Every finding on record at Welbrook Yuma Opco LLC

Based on clinical record review, staff interviews, facility documentation and policy, the facility failed to ensure that medication to regulate hypertension were administered within physician's ordered parameters for one resident (#35). The deficient practice can result in further inaccurate management of blood pressure, potentially leading to worsening outcomes. Findings Included:Resident #35 was admitted to the facility on [DATE] with medical diagnoses that included hypertensive heart and chronic kidney disease with heart failure.An admissions Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 14, indicating intact cognition. Further review of the MDS revealed the resident had an active diagnosis of hypertension and heart failure. Review of Physician's order with start date of April 2, 2026 included following medications:1) Amlodipine Besylate 5 mg oral tablet, give one tablet by mouth one time a day for HTN (Hypertension) hold if SBP (Systolic Blood Pressure) less than 120 or HR (Heart Rate) less than 55.2) Lisinopril oral tablet 5 mg, give one tablet by mouth one time a day for HTN hold if SBP is less than 120. The medication administration record (MAR) for April 2026 revealed that on April 9, 2026 Amlodipine Besylate 5mg and Lisinopril 5mg tablets were administered to the resident when the resident's SBP was less than 120. It was documented that the residents blood pressure (BP) was 114/64. Both medications were given outside the physician's ordered parameter. Additionally, there were no documentation in clinical record that indicated the reason Amlodipine Besylate 5mg and Lisinopril 5mg tablets were administered on April 9, 2026 outside the physician's ordered parameter. An interview was conducted on April 16, 2026 with Registered Nurse (RN, staff# 128) at 1:30 PM. Staff #128 confirmed that both Amlodipine Besylate 5mg and Lisinopril 5mg were given out of parameters and did not follow physician orders on April 09, 2026 as resident's BP was at 114/64. Staff #128 stated that both medications should have been held. Staff #128 stated that the risks of administering medications outside parameters can cause blood pressure to drop more causing symptoms of dizziness, hypertension and more risks for resident. An interview was conducted with Licensed Practical Nurse (LPN, staff #119) on April 16, 2026 at 1:51 PM. Staff #119 stated that Amlodipine Besylate and Lisinopril medications were administered on April 09, 2026 when it should have been held due to BP being 114/64. The LPN stated the risk of administering medications can cause blood pressure to go down real quick, can cause dizziness, headache and in the worst case hospitalization. An interview was conducted with Director of Nursing (DON, Staff #30) who confirmed that both Amlodipine Besylate 5mg and Lisinopril 5mg were given out of parameters and staff did not follow physician orders on April 09, 2026. The DON stated by administering medications outside physician's ordered parameters imposes risks of hypotension (low blood pressure). The DON stated this does not meet her expectation, and that an in-service training is done requiring staff to document blood pressure as soon as medication is passed just so staff double alerted. A policy titled, Administering Medications, dated April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. The following information is checked/verified for each resident prior to administering medications , allergies to medications; and vital signs, if necessary.

Based on clinical record review, staff and resident interviews, and facility policy review, the facility failed to ensure care and services were provided to one resident (#35) related to change in urine color. The deficient practice could result in delayed recognition of a change in condition and subsequent complications. Findings include: Resident #35 was admitted to the facility on [DATE] with medical diagnoses that included acute systolic (congestive) heart failure, myoneural disorder and stage 1 through stage 4 chronic kidney disease. The care plan dated March 28, 2026 revealed the resident had renal insufficiency CKD (chronic kidney disease), and the resident will have no signs/symptoms of complications related to fluid overload. Interventions included to monitor and report changes in mental status, lethargy, tiredness, fatigue, tremors and seizures. An admissions Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. During an observation on April 14, 2026 at 2:10 PM, the resident's catheter had red-tinged urine. Resident #35 stated around 10:00 AM her urine changed to a red color and that only the Physical Therapist had noticed it and indicated he would notify the nurse. During an observation on April 16, 2026 at 11:56 AM, resident #35's catheter was noted to contain red-tinged urine. Following the observation, resident #35 was interviewed. Resident reported that on April 15, 2026 a registered nurse ( RN, staff #107) flushed the catheter, after which the urine remained clear for the remainder of the day. The resident further stated that since the morning of April 16, 2026, the urine had become dark red and it had not been addressed by staff, except for the physical therapist who reportedly observed the dark red urine again. The resident also reported experiencing burning with urination and back pain. However, there was no documentation in the medical record indicating that the RN, staff # 107, reported hematuria (blood in the urine) or flushed the resident's catheter on April 15, 2026. The review of clinical records revealed no documentation of staff noting red- tinged urine. An interview was conducted on April 16 2026 at 12:19 PM with a Certified Nursing Assistant (CNA , staff # 115 ) who stated that she did not observe red colored urine when she emptied resident #35's catheter bag at 8:00 AM on April 16, 2026. An interview was conducted on April 16, 2026 at 12:24 PM with Licensed Practical Nurse (LPN ,staff #4), who stated she did not notice a change in urine color when she saw resident #35 that morning. At 12:25 PM the CNA informed staff # 4 that resident #35's urine was dark red. The LPN then donned PPE (Personal Protective Equipment), entered resident #35's room and assessed the resident. The LPN asked resident about the urine color, and the resident stated, yes, it has been dark red since 10:00 AM. The LPN observed dark red urine and stated to the resident, I do see there is a bit of hematuria, I just noticed it now but I do not see any blood clots. I will tell your provider to see what we can do. The LPN further asked the resident about symptoms and resident #35 stated she was experiencing irritation and burning. Resident also reported to the LPN that on April 15, 2026 the RN (staff #117) emptied the resident's catheter bag when the urine was red. During another interview with Staff #4 on April 16, 2026 at 12:30 PM, Staff #4 stated again that resident's urine was clear when she saw the resident that morning. Staff #4 further stated she did hear about the hematuria by night shift nurse, however there is no progress notes of the observation by the night shift nurse in the clinical record. Staff #4 stated staff usually record observations such as hematuria in progress notes. Staff #4 stated the risk of not recording in the clinical record is for the concern not being communicated with the rest of staff. She stated hematuria not being written in the clinical record can put residents at greater risk of not getting care that the residents needed and complications like infection and dehydration, blood clots can occur. During an interview with LPN (staff #119) on April 16, 2026 01:56 pm, staff #119 stated she will document any changes to resident's catheter in progress notes. She stated there is risk for residents not receiving care and treatment that they need if the staff fails to document changes in resident's catheter output. During an interview with the Director of Nursing (DON, Staff #116 ) on April 16, 2026 at 2:42 PM, the DON confirmed that there was no mention of RN observing residents hematuria in resident's clinical record. The DON stated it is important to document in clinical records so that staff can follow up with residents, monitor and order labs if needed. The risk of not being documented in clinical records can cause residents to be at risk for UTI complications for not ordering necessary labs needed or sending residents to hospital if needed. The DON stated this does not meet her expectations and will do more in-service training regarding documentation. A policy titled Change in Resident's Condition or Status, revised February 2021 revealed, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on clinical record review, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the regulatory timeframe of 14 days after admission for resident (#3). The deficient practice could result in delayed identification of potential risks and care needs. Findings include:-Regarding Resident # 3 Resident# 3 was admitted to the facility on [DATE] with need for assistance with personal care, malignant neoplasm of prostate, uncomplicated substance abuse, long term (current) use of anticoagulants, and acute cystitis without blood in