Every finding on record at Westside Care Center

Based on observations, review of facility policy and staff interview, the facility failed to ensure that a section of the kitchen undergoing construction was appropriately sealed off from food preparation and storage areas to prevent the spread of infection. The findings include: On 6/15/2026 at 9:55 AM, a tour of the kitchen with the Dietary Director identified an area of the kitchen undergoing construction. The area undergoing construction contained multiple surfaces and fixtures with a visible accumulation of dust and debris, including stainless steel equipment, surrounding pipes, and portions of the tile floor.The temporary plastic barrier separating the construction area from the operational kitchen was torn in several areas and secured with loose or partially detached tape. The torn sections and unsecured edges created large visible gaps in the plastic barrier between the construction area and the adjacent operational portion of the kitchen.A fan was positioned in the operational portion of the kitchen; the fan, which was in operation and mounted on the wall, faced the operational area with the torn plastic barrier behind it. The fan's casing and blades showed visible dust and residue.An interview with the Dietary Director identified that the dish room was undergoing construction for a replacement dishwasher and that construction had started in May 2026, but the director could not recall the exact date. The Dietary Director further indicated work had been done on the floor, plumbing, and electrical. Additionally, the Dietary Director indicated that the plastic barrier was intended to contain the construction area away from the operational kitchen.On 6/15/2026 at 10:30 AM, an interview with the Director of Maintenance indicated the plastic barrier had been intact when he last worked on 6/12/2026, and he thought that it may have been torn when a contractor brought the new dishwasher over the weekend.On 6/15/2026 at 2:50 PM, an interview with the Administrator indicated that construction had begun on 5/7/2026 and that construction included removing part of the floor. The administrator further indicated that construction on the floor had been completed on 6/8/2026 and that, after surveyor's inquiry, the facility would be cleaning the dust and debris from the unsealed construction area.No policy for the management of construction debris was provided by the facility upon request.

Based on resident interview, observations, review of facility documentation and staff interviews for (9 of 13) air conditioners on all units sampled, the facility failed to ensure the hallway and dining room air conditioners were maintained in a clean and sanitary manner. The facility also failed to ensure the laundry area was clean and dust free. The findings include: 1.On [DATE] at 11:19 AM, Resident #115 was interviewed on the B wing and stated that the facility's air conditioners were moldy. Resident #115 moved to the dining room and turned on the wall mounted mini split in one corner above a piano. When turned on, a distinct mildew smell was noted. Soft, black debris was seen coming from the vents and landing on the piano below. Inspection of the mini split's interior revealed black stains inside the vents and more black debris.Further observations identified there were a total of 8 residents in the dining room at the time. Three of the residents (Residents #20, 99, and 105) were readily adjacent to the mini split.On [DATE] at 12:00 PM, an observation with the Administrator and Director of Nursing Services ( DNS )was completed of the first-floor dining room mini split, including observing the black debris inside the vents and on top of the piano. On [DATE] at 1:10 PM, an interview with the Director of Maintenance indicated the air conditioners are serviced on a regular basis and the first-floor dining room air conditioner may have just been overlooked. The Director of maintenance further indicated that it was an outside company that performed the service but was not sure when the last time they came. Additionally, the Director of Maintenance indicated that cleaning of the air conditioners was performed by the housekeeping department.A review of the facilities' Monthly Heating Ventilation and Air Conditioning (HVAC) P.M. maintenance log for 2026 indicated the HVAC units in the first and second floor dining rooms and nursing units were cleaned monthly. The log indicated HVAC filters were cleaned and coils inspected on [DATE] and [DATE].On [DATE], one day after documentation indicating the air conditioners had been cleaned, an observation in all four nursing units identified eight ceiling-mounted air conditioners with thick visible dust on the filters and black stains and debris in the vents: three in Unit A, two in Unit B, two in Unit C, and one in Unit D.On [DATE] at 10:30 AM, an interview and review of the Monthly HVAC P.M maintenance log for 2026 with the Director of Housekeeping indicated that monthly maintenance of the air conditioners included cleaning the outside and vacuuming the filters. The