note interventions used and resident response, notify provider if: no BM 4+ days, signs of bowel obstructions or impaction, persistent diarrhea or bleeding. 6. Special considerations: Opioid-induced constipation; initiate stimulant laxative at some time as opioid. May require methylnaltrexone if refractory. Palliative/Hospice Residents: prioritize comfort, liberal use of laxatives and suppositories as needed. The immediate jeopardy that began on 9/24/25 was removed on 10/17/25, when the facility ensured a systemic plan to include education and monitoring of staff to ensure staff assessed and monitored residents for pain and change in condition, and that staff followed the facility bowel protocol. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Intake 2633270. 3.1-37(a)

Based on record review, observation, and interview, the facility failed to ensure a resident was assessed for and safely transferred in a mechanical lift resulting in actual harm when the resident fell from the mechanical lift sling during a transfer and sustained a fracture to the right tibia (bone in the lower leg) (Resident B), failed to ensure residents were appropriately transferred in mechanical lifts using the correct slings (Residents B and D), and to ensure a resident with multiple falls received updated interventions to prevent further falls (Resident C) for 3 of 4 residents reviewed for accidents. Findings include:1. Resident B’s record was reviewed on 7/22/25 at 11:23 a.m. Diagnoses on the resident’s profile included, but were not limited to, cerebral palsy (a group of neurological disorders that affect movement, muscle tone, and posture) and unspecified fracture of the upper end of the right tibia. A significant change Minimum Data Set (MDS) assessment, dated 7/1/25, indicated the resident had a severe cognitive impairment, was dependent for chair/bed transfers, and had one fall with a major injury since the prior assessment. A physician’s order, dated 8/29/19, indicated the resident was transferred with a mechanical lift. A care plan, initiated on 8/29/19, indicated the resident required staff assistance with activities of daily living (ADLs) related to cerebral palsy. Interventions included, but were not limited to, encourage the use of assistive devices as needed, mechanical lift. Current physician’s orders lacked documentation of orders related to the resident’s right tibia fracture. A fall risk review, dated 6/18/25, indicated the resident was a high risk for falls. A progress note, dated 6/18/25 at 12:00 p.m., indicated it was a late entry. The note indicated the Certified Nurse Aide (CNA) notified the nurse the resident slid out of the mechanical lift. The resident was found lying on the floor on her right side, and there were two CNAs in the room. The CNAs reported the resident slid out of the mechanical lift sling and landed on her right side when the resident began moving during the transfer. One CNA reported she was able to prevent the resident from hitting her head. The resident was assessed and did not complain of pain. The Nurse Practitioner (NP) was in the facility and assessed the resident. The NP stated the resident could be moved to the bed, and the resident was assisted back to bed. The resident’s family member was notified of the incident. The resident requested to get up for lunch, and the NP said the resident was able to get out of bed. The resident was assisted out of bed and went to lunch. A progress note, dated 6/18/25 at 1:10 p.m., indicated the resident fell out of the Hoyer sling, at 11:45 a.m., during a transfer from the bed to the chair. A Situation, Background, Assessment, Recommendation (SBAR) form, dated 6/18/25 at 11:45 a.m., indicated the resident had a fall, and the recommendation was to monitor the patient and use a bigger Hoyer (mechanical lift) sling when transferring. A progress note, dated 6/19/25 at 4:31 a.m., indicated x-rays were ordered for the resident’s right shoulder and right knee. A progress note, dated 6/19/25 at 4:44 a.m., indicated the mobile x-ray company was scheduled to complete the x-rays in the morning. An Interdisciplinary Team (IDT) progress note, dated 6/19/25 at 10:12 a.m., indicated the IDT was reviewing the resident’s fall from 6/8/25 [sic]. The resident slipped out of the mechanical lift sling while being transferred. The root cause was “slid out of Hoyer lift.” The intervention was to ensure the appropriate sling was being used. The IDT consisted of the Dietary Manager, MDS Coordinator, Social Services Director (SSD), and Assistant Director of Nursing (ADON). The medical record lacked documentation of an assessment of the resident for the safe use of the mechanical lift was completed. The incident investigation file contained the following two undated witness statements. A witness statement from CNA 4 stated, “I was in [Resident B’s] room providing care for her…put the Hoyer lift sling under her. [CNA 5] entered the room. We put the sling on the Hoyer lift. As I was pulling out from the bed as I was turning the Hoyer, [Resident B] began to move/wiggle in the sling. I asked her to stop moving. [CNA 5] and I were able to catch her head to prevent it from hitting the floor…” A witness statement from CNA 5 stated, “I…went into [Resident B’s] room to help [CNA 4] transfer her with the Hoyer lift. We put the sling on the Hoyer lift. As [CNA 4] was pulling the Hoyer from out from the bed and turning it, [Resident B] began to move/wiggle in the sling. [CNA 4] asked her to stop moving. I moved closer to help with the transfer, [Resident B] arched her back and slid out of the Hoyer sling. Although we did not keep her from falling, we were able to catch her head to prevent her from hitting her head….” A progress note, dated 6/19/25 at 11:45 a.m., indicated the mobile x-ray company completed the x-rays of the resident’s right shoulder and right knee. An x-ray report, dated 6/19/25, indicated the resident had a right tibia fracture. The physician signed the report and indicated, “apply splint refer to ortho [orthopedics].” A progress note, dated 6/19/25 at 12:29 p.m., indicated the resident’s x-ray results were received, and there was a fracture to the right tibia. The physician was notified and ordered a splint and orthopedic referral. The orthopedic office was contacted to schedule an appointment. A physician’s order, dated 6/20/25, indicated the resident was able to get in the wheelchair. A care plan, initiated on 6/20/25, indicated the resident had a fracture to the right tibia from a fall on 6/18/25. Interventions included, but were not limited to, handle gently when moving or positioning and maintain body alignment. An IDT progress note, dated 6/24/25 at 4:43 p.m., indicated it was an IDT fall follow up clarification. Upon chart review, there was a clarification on the date and events. The fall occurred on 6/18/25, and the IDT note, dated 6/19/25, mistakenly indicated it occurred on 6/8/25. The resident was being transferred via mechanical lift by two CNAs, became restless, and positioned her body in a straight board position. This position caused her to “maneuver herself out of the Hoyer lift sling.” The resident fell approximately three feet, and the CNAs were able to prevent her head from hitting the floor. The resident landed on her right leg. The NP was in the facility, assessed the resident, and indicated she was able to be moved from the floor to the bed. The resident was assessed and was not in pain. The root cause of the incident was the resident became restless and maneuvered herself out of the sling. Interventions included immediate assessment by the NP, staff education for mechanical lift transfers and dealing with residents who had increased agitation during a mechanical lift transfer, x-ray completed, orthopedic consult completed with a new order for a follow-up x-ray in six weeks. An orthopedic physician progress note, dated 6/24/25, stated, “…Given that the patient is nonambulatory, I strongly recommend nonoperative management, and the patient and her family concurred. Supportive care will be provided, including placing support underneath the leg during lifting and transferring. A knee immobilizer or brace is not recommended, as it may lead to increased swelling and complications…The fracture is expected to heal in approximately three to four months….” A progress note, dated 6/25/25 at 2:05 a.m., indicated the resident was seen by the orthopedic physician on 6/24/25, but the nurse had not seen any paperwork from the appointment. During an interview, on 7/22/25 at 1:42 p.m., Resident B indicated she fell out of the mechanical lift because the staff did not have her in the lift “right.” When she fell, her leg hurt. During an interview, on 7/22/25 at 2:41 p.m., Qualified Medication Aide (QMA) 7 indicated she worked 6/18/24 when the resident fell out of the mechanical lift sling. Someone reported to her the resident fell, and she went to get the ADON. The staff stated the resident “bucked” and fell out of the sling. She was not sure if that was unusual for the resident because she did not normally provide direct resident care. After the incident, the staff received training regarding mechanical lift transfers but not regarding sling size. If a resident needed a mechanical lift sling, staff retrieved it from the supply. The size should have been determined by weight. She thought the resident’s height might have been a factor in the mechanical lift sling size as well, but she was not sure about hip size. During an interview, on 7/22/25 at 2:47 p.m., CNA 8 indicated she was familiar with Resident B. There had been issues transferring the resident with the mechanical lift because of her contractures and stiffness. The facility got a new mechanical lift sling for her, and it helped. The new sling crosses between the resident’s legs. The sling they were using before was a “bath sling.” It was a large rectangle that acted like a hammock and seemed too big. She indicated the staff was not trained on which type of mechanical lift sling to use or which size. There have been times when staff used bath slings when they were not really appropriate because they were not sure what to use or the correct equipment was not available. During an interview, on 7/22/25 at 3:01 p.m., the Administrator indicated they purchased personalized mechanical lift slings for each resident who used the lift based on their weights. They wrote the residents’ name on the label. At the same time, the bath sling was observed and was noted to be a large rectangle shape. The sling was not a [mechanical lift brand name] sling. During an observation, on 7/23/25 at 9:50 a.m., CNA 4 and CNA 9 transferred Resident B from the bed to the chair with the mechanical lift. The legs of the lift were closed and under the bed. The CNAs attached the sling loops to the mechanical lift. CNA 4 lifted Resident B up and off the bed, moved the mechanical lift backwards, turned to the right, and positioned it in front of the resident’s wheelchair. Once the mechanical faced the resident’s wheelchair, CNA 4 opened the legs of the mechanical lift and pushed it towards the resident’s wheelchair. CNA 9 guided the resident into the wheelchair as CNA 4 lowered the lift. During the transfer, the straps of the mechanical lift pad were crossed between the resident’s legs, but the resident’s buttocks protruded through the opening of the mechanical lift sling and her legs hung over the sling straps at her knees. The CNAs did not support the resident’s fractured leg during the transfer. At the same time, the ADON indicated the resident’s buttocks were positioned that way due to her contractures. The mechanical lift sling was observed to have the resident’s name on it and was a different brand than the mechanical lift. The CNAs were unable to verbalize what size sling the resident required. On 7/23/25 at 10:27 a.m., the Housekeeping Supervisor provided a document titled, “Hoyer,” and indicated it was a list of residents and their weights provided to her by nursing. When she was provided with this list, she was told to order each resident on it a new mechanical lift sling based on their weight. She was not told to use any other body measurements, such as height or hip width, to determine sling size. Prior to the new slings being ordered, staff used full-body, rectangular slings for the mechanical lift for all residents. The new slings ordered were a different shape and the straps crossed between the residents’ legs. She was approved to order one new sling for the residents who required a mechanical lift for transfers and was supposed to order a second sling for each resident later. If the new sling was soiled, she had one extra of the new style sling, but only one size. Otherwise, the staff would have needed to use the old rectangular style slings they used before until the new sling was laundered. She ordered the slings through the medical supply company she always used and was not told they needed to be [mechanical lift brand name] slings. During an interview, on 7/23/25 at 10:50 a.m., CNA 4 indicated she was not notified of any requirement to do anything with Resident B’s fractured leg during transfers. She was not aware the resident’s fractured leg needed support during transfers. During an interview, on 7/23/25 at 1:22 p.m., CNA 4 and CNA 5 indicated they were the CNAs who transferred Resident B when she fell out of the mechanical lift sling. They used the rectangular lift sling. The resident stiffened up and fell out of the mechanical lift sling. They had new mechanical lift slings that crossed between the residents’ legs, and they worked better. On 7/23/25 at 1:40 p.m., the DON provided a document titled, “Interdisciplinary Resident Screen,” dated 6/19/25, and indicated it was the mechanical lift assessment for Resident B. The document indicated the resident had a recent fall and received a screening for physical therapy. The document did not include an assessment of the resident’s appropriateness or safety for use of the mechanical lift and was not a mechanical lift assessment. At the same time, the DON indicated she was not able to find any other mechanical lift assessments for the resident. On 7/22/25 at 2:55 p.m., the Administrator provided the user manual for the mechanical lift used by the facility, dated 10/1/18. The user manual indicated, “…Use common sense in all lifts. Special care MUST BE taken with people with disabilities who cannot cooperate while being lifted. [Mechanical lift brand name] slings and patient lift accessories are specifically designed to be used in conjunction with the [mechanical lift brand name] patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of [mechanical lift brand name] patient lift system…Using the sling…WARNING…If the patient is in a wheelchair, secure the wheel locks in place to prevent the chair from moving forwards or backwards…When using an adjustable lift base lift, the legs MUST be in the maximum opened/locked position before lifting the patient…The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately….” On 7/23/25 at 11:18 a.m., the DON provided a document titled, “Guidelines for Mechanical Lift Transfer/Usage,” dated 7/8/24, and indicated it was the policy currently being used by the facility. The policy indicated, “…Getting ready to use a Mechanical Lift…7) Never use a mechanical lift on a resident who is agitated, resistant or combative…10) Make sure that you have the correct sling for the resident. The sling needs to be: a) Compatible with the specific mechanical lift being used b) Correct size for the resident-this is determined using the resident’s size, weight, and hip measurements in accordance with the manufacturer’s recommendations….” 