urine. A review of the admission Minimum Data Set (MDS) dated [DATE], revealed the assessment had an assessment reference date of January 6, 2026. The assessment also revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The signature of Registered Nurse (RN) Assessment Coordinator Verifying Assessment Completion was signed as completed on January 28, 2026. An interview was conducted on January 29, 2026, at 12:00 p.m. with the MDS Coordinator (Staff #55). The MDS Coordinator stated that accurate and timely completion of the MDS is essential to ensure correct Medicare billing and to identify resident needs through Care Area Assessments that guide care planning. The MDS Coordinator stated that she is responsible for tracking Assessment Reference Dates (ARDs), completion dates, and submission dates for all required MDS assessments The MDS Coordinator stated that the ARD is critical because it establishes the assessment window and drives required completion and submission timelines. The MDS Coordinator stated that she primarily uses a manual pencil-and-paper system to track MDS due dates because the facility's current electronic record system, does not consistently reflect accurate completion dates and that multiple user support tickets have already been submitted in order to help address this issue. The MDS Coordinator stated that system and staffing limitations have affected the timely completion of MDS assessments. The MDS Coordinator stated that there is not a dedicated MDS assistant, and the current corporate-approved support of 10 hours per week is focused on care plan documentation rather than direct MDS completion. The MDS Coordinator stated that she completes approximately 60 MDS assessments per week, including admission, significant change, discharge, and interrupted stay assessments, and that timely completion is sometimes impacted when required documentation from multiple departments is not available by the ARD. The MDS Coordinator revealed that coordination of interdisciplinary contributions, including Therapy, Activities, and Social Services sections, is an area where system processes currently limit the ability to consistently meet MDS deadlines. The MDS Coordinator also stated there is not coverage available if she is unavailable for work due, so completion of the MDS is still her responsibility. Regarding Resident #3, the MDS Coordinator stated that the resident had multiple hospitalizations throughout the stay, which made obtaining interviews and determining changes challenging. The MDS Coordinator stated that after reviewing the hospitalizations and anticipated discharge, the resident's ARD was established as January 6, 2026. Based on this ARD, the latest allowable completion date was January 22, 2026; as of January 28, 2026, the MDS was six days late. The MDS Coordinator stated the completion of resident # 3 MDS the facility expectation of completing MDS assessments within the regulatory guidelines of 14 days after admission was not met. The MDS Coordinator stated that she has communicated system barriers to management and corporate leadership, including the need for additional resources, improved tracking systems, and staffing support, and is looking forward to continue working with corporate to improve processes in order to ensure timely MDS completion. An interview was conducted on January 29, 2026, at 12:30 p.m. with the Director of Nursing (DON/Staff #100). The DON stated that she does not directly supervise MDS completion, which is monitored by the facility's corporate MDS nurse. She stated that any delays or issues with MDS completion are escalated to corporate leadership and addressed through improvement initiatives or corrective actions. The DON stated that she expects assessments to be completed accurately and within required timeframes and noted that MDS completion is important for timely and accurate reimbursement and for informing care planning. The DON stated that the facility recently received MDS assistance, which began approximately three weeks ago, but the assistant is still in training and not consistently available. The DON stated that staffing limitations and absences can affect workflow and contribute to backlog, and that staff are expected to continue working on MDS assessments during absences to prevent delays. A review of Resident #3's chart revealed that the ARD was January 6, 2026, and that the MDS was not completed within the required 14-day timeframe.The facility's Comprehensive Assessments and the Care Delivery Process policy, revised December 2016, revealed the Minimum Data Set is completed within 14 days after admission, and within 14 days after it is determined that the resident has had a significant change in physical or mental condition, and annually.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of one resident (#20) to be free from abuse. The deficient practice could result in residents being at risk for abuse. The sample size was 4. The facility census was 41. Findings include, -Regarding Resident # 20 Resident # 20 was admitted to the facility on [DATE] with clinical diagnosis that included fracture of the right fibula, Type 2 Diabetes Mellitus, opioid dependence, mood disturbance, anxiety, and need for assistance with personal care. The admission Minimum Data Set (MDS) revealed that the resident had a Brief Interview Mental Status (BIMS) score of 13, indicated intact cognition. The MDS also revealed the resident had no behavioral symptoms towards others recorded during the lookback period. An incident note dated January 22, 2026, revealed that at approximately 7:10 p.m., staff intervened to separate and protect resident # 20 from verbal abuse by the resident's son. In addition, the note revealed the son was told to have no further contact with the facility or resident. An incident note dated January 22, 2026, revealed that the CNA reported hearing the two parties get into a verbal argument over bills on January 22, 2026, and that the resident reported feeling safe once his son was removed. Review of the Facility Reported Incident submitted on January 27, 2026, revealed that the facility verified the resident's son had been verbally aggressive and verbally abusive toward the resident. The report included a plan for oversight and implementation of corrective actions, which specified that all staff were informed that the son was not to have contact with the resident. Additionally, the report revealed that the front desk staff and nursing staff were instructed to screen all calls and visitors accordingly. An interview was conducted with the resident on January 28, 2026, at approximately 3:20 p.m. The resident stated that his son visited him on January 22, 2026, and during that visit, the son became verbally abusive. The resident reported being extremely satisfied with the staff's prompt response to his need for assistance and stated that he continued to feel safe at the facility. The resident declined to provide further details due to fatigue following cataract surgery earlier that day. An interview was conducted on January 28, 2026, at approximately 3:40 p.m. with Registered Nurse (RN/Staff #73). The RN stated that while residents have the right to visitors, visitors are expected to respect residents' rights, including refraining from verbal aggression or verbal abuse. The RN emphasized that resident safety is the facility's top priority and stated that if abuse is suspected, staff immediately separate the parties to ensure resident safety, remove the visitor from the room, and notify the abuse coordinator and appropriate authorities.An interview was conducted on January 28, 2026, at approximately 3:50 p.m. with a Certified Nurse Assistant (CNA/Staff #41). The CNA reported she heard loud yelling in the hallway on January 22, 2026, which was subsequently traced to Resident #20's room. The CNA stated she was not the responding CNA but reported that the incident lasted less than five minutes and involved raised voices related to a discussion about bills. The CNA stated she did not hear any profanity.A joint interview was conducted on January 28, 2026, at approximately 4:10 p.m. with the Director of Nursing (DON/Staff #100) and the Executive Director (ED/Staff #27). Both confirmed involvement in the investigation of the abuse allegation and stated that the facility substantiated the allegation of verbal abuse between the visitor and the resident. The ED stated that the investigation revealed no prior indications that the son would cause a disturbance, and no concerns were identified in the resident's assessments or prior reports. The ED added that the facility respects residents' rights to visitors and utilizes visitor screening processes to reduce the risk of abuse. The ED further stated that interventions were immediately implemented to honor the resident's request to have no further contact with the son.The facility's Protection of Resident's During abuse Investigations, revised April 2021, directed the staff to not allow unsupervised visits with the resident, if the alleged perpetrator is a resident's family member or visitor.The facility's Trauma Informed Care, revised March 2019, revealed that as part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools.