Director of Housekeeping indicated he had performed the cleaning of the air conditioners on [DATE] and [DATE] and that all air conditioners were cleaned the same day. The Director of Housekeeping indicated that he had cleaned the dining room mini split on [DATE] after being notified of the observed black debris and stains and indicated that he did not know what the black debris and stains were. The Director of Housing Keeping further indicated he had not seen the air conditioners with the black debris and stains on any of the days he had cleaned it.On [DATE] at 10:48 AM, an observation of the nursing unit air conditioners with the Administrator and the Director of Housekeeping identified an air conditioning unit in Unit D noted with a thick layer of dust covering the entire filter. The Director of Housekeeping indicated that it was possible the amount of dust on the filter had accumulated over two days.A policy for air conditioner cleaning and maintenance was not available at the facility when requested. 2. During a tour of the laundry facilities, observation on [DATE] at 11:39 AM observation identified the following:A semi-clear dirty pitcher with an unknown substance dried on the edges located between two washing machinesClean mop area had a clean mop head on the floorA drying area with clothes and medical equipment visibly uncovered in the same room as the clean laundry dryersUncovered sheets and towels above boxes on a metal rack in the folding areaThick pipes covered with a large amount of visible dust in the clean laundry folding roomTwo bags of dirty curtains are located between two washing machines waiting to be cleanedA yellow mop bucket with a garbage can liner filled with rags and another garbage can linerAn old washing machine frame filled with a large black trash bag containing used clothing, a blue purse, a sneaker with a red sole, and other unidentified clothing itemsAn open door to an outside area covered in asphalt with brown and black visibly soiled plastic curtains and a visibly soiled doorTwo uncovered racks of resident clothing, labeled, to be distributed to residents on 2 floorsBlinds visibly covered with a heavy layer of dust in the clean folding roomA dusty air conditioner under dusty blinds surrounded by sheets and blankets with a water bottle and bottle of lotion on the windowsill surrounding the air conditionerA dirty mop located in the corner beside lockers in the clean laundry folding roomUncovered bins in the labeling area with unidentified resident clothing itemsCobwebs were visibly noticeable on the windowsills behind the washing machinesInactive wired phone system located in the label/ storage room for missing and extra resident clothing and socksA wall mounted fan with blades covered in visible dust mounted in the washing machine areaInterview with Director of Maintenance on [DATE] at 11:50 AM identified that housekeeping was responsible for keeping the laundry area clean.Interview with the Housekeeper #1 on [DATE] at 12:12 PM identified the facility was aware of the items located in the washing machine room and identified the items as belonging to expired residents and were held there in case the families wanted to claim the items. Housekeeper #1 identified these items had been in the washing machine area for at least over 1 month. Housekeeper #1 identified that it was her general practice to keep the door to the washing machine area open while in use. She identified that she would use the door with the plastic curtains to bring out clean laundry and bring in dirty laundry for washing. Interview with Housekeeper #2 on [DATE] at 12:18 PM identified housekeeping was responsible for maintaining and cleaning the laundry area.Review of Personal Laundry and Handling Policy dated [DATE] directed, in part, that the facility should handle linens and personal items according to manufacturers' recommendations, wear appropriate Personal Protective Equipment such as gloves and gowns when handling soiled items, and that all clean linen should be covered with a wrapper or sheet for storage and transport.After surveyor inquiry, the facility removed items stored in the washing machine room; removed dust from blinds; removed cobwebs from windowsills; removed and rewashed the clean mop head found on the floor;

Based on clinical record review, review of facility documents, review of policy and staff interviews for 1of 3 residents (Resident # 117) reviewed for Abuse, the facility failed to ensure Resident # 59 was free from abuse. The findings include: 1. Resident #59's diagnoses included anxiety, major depression, Post Traumatic Stress Disorder (PTSD) and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact and had no mood or behavioral symptoms. The care plan dated 11/05/2025 indicated Resident #5 was independent for all activities of daily living including transfer and locomotion on the unit. The care plan further indicated Resident #59 enjoys conversing with his/her peers and can pursue his/her own activities without facility intervention. Intervention included: to monitor mood as needed for increased