2. On 7/22/25 at 1:00 p.m., the medical record of Resident D was reviewed. The resident’s most recent admission to the facility was on 10/25/24. Admitting diagnosis included but not limited to repeated falls and reduced mobility. Review of physician orders indicated the record lacked an order to use the mechanical lift for transfers. A quarterly Minimum Data Assessment (MDS), dated [DATE], indicated the resident was extensive assist with two persons for transfers and was cognitively impaired. A care plan, dated 4/12/24, indicated the resident was at risk for falls. Interventions included, but were not limited to, antiroll back in wheelchair. A care plan, dated 8/1/24, indicated resident required assistance with activity of daily living care needs. Interventions included, but were not limited to, staff assist with transfers as needed, and assess by therapy as needed. The care plan lacked documentation of use of mechanical lift to transfer. On 7/22/25 at 1:50 p.m., observed Resident D being transferred from wheelchair to bed. Observed Certified Nurse aide (CNA) 4 operating the mechanical lift and CNA 9 assisting to position the resident in the mechanical lift pad. The top back of the pad observed to be approximately 4 inches above the back of the resident’s head. The resident was lifted approximately 18 inches over the wheelchair arm rest and moved to the bed. CNA 9 failed to lock the wheelchair prior to lifting the resident from the chair. CNA 4 failed to lock the brakes on the mechanical lift prior to lowering the resident onto the bed. 3. On 7/22/25 at 2:00 p.m., the medical record of Resident C was reviewed. The most recent admission to the facility was on 10/4/24. Admitting diagnosis included, but not limited to, chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), weakness, and falls. A care plan, dated 3/29/24, indicated the resident was at risk for falls. Interventions included, but not limited to, anti rollbacks to wheelchair dated 1/24/23, color call light dated 4/4/22, and fall mat while in bed dated 9/6/23. The record indicated the resident had fallen on the following dates. On 6/22/25 the resident fell out of the wheelchair. On 6/28/25 the resident fell on the floor in front of her wheelchair. On 7/11/25 the resident fell out of wheelchair in the hall. On 7/14/25 the resident fell out of bed onto a mat. On 7/18/25 the resident was found sitting on the floor in the hallway in front of the wheelchair. The medical record lacked documentation of new preventive interventions being implemented after each fall. A fall risk assessment, dated 6/28/25, indicated the fall risk score was 13 and the resident was a high fall risk. A quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was cognitively impaired. A fall risk assessment, dated 7/19/25, indicated the fall risk score was 17 and the resident continued to be high fall risk. On 7/23/25 at 11:13 a.m., during an interview the Director of Nurses (DON) indicated the care plans were updated after incidents during the IDT (inter disciplinary team) meeting. The DON indicated the MDS Coordinator would update the care plan with interventions at that time. Review of four employee files hired between 2/7/24 and 7/31/24 lacked documentation of competency skills evaluations for use of mechanical lifts. On 7/23/25 at 11:42 a.m., observed Resident C laying on her back across the bed sleeping. Observed the wheelchair in front of the resident. Call light had red tape on the light, the wheelchair had anti tip bar on the back, there was not a mat on the floor next to the bed. On 7/22/2025 at 2:55 p.m., the provided a document titled, “Guidelines for incidents, accidents, falls,” dated 6/30/23, and indicated it was the policy currently being used by the facility. The policy indicated, “ .11. Each fall needs a new care plan intervention rolled out…15. Based on the results of the incident, accident, fall, the resident’s care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place….” This citation relates to Complaint 1380602. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure staff were competent in performing mechanical lift transfers during 2 of 2 observed mechanical lift transfers (Residents B and D). This deficient practice had the potential to affect 15 of 15 residents who required a mechanical lift for transfers. Findings include:1. Resident B’s record was reviewed on 7/22/25 at 11:23 a.m. Diagnoses on the resident’s profile included, but were not limited to, cerebral palsy (a group of neurological disorders that affect movement, muscle tone, and posture) and unspecified fracture of the upper end of the right tibia. A significant change Minimum Data Set (MDS) assessment, dated 7/1/25, indicated the resident had a severe cognitive impairment, was dependent for chair/bed transfers, and had one fall with a major injury since the prior assessment. A physician’s order, dated 8/29/19, indicated the resident was transferred with a mechanical lift. A progress note, dated 6/18/25 at 12:00 p.m., indicated it was a late entry. The note indicated the Certified Nurse Aide (CNA) notified the nurse the resident slid out of the mechanical lift. The resident was found lying on the floor on her right side, and there were two CNAs in the room. The CNAs reported the resident slid out of the mechanical lift sling and landed on her right side when the resident began moving during the transfer. A progress note, dated 6/19/25 at 4:31 a.m., indicated x-rays were ordered for the resident’s right shoulder and right knee. An interdisciplinary team (IDT) progress note, dated 6/19/25 at 10:12 a.m., indicated the IDT was reviewing the resident’s fall from 6/8/25 [sic]. The resident slipped out of the mechanical lift sling while being transferred. The root cause was “slid out of Hoyer lift.” The intervention was to ensure the appropriate sling was being used. The IDT consisted of the Dietary Manager, MDS Coordinator, Social Services Director (SSD), and Assistant Director of Nursing (ADON). An x-ray report, dated 6/19/25, indicated the resident had a right tibia fracture. The physician signed the report and indicated, “apply splint refer to ortho [orthopedics].” An IDT progress note, dated 6/24/25 at 4:43 p.m., indicated it was an IDT fall follow up clarification. Upon chart review, there was a clarification on the date and events. The fall occurred on 6/18/25, and the IDT note, dated 6/19/25, mistakenly indicated it occurred on 6/8/25. The resident was being transferred via mechanical lift by two CNAs, became restless, and positioned her body in a straight board position. This position caused her to “maneuver herself out of the Hoyer lift sling.” The resident fell approximately three feet, and the CNAs were able to prevent her head from hitting the floor. The resident landed on her right leg. The NP was in the facility, assessed the resident, and indicated she was able to be moved from the floor to the bed. The resident was assessed and was not in pain. The root cause of the incident was the resident became restless and maneuvered herself out of the sling. Interventions included immediate assessment by the NP, staff education for mechanical lift transfers and dealing with residents who had increased agitation during a mechanical lift transfer, x-ray completed, orthopedic consult completed with a new order for a follow-up x-ray in six weeks. An orthopedic physician progress note, dated 6/24/25, stated, “…Given that the patient is nonambulatory, I strongly recommend nonoperative management, and the patient and her family concurred. Supportive care will be provided, including placing support underneath the leg during lifting and transferring. A knee immobilizer or brace is not recommended, as it may lead to increased swelling and complications…The fracture is expected to heal in approximately three to four months….” The incident investigation file contained the following two undated witness statements. A witness statement from CNA 4 stated, “I was in [Resident B’s] room providing care for her…put the Hoyer lift sling under her. [CNA 5] entered the room. We put the sling on the Hoyer lift. As I was pulling out from the bed as I was turning the Hoyer, [Resident B] began to move/wiggle in the sling. I asked her to stop moving. [CNA 5] and I were able to catch her head to prevent it from hitting the floor…” A witness statement from CNA 5 stated, “I…went into [Resident B’s] room to help [CNA 4] transfer her with the Hoyer lift. We put the sling on the Hoyer lift. As [CNA 4] was pulling the Hoyer from out from the bed and turning it, [Resident B] began to move/wiggle in the sling. [CNA 4] asked her to stop moving. I moved closer to help with the transfer, [Resident B] arched her back and slid out of the Hoyer sling. Although we did not keep her from falling, we were able to catch her head to prevent her from hitting her head….” During an interview, on 7/22/25 at 2:41 p.m., Qualified Medication Aide (QMA) 7 indicated she worked 6/18/24 when the resident fell out of the mechanical lift sling. Someone reported to her the resident fell, and she went to get the ADON. The staff stated the resident “bucked” and fell out of the sling. She was not sure if that was unusual for the resident because she did not normally provide direct resident care. After the incident, the staff received training regarding mechanical lift transfers but not regarding sling size. If a resident needed a mechanical lift sling, staff retrieved it from the supply. The size should have been determined by weight. She thought the resident’s height might have been a factor in the mechanical lift sling size as well, but she was not sure about hip size. During an interview, on 7/22/25 at 2:47 p.m., CNA 8 indicated she was familiar with Resident B. There had been issues transferring the resident with the mechanical lift because of her contractures and stiffness. The facility got a new mechanical lift sling for her, and it helped. The new sling crossed between the resident’s legs. The sling they were using before was a “bath sling.” It was a large rectangle that acted like a hammock and seemed too big. She indicated the staff was not trained on which type of mechanical lift sling to use or which size. There had been times when staff used bath slings when they were not really appropriate because they were not sure what to use or the correct equipment was not available. During an observation, on 7/23/25 at 9:50 a.m., CNA 4 and CNA 9 transferred Resident B from the bed to the chair with the mechanical lift. The legs of the lift were closed and under the bed. The CNAs attached the sling loops to the mechanical lift. CNA 4 lifted Resident B up and off the bed, moved the mechanical lift backwards, turned to the right, and positioned it in front of the resident’s wheelchair. Once the mechanical faced the resident’s wheelchair, CNA 4 opened the legs of the mechanical lift and pushed it towards the resident’s wheelchair. CNA 9 guided the resident into the wheelchair as CNA 4 lowered the lift. During the transfer, the straps of the mechanical lift pad were crossed between the resident’s legs, but the resident’s buttocks protruded through the opening of the mechanical lift sling and her legs hung over the sling straps at her knees. The CNAs did not support the resident’s fractured leg during the transfer. At the same time, the ADON indicated the resident’s buttocks were positioned that way due to her contractures. The mechanical lift sling was observed to have the resident’s name on it and was a different brand than the mechanical lift. The CNAs were unable to verbalize what size sling the resident required. During an interview, on 7/23/25 at 10:50 a.m., CNA 4 indicated she was not notified of any requirement to do anything with Resident B’s fractured leg during transfers. She was not aware the resident’s fractured leg needed support during transfers. During an interview, on 7/23/25 at 1:22 p.m., CNA 4 and CNA 5 indicated they were the CNAs who transferred Resident B when she fell out of the mechanical lift sling. They used the rectangular lift sling. The resident stiffened up and fell out of the mechanical lift sling. They had new mechanical lift slings that crossed between the residents’ legs, and they worked better. On 7/22/25 at 2:55 p.m., the Administrator provided the user manual for the mechanical lift used by the facility, dated 10/1/18. The user manual indicated, “…Use common sense in all lifts. Special care MUST BE taken with people with disabilities who cannot cooperate while being lifted. [Mechanical lift brand name] slings and patient lift accessories are specifically designed to be used in conjunction with the [mechanical lift brand name] patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of [mechanical lift brand name] patient lift system…Using the sling…WARNING…If the patient is in a wheelchair, secure the wheel locks in place to prevent the chair from moving forwards or backwards…When using an adjustable lift base lift, the legs MUST be in the maximum opened/locked position before lifting the patient…The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately….” On 7/23/25 at 11:18 a.m., the DON provided a document titled, “Guidelines for Mechanical Lift Transfer/Usage,” dated 7/8/24, and indicated it was the policy currently being used by the facility. The policy indicated, “…Getting ready to use a Mechanical Lift…7) Never use a mechanical lift on a resident who is agitated, resistant or combative…10) Make sure that you have the correct sling for the resident. The sling needs to be: a) Compatible with the specific mechanical lift being used b) Correct size for the resident-this is determined using the resident’s size, weight, and hip measurements in accordance with the manufacturer’s recommendations….” 2. On 7/22/25 at 1:50 p.m., observed Resident D being transferred from wheelchair to bed. Observed Certified Nurse aide (CNA) 4 operating the mechanical lift and CNA 9 assisting to position the resident in the mechanical lift pad. The top back of the pad observed to be approximately 4 inches above the back of the residents head. CNA 4 asked the resident not to hold onto the bar and instructed her to move her arms back and downward. When the resident pulled her arms back, both arms were moved down between the bar and the lift pad. The resident was lifted approximately 18 inches over the wheelchair arm rest and moved to the bed. CNA 9 failed to lock the wheelchair prior to lifting the resident from the chair. CNA 4 failed to lock the brakes on the mechanical lift prior to lowering the resident onto the bed. On 7/23/25 at 9:45 a.m., during a random observation, observed Resident (E) sitting in wheelchair in the main dining room. The resident was sitting on a mechanical lift sling. Observation of the label indicated the residents name was not on the label. On 7/23/25 at 10:00 a.m., during a random observation noted 2 mechanical lift slings were labeled with the residents names and dated 7/9/25. On 7/22/25 at 2:10 p.m., during interview CNA 4 indicated she did not know how to determine the correct size of the lift pad to be used for the resident. She indicated she thought the lift pad was the correct size to be used for the resident. She acknowledged she should have locked the wheelchair prior to lifting the resident from the wheelchair. On 7/22/25 at 2:20 p.m., during interview Qualified Medication Aide (QMA) 6 indicated she did not know how to determine the correct side of a mechanical lift pad to be used for a resident and she would determine the size by looking at the resident and if the lift pad was higher over the back of the residents head the pad would be too big. She indicated when she was transferring a resident from a wheelchair she would raise the bed to be even with the edge of the wheelchair arm rest and would raise the resident up just enough to clear the arm rest on the wheelchair. On 7/23/25 at 1:22 p.m. during interview CNA 4 and CNA 5 indicated they transferred the resident the way they did today during the observation except the resident moves a lot and stiffens up. They were using the rectangular lift pads. CNA 5 indicated she doesn’t normally work that hall, so she hasn’t had any training specific to how to transfer based on the residents risk factors. When they were hired/before the incident they demonstrated how to use the lift properly. After the incident, they had to re-do the mechanical lift competencies and the Assistant Director of Nursing (ADON) observed them do it to make sure they were able to do it. On 7/23/25 at 1:22 p.m. during interview CNA 4 and CNA 5 indicated they transferred the resident the way they did during the observation except the resident moved a lot and stiffens up. They were using the rectangular lift pads. CNA 5 indicated she didn’t normally work that hall, so she had not had any training specific to how to transfer based on the resident risk factors. When they were hired /before the incident they demonstrated how to use the lift properly. They felt like they were provided with equipment, staffing, etc. that they needed to take care of the residents. All residents had their own Hoyer lift pads with their names on them. If the pad needed laundered they put it in the laundry and then got a different pad. They usually got back pretty quickly. They would use the rectangle one right now until the other one came back until the second set of resident specific ones came in. On 7/22/25 at 2:47 p.m. during interview CNA 8 indicated she was not sure everyone was trained on which Hoyer slings to use or what size should be used per sling. There had been times where people had used “bath slings” even when that was not really appropriate either because they didn’t know what to use or because they didn’t have the correct thing available. On 7/22/25 at 2:30 p.m., the medical record of Resident D was reviewed. The residents most recent admission to the facility was on 10/25/24. The record lacked documentation of a physician order to use a mechanical lift for transfers. A quarterly Minimum Data Assessment (MDS) dated [DATE] indicated he resident was extensive assist with two persons for transfers and was cognitively impaired. The residents weight was obtained on 7/8/25 and recorded as 127 lb. According to the manufacture guidelines the residents weight determined she was to use a small mechanical lift pad. On 7/22/2025 at 2:55 p.m., the Administrator provided a document titled, “Guidelines for Mechanical lift Transfer/Usage,” dated 7/8/24, and indicated it was the policy currently being used by the facility. The policy indicated, “ .Getting ready to use a mechanical lift… 3. Be sure that you have the proper mechanical lift for the resident as per the physician’s order and the resident’s care plan. 4. Be sure the residents weight is appropriate for the lift to be used…10…b. Correct size for the resident this is determined using the residents size, weight, and hip measurements in accordance with the manufacture’s recommendations…About the mechanical lift itself…17, Position the lift and receiving surface at correct height to transfer resident easily. This can be with the bed at a higher than usual level or the waist level of the transferring staff, depending on the situation for safety and smooth transferring…Using the Mechanical Lift…34. Apply the wheel lock so it does not move once the mechanical lift is in position…43. Slowly lift the resident only as high as necessary to complete the desired transfer…48. Once the lift is locked and in position lower the lift….” This citation relates to Complaint 1380602. 3.1-14(i)