Based on clinical record review, staff interviews, review of facility documentation and policies, the facility failed develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime for one resident (# 95) with an allegation of physical abuse. The sample size was one.Findings include, Resident # 95 was admitted to the facility on [DATE], with diagnoses that included subsequent encounter for closed fracture of left femur with routine healing, other fall on same level due to collision with another person, need for assistance with personal care, anxiety disorder, and depression. A clinical admission progress note dated December 12, 2025, documented that the resident presented with racing thoughts, unwanted behaviors, anxiety related to a neighbor that consumes alcohol (Neighbor #38). In addition, the note indicated that a bruise observed on the resident's left breast was attributed to Neighbor #38. The note further stated that Resident #95 was reassured of her safety and that the director was notified of the reported abuse.A Skin and Wound Evaluation note, dated December 12, 2025, revealed a bruise, present on admission, was reported to the provider.A progress note, dated December 16, 2025, revealed the Executive Director (ED/Staff # 6) met with Resident #95, regarding the December 12,2025 allegation of abuse. The note revealed that the resident stated that she did not feel abused or was abused by Neighbor # 38, but rather that this neighbor abused alcohol. A care plan, dated December 16, 2025, revealed an area of focus for Resident #95's risk for psychosocial well-being related to family discord; included a precaution that would not allow neighbor #38 entry into the facility. However, the care plan did not support evidence of a focus or intervention for this risk prior to December 16, 2025. An incident note, dated December 17, 2025, revealed the Director of Nursing (DON/Staff #52) met with Resident #95 to gain further clarification on the allegation of abuse reported on admission. The note revealed that during the discussion, the guest stated that the abuse allegation report was a misunderstanding, and that neighbor #38 abused alcohol, not that he had abused her. Review of the clinical recorded revealed no evidence that Law Enforcement officials were notified of the allegation. A review of the Brief Interview for Mental Status (BIMS) evaluation, dated December 17, 2025, revealed a score was 14, which indicated intact cognition. The Facility Reported Incident follow up report, submitted December 17, 2025 revealed the facility reported the allegation of abuse to the Adult Protective Services (APS) and the Ombudsman on December 16, 2025 at 6:30 p.m. The report also revealed that on December 12, 2025, the administrator was notified, who then notified the Department of Health Services (DHS) via online portal. However, the report revealed no evidence that Law Enforcement was notified regarding the allegation, per the facility policy.A review of the facility's Self-Report Complaint form, in reference to the date and time of alleged incident/violation at December 12, 2025 at 5:21 p.m., revealed no date of submission to DHS. Review of DHS Long-term Care Complaint Portal, revealed no evidence that a facility reported incident was submitted regarding Resident #95's complaint of abuse on December 12, 2025.An un-successful attempt to contact the resident was conducted on December 29, 2025 at 11:10 a.m. An interview was conducted on December 29, 2025, at approximately 11:30 a.m. with Certified Nurse Assistant (CNA/Staff #41). Staff #41 stated that if bruising or injuries are observed on a newly admitted resident, the nurse is immediately notified. The CNA reported receiving abuse prevention training upon hire, annually, and during in-services. The CNA also served as the facility's shower aide and stated they were trained to pay attention to residents' bodies during showers and to notify the nurse of any concerns. Staff #41 recalled showering the resident only once and stated the resident was very nice and did not observe any fresh bruising at that time.An interview was conducted on December 29, 2025, at approximately 1:28 p.m. with a Registered Nurse (RN/Staff #24), who stated that upon admission the resident appeared anxious. While assessing and repositioning the resident, staff #24 stated bruising was observed on the resident's body. The RN also reported that the resident spoke repeatedly about a neighbor (Neighbor # 38), and stated Neighbor # 38 had abused her and a friend. The RN stated that the resident's conversation frequently returned to the neighbor topic and described the interaction as tangential. The RN also stated that he listened to the resident's concern about abuse, and provided information regarding courses of action. The RN further stated the resident confirmed that he felt the incident constituted abuse. Staff # 24 stated that the resident as agreeable to report the concern of abuse to the appropriate authorities. The RN stated that the resident did not express being fearful at the time, but did reveal to the nurse, not feeling safe around Neighbor # 38. The RN voiced that he made sure to clarify the allegation with the resident, in order to ensure accuracy when reporting the allegation of abuse. The RN stated that after hearing the concern from the resident, he attempted to contact the Executive Director (ED) first by phone, which went unanswered, and then by text message. Staff # 24 revealed the ED responded within the hour and instructed him to complete a written statement and that neighbor # 38 was not allowed into the facility. Staff #24 revealed that when bruising appears suspicious upon admission, staff is expected to investigate. The nurse stated that allegations of abuse are immediately reported to the ED, and the ED has 24 hours to report the allegation. The RN stated that he believed law enforcement was contacted, due to receiving a text message response from the ED that the incident was being reported. Staff # 24 stated that involving law enforcement is important when there is an allegation of abuse, because they can conduct a more thorough investigation, including interviews and evidence collection, and can also help ensure the resident's safety beyond the facility.An interview was conducted on December 29, 2025, at approximately 12:55 p.m. with the Social Services Director (SSD/Staff #10). Staff #10 stated that her role as a social worker included assessing resident safety, asking about the home environment, mental health history, medications, and identifying any potential triggering behaviors. Staff #10 stated that her responsibilities in abuse investigations included assisting with verification of allegations, providing resident support, completing assessments, and helping report incidents to appropriate agencies to maintain compliance. Staff #10 stated that her role in concluding an allegation of abuse investigation, included completing her assessment, documenting findings, coordinating with APS, and assisting with the resident's discharge planning to ensure the resident's needs were met. Staff #10 stated that she received a text from the admissions nurse over the weekend regarding the resident and stated that she followed up on the allegation Monday, December 15, 2025. Staff #10 stated that during her follow-up conversation, the resident reported the incident was an accident and explained that they were dancing, indicating it was not abuse. Staff #10 stated that the resident was experiencing depression related to a prior injury that took more than a year to recover from. Staff #10 stated that she worked on the resident's discharge plan and ensured the resident was appropriate and safe for discharge. Staff #10 stated that abuse training was completed annually and had been ongoing since she began employment. Staff #10 stated that Adult Protective Services (APS) was contacted. Staff #10 stated that she believed law enforcement may have been contacted over the weekend but stated she was not certain. Staff #10 stated that when there is an allegation of abuse, law enforcement should be notified, as police can help ensure resident safety and collect evidence.An interview was conducted on December 29, 2025, at approximately 2:00 p.m. with the Director of Nursing (DON/Staff #52). The DON described when an allegation of abuse occurs, the first step was to ensure the resident's safety and the prevention of the alleged perpetrator from having access to the resident. The DON stated that staff were instructed to report allegations directly to the Executive Director (ED) and, if the ED could not be reached, to contact the DON. The DON stated that allegations of abuse were reported to the state agency, the resident's medical provider, the ombudsman, and the resident's family. The DON stated that reports were made within two hours if serious bodily injury was suspected and within 24 hours if serious bodily injury was not present. The DON stated that allegations of abuse are reported to law enforcement when required and that the ED determines whether police involvement was necessary. The DON stated she became aware of the resident's allegation of abuse on the day of admission through the facility's text messaging system. The DON stated that when she discussed the matter with the ED, the ED indicated he would handle the reporting. The DON stated that although the resident later recanted the allegation, the facility operated under the assumption that there was a valid allegation of abuse from the time of admission (Friday, December 12, 2025) until the resident recanted on Monday, December 15, 2025. The DON stated that the recantation occurred due to a miscommunication between the admissions nurse and the resident. The DON revealed that although there was a miscommunication, the facility policy was expected to be followed during the time period when the allegation of abuse was believed to be valid, which was from December 12, 2025 to December15, 2025. The DON stated that following the recantation, the facility continued to provide resident support, maintained open communication, and ensured that Neighbor #38 did not have access to the resident while in the facility. The DON stated that she expected allegations of abuse to be documented in the medical record and addressed in the care plan. The DON stated that facility expectations required allegations of abuse to be reported within 24 hours and that the remaining investigation documentation was completed within five days. The DON explained that law enforcement has a unique role in abuse investigations by determining whether abuse occurred with criminal intent, preventing further harm to others, and ensuring resident safety. The DON stated that law enforcement could also assess whether it was safe for a resident to return to an environment where alleged abuse occurred and had a more specialized skill set for the criminal aspects of abuse investigations. The DON stated she was unable to confirm when or whom the ED contacted regarding reporting the allegation of abuse.An interview was conducted on December 29, 2025, at approximately 2:13 p.m. with the ED. The ED described his responsibilities as the facility's abuse coordinator included receiving allegations of abuse or abuse-type situations from staff, visitors, or guests; following up on complaints; assigning assistance from leadership staff, such as the Director of Nursing or Social Services, and to complete the investigation within five days. The ED stated that the Social Services Director (Staff #10) assisted with resident # 95's abuse allegation investigation. The ED stated that the facility expectation was for allegations of abuse to be reported within two hours and that reports were made to the Department of Health Services, Adult Protective Services (APS), the Ombudsman, the resident's provider, the medical director, and law enforcement if needed. The ED stated that nursing staff were expected to document allegations of abuse in the resident's medical record and that information obtained during the investigation was also documented in the five-day investigation report. The ED stated that contacting law enforcement was dependent on the circumstances of the investigation, explaining that police are typically contacted for internal allegations, while this particular allegation occurred outside of the facility, and was considered