anger, labile mood or agitation, or thoughts of wanting to hurt others. A facility Incident Report dated 1/23/2026 indicated at 8:30 PM Resident #5(the alleged victim) and Resident #117 ( the alleged perpetrator) were in the dining room involved in a physical altercation from which no injuries were found on either resident. The residents were separated and both placed on 15-minute checks per the facility resident to resident protocol. The Advanced Practice Registered Nurse (APRN), family and police were notified and an investigation was started. The Registered Nurse (RN) supervisor, RN #5 completed an investigation sheet dated 1/23/2026 at 8:30 PM indicating Resident #5 and Resident #117 had an altercation in the dining room at 8:30 PM and Resident #117 had confronted Resident #5 about an incident that occurred months ago which on the current day resulted in a physical altercation. Staff interviews were conducted with no staff seeing the incident but a staff member indicated Resident (#115) had witnessed the altercation. A physician's order dated 1/24/2026 at 12:30 AM (effective 1/23/2026 at 11:00 PM) directed to provide neurological checks every shift for 3 days due to altercation. The care plan dated 1/29/2026 indicated Resident #59 was involved in a resident-to-resident altercation. Intervention included: to allow the resident to discuss frustrations, Social Worker and psychiatric services along with medications as needed. A late entry Registered Nurse (RN) nursing note with effective date of 1/23/2026 at 11:10 PM indicated Resident #5 was observed to be involved in a negative community altercation with another (Resident #117). Both residents were separated once staff arrived on scene. Vital signs taken and assessed for injuries with none noted. The APRN was notified with new orders for vital signs, neurological checks every shift for 3 days and a psychiatric referral. The Conservator of Person (COP) was notified along with notification of the police. An eInteract SBAR summary for providers notes completed on 1/23/2026 at 11:29 PM noted a report of a change of condition including vital signs, APRN notification and physician's orders directing staff to follow facility protocol for a resident-to-resident altercation. Facility documentation of 15-minute checks used as a nursing measure for both Resident #59 and Resident #117 were put into place and continued until the psychiatric evaluations were completed. A resident statement/interview form completed by Social Worker ( SW #2 )on 1/27/2026 at 11:00AM indicated Resident #59 said s/he was walking down the hallway and Resident #117 swung his/her cane at Resident #5 at which time s/he pushed Resident #117 and punched him/her in the face a couple of times while the other resident pushed during the interaction. A late entry psychosocial note dated effective date of 1/27/2026 at 2:35 PM indicated the social worker followed up with Resident #59 who indicated the two residents apologized and are on amical terms. The social worker documented subsequent follow-up visits on 1/28/2026 at 2:35 PM and 1/29/2026 at 2:37 PM with no issues or concerns. On 2/03/2026 the social worker note indicated s/he was following up regarding a room change but Resident #5 still declined a room change. Resident #59 had a psychiatric visit note dated 1/27/2026 signed at 4:09 PM indicating the resident was being evaluated due to a peer-to-peer incident. Resident #5 indicated there was no change in his/her mood, alternative ways to handle the situation were discussed, Resident #5 indicated feeling safe in the current environment with no latent psychological concerns from the incident. Resident #5 was found not a risk to others or danger to him or herself. On 1/27/2026 the psychotherapist visited Resident #59 with the visit note signed at 4:48PM indicating had followed up with Resident #59 regarding the recent altercation and discussed steps to take to help reduce escalation of an event in the future. Subsequent visit to Resident #59 occurred on 1/29/2026 with the note signed at 4:48 PM and on 2/03/2026 Signed at 1:40 PM both visits without any new concerns. 2. Resident #117's diagnosis includes depressive episodes. The annual MDS assessment dated [DATE] indicated Resident #117 was cognitively intact and had some depressive symptoms but no behavioral symptoms. The care plan dated 11/20/2025 indicted Resident #117 had a self-care deficit due to weakness and depression but was able to self-transfer with a walker. The care plan further indicated Resident #117 pursued his/her own leisure activities and enjoyed the coffee social and exhibits verbal aggression including yelling at staff during periods of frustration or emotional dysregulation. Interventions, in part, included for the social worker to meet weekly or as needed to discuss triggers, coping skills and emotional regulation, and reinforce expectations for respectful communication. The resident interview conducted by SW#2 on 1/27/2026 at 11:15 AM indicated Resident #117 was not forth coming with any information regarding the incident and only indicated