Based on record review and interview, the facility failed to ensure a resident's family member was notified in a timely manner of a resident's fracture for 1 of 4 residents reviewed for accidents (Resident B). Findings include: Resident B's record was reviewed on 7/22/25 at 11:23 a.m. Diagnoses on the resident's profile included, but were not limited to, cerebral palsy (a group of neurological disorders that affect movement, muscle tone, and posture) and unspecified fracture of the upper end of the right tibia. A significant change Minimum Data Set (MDS) assessment, dated 7/1/25, indicated the resident had a severe cognitive impairment, was dependent for chair/bed transfers, and had one fall with a major injury since the prior assessment. A progress note, dated 6/18/25 at 12:00 p.m., indicated it was a late entry. The note indicated the Certified Nurse Aide (CNA) notified the nurse the resident slid out of the mechanical lift. The resident was found lying on the floor on her right side, and there were two CNAs in the room. The CNAs reported the resident slid out of the mechanical lift sling and landed on her right side when the resident began moving during the transfer. One CNA reported she was able to prevent the resident from hitting her head. The resident was assessed and did not complain of pain. The Nurse Practitioner (NP) was in the facility and assessed the resident. The NP stated the resident could be moved to the bed, and the resident was assisted back to bed. The resident's family member was notified of the incident. The resident requested to get up for lunch, and the NP said the resident was able to get out of bed. The resident was assisted out of bed and went to lunch. A progress note, dated 6/19/25 at 4:31 a.m., indicated x-rays were ordered for the resident's right shoulder and right knee. A progress note, dated 6/19/25 at 4:44 a.m., indicated the mobile x-ray company was scheduled to complete the x-rays in the morning. A progress note, dated 6/19/25 at 11:45 a.m., indicated the mobile x-ray company completed the x-rays of the resident's right shoulder and right knee. An x-ray report, dated 6/19/25, indicated the resident had a right tibia fracture. The physician signed the report and indicated, apply splint refer to ortho [orthopedics]. A progress note, dated 6/19/25 at 12:29 p.m., indicated the resident's x-ray results were received, and there was a fracture to the right tibia. The physician was notified and ordered a splint and orthopedic referral. The orthopedic office was contacted to schedule an appointment. The note lacked documentation the resident's family member was notified. A progress note, dated 6/20/25 at 10:30 a.m., indicated the resident's Power of Attorney (POA) was notified of the resident's right tibia fracture. The record lacked documentation the resident's POA was notified prior to this date and time. During an interview, on 7/23/25 at 9:20 a.m., the Director of Nursing (DON) indicated she noticed in the morning meeting, on 6/20/25, Resident B's family member had not been notified of the resident's fracture. They followed up with the staff nurse and verified the family member had not been notified, and the staff nurse indicated she had not notified the family. Once they found the notification was not completed, the DON notified the resident's family member. The resident's family member should have been notified of the new fracture on the same day it was found. On 7/23/25 at 11:09 a.m., the DON provided a document titled, Change in a Resident's Condition or Status, last revised in February 2021, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement: Our facility notifies the.resident representative of changes in the resident's medical.condition.Policy Interpretation and Implementation.4.a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury.b. there is a significant change in the resident's physical.status. This citation relates to Complaint 1380602. 3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) (daily self-care activities) received assistance with removal of facial hairs for 3 of 3 residents reviewed for facial hair (Residents E, F, and G), failed to clean and cut finger nails for 1 of 4 residents reviewed for ADL care (Resident B), and the facility failed to ensure a resident was provided showers for 1 of 3 residents reviewed for showers (Resident D). Findings include: 1. During an observation, on 11/22/24 at 12:00 p.m., Resident B was observed seated at a table in the dining room with long, jagged nails, that contained dark debris underneath them. Resident B's record was reviewed, on 11/22/24. A quarterly Minimum Data Set (MDS) assessment, dated 10/14/24, indicated the resident had severe cognitive impairment and required extensive assistance of two persons for care. A care plan, dated 6/4/22, indicated the resident received antianxiety medications. Interventions included, but were not limited to, the resident will have all needs met throughout the day being clean and odor free, all ADLs provided daily. 2. During an observation, on 11/22/24 at 12:00 p.m., Resident E was observed seated at a table in the dining room with multiple chin hairs. Resident E's record was reviewed, on 11/22/24. A quarterly Minimum Data Set (MDS) assessment, dated 9/23/24, indicated the resident was cognitively intact and required extensive assistance of one person for bed mobility, transfers, toileting, personal hygiene, and bathing. A care plan, dated 11/26/21, indicated the resident required assistance with ADLs due to poor activity endurance with interventions included, but were not limited to, encourage the resident to complete as much as they are able, and resident will perform ADLs with limited assistance by discharge to home. 3. During an observation, on 11/22/24 at 12:00 p.m., Resident F was observed seated at a table in the dining room with multiple chin hairs. Resident F's record was reviewed, on 11/22/24. A quarterly Minimum Data Set (MDS) assessment, dated 8/27/24, indicated the resident had severe cognitive impairment and required extensive assistance of two persons for bed mobility, transfers, toileting, personal hygiene, and bathing. A care plan, dated 8/23/24, indicated the resident required assistance with ADLs due to poor activity endurance with interventions included, but were not limited to, encourage the resident to complete as much as they are able, and set up and assist with shower 2 times per week and as needed. 4. During an observation, on 11/22/24 at 12:00 p.m., Resident G was observed seated at a table in the dining room with multiple chin hairs. Resident G's record was reviewed, on 11/22/24. A quarterly Minimum Data Set (MDS) assessment, dated 8/27/24, indicated the resident had severe cognitive impairment and required extensive assistance of one person for bed mobility, transfers, toileting, personal hygiene, and bathing. A care plan, dated 3/29/24, indicated the resident required assistance with ADLs related to diagnosis of reduced mobility, lack of coordination, schizophrenia (a serious mental condition that affects the way a person, thinks, acts and feels) with interventions included, but were not limited to, encourage the resident to complete as much as they are able, and bathe per resident preference 2 times per week and as needed. 5. During a review of a grievance form, dated 10/31/24, Resident D's family member had concerns about his showers and if his feet were being washed and dried properly. The form lacked documentation that staff were questioned about the showers. Resident D's record was reviewed, on 11/22/24. A quarterly Minimum Data Set (MDS) assessment, dated 9/24/24, indicated the resident had severe cognitive impairment and required extensive assistance of two persons for bed mobility, transfers, toileting, personal hygiene, and bathing. A care plan, dated 09/2023, indicated the resident required assistance with ADLs due to poor activity endurance with interventions included, but were not limited to, bathe per resident preference two times per week and as needed, set up and assist with shower two times per week and as needed, and refer to most current Choices for Resident Care document for resident preferences. A choices for resident care form, dated 9/25/23, indicated Resident D preferred showers twice a week. Review of an activity resident interview, dated 9/24/24, indicated Resident D's family member found it to be very important for him to be able to choose between a tub bath, shower, bed bath, or sponge bath. Review of point of care documentation, dated October 25, 2024, to November 22, 2024, indicated Resident D received three showers. The showers were documented for October 25th, November 4th, and November 10th. The record lacked any other showers documented for the last 30 days. During an interview, on 11/22/24 at 11:59 a.m., the Director of Nursing (DON) indicated she was not aware of anyone complaining about not getting their showers as preferred, but she was aware the Administrator was looking into using shower sheets again and binders for the Certified Nursing Aides (CNA). During an interview, on 11/22/24 at 12:10 p.m., Qualified Medication Aide (QMA) 3 indicated Resident D was on the evening shift shower schedule and required a Hoyer (mechanical) lift for transfers. During an interview, on 11/22/24 at 1:24 p.m., the DON indicated she was unable to find further documentation that Resident D had received more showers than the three that were documented in the last 30 days. She was unable to find an updated choices for resident care form since September of 2023. During a confidential interview, on 11/22/24 at 2:00 p.m., they indicated they had to shave Resident D yesterday 11/21/24 because it had been over a week since he was last shaved by the staff. There had been times when they had visited, and the resident's face and behind his ears were not clean and his feet were dry. They had questioned if he was being cleaned properly on his shower days. During an interview, on 11/22/24 at 12:25 p.m., Qualified Medication Aide (QMA) 5 indicated the staff would shave residents after showers which are two to three times per week. They would also clean and cut nails on shower days. During an interview, on 11/22/24 at 1:35 p.m., the Director of Nursing (DON) indicated staff should shave the residents and cut their nails on the residents' shower days. She further indicated if a resident was alert and oriented and had a preference not to be shaved it would be in the care plan. On 11/22/24 at 1:54 p.m., the DON provided an undated document titled, Activities of Daily Living, and indicated it was the policy currently being used by the facility. The policy indicated, .ADL care is provided throughout the day, evening and night as care planned and/ or as needed .Assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, nail care, appropriate skin care (as indicated and as per care plan) .Do all required ADL documentation as required per policy and regulations This citation relates to Complaint IN00446843. 3.1-38(a)(3)

Based on interview and record review, the facility failed to notify a resident's representative of changes in condition and treatment for 1 of 3 residents reviewed for family and /or representative notification. (Resident B) Findings include: On 11/22/24 at 10:00 a.m., during a phone interview, the Power of Attorney (POA) of Resident B indicated she had not been notified of changes in the condition of the resident including an incident which occurred between Resident B and another resident, or that the resident was to be sent to a psychiatric facility. Resident B was on hospice services and the hospice agency had not been informed of an order to transfer the resident. She indicated she had not been notified of medication changes such as a treatment for a rash or that the resident had been placed in isolation. On 11/22/24 at 10:30 a.m., the medical record of Resident B was reviewed. The resident was admitted to the facility on [DATE]. The most recent re-admission was on 1/13/24. Admission diagnosis included but were not limited to chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), unspecified dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) with other behavioral disturbance, chronic heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), anxiety disorder (a feeling of fear, dread, and uneasiness). Physician orders included, but were not limited to, Sertraline (antidepressant) oral tablet 100 milligrams (mg) 1 tablet by mouth in the morning for depression, xanax (antianxiety) oral tablet 0.5 mg 1 tablet in the evening for anxiety, alprazolam (antianxiety) tablet 0.5 mg, give 1 tablet by mouth every 6 hours as needed for anxiety A quarterly Minimum Data Set (MDS) assessment, dated 10/14/24, indicated the resident was not cognitively intact and required extensive assistance of two persons for care. A care plan, dated 6/4/22, indicated the resident received anti-anxiety medications and was at risk for side effects related to diagnosis of anxiety and nervousness. Interventions included but were not limited to administer medications per physician orders, provide TLC (tender loving care), reassure resident as needed, redirect resident as needed. The nurse progress notes, dated 10/30/2024 at 7:09 p.m., indicated an incident had occurred between Resident B and another resident. The residents were separated and Resident B continued to be agitated. The staff stayed one on one with Resident B so the nurse could contact the doctor for further orders. On 10/30/24 at 7:47 p.m., the medical record indicated the physician was notified and an order was obtained to transfer the resident to a psychiatric facility for evaluation. The record lacked documentation of POA or hospice notification of the incident or the transfer the psychiatric facility. The medical record indicated on 9/12/24 a chest x-ray was administered to Resident B and on 9/13/24 the resident was placed on an antibiotic. The record lacked documentation of POA notification of medication order or change in condition. On 9/23/24 the medical record indicated a change in condition and the resident