an external allegation. The ED stated that because emergency services transported the resident to the hospital, he determined there was no further need to contact law enforcement at that time. The ED stated that the facility's investigation ultimately determined the resident's allegation of abuse was unsubstantiated. The ED stated that he was notified of Resident #95's allegation of abuse on Friday, December 12, 2025, at approximately 5:30 p.m. by RN (Staff #24). The ED stated that, according to his records, the Department of Health Services was contacted on Friday, December 12, 2025, at approximately 5:21 p.m. The ED stated that APS and the Ombudsman were contacted on December 16, 2025, at approximately 6:30 p.m., after the investigation was completed. The ED further clarified that law enforcement was not contacted because the incident occurred outside the facility and emergency services had already been involved on the date of the incident. The ED declined to provide a response on the role of police in abuse allegations, due to the question being subjective. The ED stated that he did not see documentation confirming whether the medical director or the resident's provider had been notified and said additional review would be needed to verify this. The ED explained that APS and the Ombudsman were not contacted until December 16, 2025, because by December 15, 2025, he had concluded the incident was not an abuse situation and intended to report it as such. The ED verbalized that from December 12 through December 15, 2025, the facility had operated under the assumption that the resident # 95 allegation of abuse was valid, and that the abuse allegation was considered active from December 12 -14, 2025. To ensure the safety for resident #95, the ED revealed a message was sent to all department managers instructing that neighbor #38 was not to have any contact with the resident. The ED stated that he did not believe the facility policy differentiated between internal and external allegations in order to determine engagement with law enforcement. The ED revealed receiving and taking part in abuse training as recently as of November and December 2025. The ED stated that either he or the Director of Staff Development are responsible for conducting the training, and expect for the staff to follow the policy. The ED stated that it was the facility's expectation that the abuse policy be followed whenever there was an allegation of abuse.The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, directed the facility to investigate and report any allegations within timeframes required by federal requirements.A policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised April 2021, revealed the administrator or the individual making the allegation immediately reports his or her suspicions to the: state licensing/certification agency, the ombudsman, the resident's representative, Adult protective services, law enforcement officials, the resident's attending physician, and the facility medical director. In addition, the policy defined immediately as within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. A policy titled, Care Plans, Comprehensive Person-Centered, revised April 2021, revealed areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. A policy titled, Protection of Residents During Abuse Investigations, revised April 2021, informed the staff that if the alleged perpetrator is a resident's family member or visitor, this person (s) is not allowed unsupervised visits with the resident.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure that one resident (resident #129) was free from verbal abuse from a visitor. The deficient practice could result in further instances of verbal abuse from a visitor, creating an unsafe resident environment. Findings include: -Resident # 129 was admitted on [DATE] with the diagnosis of encounter for other orthopedic aftercare. Resident was discharged on [DATE]. An incident note dated May 17, 2024 revealed that an incident occured on May, 16, 2024. This note revealed the details of the incident, and that Resident #129 was separated from the alleged perpetrator (family member to resident #129), to which Resident #129 stated that they were afraid to return to their room and 'hoped' that the perpetrator had 'calmed down' by the time they returned to the room. This note also revealed that Resident #129 shared their history with the perpetrator, that the perpetrator had made Resident #129 cry prior to the incident. The note also revealed that the perpetrator was asked to leave the facility immediately, pending the investigation. A care plan focus was initiated on May 17, 2024, following the incident. The goal stated that the resident will have no indications of psychosocial well-being problems, as the focus of the goal were the potential for psychosocial well-being following the alleged verbal abuse. The interventions for this goal included allowing the resident time to answer questions and to verbalize their feelings and fears, to consult with social services, encourage resident participation from ma resident who depends on others to make their own decisions, to increase communication with the resident, family and caregivers about their care and living environment, and to remove the resident into a safe environment if further conflict arises. An admission MDS (minimum data set) dated May 20, 2024 revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating that Resident #129 had an intact cognition. A progress note dated May 21, 2024 revealed that the investigation had been completed and that the perpetrator would be able to visit Resident #129. There are no other progress notes and care plans interventions specifically addressing future interactions with the perpetrator, despite two witness statements indicating their observations of the incident of verbal abuse. Being that the perpetrator is a family member that consistently visited the resident, the perpetrator will be able to visit the resident following the incident, with no specific intervention for the future visits for Resident #129, creating the potential for further occurrences of verbal abuse. An interview was conducted on January 7, 2025 at 1:11PM with a physical therapist (PT/Staff #2) where staff #2 stated they can recall the incident, but did not witness the incident themselves. Staff #2 had also recalled the perpetrator and stated that they were 'firm' and 'blunt' when talking to the resident. An interview with an occupational therapist (OT/Staff #105) on January 7, 2025 was conducted at 1:23PM, where staff #105 stated that they witnessed the incident and reported the incident immediately (Staff #105 is one of two witnesses to the incident). Staff #105 stated that they were in Resident #129's room, with the resident, where they discussed the resident's ability to wheel themselves out and about in their room and the facility, and that it was encouraged by the facility. Then, stated that at this point in the incident, the perpetrator entered the room and interjected themselves into that conversation, and presented verbally aggressive in that situation. Staff #105 attempted to de-escalate the situation and had decided to take the resident to their rehabilitation room to chat with them without the perpetrator present. There in the rehabilitation room, the resident shared with Staff #105 that the resident 'hope' that the perpetrator 'calms down' before they head back to the resident's room. Staff #105 stated that they reported this incident immediately after this conversation with Resident #129, due to the resident stating feeling 'afraid' of the perpetrator and that the perpetrator had made the resident cry in the past. Staff #105 also stated during this interaction with Resident #129, that they get a sense that fear of retaliation to follow from the report from the perpetrator as the perpetrator called the resident a 'burden' to their family, and that the perpetrator is the only one who is willing to take care of the resident, and the resident should 'just listen' to the perpetrator. Staff #105 stated that the incident was viewed as verbal abuse as stated in their trainings from the facility, and from the training and education received for their profession and licensure. Staff #105 stated that they completed their part of the abuse reporting process as a mandated reporter, which included a completed witness statement, and the notification to the director of rehab, and the executive director. A phone interview with another witness (a previous employed occupational therapist/Staff #275) was attempted on January 7, 2025 at 2:26PM but was unsuccessful as she did not respond or return the call. An interview with the director of nursing (DON/ Staff # 162) was conducted on January 8, 2025 at 10:12AM where she shared their understanding of verbal abuse as threatening residents, telling the resident to 'not' do something if they do not want something to happen, telling a resident that they are taking something of theirs away, not taking them home or letting them leave, and, raising their voice and tone to a resident. The DON stated that any instances of alleged abuse, including verbal abuse, will be immediately reported to the executive director for further investigation. During this interview, a review of the incident report was done. Following this review, Staff #162 stated that their involvement with the reporting process does not extend into the investigation, but were familiar of the incident between the perpetrator and resident #129. Staff #162 stated that they spoke to the resident following the incident, where Resident #129 stated their sympathy for the perpetrator as the perpetrator is the only entity that takes care of the resident from her family, and what the occupational therapist saw was not true, and to let the perpetrator back to the facility. Staff #162 also stated that the conversation of alleging abuse is frequent with resident #129 and the perpetrator, as the perpetrator has stated to Staff #129 that this is not the first time she (the perpetrator) had been accused of abuse to resident #129. An interview with executive director (Staff #247) was conducted on January 8, 2025 at 10:25AM where the executive director stated that they received the allegation from an OT. During this interview, Staff #247 utilized their copy of the incident to ensure their accurate recollection. Staff #247 stated that following their investigation, they could not substantiate that Resident #129 was verbally abused from the perpetrator due to Resident #129 being informed of the investigation process, realized that the perpetrator would not be able to visit, and stated that the incident was a misunderstanding, despite having two mandated reporters complete full witness statements, and, with no plan to ensure a safe resident environment for Resident #129. A policy titled, Abuse prevention program revealed that the facility will protect residents from abuse by anyone including family and visitors. The policy also revealed that the facility requires staff to complete training and orientation that include the prevention, identify, and report abuse.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#50) was free from preventable pressure related injuries. The deficient practice could lead to other resident's developing preventable injuries. Findings include: -Resident #50 was admitted to the facility on [DATE], with diagnoses that include osteoarthritis, weakness, depression, rheumatoid arthritis, and a left knee replacement. A care plan initiated on August 11, 2024 revealed the resident was at risk of altered skin integrity as evidenced by decreased mobility with a goal of the resident having no new alterations in skin integrity, with noted interventions of notifying the doctor for any changes. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had no cognitive impairment. A review of the clinical record progress notes for resident #50 dated August 7, 2024 at 10:32 a.m. revealed resident #50 is having pain to left lateral side of leg. Upon arrival resident had ted hose on pulled down to calf area, stated ted hose had rolled down to knee area and have caused discomfort, noted popped blister to area. Another skin care plan added August 7, 2024 revealed the resident has an open blister to left lateral leg, with a goal of being free from infection through the review date and noted interventions of monitor and document size and treatment, as well as report abnormalities, failure to heal, and signs and symptoms of infection. A second progress note dated August 12, 2024 at 2:07 p.m. revealed that resident #50 continues with open blister to left lateral leg, provider updated regarding scant slough noted to lateral leg. Received ok to place mepilex ag and foam and continue to monitor. A third progress note dated August 13, 2024 at 10:50 a.m. revealed that the resident #50 acquired a pressure sore that was noted to left knee. The note stated resident #50 was seen by her ortho doctor. The note stated to Continue to ED for I&D (Incision & Drainage) of stage 3 pressure sore. An interview was conducted with a Nurse Practitioner (NP/staff #15) on August 26, 2024 at 2:40 p.m. The NP stated that resident #50 was sent to the skilled nursing facility on August 1, 2024, and seen for a follow up outpatient on August 13, 2024. The NP stated that when resident #50 was seen for the follow up that she was readmitted and taken into surgery same day because of how bad resident #50's pressure injury was on examination. The NP also stated the wound was also infected and required antibiotic treatment. The NP further concluded that the resident is presently following up with infectious disease and required a wound vac for proper healing. The NP concluded that when the injury was reported to their office, the skilled nursing staff reported it was just a blister. The NP stated it was clearly not a blister as it required multiple treatments and surgical intervention. An interview was conducted with a Licensed Practical Nurse (LPN/staff #35) on August 26, 2024 at 3:20 p.m. The LPN stated that the reported incident involved a physical therapy staff member reporting the resident was complaining about her knee. The LPN further stated that when she examined the resident it looked like a big fluid filled blister. However, the LPN also stated that they do not have a wound certification. An interview with a Nurse Practitioner (NP/staff #17) was conducted on August 26, 2024 at 3:55 p.m. The NP stated that they were upset by the situation because it's a big deal. The NP further stated that when they were contacted on August 7, 2024 about the injury, it was described as a blister getting a little red. However, the NP further stated when they examined the resident, was not an accurate assessment on the part of the nursing staff. The NP stated that it appeared to be an infection of concern. The NP concluded that it was the ted hose that was the issue, specifically that it was too tight of a ted hose that was used. An interview with the Certified nursing assistant (CNA/staff #22) was conducted on August 26, 2024 at 4:25 p.m. The CNA stated that resident #50 was there for a knee replacement, and that the resident was alert and oriented and able to make her needs known. The CNA stated that the resident did have ted hose and stated the CNA's applied the ted hose in the morning. An interview with the Director of Nursing (DON/staff #5) was conducted on August 26, 2024 at 5:30 p.m. The DON stated that the resident developed a blister while she was here and that it got worse. The DON further stated that her wound nurse notified her of the wound, and notified the provider for instructions. The DON concluded that her expectation is that nurses document accurately what happens to the residents, as well as letting the provider and the surgeon know of changes that occur, especially when it's a surgical incision. Review of information received from the SA complaint tracking system revealed that on August 13, 2024, at 4:08 p.m. a clinical provider reported the resident was readmitted to the hospital for surgical debridement, wound closure and wound vac application for a stage 3 pressure ulcer on the resident's left leg, that the facility did not communicate with the surgeon that operated on the resident initially, and that this negligence let to patient harm as evidenced by this injury. A review of facility policy titled 'Pressure Ulcers / Injuries Overview' revised July 2017, revealed that avoidable means that the resident developed a pressure injury and that one of the following was not completed. - Evaluation of the resident's clinical condition and risk factors; - Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; - Monitoring or evaluation of the impact of the interventions; - Revision of the interventions as appropriate. A review of facility policy titled 'abuse and neglect - clinical protocol' revised March 2018 revealed the nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear.

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided does not meet the assessed needs of the residents. Findings include: A review of the personnel file for the activities manager (AM/staff #21) revealed staff #21 was hired on June 8, 2021; and that, staff #21 had a current license as a CNA (certified nurse assistant. Per the record, staff #21 was in this position as of June 2021. The recreational services form for activities manager signed by the administrator and the staff #21 on June 2, 2021 indicated a primary purpose of the job position was to plan, organize, develop and direct overall operation of the recreation service department. Education qualifications included: certification from State Approved Program and a degree was preferred but not necessary. It also included that the activities manager must have as a minimum, two years' experience in social or recreational program within the last five years, one of which was full-time in-patient activities program in a health care setting. However, continued review of the personnel file revealed no documentation of these qualifications found for staff #21 as activities manager. An interview was conducted with staff #21 on June 22,2023 at 9:15 a.m., staff #21 stated she was hired as the Activities Director/Recreational Therapy Director in June 2021; and that, when she was hired, all she had was a CNA certification, food handlers, and cardiopulmonary resuscitation training. Staff #21 stated the facility required her to have activities certification; and that, she was working towards getting the activity certification. Staff #21 stated she worked as an activities assistant for a year at another facility; and, was recommended by the admissions nurse whom she worked with previously. Further, she stated that prior to being hired as the activities manager/director she had no other activity manager/director experience. The facility policy on Hiring revealed that the facility provides an equal employment opportunity to all persons qualified to perform the essential functions of the position that is to be filled. The following criteria will be considered in determining whether an applicant is qualified for a particular job position: a. Ability to perform the essential functions of the job (with or without reasonable accommodations); b. Skill, knowledge, training, efficiency, etc.; and, c. Certifications and licenses The policy included that the administrator will determine, which, if any, applicants are qualified for consideration for the position(s) in question.

Based on observation, staff interview, facility policy and procedure review, the facility failed to ensure that two medications were disposed of in accordance with professional standards of practice; and, failed to ensure all controlled drugs were accurately reconciled. The deficient practice could result in medications not being disposed properly; and, the risk of misappropriation of residents' medications. The sample was 25 medication administrations observed. Findings include: -Regarding Medication Disposal: During the medication pass observation with a licensed practical nurse (LPN/staff #39) conducted on June 20, 2023 at 7:33 a.m., the LPN attempted to administer Senna (laxative) to a resident who refused it. The LPN donned gloves, remove the Senna from the medication cup, and removed the glove with the Senna wrapped in it and throw both the used gloves and Senna tablet in the resident's trash can. In another medication administration observation with staff #39 conducted on June 20, 2023 at 8:05 a.m., the LPN dropped a gabapentin (anticonvulsant) 300 mg (milligram) capsule on to the top of the medication cart. She then picked up the dropped capsule up off the top of the medication cart and disposed of it in the trash can that was underneath the sharp's container on the medication cart. An interview was conducted on June 21, 2023 at 10:50 a.m. with the Director of Nursing (DON/staff #33) who stated that the facility policy was to discard any unused or wasted medications in the sharps container. She also stated the nurse (staff #39) discarding of the unused or wasted medication in the resident's trash can or the medication cart trash bin did not meet her expectation. The DON stated that both Senna and gabapentin should have been discarded in a sharps' container and not in the trash can. She stated the risk of placing discarded medications in a trash can could result in anyone being able to access and take the medication. Review of a facility policy on Discarding and Destroying Medications revealed that medications will be disposed of in accordance with Federal, State and local regulations. Non-controlled (non-hazardous) substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. Non-controlled substances may be disposed of in a collection receptacle located at the facility. -Regarding Narcotic Reconciliation: During the observation of medication cart #1 conducted with another licensed practical nurse (LPN/staff #100) on June 20, 2023 at 10:23 a.m., the LPN stated that the nurses' signature on the narcotic sheets indicated that a complete narcotic count had been done. She stated that the facility policy for narcotic reconciliation included that 2 nursing staff (on-going/off-going) were to sign the form when they had completed the narcotic count at the start of each shift. A review of the narcotic count sheet was conducted with the LPN during the observation. The LPN stated that there were 3 shifts in which there was only one nurse who signed and indicated completing the narcotic count. The LPN further stated that this did not meet the facility's policy and expectation on narcotic count reconciliation. In subsequent observation of the medication cart 2 conducted with the LPN (staff #100), the LPN reviewed the narcotic count verification sheet dated June 16, 2023 and stated that there was one occasion in which 2 nurses did not sign the form as completing the narcotic count. Further, the LPN said that on June 20, 2023, there was only one nurse who signed the narcotic reconciliation count; and that, this did not meet the facility policy and expectation for narcotic count reconciliation. An interview was conducted on June 21, 2023 at 10:50 a.m. with the DON (staff #33) who stated that the narcotic reconciliation process should be completed at the end of each shift; and that, two nurses were required to complete the narcotic count reconciliation at the beginning/end of each shift. She also stated that the nurses were expected to sign the narcotic sheet and mark Y if count was correct or N if not. The DON stated that risk of not completing the narcotic count with 2 nurses could result in an error, a resident receiving medication that was not recorded, or someone else could have taken them. During the interview a review of the narcotic count sheets for both unit 1 and unit 2 was conducted with the DON who stated that the narcotic count sheet for unit 2 was not signed at 6:00 p.m. on June 20, 2023 when the nurse had completed her shift. She stated that there were 3 occasions that two nursing staff did not sign the narcotic count sheet for the medication cart 2; and, the narcotic count sheet for cart 1 have no signatures from two 2 nurses on June 17, 18 and 20, 2023. Further, the DON stated that this did not meet her expectations; and, the risk could result in not holding someone responsible for the narcotic count, and residents might not receive medications as ordered. Review of the facility policy on Controlled Substances revealed that the facility shall comply with all laws, regulations, and other requirements related to handling, storage and documentation of controlled substances. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing services.