Resident #59 was a thief. The social worker note indicated education and support was provided and the administrator and Director of Nursing Services (DNS) were updated. The psychosocial note written by SW #2 on 1/27/2026 at 2:38 PM indicated Resident #117 stated s/he was now on amical terms with Resident #5 further follow up visit notes by SW#2 were documented on 1/28/2026 at 2:41 PM and 1/29/2026 at 2:42 PM with no concerns noted. A psychiatric visit note dated 1/27/2026, signed at 4:22 PM, indicated visiting the resident on this day due to a peer-to-peer incident. The note indicated Resident #117 was not very engaging and did not want to provide any details about the event but affirmed feeling safe in the facility. The resident did indicate having increased anxiety and a medication adjustment was made with recommendations to continue psychotherapy. A psychotherapy visit note on 1/29/2026 signed at 5:16 PM indicated some conversation regarding Resident #117's perspective regarding the past incident. An interview with Resident #115 on 6/22/26 at 9:50 AM indicated she/he did recall the incident but no details. An interview, facility document and clinical record review with the Director of Nursing Services (DNS) on 6/22/26 at 9:51 AM indicated Resident #117 allegedly had a history of sharing his/her items with others and mistakenly accused and then approached Resident #59 of taking his/her coffee grounds. The resident witness (Resident # 115) had indicated in a statement Resident #117 had an open palm to the shoulder at Resident #5. The residents made up the next day, and it was identified the coffee grounds had been given by Resident #117 to another resident. The DNS indicated there were no staff in the dining room as they were transporting residents and providing care at the time per the statements when the incident occurred. However, when staff members heard Resident # 5 and Resident # 117 discussion escalate, they came in and separated the residents although the statements and incident reports did not indicate what staff separated the residents and no documentation of Resident #5's or Resident #117's statement of what occurred on that date. A full statement provided by Resident #5 to SW#2 on 1/27/2026 (upon return to work after the weekend off) indicated Resident # 117 had raised a cane at him/her and pushed the Resident # 59 then Resident # 59 punched Resident # 117 in the face a couple times. During the resident and witness statement inquiry the DNS indicated since there was a witness who said it was an open palm on a shoulder versus the incident described during SW#2's interview on 1/27/2026 with Resident #115 with Resident #117 not being forthcoming with any details they had to go with the witness statement. The DNS indicated RN #8 the supervisor on duty during the incident and the charge nurse on duty LPN #5 might have more information since no detailed interviews were taken and documented from Resident #59 or Resident #117 at the time of the incident which would have been most accurate, the DNS indicated RN #8 was on vacation through the week and weekend but would try to reach him/her. The DNS indicated psychiatric services followed up with both residents and they are given all the investigative documents before they see the residents. At 12:05 PM the DNS indicated s/he was unable to reach RN #8. On 6/22/26 at 10:59 AM an interview with SW#2 who no longer employed by the facility indicated she/he could not recall the written interview with Resident # 59. When surveyor read the interview to SW # 2 she/he still indicated she/he could not recall. SW#2 did indicate after the interview s/he did update the DNS and administrator. An interview with the DNS on 6/24/2026 indicated she/he called the staffing agency of LPN #5 to work but was unsuccessful in obtaining LPN #5 phone number. An interview at 12:07 PM on 6/24/2026 with charge nurse on the other unit, LPN #4 indicated she recalled hearing Resident #117 yelling and when she/he went toward the dining room, the residents were already being separated by the agency charge nurse (LPN #5) on the other unit. LPN #4 indicated Resident # 115 who resided on the charge nurse's unit told him/her what occurred when LPN #4 entered the dining room but at this time cannot remember exactly what was said or who the other resident was since it was not on her unit. LPN #4 then recalled something that was said about a walking stick and Resident #117 might have been threatening to hit another resident with it. Interview with RN #8 during the survey was unsuccessful.The facility provided documented education of staff regarding the abuse policy and recreation staff had met with some residents to remind them to obtain a staff member when an altercation occurs. The facility policy labeled Abuse indicated in part notes residents will not be subjected to abuse (example- verbal or physical) by anyone including other residents. Allegations of abuse will be reported immediately and thoroughly investigated. The alleged abuser would be removed from the other residents, consultation with law enforcement, family