was administered intravenous fluids (fluids administered through a vein). The record lacked documentation of POA notification. On 10/4/24 the medical record indicated the resident had a change in condition and was sent to the hospital emergency room (ER) for evaluation and treatment. The record lacked documentation of POA notification On 11/22/24 at 12:25 p.m., during an interview, Qualified Medication Aide (QMA) 3 indicated if a resident had a change in condition they would notify the nurse, and the nurse would call the physician and the family. On 11/22/24 at 1:27 p.m., during an interview, Registered Nurse (RN) 4 indicated if a resident had a change of condition the RN would notify the family and document the notification in the assessment and in the nurses notes. If the nurse needed to send a resident out to the hospital the nurse would call an ambulance first then call the family. The RN indicated if a resident was on hospice services the nurse would contact the hospice nurse first and await directives from the hospice nurse and physician. On 11/22/24 at 1:35 p.m., during an interview, the Director of Nursing (DON) indicated if there was a change of condition in a resident the nurse should notify the family or responsible party first and notify them they had an order to send the resident to the hospital. She indicated if there was a change in medication the family or POA should be notified. On 11/22/2024 at 1:54 p.m., the DON provided an undated document titled, Your Rights and Protections as a Nursing Home Resident, and indicated it was the policy currently being used by the facility. The policy indicated, .Have Your Representative Notified: The nursing home must notify your doctor and, if known, your legal representative .when the following occurs: Your physical, mental, or psychological status starts to get worse .The nursing home decides to transfer or discharge you from the nursing home On 11/22/2024 at 1:55 p.m., the DON provided an undated document titled, Change in Resident's Condition Status, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status .Procedure .2. Unless otherwise instructed the resident (if the resident is alert and oriented and their own representative) the nurse will notify the resident's representative when .Abuse situations or allegations of abuse. There is significant change in the resident's physical, mental or psychosocial status .A decision has been made to discharge the resident from the facility; and/or it is necessary to transfer the resident to the hospital This citation relates to Complaint IN00446280. 3.1-5(a)

Based on record review and interview, the facility failed to ensure transfer and discharge documents were completed and provided to a resident's representative for a discharge to the hospital for 1 of 2 residents reviewed for hospitalization (Resident 57). Findings include: Resident 57's record was reviewed on 10/8/24 at 12:17 p.m. The profile indicated the resident's diagnoses included, but were not limited to, vascular dementia (a chronic condition that occurs when blood flow to the brain is disrupted, damaging brain tissue and affecting memory, thinking, and behavior). A quarterly Minimum Data Set (MDS) assessment, dated 8/27/24, indicated the resident had severe cognitive deficit with no documented behaviors. A care plan, with a revised date of 3/25/24, indicated the resident exhibited socially inappropriate behavior and other socially inappropriate verbal behaviors, regarding staff of color. A progress note, dated 3/24/24 at 7:35 a.m., indicated a Certified Nursing Assistant (CNA) had reported that the resident had put her hands between a male resident's legs while sitting next to each other in the dining room. The resident's had been separated from one another, assessed by a nurse, and placed on 15 minute checks. A Social Service progress note, dated 3/24/24 at 2:16 p.m., indicated Resident 57 had been referred to a Behavioral Health Care (BHC) hospital following the incident with the male resident earlier in the day. A historical review of the resident's physician's orders lacked documentation of an order to send the resident to the BHC hospital. The record lacked documentation that transfer and discharge forms had been completed and provided to the resident's representative. During an interview, on 10/8/24 at 3:16 p.m., Regional Clinical Consultant 18 indicated the facility had been unable to locate the transfer and discharge documents for the resident's BHC hospital transfer. The documents were required to be completed and provided to the resident or responsible party and a copy should have been placed into the resident's medical record. On 10/9/24 at 9:30 a.m., Regional Clinical Consultant 18 provided an undated document titled, Transfer and Discharge Policy and Procedure, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .2 .Notice will be given the resident/responsible party .7. Before a facility transfers a resident to a hospital .the nursing facility will provide information to the resident/responsible party 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii)

Based on record review and interview, the facility failed to ensure bed hold documents were completed and provided to a resident's representative for a discharge to the hospital for 1 of 2 residents reviewed for hospitalization (Resident 57). Findings include: Resident 57's record was reviewed on 10/8/24 at 12:17 p.m. The profile indicated the resident's diagnoses included, but were not limited to, vascular dementia (a chronic condition that occurs when blood flow to the brain is disrupted, damaging brain tissue and affecting memory, thinking, and behavior). A quarterly Minimum Data Set (MDS) assessment, dated 8/27/24, indicated the resident had severe cognitive deficit with no documented behaviors. A care plan, with a revised date of 3/25/24, indicated the resident exhibited socially inappropriate behavior and other socially inappropriate verbal behaviors, regarding staff of color. A progress note, dated 3/24/24 at 7:35 a.m., indicated a Certified Nursing Assistant (CNA) had reported that the resident had put her hands between a male resident's legs while sitting next to each other in the dining room. The resident's had been separated from one another, assessed by a nurse, and placed on 15-minute checks. A Social Service progress note, dated 3/24/24 at 2:16 p.m., indicated Resident 57 had been referred to a Behavioral Health Care (BHC) hospital following the incident with the male resident earlier in the day. A historical review of the resident's physician's orders lacked documentation of an order to send the resident to the BHC hospital. The record lacked documentation that a bed hold policy had been completed and provided to the resident's representative. During an interview, on 10/8/24 at 3:16 p.m., Regional Clinical Consultant 18 indicated the facility had been unable to locate the completed bed hold policy documents for the resident's BHC hospital transfer. The documents were required to be completed and provided to the resident or responsible party and a copy should have been placed into the resident's medical record. On 10/9/24 at 9:30 a.m., Regional Clinical Consultant 18 provided an undated document, titled, Bed Hold, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: It is the policy of the facility to provide the Resident, Resident's family member and/or the Resident's legal representative .prior to transfer to a hospital .information regarding the Resident's facility bed status and how the bed will be held. Note: A copy of the Bed Hold policy given to the Resident, Resident's family member and/or Resident's legal representative will be placed in the resident's record 3.1-12(a)(25)(A) 3.1-12(a)(25)(B) 3.1-12(a)(26)

Based on observation, record review, and interview, the facility failed to ensure a resident's bilevel positive airway pressure (BIPAP) equipment (machine used to provide assistance during inspiration and expiration) was implemented upon hospital discharge, and failed to assess the resident's change in condition after not receiving a BIPAP for 3 days for 1 of 4 residents reviewed for quality of care (Residents B). Based on observation, record review, and interview, the facility failed to ensure a resident with a continuous positive airway pressure (CPAP) machine had physician orders and a plan of care for the CPAP machine for 1 of 4 residents reviewed for quality of care (Resident E). The immediate jeopardy began on [DATE] when Resident B returned from the hospital with orders for the resident to wear a BIPAP after the resident was in the intensive care unit (ICU) due to hypercapnia (elevated carbon dioxide [CO2] levels) on [DATE] requiring treatment with a BIPAP machine. The resident's BIPAP was not unboxed or set up until [DATE]. The resident was lethargic on [DATE] and [DATE]. No follow-up or physician notification on the resident's change in condition or follow-up related to the 3 days without the BIPAP were completed. The resident died on [DATE]. The Administrator was notified of the immediate jeopardy at 4:04 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During an interview on [DATE] at 9:16 a.m., Family Member 2 indicated Resident B was in the hospital from [DATE] to [DATE] with diagnoses of high CO2 levels of 99 milliequivalents per liter (mEq/L) (normal range is 23 to 30 mEq/L). The resident was placed in the ICU where she was put on a BIPAP machine to blow off the CO2. The resident discharged to the nursing facility on [DATE]. On [DATE] Resident B was sent back to the hospital and again diagnosed with high CO2 levels and was placed on BIPAP in the ICU. When the resident went back to the facility on [DATE] she had orders to have a BIPAP at the skilled nursing facility. Family visited on [DATE] and found the BIPAP still in the plastic wrap in the box sitting on the bedside stand. The facility never took the machine out of the original package. Staff told family they had no idea she needed the BIPAP and indicated they had no orders from the hospital. The resident became lethargic, unresponsive, and subsequently died . Nursing staff should have known to call and clarify with the hospital or the physician if they were not sure of the resident's orders. During an interview on [DATE] at 9:16 a.m., Family Member 1 indicated when they visited Resident B on [DATE] around noon, the resident was found to be lethargic, slow to respond, and was not wearing her BIPAP. Family Member 1 found the BIPAP in the box in the resident's room. Family Member 1 unpackaged the BIPAP, set it up, and put it on Resident B. The facility staff had no answers for their lack of actions in implementing the BIPAP. There was a therapist, an aide, and Resident B in the room when Family Member 1 spoke with the Administrator about having to set up the BIPAP. Resident B had been back from the hospital for 3 days. Family Member 1 should not have had to set the BIPAP up. On [DATE] at 1:11 a.m. (family lived out of state in a time zone 1 hour behind the facility) they received a call Resident B had died . The nursing facility completely ignored Resident B's care. The facility knew the resident was retaining CO2 and had 2 hospital stays in July due to high CO2. The facility should have been monitoring and treating her condition. Family Member 1 was so upset they texted Family Member 2 and provided a screen shot of the text message with a time stamp. Screen shot of text, dated [DATE] at 11:44 a.m., indicated: Family Member 1: very lethargic, not very responsive. Opens her eyes and grins and back shut again. The CPAP [sic] machine had never been opened and put on her. She's been back here for three nights. Family Member 2: Oh. Did you ask them why? Family Member 1: They had no idea she was supposed to have it on Family Member 2: Why Family Member 1: No communication at this place or from doctor at [hospital name] Resident B's record was reviewed on [DATE] at 9:25 a.m. Diagnoses on Resident B's profile included but were not limited to chronic obstructive pulmonary disease (COPD) (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and respiratory failure (serious condition that makes it difficult to breath on one's own when the lungs can't get enough oxygen into the blood). Hospital records, dated [DATE] to [DATE], indicated Resident B presented to the emergency department (ED) with respiratory distress, oxygen saturations 60% on room air (normal 95 - 100%), she was placed on high flow oxygen at 10 L. ABG's (arterial blood gas analysis measuring the balance of oxygen and carbon dioxide in the blood to see how well the lungs are working) on arrival notable PCO2 (Partial pressure of carbon dioxide in arterial blood) at 99 millimeters of mercury (mmHg) (normal range is 35 to 45 mmHg) and PO2 (partial pressure of oxygen) at 69 mmHg (normal range ,d+[DATE] mm Hg) indicating high levels of carbon dioxide and low levels of oxygen in the resident's blood. Resident was placed on BIPAP and put in ICU for advanced care and further monitoring. Diagnoses during the admission included exacerbation COPD, encephalopathy (brain disease that alters brain function and structure), and acute hypercapnia respiratory failure (an increase in arterial carbon dioxide due to respiratory failure or increased CO2 production, treated by wearing a CPAP or BIPAP machine). A progress note, dated [DATE] at 9:19 a.m., indicated the resident was able to make needs and wants known. Resident transferred with the assist of one staff. A progress note, dated [DATE] at 3:11 a.m., indicated the resident was alert and oriented to self with confusion. Able to voice needs, ambulates with standby assistance. A progress note, dated [DATE] at 4:22 p.m., resident had an episode of choking at lunch today, was able to clear airway on her own. Resident heart rate at this time was 105 (normal 60 - 100) beats per minute. A few hours later resident found to have heart rate of 115, and shallow respirations. Resident transferred to nearby hospital for evaluation and treatment, she was admitted . Hospital records, dated [DATE] to [DATE], indicated Resident B presented to the ED with respiratory distress, her CO2 level was 138, she was immediately put on a BIPAP and admitted to ICU. Resident was not responding to any stimuli upon arrival. Admitting diagnosis was chronic respiratory failure with hypoxia and hypercapnia. A Discharge Summary from the hospital, dated [DATE], indicated three orders, a. Respiratory assistive device, Bi-level, pressure capability (BIPAP). Description: humidifier, heated, used with positive airway pressure device. Type of BIPAP: without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device). The instructions lacked documentation of frequency or times the BIPAP was to be worn. b. Amoxicillin-clavulanate (Augmentin an antibiotic) ,d+[DATE] milligrams (mg) give 1 tablet by mouth twice daily for 8 doses, for pneumonia caused by inhaling substance into the lungs. c. Anoro Ellipta 62XXX,d+[DATE].5 microgram (mcg) inhaler (non-steroidal medication used to treat COPD) give 1 puff by inhalation daily. An Admission/Re-Admission Screener, dated [DATE], indicated Resident B was admitted from the hospital for respiratory failure. The resident's respiration rhythm was irregular, and breath sounds diminished in the right and left upper and lower lungs. The resident was on a BIPAP, and oxygen per nasal cannula. A physician's order written by Registered Nurse (RN) 6, dated [DATE], indicated oxygen at 2 liters (L) per nasal cannula continuously for shortness of breath. A physician's order written by the Director of Nursing (DON), dated [DATE], indicated BIPAP at bedtime related to respiratory failure, unspecified with hypoxia (deficiency in the amount of oxygen reaching the tissues in the body). BIPAP settings: ST (spontaneous time) 15, IPAP (inspiratory pressure) 5, (optimal level is 4, with maximum 10, the higher level will help the lungs inflate to a larger volume and help with the clearance of CO2), EPAP (expiratory pressure) 28%. A physician's order, dated [DATE], indicated BIPAP every shift related to respiratory failure, unspecified with hypoxia. Resident to wear BIPAP at all times while sleeping day and night. BIPAP settings: ST 15, IPAP 5, (EPAP expiratory pressure) 28%. A Medication Administration Record (MAR), dated [DATE], indicated Registered Nurse (RN) 10 signed as having put the BIPAP machine on the resident on [DATE], [DATE], and [DATE]. In a progress