Based on observations, staff interview, and policy review, the facility failed to ensure food items were not moldy/rotten and the nourishment refrigerator temperature log was maintained. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding moldy/rotten food During the initial kitchen observation conducted on July 18, 2022 at 10:37 a.m., a moldy jalapeno was found stored in a bin in the walk-in refrigerator. Another observation of the kitchen was conducted on July 20, 2022 at 10:55 a.m. During this observation, a rotten/moldy yellow onion and a container of overripe brown bananas which included one with its peel cracked open and others that had white moldy stems were found in the dry storage area. In an interview conducted with the director of culinary services (staff #34) on July 20, 2022 at 1:36 p.m., she stated that they store their food items according to their food storage policy. The kitchen's 2018 policy and procedure manual titled Food Storage and Date Marking revealed all stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. Old stock is always used first (first in- first out method). The policy stated all food including produce, frozen items, refrigerated items, and non-perishables are checked for wholesomeness prior to use. Items not fit for consumption are discarded. Regarding temperature log During the initial walk-through of the resident hallway and nurse's station conducted on July 18, 2022 at 11:03 a.m., the nourishment refrigerator located at the nurse's station was observed to have an incomplete temperature log. The log was missing documentation for the morning temperature from June 12-30, 2022; afternoon temperature from June 12-15, 21-23, and 28-29, 2022. For the month of July 2022, the log was missing the morning temperature check for July 16-18 and the afternoon temperature for July 8, 12-13. The nourishment refrigerator was stocked with 16 prune juices, 5 peaches, 6 yogurts, 9 flavored shakes, 2 sodas and 5 apple sauces. An interview was conducted with the kitchen manager (staff #34) on June 29, 2022 at 1:36 p.m. Staff #34 stated that the nourishment fridge at the nurse's station is theirs. She said that the log should be maintained by whoever is assigned to that area in the morning. The kitchen's 2018 policy and procedure manual titled Food Storage and Date Marking indicated that temperatures for refrigerators may be between 35 to 41 degrees Fahrenheit. Thermometers should be checked routinely. Check for proper functioning of the unit at the same time.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure one sampled resident (#126) was adequately supervised to prevent a fall. The deficient practice could result in falls and resident injuries. Findings include: Resident #126 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] and [CONDITION(S)], muscle weakness, difficulty walking, and cognitive communication deficit. Review of the Fall Risk Evaluation assessments revealed: -October 28, 2021, a fall score of 10, indicating at risk for falls. -October 31, 2021, a fall score of 15, indicating at risk for falls. -November 11, 2021, a fall score of 7, indicating moderate fall risk. -November 15, 2021, a fall score of 14, indicating risk for falls. Review of the care plan included: -A care plan focus initiated on October 28, 2021 that stated the resident is at high risk for falls related to history of falling at home. Interventions included anticipating and meeting the resident's needs, prompt response to all requests for assistance, following the facility fall protocol, -A care plan focus initiated on October 28, 2021 that stated the resident had an ADL (activities of daily living) self-care performance deficit related to general weakness, with interventions for a Physical Therapy (PT) and Occupational Therapy (OT) evaluation and treatment as per orders. - A care plan focus initiated on November 1, 2021 that stated the resident is at risk for falls. Interventions stated sensor pressure sensitive alert mat to bed and chair, assist the resident with ambulation and transfers, self-transfers and slides out of the wheelchair seat, non-slip matting to wheelchair (initiated on November 11, 2021), use shower chair (initiated on November, 15, 2021). -A care plan focus initiated on November 1, 2021 that stated the resident is dependent on staff for meeting physical and intellectual needs related to physical limitations. Interventions stated the resident needs assistance with ADLs as required. -A care plan focus initiated on November 2, 2021 that stated safety, with interventions for safety measures including strategies to reduce falls as appropriate. - A care plan focus initiated on November 7, 2021 that stated a new onset of weakness. Interventions included determining the level of needed assistance based on the ADL evaluation, evaluating for cognitive changes. Review of an OT Plan of Care dated October 29, 2021, stated the resident's current level of function required substantial/maximal assistance for shower/bath, and toileting hygiene. Review of a Speech Therapy (ST) daily treatment note dated October 29, 2021, revealed a recommendation for a cognitive linguistic evaluation due to increased confusion. Review of a PT Plan of Care dated October 29, 2021 revealed the resident required fall risk precautions, and partial/moderate assistance for lift and hold support of trunk or limbs. Further review of a PT progress note dated November 4, 2021, revealed the resident required partial/moderate assistance for sit to stand. It further stated that the treatment diagnosis included difficulty in walking and unsteadiness of feet. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment included that the resident required total assistance for bathing with one-person assistance. It also revealed that the resident's balance during transition was not steady, only able to stabilize with staff assistance. Review of an OT Daily Treatment Note dated November 15, 2021 revealed the resident was seen for skilled OT services and had agreed to a shower. It further stated the therapist (Certified Occupational Therapy Assistant (COTA/staff #51) was going to get the resident a new brief when the resident got up utilizing the grab bars, the resident lost his balance and fell . It further revealed that the resident required maximum assistance to don briefs/pants. Review of an Incident Note dated November 15, 2021, revealed the nurse was informed the resident had finished a shower with the therapist, when the resident was standing holding onto the grab bar the therapist had turned around to get a brief and the resident could not stand and lost his balance and fell on to his buttocks. It further stated that no visible injuries were noted, no new redness or bruises. It also stated that the resident's spouse would like a shower chair to be used in the shower so the resident will not stand up. A review of a PT progress note dated November 15, 2021, revealed treatment as provided to increase strength while managing soreness from earlier fall. It also stated that the resident's status had declined, and the resident reported feeling sore after a fall in the shower. A Fall Investigative Report dated November 15, 2021 revealed the fall was witnessed. It further revealed that a therapist was assisting the resident with a shower, the therapist turned around to get a brief and the resident lost his balance and fell sitting on buttocks. It also stated that predisposing factors included a wet floor, and weakness. Review of a Post Fall Evaluation report dated November 15, 2021 stated the resident was in the shower with a therapist assisting. The resident was standing holding onto a grab bar, the therapist turned around to get a brief and the resident lost his balance and fell on to buttocks. The report stated that a wet floor was a predisposing environmental factor, and weakness was a predisposing physiological factor. An interview was conducted on July 20, 2022 at 8:45 AM with a Licensed Practical Nurse (LPN/staff #96), who stated that she was familiar with resident #126 and that he had frequent falls, was heavy transfer and worked with therapy. She further stated that when a resident is at risk for falls staff must stay with them at all times during a shower, and make sure that all items needed are available, and not to turn your back to the resident. She reviewed the medical record and stated that the resident was a moderate fall risk, due to previous falls. She reviewed the progress notes dated November 15, 2021 and stated that the resident fell in the shower with a therapist in attendance, as the therapist had turned away from the resident to retrieve a brief. She also stated that the therapist should have collected all items needed and had them within reach for use after the shower. She stated that this did not follow the standard of care to leave a resident who was a high fall risk standing in the shower, and turn away from the resident to retrieve something. An interview was conducted on July 20, 2022 at 10:56 AM with a Certified Nursing Assistant (CNA/staff #77), who stated that in preparation of a shower they gather all linens, towels, and clothing, including briefs. She further stated that if a resident has a bed or chair alarm (fall risk) that she would not turn her back on a resident, but would always need to keep the resident in her sight. She also stated that if an item is needed, they are expected to call another CNA to retrieve the item. The CNA stated that OTs do assist with showers, and CNAs stand by if they need anything, and change the bed linens. An interview was conducted on July 20, 2022 at 11:25 am with a CNA (staff #41), who stated that the shower process includes gathering supplies that included briefs, prior to the shower. She also stated that there are briefs in a drawer in the bathroom on the opposite