notes, dated [DATE] at 3:20 p.m., RN 6 documented report received from local hospital, Resident B was to return to the facility, after being admitted to the hospital on [DATE] for respiratory failure and aspiration pneumonia. Resident was currently on oral antibiotics, and she was using a BIPAP along with 2 L O2 per nasal cannula (NC). The resident was a 1 assist with transfers, and currently in route per facility van. A progress note, dated [DATE] at 6:40 p.m., RN 6 documented resident arrived at approximately 4:30 p.m. She had been in bed since her return, non-responsive to verbal and tactile stimulation. O2 in place per NC at 2 L, uses BIPAP at HS (bedtime). A progress note, dated [DATE] at 5:01 a.m., LPN 10 documented the resident's only medication was an inhaler. A care plan for Resident B, dated [DATE], indicated the resident required the use of BIPAP due to respiratory failure with hypoxia. The goal was for the resident to be regulated with use of the BIPAP. Interventions included ensure mask/cannula fit properly and was functioning properly, ensure that the pressure settings of the device reflected what was ordered, ensure the device was functioning properly and refer to care manual as needed, notify the physician of any changes, observed oxygen saturations and vital signs as needed, and observed for side effects (i.e., headache, skin irritation, stomach bloating, nasal congestion, runny nose, anxiety, and claustrophobia). A progress notes, dated [DATE] at 6:46 a.m., indicated the resident to be alert and oriented to person. Resident B transferred with the assist of 2 staff. The Medicare 5 day Minimum Data Set (MDS) assessment, completed on [DATE], assessed the resident as having had oxygen therapy before and after admission, no invasive respiratory equipment, and no respiratory therapy. A progress notes, dated [DATE] at 4:31 a.m., indicated resident alert and oriented to self. Assist of 1 staff for activities of daily living (ADL's, daily self-care activities) and 2 staff with transfers using a mechanical lift. Resident was quiet, did not eat any evening meal, and had been sleeping throughout night with BIPAP on. A progress notes, dated [DATE] 7:49 a.m., indicated resident was alert and oriented to person. Transferred with the assist of 2 staff, and total assist with ADL's. A progress notes, dated [DATE] at 2:21 a.m., patient was checked on by nurse about 2:00 a.m. and found to be deceased . Resident record lacked documentation the physician was notified of the BIPAP not having been administered as ordered from [DATE] to [DATE] or the resident's declining condition. The record lacked documentation that follow up assessments of the resident were completed related to not having the BIPAP administer after being admitted with a history of high CO2 levels. During an interview, on [DATE] at 10:54 a.m., the Director of Nursing (DON) indicated, Resident B returned from the hospital on Friday [DATE] with orders for BIPAP at bedtime (HS). On Monday [DATE] the resident was not waking up during the day, so the DON changed the order for the resident to have BIPAP anytime she was in bed sleeping. DON indicated she had not been aware of the incident of family members being mad related to the BIPAP still being in the box when they visited, or that they had involved the Administrator in the incident, due to that being her day off. During an interview on [DATE] at 11:38 a.m., the Administrator indicated he had never spoke to Family Member 2, but he did remember a conversation with Family Member 1. The Administrator could not remember the timeline, but they spoke around noon one day, and had a good conversation. Family Member 1 informed him they had found the resident's BIPAP still in the box, and as the family member had set it up before they felt comfortable putting it together. The Administrator had not seen the BIPAP in the box. He went to see the nurse on the unit, Licensed Practical Nurse (LPN) 8, for clarification of the orders and was told the order read for the BIPAP to be worn at night. Then he went to the DON and had the order changed to be worn when in bed. As the resident was sleeping a lot of the time, it made sense to put it on thru the day and not just at bedtime. During a review of Resident B's record, on [DATE] at 2:35 p.m., with the Administrator, DON, and Regional Nurse Consultant, the DON indicated the resident was originally admitted to an area hospital on [DATE] and had orders for a BIPAP machine and oxygen while in ICU. Before being discharged the resident was on back to breathing on room air. The resident admitted to the nursing home on [DATE] with diagnoses of encephalopathy, and acute hypercapnia respiratory failure secondary to COPD exacerbation. Her only medication order at that time was an inhaler. On [DATE] the resident went back to the hospital due to tachycardia (high heart rate). The resident was alert, oriented and responsive when she left the facility. When Resident B reached the ED she was not responding to stimuli and was admitted with diagnoses of shortness of breath (SOB), possible aspiration pneumonia although an x-ray showed no infiltrates, and was ordered for antibiotic for empiric (based on experience and observation rather than on systemic logic) reasons. On [DATE] Resident B returned to the facility with orders for oxygen at 2 L, BIPAP, and inhaler, and antibiotics for empiric reasons. RN 6, the admitting nurse, indicated when the resident arrived at the facility, she got the BIPAP out of the medication room, and put it on the nurse's cart for the night nurse to put in room. The night nurse LPN 10 told the DON she could not remember if she set up the BIPAP or not. During an interview on [DATE] at 10:53 a.m., OTR (Occupational Therapist Registered) 7 indicated on [DATE] she had been in the room with Resident B to do her initial OT (occupational therapy) evaluation for the current visit, and during that time assisted to get her up in a chair for the family member to feed her. This was the last time she saw the resident awake. She did not awake the next day for therapy when checked on a few different times. On [DATE] Family Member 1 indicated they had taken the BIPAP out of the box and set it up. The family member was asking the OTR questions about the resident's BIPAP orders, and explained to OTR the resident's course of stay in the hospital and why the BIPAP machine was set up the way it was to lower the resident's CO2 levels. The OTR indicated she had never seen a BIPAP set up as this one and that questions about the BIPAP set up needed to be addressed by the nurse. But when LPN 8 was asked, she did not know the answers either. During an interview on [DATE] at 11:08 a.m., LPN 8 indicated she had a discussion with Resident B's family member on [DATE] about the BIPAP orders and she explained to them at that time the BIPAP orders were for hours of sleep at night. Family Member 1 told her the resident had not had the BIPAP on the night before, so he had set it up and put it on her. The Administrator spoke with the family about the BIPAP orders, and after their conversation the orders for the BIPAP were changed to have the resident wear anytime she was sleeping or in bed. On [DATE] the evening nurse LPN 12 had a hard time getting the BIPAP on the resident and had to get help from an agency nurse to put it on. LPN 8 indicated she had never seen the resident wearing the BIPAP until after the order was changed on [DATE]. Upon review of the interdisciplinary team notes in Resident B's record, LPN 8 indicated there was no documentation the physician had seen the resident after her re-admission on [DATE], no documentation of the resident not getting her BIPAP per orders, no documentation the physician was made aware of the resident not getting her BIPAP per orders from ,d+[DATE] to ,d+[DATE], or how the resident tolerated always having the BIPAP on [DATE]. LPN 8 indicated the physician visited residents in the facility on Thursdays, but at this time he was out of the country. During a phone interview, on [DATE] at 11:53 a.m., the primary care physician (PCP) indicated he routinely visited the facility in person weekly and was available via phone at any time to the staff for resident concerns. The resident was readmitted to the facility on Friday [DATE] and expired Wednesday [DATE], he did not see her during that time. He did not receive a call from the facility regarding the resident not receiving her BIPAP per orders, or that she had a decline in condition during her stay. The resident had many co-morbidities that contributed to her death. He would have ordered BIPAP at night only for treatment of the exacerbation of COPD. To treat a diagnosis of acute hypercapnia respiratory failure possibly secondary to acute COPD exacerbation, he would have ordered the BIPAP full time to help reduce the CO2 levels. In his opinion the primary cause of death could have been related to the aspiration pneumonia which unfortunately happened and was being treated with antibiotics. But the buildup of CO2 from not having the BIPAP as ordered certainly could have contributed to her death. His question was if the resident still had above average CO2 levels before discharge from the hospital, why was the BIPAP ordered only for bedtime? Review of hospital discharge records available indicated there was no frequency documented for the BIPAP. The DON indicated she would contact the hospital for orders to clarify. During an interview on [DATE] at 12:25 p.m., Certified Nursing Aide (CNA) 13 indicated she had cared for Resident B during her stay. She was assigned to care for the resident on [DATE]. She entered the room when Family Member 1 was visiting and indicated the resident's BIPAP had still been in the box, and the family member had set it up and put it on the resident. The resident was sleepier and kind of nonresponsive the last few days she was at the facility. She primarily worked day shift but at times would come in a 2:00 a.m. She had never seen Resident B wearing a BIPAP until the afternoon of [DATE]. Attempts to contact LPN 10 multiple times during the survey were unsuccessful. During an interview on [DATE] at 12:49 a.m., RN 6 indicated on [DATE] she had worked a 2:00 p.m. to 6:00 p.m. shift. RN 6 had taken report from a hospital nurse and was told the resident would return with orders to have oxygen and BIPAP at night. RN 6 indicated she took the boxed BIPAP machine out of the mediation room and sat it on the mediation cart inside the nurse's station for the on-coming nurse LPN 10 to find and apply as ordered. Before leaving RN 6 gave report to LPN 10. RN 6 indicated, the hospital had faxed Resident B's orders to include the BIPAP ahead of the resident's return, and another nurse had put the orders into a queue to be activated when the resident arrived. When she heard the resident was coming, she activated the order and put in the BIPAP settings. RN 6 indicated she could not remember the specific orders for frequency at this time and was not sure if the orders from the hospital matched the orders input into the resident's electronic medical record (EMR). During an interview on [DATE] at 2:35 p.m., the DON indicated ahead of Resident B's re-admission orders on [DATE], the DON had received orders for the BIPAP and contacted the contracted durable medical equipment supplier for respiratory supplies, and the supplier had preset the BIPAP settings according to the physician's orders. The BIPAP arrived on [DATE] ahead of the resident's return and was stored in the medication room. Upon review of re-admission/hospital paperwork for [DATE], the DON indicated she could not find orders for frequency of the BIPAP, either at bedtime or to be always worn when in bed. When a resident was admitted to the facility, the receiving nurse was responsible for making sure resident orders were correct, and hospital orders matched the orders in the EMR. The DON indicated she had not been made aware Resident B had not received her BIPAP for 3 days upon re-admission, she would have notified the physician immediately for further instructions. DON indicated she was the nurse who changed the order on [DATE] per the Administrator's request for the resident to wear her BIPAP when in bed. DON indicated she had gotten the order by calling the physician but did not document in the resident record she had spoken to the physician or the reasoning for changing the order. During an interview on [DATE] at 2:40 p.m., LPN 4 indicated he and his peers had been helping to input physician's orders on [DATE] as there were multiple resident admissions. He did not remember writing orders for Resident B and had no knowledge of her BIPAP orders. During an interview on [DATE] at 3:25 p.m., the Administrator indicated after finding the resident had not been wearing her BIPAP as ordered for 3 days, he had not back tracked to figure out why the order had been dropped. He thought the issue was resolved, so he moved on. There was no follow up completed with staff to determine the root cause of the entire situation. During an interview on [DATE] at 12:30 p.m., RN 5 indicated she had cared for Resident B on the day shifts of [DATE], [DATE], and [DATE]. She had never seen the resident wearing a BIPAP when she arrived at work in the morning and had no knowledge of the resident having a BIPAP machine or physician's orders to wear one. During an interview on [DATE] at 12:48 p.m., CNA 14 indicated she was the aide assigned to care for Resident B from 6:00 p.m. to 6:00 a.m. on the nights of [DATE], [DATE], and [DATE]. The resident required total care with her ADL's, and she never saw her out of bed. CNA 14 indicated the resident was observed to wear oxygen per NC from a concentrator that sat on the right side of her bed. She did not remember seeing Resident B wearing a BIPAP on those nights she cared for her, and never saw any BIPAP equipment in the room. 2. On [DATE] at 10:40 a.m., Resident E was observed sitting in a low to the ground wheelchair at bedside, with a blue mechanical lift pad under her. A CPAP machine was sitting on the bedside stand and an oxygen concentrator beside the bedside stand and behind the resident. The resident was alert, oriented, and talkative about the circumstances that led her to be in the nursing home. Resident E indicated, approximately [AGE] years ago she had participated in a sleep study. That was when she had been given the CPAP machine to wear when sleeping, the machine still had the same original settings. Her last visit to a pulmonologist (physician who specializes in the respiratory system) was about 2 years ago. The day prior, [DATE], staff had come into her room and rinsed the filter in her CPAP and hung a respiratory sign on her door, they had not done those things before. Resident E's record was reviewed on [DATE] at 2:45pm. The census information indicated the resident was admitted on [DATE], with diagnoses that included, but were not limited to, sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). An Admission/Re-Admission Assessment, dated [DATE], indicated oxygen at 2 L and CPAP, there was no documentation to indicate frequency for use of the CPAP. A physician's order, dated [DATE], indicated oxygen at 2L via CPAP at bedtime in the evenings for shortness of breath. The order lacked documentation of CPAP settings. MARs dated May, June, and [DATE], indicated there was no documentation to indicate a CPAP was worn at night for shortness of breath or sleep apnea. A MAR, dated [DATE], indicated a new order [DATE] for oxygen at 2L via CPAP at bedtime in the evening for shortness of breath, 7:00 p.m. to 11:00 p.m. Interdisciplinary notes, dated July and [DATE], indicated there was no nursing or physician documentation related to the resident using a CPAP at night, respiratory status related to CPAP use, or tolerance to the CPAP at current settings. During an interview on [DATE] at 9:52 a.m., the DON indicated during an audit on [DATE] she found that Resident E had no orders for her CPAP. The resident had admitted to the facility in [DATE] and brought her CPAP machine from home with preset settings from another oxygen company the facility did not use. The DON indicated she had known the resident had a CPAP and knew she had worn it for years while home and in the facility at night since being admitted . The DON indicated she just did not realize the resident had no physician's order to use the CPAP while in the facility. The DON indicated once she realized Resident E had no order for the CPAP, she wrote an order on [DATE] for the resident to have the CPAP at bedtime for shortness of breath. The family of Resident E had visited on the evening of [DATE], and the DON was able to obtain history of the CPAP use, but she now needed to contact the physician to get his order for use. The DON indicated she had no orders for settings on the CPAP machine, could not verify the settings as it had come from home and had been preset in the past, and had not notified the physician before writing the orders for CPAP use on [DATE]. A care plan for Resident E, dated [DATE], indicated she required oxygen use due to low oxygen saturations. The goal was for the resident to have no complications from oxygen use. Interventions included change oxygen tubing/apply oxygen tubing per facility policy, labs as ordered by physician, medications per physician's orders, oxygen as ordered per physician, and report changes to the physician as needed. The resident record lacked a care plan for need and use of a CPAP machine until [DATE] during the survey. National Library of Medicine, Biotech Information at https://www.sleepfoundation.org/sleep-apnea/hypercapnia, ([DATE]) was retrieved on [DATE]. The guidance included an explanation of hypercapnia.Hypercapnia occurs when the concentration of carbon dioxide in the bloodstream rises above a certain level. This can upset the acid-base balance in the bloodstream and cause a range of mild to severe symptoms. Hypercapnia is considered a sign of a larger issue instead of being a standalone disease. It can occur suddenly, or it can exist in chronic form. Symptoms included labored or shallow breathing, wheezing, altered consciousness or confusion, fever, flushed skin, sweating profusely, fatigue or sleepiness, headache or nausea, and irritability On [DATE] at 2:35 p.m., DON provided a Physician's Orders - (Following Physician Orders) policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, .It is the policy of the facility to follow the orders of the physician. At the time of admission, the facility must have orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission .3. Orders that accompany the resident on admission will be clarified by the physician through action of the nurse who will contact the physician for clarification upon the resident's admission On [DATE] at 2:35 p.m., DON provided a Change in Resident's Condition or Status policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, .It is the policy of the facility to ensure that the resident's attending physician and representative are notified of changes in the resident's condition or status. 1. The nurse will notify the resident's attending physician when .There is a significant change in the resident's physical, mental, or psychological status. There is need to alter the resident's treatment plan significantly .6. The nurse will record in the resident's medical record any changes in the resident's medical condition or status On [DATE] at 3:15 p.m., the DON provided a BIPAP/CPAP policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, .To provide non-invasive breathing support for residents who are diagnosed with obstructive sleep apnea [[NAME]], COPD, CHF, and neuromuscular disease .BIPAP-[bi-level positive airway pressure] provides assistance during inspiration and expiration . IPAP- [inspiratory positive airway support] this is the inspiratory pressure that is set when BIPAP is used. EPAP- [expiratory positive airway pressure] this is the expiratory pressure that is set when BIPAP is used. Equipment: BIPAP/CPAP machine, face mask when head gear and straps-may be full face, partial face or nasal, oxygen source and tubing [as ordered], humidification source [if applicable], pulse oximetry. 1. Verify physician's order for pressure, oxygen, and parameters for pulse oximetry .2. Assemble equipment .6. Check equipment function - follow manufacturer's recommendations. 7. Place mask over resident's face. 8. Turn machine on. 9. Attach headgear and straps -verify there are no air leaks 10. Check pulse oximetry as per physician order .11. Monitor the resident throughout the night for any adverse reactions. 12. Report any issues or problems to the physician as appropriate. 13. Document in the progress notes the resident comfort and response to the efficacy of the current treatment The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility ensured residents with respiratory orders had the required equipment, medication, and assessments as ordered. The facility ensured all residents with respiratory orders were assessed for appropriate orders and treatment. Staff were in-serviced on re-admission procedure, assessing for respiratory symptoms and change of condition, following physician orders, and notifying the physician of missing orders. The facility created a plan to monitor for implementation of orders for respiratory equipment and respiratory care. This Federal tag relates to Complaint IN00413639. 3XXX,d+[DATE](a)(6)

Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from involuntary seclusion (separation of a resident from other residents or from the resident's room or confinement to resident's room against the resident's will, or the will of the resident representative) for 4 of 6 residents reviewed for abuse, when staff confined the residents in their room by tethering the door handles to the handrails in the hallway (Residents G, H, J, and K). Using the reasonable person concept, it is likely that this would lead to mental anguish including anger, distrust, and chronic or recurrent fear and anxiety. Findings include: On 12/8/22 at 10:31 a.m., the area Ombudsman reported she had received multiple anonymous phone calls indicating confused and mobile residents, who had been moved and were currently in isolation rooms on the end of the skilled nursing facility (SNF) hallway, had been secluded in their rooms against their will at the direction of the Director of Nursing (DON). Over the weekend of 12/3/22 evening staff members had used a gait belt and a regular belt to tie the doors to the handrail preventing the residents from leaving their rooms. She had received pictures of the tethered doors as proof from a complainant. Complainants indicated they were upset about the treatment of the residents. During an interview on 12/8/22 at 1:32 p.m., Qualified Medication Aide (QMA) 9 indicated she worked primarily on the Skilled Nursing Facility (SNF) unit. There were currently 3 resident rooms at the end of the hallway with residents in isolation. Residents were kept in their rooms and redirected if they tried to come out. Resident G routinely screamed with all care, or just laid in bed and screamed help for no reason, but she was able to transfer and move around in her wheelchair independently. QMA 9 indicated she had heard girls on 2nd shift barred the door to Resident G's room, but she did not know staff names. During an interview on 12/8/22 at 2:04 p.m., CNA 13 indicated she routinely worked evening shift on the SNF hallway. There were currently 3 rooms with 5 residents in isolation on the end of the hallway due to COVID-19 who had dementia and keeping the residents in their rooms included a lot of redirection. On 12/2/22 she had observed Residents G, H, J, and K's rooms tied shut with a gait belt and what looked like a thread. Upon observation she approached the nurse and was told she was not sure what it was, but they were told to make sure the residents stayed in their rooms. LPN 17 went and looked, and CNA 13 thought she removed it. It was not okay for the resident doors to be tied. During an interview on 12/8/22 at 3:35 p.m., the DON indicated she did not remember but thought she had been informed of the residents being tied into their rooms by the ADON by phone call on Friday 12/2/22 between 7:00 p.m. to 8:00 p.m. She had been informed a gait belt or something was on wandering residents' doors tying Residents G, H, J, and K into their rooms. Staff were told they were not allowed the tie the doors shut. DON indicated if residents wandered out, they were to be redirected back into their room. The DON indicated she had the ability to view the facility camera per her cellphone and looked at footage of the hallway and could see something but could not make out what was on the doors. She then called staff and told them if the doors were tied, they had to remove the ties immediately. There was no reason for the staff to have tied the doors as they were in the hallway and should have just re-directed as best as they could. During an interview on 12/8/22 at 5:20 p.m., the DON indicated she did not have pictures on her phone of the resident doors being tied shut, she must have just been showed the pictures by the ADON on Friday evening 12/2/22 while still in town at a parade the facility was participating in. The DON indicated upon seeing the pictures she had called the facility and spoke to LPN 17 and QMA 18. On 12/9/22 at 10:30 a.m., the DON provided a typed statement, dated 12/3/22, unsigned, indicated it was a statement from the Administrator. The statement indicated, Investigation: Per staff statements: CNAs secured doors to [room numbers] for approximately 90 minutes. Staff entered the room every 15 - 20 minutes. Staff was in area of rooms through the time doors were secured. Doors could be opened to approximately 1 foot. Residents did not appear to be in distress during staff visits to room. It was not the intent of staff to cause harm to residents in these rooms, intent was to prevent other residents from infection [COVID-19]. Conclusion: All staff in-serviced on proper protocol of isolation for COVID-19, Abuse, Customer Service, and Administrator notification. Confidential interviews were conducted during the survey indicated the following: a. The employee indicated there were 3 rooms with 5 residents on the SNF unit where residents were residing temporarily due to COVID-19 and need for isolation. She had heard on Friday evening 12/2/22 Residents G, H, J, and K's rooms had been tied shut on evening shift to prevent them from getting out and wandering in the hallway. During the day on Friday there was an extra aide just to provide oversight for the 3 isolation rooms but only 2 staff members on the evening shift, and when busy the aide on this end of the hallway indicated they could not provide oversight for them and put the other residents to bed. When the night shift came to work, they were not comfortable with having the doors tied closed and untied them. Pictures the employee saw showed Residents J and K's door was tied shut with some type of black belt and Resident's G and H's room was tied shut with a white sheet. b. The employee indicated on 12/2/22 at approximately 9:30 p.m., evening CNAs 13 and 21 were overheard discussing tying the doors shut to Resident G, H, J, and K rooms as the residents had COVID-19 and staff were having a hard time keeping Resident H in her room, she kept coming out and trying to walk per her normal routine. Employee was not comfortable with having the resident doors tied and along with another staff member viewed the doors and untied them. Understanding was day shift had a 3rd aide on the hallway to oversee the isolated residents until 6:00 p.m., and after that aide left CNAs 13 and 21 kept having to put Resident H back into her room so they tied the hallway door shut. Resident H was able to access Residents J and K's room through the connecting bathroom, so their door was tied shut also. Evening staff indicated management knew and had approved of the doors being tied. When the evening staff left the facility the night staff did not know what to do so they took pictures of the situation and sent them to the ADON with text asking if administration had approved of this. The ADON responded to no one had informed her about this. c. Employee indicated on Friday evening 12/2/22 evening CNA's 13 and 21 were overheard talking about tying the doors shut to Resident G, H, J, and K's rooms. Employee indicated this was illegal, so went with another staff member and looked at the doors and found the doors tied with gait belts with a crack in them, maybe could open 2 inches tops. The evening shift employees said management was aware, but the employee did not believe the Administrator or DON would allow this. The employees who had concerns about the doors being tied shut sent pictures as evidence to the ADON between 10:00 p.m. and 10:30 p.m., as she was usually awake late, and then untied the doors. The employee believed the staff had tied the doors out of frustration as these 4 residents had dementia and it was hard dealing with them. The 2 pictures were provided and observed. In the pictures Residents G and H's door was tied tight from the door handle to the railing with a white gait belt. Residents J and K's door was tied tight with a black belt from the door handle and the railing. Neither picture looked as if the doors could have been opened. d. Employee indicated, around 9:30 p.m. had overheard CNAs 13 and 21 discussing Resident H who liked to wander and how they were having a hard time keeping her in her room for isolation, and upper management said to tie her in her room. Employee indicated upper management would never have told staff to do that. Hearing the residents' doors were tied, instantly made the employee mad. What would have happened if a fire broke out, or the residents started fighting? They were all confused residents and had behaviors, like Resident G who threw things. It was not right to tie the residents up. This was abuse. Night CNAs observed the doors and untied them. Care of confused residents with COVID-19 was a little different as doors needed to be closed, but staff could not tie the doors, could not hold the doors shut, or forcefully keep them in there. This was abuse. e. Employee indicated, on 12/2/22 between 9:00 p.m. and 9:30 p.m. it was brought to her attention the doors to Residents G, H, J, and K's rooms were tied closed. They were supposedly the biggest wanderers. CNAs 13 and 21 indicated upper management was aware of it. Night CNAs went and untied the doors. Pictures of the tied doors had been texted to the ADON. This was abuse. During an interview on 12/8/22 at 5:25 p.m., QMA 18 indicated, he had been passing medications on the skilled unit the evening of 12/2/22. Residents G, H, J, and K were supposed to be in isolation, but would routinely wander. At 6:00 p.m. a CNA went home and CNAs 13 and 21 were left trying to figure out how to keep the residents in their rooms and finish their work. So, they decided to tie the doors around the doorknobs until they finished their work. QMA 18 indicated he did not believe LPN 17 gave permission for them to tie the doors, but they both knew about the situation and did not say anything to correct it. He did not know how long for sure the doors were tied shut but thought maybe 1 to 11/2 hours before the DON called and said to remove the ties. During a phone interview on 12/9/22 at 8:53 a.m., the ADON indicated on Friday evening 12/2/22 she had received a text message from a CNA during the town parade around 7:00 p.m. to 8:00 p.m. The text was 2 pictures of Residents G, H, J, and K's doors tied shut, and she responded she did not know what that was. ADON indicated the staff had no permission to do that and were to remove it immediately. ADON then showed the picture to the DON, and she thought the DON went to the facility to make sure the ties had been removed after the parade. On 12/3/22 the ADON was informed CNA's 13 and 21 were responsible for tying the resident doors closed, they admitted to tying the doors but indicated they had been told to do so by QMA 9. When asked if they knew tying the doors closed was wrong, CNA's 13 and 21 indicated they had questioned this among themselves but were told to do it and had no answer to why they had not notified the ADON, DON, or Administrator. The plan for keeping isolated residents with dementia in their rooms included re-directing them back to their rooms as they cannot wander the hallways. During an interview on 12/9/22 at 9:53 a.m., CNA 21 indicated on 12/2/22 she had worked the evening shift with CNA 13 on the SNF hallway. There had been another CNA from day shift who stayed until 6:00 p.m., then it was just the 2 CNAs who were working the floor and could not just sit with the isolated residents. They used PPE and went in about every 15 to 20 minutes to check on the residents. Resident H was the main resident coming out, going back and forth to Resident G's room through the adjoining bathroom, wandered and kept coming out of her room. After the belts were applied to the resident doors, Resident H kept knocking on the door asking if anyone was out there. Even with the belt attached the door to Resident H's room opened inches where she could have taken the belt off if she pushed hard enough. CNA 21 indicated she and CNA 13 went to the nurse's desk and asked how they were going to do work and care for the residents, and QMA 9 told them night and day shift had tied the doors shut with belts. QMA 9 then handed the aides a gait belt and one regular belt, so at that point they assumed it was ok. They did not contact management and get approval. About an hour later the DON called and said the belts had to come off. LPN 17 and QMA 18 knew of the belts as they were sitting at the desk and overheard the discussion. CNA 21 indicated at the time they were under the impression the DON had approved the belts for medical purposes, but later found out that was not true as the DON was very upset with them. CNA 21 indicated she had been trained on abuse for years to include involuntary seclusion, so knew it was not right. But took the word of another staff and assumed it was okay. She should have called the DON and questioned the situation but trusted the QMA and took her word. Attempts were made to interview LPN 17 during the survey without a response. On 12/9/22 at 3:20 p.m., DON indicated she had been shown the pictures of the residents' doors being tied shut on Friday evening 12/2/22 by the ADON after the parade around 8:00 p.m. to 8:30 p.m. She did not come to the facility to investigate but called the facility and told them to remove the ties. The DON had the capacity to view video of the hallway to determine how long the ties had been on the doors but did not. She knew the ties were not on the doors at 6:30 p.m. when they left the facility so knew they could not have been on the doors long. When asked if any reasonable person who was alert and oriented had been tied in their room and unable to get out, would you expect them to be upset and angry, the DON indicated oh yea without a doubt. 