end of the shower bench. The CNA stated that she would have the clean clothes, and briefs gathered and placed next to the shower bench and within reach. She further stated that it is the facility process to always keep the resident in their vision during showers, and when dressing. She stated that she is familiar with the resident's care and that the resident requires two-person assistance with transfers to the shower chair. She stated that the resident fell in the shower with a therapist. She also stated that the resident should not be left unattended in the shower, because the resident did not know his own limitations. She also stated that the resident was a fall risk and had a wheelchair and bed alarm at the time of the fall. An interview was conducted on July 20, 2021 at 12:06 PM with the Director of Rehabilitation Services (staff #43), who reviewed the OT progress note dated October 29, 2021 which indicated the resident was at risk for falls and required contact guard assistance. She stated that the process during shower assistance included gathering all equipment, including clothing and briefs prior to the shower. She also stated that if a resident is a high fall risk, the expectation is that staff will not leave the resident. She stated that the resident was assessed as requiring intermittent cueing, and the standard of care included to watch the resident during a shower at all times. She further stated that due to the documentation regarding the resident's cognition, the COTA should have kept his eyes on the resident at all times, and used the call light if he required assistance. An interview was conducted on July 20, 2021 at 12:11 PM with a COTA (staff #51), who stated that OT assesses a resident's fall risk during the initial evaluation. He further stated that if a resident is a fall risk it would be documented in the therapy notes, and identified as a precaution on the therapy schedule. He stated that during assistance with showers that staff should be with the resident at all times, if the resident has been assessed as a fall risk. He stated the expectation is to make sure the resident is as safe as possible, and to assist with dressing in the shower area. He further stated that there is never a time that he would leave a resident standing in the shower unattended. He further stated that he keeps all dressing items needed on the sink for use after the shower. The COTA stated that he remembered that resident #126 was a fall risk, and fell during a shower in which he was assisting. He reviewed the medical record and stated that on November 15, 2021 he had completed the resident's shower. He stated that he told the resident to stay seated on the shower bench, that he needed to get a brief. He also stated the resident would do things that he was not asked to do. He further stated that the resident started to stand up, that he could not get to the resident in time, and the resident fell . He stated that the resident had previously not followed instructions, but not when he asked him to stay seated. The COTA stated that he felt like the resident was safe when he went to get the briefs out of a drawer at the end of the shower, opposite the shower bench, and knew that the resident was a fall risk at the time. An interview was conducted on July 20, 2022 at 2:14 PM with the Director of Nursing (DON/staff #1), who stated that the facility expectation regarding showers is safety, related to being stable, knowing whether the resident can stand or sit, and the strength of the person. The DON further stated, regarding a resident's identified as a fall risk, that the expectation during showers is for staff to remain at the resident's side. Another interview was conducted on July 21, 2022 at 8:44 AM with the DON (staff #1), who stated that she was familiar resident #126. She reviewed the medical record and stated that the resident was assessed as a risk for falls upon admission. She further stated that the resident had multiple falls, including a fall during a shower with a therapist in attendance. She reviewed the incident report dated November 15, 2021, and stated that there was no injury sustained. She also stated that the fall interventions in place prior to the fall included a chair and bed alarm, anticipate needs, and safety reminders. She further stated that a shower chair had been added to the care plan after the fall. The DON further stated that the expectation regarding staff assistance with showers includes staying within arm's reach of the resident at all times, especially if the resident is unstable/fall risk. She stated that if the resident would start to fall they would be able to assist the resident quickly. A review of the facility policy titled, Shower/Tub Bath, revealed the general guideline is that staff are to stay with the resident throughout the bath, never leave the resident unattended in the tub or shower. Use the emergency call light to signal for assistance if needed. Arrange supplies so they can be easily reached A review of the facility policy titled, Managing Falls and Fall Risk, revealed based on previous evaluations and current data, staff will try to prevent the resident from falling.

Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure a medication with parameters was administered according to professional standards of practice for one resident (#1). The sample size was 5 residents. The deficient practice could result in adverse effects to the resident. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the June 2022 Medication Administration Record (MAR) from June 18, 2022 to June 30, 2022 revealed the resident was administered [MEDICATION(S)] 20 mg 1 tablet by mouth at 8:00 AM, six times when the most recent B/P recorded prior to 8:00 AM in the Weights and Vitals Summary was under 110/60 mmHg. Review of the July 2022 MAR from July 1, 2022 to July 21, 2022 revealed the resident was administered [MEDICATION(S)] 20 mg 1 tablet by mouth at 8:00 AM eleven times when the most recent B/P recorded prior to 8:00 AM in the Weights and Vitals Summary was under 110/60 mmHg. Review of the nursing notes revealed no documentation of why the medication was given with the B/P under 110/60 mmHg. An interview was conducted on July 21, 2022 at 11:42 AM with a Certified Nursing Assistant (CNA/staff #10). She stated vitals are done one time per shift and when the nurse requests them. The CNA stated vitals are recorded in Point Click Care (PCC) in the Weights and Vitals Summary and any vital signs that are too high or too low would be reported verbally to the nurse. She further stated PCC gives an option for re-entering any vitals if they need to retake vital signs including B/P, pulse, respirations, oxygen saturations. An interview was conducted on July 21, 2022 at 11:45 AM with a Licensed Practical Nurse (LPN/staff #45). She stated if a resident's B/P was low, she would assess the resident, view in PCC what the normal range for the resident is, see if they are on a medication that lowers the B/P or medications that are supposed to, notify the provider to see if the dose needs to be changed, assess to see if there is something going on that would be causing it, make a health status progress note, a communication to physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated B/P medications and some glucose medications require specific parameters prior to administering the medication. She stated the CNAs obtain vital signs first thing in the morning and if the B/P was done within an hour or so, she would use this B/P, otherwise she would retake the B/P and document it in PCC's weight/vitals section. She stated it is important to have parameters on B/P medications for resident safety, in order to protect them from adverse effects. She further stated the provider's order for resident #1 has parameters to hold the medication if the B/P is under 110/60. The LPN stated PCC has a button you can click if vital signs are outside of the parameters to initiate supplementary documentation. The LPN also stated the nurse is responsible to monitor the parameters prior to giving the medication and give the medication per the provider orders. An interview was conducted on July 21, 2022 at 12:53 PM with the Director of Nursing (DON/staff #1). She stated when a resident's B/P is too low she would expect the nurse to place the resident in a Trendelenburg position, notify the provider and review their baseline status and medications. She stated hypertensive medications would have parameters to follow prior to administration. The DON stated the nurse would either review the vital sign sheet the CNA uses or the Weights and Vitals section of PCC prior to administering the medication. She stated when a hypertensive medication order is put into PCC there are additional directions, using the supplementary documentation button, that will prompt you to input the B/P or pulse. The DON stated it is important to have parameters on medications so the resident would not have adverse effects to the medication. She further stated for resident #1, the order for [MEDICATION(S)] 20 mg 1 tablet by mouth one time a day for [CONDITION(S)], hold for blood pressure (B/P) under 110/60, does have parameters, but the order was not put into PCC to include documentation of the B/P using the supplementary documentation button when the order was initiated. She stated the [MEDICATION(S)] was scheduled for 8:00 AM and is given between 07:00 AM and 09:00 AM usually. The DON also stated there were multiple days, during the month of July 2022, the [MEDICATION(S)] medication was given when the B/P was under 110/60 mmHg. The facility's Documentation of Medication Administration Policy, revised April 2007, stated a nurse or certified medication aide shall document all medications administered on the MAR and must be documented immediately after it is given. It further stated documentation must include, at a minimum, the name and strength of the medication, dosage, method of administration, date and time of administration, reason why a medication was withheld, not administered, or refused if applicable, signature and title of the person administering the medication, and resident response to the medication if applicable. The facility's Medication Administration Policy, revised April 2019, stated medications are administered in accordance with prescriber orders, including any time frame. The policy stated if a dosage is believed to be inappropriate or excessive for the resident, or a medication has been identified as having potential for adverse consequences, the person preparing or administering the medication will notify the prescriber to discuss the concerns. It further stated allergies to medications and vital signs, if necessary, are to be checked/verified for each resident prior to administering medications.