1. During the initial tour on 12/5/22 at 11:05 a.m., Resident G's door was observed to be closed with a red stop sign taped to the door. The DON indicated the resident was in isolation after being symptomatic and testing positive for COVID-19. The resident's normal routine was to wander daily with another resident. The DON indicated Resident G was not doing well with isolation, she would yell and scream unless someone was in the room with her. Resident G's record was reviewed on 12/9/22 at 10:17 a.m. Diagnoses on Resident G's profile included, but were not limited to schizophrenia, dementia, anxiety disorder, history of falls, and convulsions. A physician's order for Resident G, dated 12/1/22, indicated transmission based contact/droplet isolation every shift. A progress notes for Resident G, dated 12/1/22 at 3:52 a.m., indicated the resident was positive for COVID-19, the family was notified, and the patient was in isolation. A social service notes for Resident G, dated 12/1/22 at 4:55 p.m., indicated resident had a diagnosis of COVID-19 and was in isolation. Resident had exhibited increased behavioral episode today of throwing things at the door and hitting at staff. Resident received an order for Haldol (antipsychotic to treat mental disorders) 0.2 ml (milliliter) and Risperdal (antipsychotic to treat schizophrenia) 0.25 mg (milligram). Resident had a diagnosis of undifferentiated Schizophrenia with Risperdal 0.25 mg twice daily. Resident was able to be redirected and calmed down to where staff could provide care. A progress notes for Resident G, dated 12/1/2022 at 7:04 p.m., indicated resident was extremely agitated this shift. The Physician was notified, and a new order obtained to give the resident Haldol IM (intramuscular). The resident record lacked documentation of behaviors in November 2022, then antipsychotic medications administered 12/1/22 due to increased behaviors after being placed in isolation and the door closed. The resident record lacked documentation the physician or responsible party had been made aware the resident was involuntarily secluded in her room by use of a gait belt to secure the door shut, assessed for injury, or that psychosocial assessments were completed following the incident. A quarterly Minimum Data Set (MDS) assessment, completed on 12/2/22, assessed Resident G as being unable to complete the BIMS (Brief Interview for Mental Status) assessment as the resident rarely/never understood the questions. She displayed signs and symptoms of delirium to include inattention, and disorganized thinking. Physical, verbal, and other signs of behaviors such as hitting or scratching self, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds. There was documentation of rejection of care. Extensive assistance of 2 or more persons (+) physical assist for bed mobility, transfers, dressing, and toilet use. She was a limited assistance of 1 person physical assist for locomotion on and off the unit. Mobility devices included a wheelchair. A care plan for Resident G indicated she was at risk for falls due to a history of falls and dementia. The medical record lacked documentation of a current care plan related to being positive for COVID-19, being placed in isolation, or interventions to address the resident's increased behaviors related to isolation and being prevented from routine wandering. 2. During the initial tour on 12/5/22 at 11:07 a.m., Resident H's door was observed to be closed with a red stop sign taped to the door. The DON indicated the resident had been moved from her primary room to cohabitate with another resident in isolation after being symptomatic and testing positive for COVID-19. The resident's normal routine was to wander daily with another resident. When asked how the residents were kept isolated if they liked to wander, the DON and Administrator indicated they did the best they could, but at times the residents were placed in personal protective equipment (PPE), the other resident doorways to the hallway closed, and the residents were allowed to wander at the end of the hallway a bit. Resident H's record was reviewed on 12/9/22 at 10:48 a.m. Diagnoses on Resident H's profile included, but were not limited to, Alzheimer's disease, disorientation, and history of falling. A physician's order for Resident H, dated 5/11/20, indicated up ad lib (as wanted). A physician's order for Resident H, dated 12/2/22, indicated transmission based contact/droplet isolation every shift. A progress notes for Resident H, dated 12/1/22 at 7:00 p.m., indicated resident tested positive for COVID-19 and was immediately isolated to a room by herself, then moved to another room with another COVID-19 positive resident. A progress notes for Resident H, dated 12/3/2022 at 5:42 p.m., indicated resident alert and oriented to self with noted confusion and forgetfulness per usual self. Trying to wander into hallway, redirected with little difficulty. A progress notes for Resident H, dated 12/4/22 at 3:53 a.m., indicated made some attempts to leave room early in shift, however, staff was able to get resident calmed down drew attention away from door, remains under isolation precautions. A progress notes for Resident H, dated 12/4/2022 at 11:11 a.m., indicated resident with noted confusion and forgetfulness per usual self. Trying to wander into hallway, redirected with little difficulty. Resident record lacked documentation the physician and responsible party had been made aware the resident was involuntarily secluded in her room by use of a gait belt to secure the door shut, assessed for injury, or that psychosocial assessments were completed following the incident. An annual MDS assessment, completed on 11/29/22, assessed Resident H as being unable to participate in the BIMS assessment due to rarely/never understood the questions. Resident displayed signs or symptoms of delirium to include inattention and disorganized thinking. No symptoms of behaviors or rejection of care but did wander daily. Resident required extensive assistance of one person physical assist for bed mobility, and transfers. Resident required limited assistance of one person physical assist for walking in the room, and limited assistance of 2+ persons physical assist for walking in the corridor. Supervision and one person physical assist were needed for locomotion on and off the unit. No mobility devices were utilized. A care plan for Resident H, dated 5/12/20, indicated the resident wandered without natural purpose. The goal was for the resident to be safe while wandering in the facility. Interventions included, allow resident to vent, offer snacks and fluids, reassure resident as needed, redirect resident to activity of choice, refer to psychologist as needed, tender loving care, and wanderguard placed with placement and function checks every shift. A care plan for Resident H, dated 12/2/22, indicated the resident tested positive for COVID-19 and was to be placed in transmission based-droplet isolation. The goal for the resident was for the resident to be free from signs and symptoms of acute respiratory distress and secondary infections such as pneumonia. Interventions included the resident was to remain in her room with all services proved in her room, and to place in a private room if available. Observe for changes in mood and/or psychosocial changes such as increased confusion, changes in sleep patterns, changes in behavior, nervousness, weight loss, or crying episodes. The resident record lacked documentation of interventions to address the resident's behaviors related to isolation and being prevented from routine wandering. 3. During the initial tour on 12/5/22 at 11:16 a.m., Resident J's door was observed to be closed with a red stop sign taped to the door. The DON indicated the resident had been moved from her primary room to cohabitate with another resident in isolation after being symptomatic and testing positive for COVID-19. Resident J's record was reviewed on 12/9/22 at 12:20 p.m. Diagnoses on Resident J's profile included, but were not limited to, schizoaffective disorder bipolar type, delusional disorders, major depressive disorder, dementia, history of falling and repeated falls. A physician's order for Resident J, dated 12/1/22, indicated transmission based contact/droplet isolation every shift. A progress notes for Resident J, dated 11/30/22 at 4:40 p.m., indicated the resident was symptomatic and tested positive for COVID-19. The resident was moved to the skilled unit. A social service progress notes for Resident J on 12/4/22 at 2:58 p.m., indicated the resident liked to wander with no rational purpose. Resident was currently in isolation due to diagnosis of COVID-19-19. Resident record lacked documentation the physician and responsible party had been made aware the resident was involuntary secluded in her room by use of a gait belt to secure the door shut, assessed for injury, or that psychosocial assessments were completed following the incident. A Medicare 5 day MDS assessment complete on 12/5/22, assessed Resident J as not being able to complete a BIMS assessment due to her mental status. The resident displayed signs and symptoms of delirium to include inattention and disorganized thinking, and she wandered daily. Extensive assistance of one person physical assist for bed motility and transfers and walking in the room, she did not walk in the corridor. Supervision and one person physical assist for locomotion on the unit. Supervision and set up help only for locomotion off the unit. Mobility devices included a wheelchair. A care plan for Resident J, dated 8/2/22, indicated the resident exhibited physically aggressive behavior toward peer such as hitting at peers. The goal for the resident was to have no further increased behavioral episodes of hitting at peers. Interventions included explain appropriate behavior, redirect, refer to consulting psychologist, and visit with resident routinely to assess for any further behavioral episodes. A care plan for Resident J, dated 3/19/19, indicated the resident tended to speak unkindly to staff and peers at times, and she had exhibited verbal and physical aggressive behaviors. The goal was for the resident to speak kindly to staff and peers, be easily redirected when she was speaking rudely to staff and peers and have no further aggressive behaviors. Interventions included, allow resident to vent in a private location so that other residents cannot overhear her complaints, attempt redirection when resident was becoming rude with staff and/or peers, explain to resident inappropriate behavior when she was speaking rudely or unkindly to staff and/or peers, notify the physician with concerns, and redirect and explain inappropriate behaviors, and refer to consulting psychologist as indicated. The medical record lacked documentation of a current care plan related to being positive for COVID-19, being placed in isolation, or interventions to address the resident's behaviors related to isolation and being prevented from routine wandering, and how her aggressive behaviors toward others were being monitored with the door closed. 4. During the initial tour on 12/5/22 at 11:11 a.m., Resident K's door was observed to be closed with a red stop sign taped to the door. The DON indicated the resident had been moved from her primary room to cohabitate with another resident in isolation after being symptomatic and testing positive for COVID-19. Resident K's record was reviewed on 12/9/22 at 1:55 p.m. Diagnoses on Resident K's profile included, but were not limited to schizoaffective disorder bipolar type, vascular dementia, severe manic episodes, and history of falling. A physician's order, dated 11/28/20, indicated up ad lib. A physician's order for Resident K, dated 11/30/22, indicated transmission based contact/droplet isolation every shift. A progress notes for Resident K, dated 11/30/22 at 7:16 a.m., indicated the resident tested positive for COVID-19 and was placed in isolation. A progress notes for Resident K, dated 11/20/22 at 9:45 a.m., indicated the resident was found lying on the floor between the bed and three drawer chest. Abnormal vital signs included temperature 101.5 F (Fahrenheit) (normal 98.6), blood pressure 160/80 (normal less than 120 /80), pulse 102 (normal 60 - 100), and respirations 18 (normal 13 - 19). New orders for x-rays to left foot and toes. A social service progress notes for Resident K, dated 11/30/22 at 5:20 p.m., indicated resident required cues and redirection and wandered with no rational purpose and wander guard in place. A progress notes for Resident K, dated 12/4/22 at 4:11 a.m., indicated the resident did not appear to feel well, had a poor appetite, was cooperative with care, and remained under isolation precautions. A progress notes for Resident K, dated 12/5/2022 at 5:15 p.m., indicated the resident was found on the floor on her back by staff during rounds. Resident record lacked documentation the physician and responsible party had been made aware the resident was involuntary secluded in her room by use of a gait belt to secure the door shut, assessed for injury, or that psychosocial assessments were completed following the incident. A quarterly MDS assessment, completed on 12/2/22, assessed Resident K as not being able to participate in the BIMS assessment as she rarely/never understood. She displayed signs and symptoms of delirium to include inattention, disorganized thinking, and altered level of consciousness. She required extensive assistance of one person physical assist for bed mobility, transfers, locomotion on the unit, toilet use, and personal hygiene. She required limited assistance of 2+ persons physical assist for walking in the room and corridor. Limited assistance of one person physical assist for locomotion off the unit and eating. No history of falls was documented. A care plan for Resident J, dated 5/24/22, indicated the resident had to be redirected to her room and would attempt to go in other rooms at times. The goal was for the resident to be safe while lying in different positions and being redirected. Interventions included encourage resident to lie in proper positioning, redirect resident to own room, and sign in bright color for cue of her room. A care plan for Resident J, dated 3/5/22, indicated she was at risk for falls due to decreased mobility and weakness. The goal for the resident to be free from major injury related to falls. Interventions included assist resident with ADL's (activities of daily living) as needed, decreased mobility and weakness, encourage resident to use call light for assistance from staff. Encourage resident to wear non-skid footwear when out of bed. Due to COVID-19 positive changes in environment will be made. She was in isolation and generally weak at this time with new onset of pain. Resident continued with changes related to COVID-19 positive and was generally weak with temperature. A care plan for Resident J, dated 12/2/20, indicated resident wandered without natural purpose. The goal was for the resident to be safe wandering in the facility. Interventions included, allow resident to vent, offer snacks and fluids, reassure resident as needed, redirect to activities, refer to psychologist as needed, tender loving care, and wanderguard in place and check placement and function every shift. The medical record lacked documentation of interventions to address the resident's falls and behaviors related to isolation and being prevented from routine wandering, and how her aggressive behaviors toward others were being monitored with the door closed. On 12/9/22 at 10:30 a.m., the DON provided an Abuse Prevention Policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, It is the policy of this facility to prevent resident abuses, neglect, mistreatment, and misappropriation of property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings .Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observed, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator All incidents will be documented, whether or not abuse occurred, was alleged or suspected .Staff who are suspected of abuse or misconduct shall immediately (regardless of time left on shift) be barred from any further contact with residents of the facility and be suspended from duty, pending the outcome of the investigation .Involuntary seclusion: separation of the resident from other residents or from his or her room or confinement to his or her room [with or without roommates] against the resident's will, or the will of the resident's legal guardian or representative .Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse . Using the reasonable person concept, it is likely that residents being restrained in their rooms would lead to the residents having mental anguish including anger, distrust, and chronic or recurrent fear and anxiety. This Federal tag relates to Complaint IN00396693. 3.1-27(a)(4)

Based on record review and interview, the facility failed to ensure interventions were implemented, and the physician was notified of weight loss, and failed to add the resident with significant weight loss to a weekly skin and weight assessment team (swat) to closely monitor weight loss resulting in harm to the resident when the resident experienced a significant weight loss of 13% of her body weight in 30 days and was determined to be at risk of malnutrition per the mini nutritional assessment (MNA) for 1 of 3 residents reviewed for nutrition (Resident F). Findings include: Resident F's record was reviewed on 2/3/21 at 11:05 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 8/21/20, indicated the resident had a significant weight loss, and was not on a physician prescribed weight loss regimen. A laboratory result report, dated 8/6/20, indicated the resident had the following abnormal results: BUN (blood urea nitrogen (measures how well your kidneys and liver are working)) was 39 mg/dl (high) with a reference range of normal between 7 and 25 mg/dl. Creatinine (assesses kidney function) was 2.0 mg/dl (high) with a reference range of normal between 0.6 and 1.3 mg/dl. White blood count (used to measure white blood cells that help fight infection) was 3.0 k/cmm (low) with a reference range of normal between 4.5 and10.8 k/cmm, red blood count (delivers oxygen to the body tissues) was 2.92 m/cmm (low) with a reference range of normal between 3.90 and 5.40 m/cmm. Hemoglobin (a red protein responsible for transporting oxygen in the blood) was 9.4 g/dl (low) with a reference range of normal between 12.0 and 16.0 g/dl. Hematocrit (measurement of red blood cells in the blood) was 29.3 (low) with a reference range of normal between 36.0 and 48.0 g/dl. A weight summary indicated the following weights: a. 8/7/20: 148.2 pounds (lbs.). b. 9/9/20: 131 lbs. c. 10/17/20: 127 lbs. d. 11/1/20: 123 lbs. e. 1/6/20: 108.4 lbs. The weight summary lacked documentation of additional weights from 8/6/20 to 1/6/20. During an interview, on 2/2/21 at 2:37 p.m., the Dietary Manager indicated from 8/7/20 to 9/9/20 the resident had lost 17.2 lbs., which indicated a significant weight loss of 13% in 30 days. From 8/7/20 to 11/1/20 the resident had lost 25.2 lbs., which indicated a 17% weight loss in 90 days. The resident was not weighed in December due to there being an outbreak of COVID-19 in the facility. An annual assessment was completed, on 11/20/20, and the resident had already been receiving a supplement of a magic cup with all meals. The resident's body mass index (BMI) was 21.8 and her mini nutritional assessment (MNA) was a 7 which indicated the resident was malnourished. During that assessment the Registered Dieticians (RD) summary had indicated to continue magic cup and consider medication pass supplement twice daily. The resident should have been placed on SWAT and monitored weekly for weight loss, and once weight was stable returned to monthly weights. She was unsure why that had not happened. The recommendation for the supplement should have been followed through and the physician should have been notified. There were weeks where the SWAT team had not met due to changes of staff and she had to complete the weekly SWAT weight reviews herself. A handwritten communication from the DM to the RD, dated 11/30/20, indicated add medication pass 120 milliliters (mL) every with evening meals. At this time, the Dietary Manager indicated she had provided this information to the Assistant Director of Nursing. A review of the medical record lacked documentation the physician had been notified of the resident's weight loss and the recommendation of a medication pass supplement twice daily be added. The physician's orders [REDACTED].>A care plan, initiated 2/29/16 and updated 11/2/20, indicated the resident was significant weight loss for 90 days and 180 days (16%). The resident goal included, but was not limited to, resident will eat 50-100% of her meals with no further significant weight change. Interventions included, but were not limited to, encourage resident to eat, notify physician of any changes, and resident referred to RD as needed. A documentation survey report, dated August 2020, indicated the resident consumed 25% or less the following number of times: 9 meals 0-25%, 4 meals refused, and 5 meals lacked any documentation for amount eaten. A documentation survey report, dated September 2020, indicated the following for eating self-performance and support provided: The resident was independent with set up only for 35 meals, 6 meals lacked any documentation, and 3 meals indicated activity did not occur. The percentage eaten indicated the resident consumed 25% or less the following number of times: 17 meals 0-25%, 12 meals refused, and 5 meals lacked any documentation for amount eaten. A documentation survey report, dated October 2020, indicated the following for eating self-performance and support provided: The resident was independent with set up only for 17 meals, intendent with no set up or physical help for 6 meals, 2 meals lacked any documentation, and 5 meals indicated activity did not occur. The percentage eaten indicated the resident consumed 25% or less the following number of times: 8 meals 0-25%, 10 meals refused, and 2 meals lacked any documentation for amount eaten. A documentation survey report, dated November 2020, indicated the following for eating self-performance and support provided: The resident was independent with set up only for 36 meals, independent with no set up or physical help for 1 meal, 6 meals lacked any documentation, and 7 meals indicated activity did not occur. The percentage eaten indicated the resident consumed 25% or less the following number of times: 7 meals 0-25%, 13 meals refused, and 5 meals lacked any documentation for amount eaten. A review of the medical record, dated 11/30/20 to current, lacked documentation of communication from the DM to the ADON, and any communication to the physician of weight loss and the recommendation of a medication pass supplement. The physician's orders [REDACTED]. A Laboratory Report, dated 12/7/20, indicated the resident tested positive for COVID-19. On 2/4/21 at 12:12 p.m., the ADON provided a document, undated, and titled, S.W.A.T Program (Skin and weight assessment team). Purpose: To identity those residents at nutritional risk for related medical concerns. Policy: It is the policy of this facility to assess the nutritional status of each resident. SWAT is designed to aggressively review and address those residents exhibiting significant weight change .These residents will be monitored through this team effort on a weekly basis, involving all applicable disciplines to best cater to the improvement of the resident's nutritional status. The interdisciplinary team monitoring residents at nutritional risk consist of, but not limited to: Director of Nursing, Nursing management staff, Dietary Manager, Dietician, MDS Coordinator, Wound Care Specialist. This team will appropriately determine clinical and dietary interventions to best address each resident's needs. Any dietary interventions and/or issues in need of review by the Dietician will be listed on the Dietician referral form and addressed at the routine visit. Indicators determining implementation of S.W.A.T monitoring: 5% or more weight change (undesirable) in 30 days. 10% or more weight change (undesirable) in 180 days. Procedure: .5. Interventions determined by the team will be recorded on the individual resident monitoring record form .Physician orders [REDACTED]. 6. On-going weekly monitoring shall continue on each resident of S.W.A.T. until one of the following conditions has been met .b Weight loss- Eight weeks at stable weight unless medical condition dictates otherwise This Federal tag relates to Complaint IN 027. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure resident to resident abuse did not occur for 1 of 3 allegations of abuse reviewed, which resulted in injury to Resident C (Residents B and C). Finding includes: During an initial tour 1/8/19 which began at 10:25 a.m., with the Assistant Director of Nursing, Resident C was identified as up ad lib, and sat with his wife in common areas (also a resident). The resident was not observed in his room. Resident B was identified as a discharged resident who had resided next door to Resident C. On 1/9/18 at 1:20 p.m., with Licensed Practicial Nurse (LPN) 4, Resident C was observed. The resident had a healing scar on his left hand. He indicated he had a cut and did not know how it occurred. No other injuries were observed. A facility reported incident, dated 12/28/17, reviewed on 1/8/18 at 9:45 a.m., Resident C had reported to a nurse he had been mugged by Resident B. Both residents had been physically assessed. Resident C had a 2.4 centimeter (cm) laceration with bruising on inside of left hand. A 0.5 cm abrasion was observed on the right side of the resident's nose and a 0.5 cm abrasion to the corner of his mouth. Resident B had a laceration to right ring finger. During an interview, which included the Administrator on 1/9/18 at 11:00 a.m., the Administrator indicated resident to resident abuse had been substantiated. During an interview on 1/9/18 at 1:20 p.m., LPN 4 indicated Resident B had wandered every where in the facility during his admission, mostly on the ICF and Hope Springs units. He had entered other residents' room at times lying on their beds. The Social Service Director was interviewed on 1/9/18 at 1:29 p.m. She indicated Resident B had been admitted , 12/19/17, from a behavior unit. Prior to entering the behavior unit he had resided at home with his wife. It had been reported his behavior had suddenly changed at home and he had new behaviors of agitation, throwing things, and threatening his wife. He had been placed in a room with no roommate. Documentation on the Resident B's behavior tracking addressed the behavior of Wanders with no rational purpose. The interventions included redirect, reassure, and refer to psychologist. Documentation of the behavior was noted on night shift - daily from 12/21/17 to 12/28/18. One or all of the interventions had been implemented with unchanged outcome. The same was documented for evening shifts of 12/22/17 through 12/28/18 and day shifts from 12/23/18 through 12/28/17. The resident was discharged on [DATE]. Care plans had been implemented prior to the incident (12/28/17) of Physically Aggressive Behavior i hitting, slapping at staff and peers - receives antipsychotic - at risk for side effects dated 12/25/17; Increased Delusional Behavior - i.e. talking to people not present dated 12/25/17; Res (resident) is a new admission and requires adjustment time dated 12/22/17; Resident exhibits, intrusive wandering at times-r/t (related to) dx (diagnosis) of dementia dated 12/24/17. Interventions included: allow to vent, offer snacks and fluids, reassure resident as needed, redirect to activities of choice, refer to psychologist as needed. Resident B's closed clinical record was reviewed on 1/9/18 at 11:46 a.m. An admission MDS (Minimum Data Source) assessment was dated 12/22/17. A Brief Interview for Mental Status (BIMS) was not been done. A staff assessment for mental status coded the resident with short and long term memory problems, moderately impaired cognition. No behaviors during the assessment period. Resident C's clinical record was reviewed on 1/9/18 at 10:18 a.m. A quarterly MDS was dated 11/2/17. A BIMS had not been done. A staff assessment for mental status coded the resident with short and long term memory problems, moderately impaired cognition. No behaviors occurred during the assessment period. A facility policy titled Abuse Prevention Program, no date, provided by the Administrator on 1/8/18 at 10:20 a.m., included but was not limited to: 1. Abuse the willful infliction of injury, unreasonable confinement, .with resulting physical harm, .by an individual This deficiency is related to Complaint IN 773. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to provide care in accordance with the resident's plan of care for 1 of 1 resident reviewed for transfer techinque which resulted in injury of the resident (Resident D). Finding includes: On 1/8/18 at 10:30 a.m., with the Assistant Director of Nursing, Resident D was observed in a wheelchair in room, outside of the bathroom door, yelling, with a skin tear above the right elbow and blood on the area and rolled up sleeve. Both forearms were observed to be heavily bruised. A stand up lift was observed in the room. Certified Nursing Assistants (CNA) 2 and 3 were in the room. The staff indicated the resident had been transferred from the toilet with the stand up lift, to the wheelchair and had scraped her arm on the doorframe. Licensed Practical Nurse (LPN) was interviewed on 1/8/18 at 1:40 p.m. He indicated the resident was to have been transferred with a sling Hoyer lift. He indicated he had in-serviced the staff on proper transfers. A plan of care, provided by the Administrator on 1/9/18 at 1:25 p.m., addressed the problem of resident at fall risk, . related to increased behaviors at times, .confusion, and assistive device. Interventions included, but not limited to, hoyer lift transfers for bed to chair and reverse. Initiated on 7/19/17. The approach was updated and continued 1/8/18. The resident's clinical record was reviewed on 1/8/18 at 2:15 p.m. A quarterly Minimum Data Set (MDS), dated [DATE], coded the resident with short and long term memory impairment, moderate cognitive impairment. The assessment coded the resident as total assistance of two for transfers. A Nursing Assistant Pocket Worksheet, edited 12/22/17, provided by Certified Nursing Aide (CNA) 5 1/8/17 at 1:45 p.m., indicated the resident was to be transferred with a hoyer lift. 3.1-45(a)(2)