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#7) and/or the resident's representatives were provided written information regarding the facility's bed hold policy before transfer to the hospital or in 24 hours. The sample size was 2 residents. The deficient practice could result in residents not being informed of the facility's bed hold policy. Findings include: Resident #7 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a health status progress noted dated July 14, 2022, revealed that the resident was transported to the emergency department. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the clinical record including the progress notes dated July 14, 2022, did not reveal the resident or the resident's representative had been informed in writing of the facility's bed hold policy. An interview was conducted on July 21, 2022 at 11:31 AM with a Licensed Practical Nurse (LPN/staff #38), who stated that she has never heard of a bed hold form, and that she has never completed a form for resident's discharged to the hospital. She stated that they would complete a discharge summary, and call the hospital to follow-up on the status of the resident. An interview was conducted on July 21, 2022 at 11:45 AM with the Social Services Director (staff #33), who stated that the facility is not currently issuing bed hold forms to the residents at the time of hospitalization , but that admissions will hold beds for three days. She also stated that there is no bed hold form that resident's sign when they are discharged to the hospital regarding notification of bed hold. An interview was conducted on July 21, 2022 at 12:38 PM with the Director of Nursing (DON/staff #1), who stated that the facility's expectation regarding transfer to the hospital includes a copy of the history and physical, medication list, code status, completion of the transfer form, and documentation in the progress notes. The DON also stated that the bed-hold form is not being completed for discharges to the hospital at this time. Review of the Notice of Bed Hold Policy, located in the facility Guest Admission Agreement, revealed that upon request, the facility shall hold the guest's bed for medical leave. The guest will be notified if bed-hold charges will be assessed, and must consent in writing to the charge.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide evidence that the Skilled Nursing Advanced Beneficiary Notice (SNFABN) was issued to one resident (#76). The sample size was 4. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #76 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Record face sheet revealed the resident was their own responsible party. A Progress note dated April 13, 2021 stated that resident #76 and their representative was notified that the last covered date was for April 15, 2021. Additionally, the notes stated that per the resident and family, an appeal was filed via phone call at approximately 5:00 PM. Review of the Notice of Medicare Non-Coverage (NOMNC) signed by the resident on April 13, 2021 revealed the last day of coverage was on April 15, 2021. Further review of the notice was a hand-written note that stated resident #76 and their representative were notified of their appeal rights and were provided with information to appeal the resident's last covered date for April 15, 2021. Review of the resident's QIO (Quality Improvement Organization) appeal dated April 13, 2021 revealed the QIO reviewer agreed with the termination of skilled nursing services for resident #76. Further, the determination revealed that the beneficiary (resident #76) liability started on April 16, 2021. Review of a progress note dated April 14, 2021 at 5:12 PM stated that the writer spoke with the family and the resident and notified them that the resident will no longer be receiving therapy as of April 16, 2021. The note also stated that the determination from the QIO for the appeal submitted on April 13, 2021 was to terminate services. Additionally, the note stated that the resident was notified that the last therapy session will be on 4/15/2021 and that the resident was able to remain in the facility for nursing services and discharge planning. However, no evidence was revealed in the medical record that the SNFABN form informing the resident of care Medicare may not pay beginning on April 16, 2022 was issued to the resident. A Physician's order dated April 30, 2021 stated discharge home on April 30, 2021 with all medications and narcotics. The discharge Minimum Data Set assessment dated [DATE] revealed a score of 13 on the Brief Interview for Mental Status which indicated the resident had intact cognition. Review of the census for resident #76 revealed the resident was discharged on [DATE]. An interview was conducted on July 19, 2022 at 12:53 PM with the Social Services Director (SSD/staff #83). The SSD stated the process to discharge a resident is to meet weekly with the interdisciplinary team (IDT) and discuss the residents in the facility. Further, she explained that once the IDT team determines a discharge date appropriate for each resident she will meet with the resident and make sure the resident has the appropriate equipment at home and inform the resident about the plan. The SSD stated that she will then have the resident sign a NOMNC letter that formally notified the resident of their rights to appeal the discharge. Additionally, the SSD stated that she will review the NOMNC and help the resident with the appeal if they need assistance. The SSD stated that the facility will issue a NOMNC with a minimum of 2 days' notice, so that the resident has time to file an appeal if they choose to do so. She also stated that if the QIO denies the appeal, then the resident can do a second appeal. Additionally, she stated that they will communicate the risk for payment if the resident stays. The SSD stated that the facility is primarily a short stay rehab center and that she is a newer employee so she has never had to issue a SNFABN form. An interview with the Director of Nursing (DON/staff #1) was conducted on July 20, 2022 at 8:42 AM. The DON stated that resident #76 was admitted to the facility and had only 32 days of Medicare covered days. The DON stated that when a resident is ready to discharge after the IDT team has determined a discharge date , they communicate to the family and the resident the plan and notify them with a NOMNC that tells the resident and the family about appeal rights. Further, she stated that the SSD will set up any services or equipment the residents may need, then discharge the resident. The DON stated resident #76 was provided a NOMNC on the 4/13/2021 for a discharge off of therapy, but the resident stayed in the facility for skilled medical needs and utilized the Medicare days. She explained that the resident and the family were notified that they can stay in the facility with the option to pay privately; however, this was told to them verbally and a SNFABN form was not provided, the information was not provided in writing. The DON stated that the facility staff were not aware the resident had to be provided a SNFABN form. An interview was conducted on July 20, 2022 at 10:30 AM with the Executive Director (ED/staff #95). The ED stated the facility is new and that they were learning the systems for discharge. The ED stated that the resident appealed the discharge off of therapy services and the resident remained in the facility for skilled services for medical issues. The ED further explained that the QIO only denied the therapy services not the skilled nursing services. The ED stated that the initial NOMNC was issued to the resident in error and that since resident #76 had Medicare days that remained and had a skilled need, the NOMNC should not have been issued to the resident. The ED reviewed the QIO appeal for resident #76 that stated skilled nursing services would be terminated and the resident's financial liability began April 16, 2022. Review of the facility policy titled Notice of Covered and Non-Covered Services revealed residents are notified of the covered and non-covered items and services provided by the facility. Prior to or upon admission, and periodically throughout the resident's stay, a representative of the business office provides the resident with a notice of covered and non-covered items and services. Covered items and services are those that are included as part of a covered Medicare/Medicaid stay and for which residents may not be charged. Non-covered items and services are those that are not included as part of the Medicare/Medicaid covered stay or the facility per diem rate, but that the facility offers and for which the resident may be charged. The policy stated that if changes in coverage are made to items and services covered by Medicare or Medicaid, residents are notified in writing as soon as possible.