physician and the state agency as required. Social Work staff will assess the resident for psychological effects and provide supportive counseling as needed. The facility during the survey alleged Past Non-Compliance based on the following below:Date of Alleged Incident 1/23/261.Resident # 117 continues to receive care in the facility and report feeling safe, comfortable at the facility and had no psycho-social effects from the alleged incident.2. Resident # 5 the offending party has been educated by the social worker, local police department, psychiatric APRN pertaining to her/his actions. In addition, Resident # 5 told to have no contact with Resident # 117. Both Resident # 117 and Resident # 5 were offered room changes, but both parties declined. Resident # 117 and Resident # 5 care plans have been updated.3. Any resident who has diagnosis of bipolar disorder with an adjustment disorder and is seeking to resolve an incident with their peers, without staff mediation has the potential to be affected by the alleged deficient practice.4. Residents will be educated on informing staff regarding any issue or concerns they may potentially have with their peers, rather than addressing the concerns independently to avoid any altercations. Facility staff will be educated on the facility abuse policy, and the importance of resident-to-resident altercations not occurring with immediate intervention. Education will be completed by January 23, 2026.5. To ensure compliance, weekly random audits will be conducted to ensure Resident # 5 and other residents feel comfortable in their surroundings amongst their peers. These audits will commence on January 29,26 and will continue for the next 30 days until substantial compliance has been achieved. Results of these audits results will be forwarded to QAPI Committee for review. The DNS is responsible for this plan of action. Based on the following information above the facility provided the necessary information for Past Non- Compliance.

Based on clinical record review, review of facility documentation, review of policy and staff interviews, the facility failed to conduct a thorough Resident-to-Resident abuse investigation when Resident # 59 told RN # 5 she/he hit Resident # 117 when Resident # 117 attempted to strike at her/him with a cane. The findings include: Resident #59's diagnoses included anxiety, major depression, Post Traumatic Stress Disorder (PTSD) and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact and had no mood or behavioral symptoms. The care plan dated 11/05/2025 indicated Resident #5 was independent for all activities of daily living including transfer and locomotion on the unit. The care plan further indicated Resident #59 enjoys conversing with his/her peers and can pursue his/her own activities without facility intervention. Intervention included: to monitor mood as needed for increased anger, labile mood or agitation, or thoughts of wanting to hurt others. A facility Incident Report dated 1/23/2026 indicated at 8:30 PM Resident #5(the alleged victim) and Resident #117 ( the alleged perpetrator) were in the dining room involved in a physical altercation from which no injuries were found on either resident. The residents were separated and both placed on 15-minute checks per the facility resident to resident protocol. The Advanced Practice Registered Nurse (APRN), family and police were notified and an investigation was started. The Registered Nurse (RN) supervisor, RN #5 completed an investigation sheet dated 1/23/2026 at 8:30 PM indicating Resident #5 and Resident #117 had an altercation in the dining room at 8:30 PM and Resident #117 had confronted Resident #5 about an incident that occurred months ago which on the current day resulted in a physical altercation. Staff interviews were conducted with no staff seeing the incident, but a staff member indicated Resident (115) had witnessed the altercation. A physician's order dated 1/24/2026 at 12:30 AM (effective 1/23/2026 at 11:00 PM) directed to provide neurological checks every shift for 3 days due to altercation. The care plan dated 1/29/2026 indicated Resident #59 was involved in a resident-to-resident altercation. Intervention included: to allow the resident to discuss frustrations, Social Worker and psychiatric services along with medications as needed. A late entry Registered Nurse (RN) nursing note with effective date of 1/23/2026 at 11:10 PM indicated Resident #5 was observed to be involved in a negative community altercation with another (Resident #117). Both residents were separated once staff arrived on scene. Vital signs taken and assessed for injuries with none noted. The APRN was notified with new orders for vital signs, neurological checks every shift for 3 days and a psychiatric referral. The Conservator of Person (COP) was notified along with notification of the police. An eInteract SBAR summary for providers notes completed on 1/23/2026 at 11:29 PM noted a report of a change of condition including vital signs, APRN notification and physician's orders directing staff to follow facility protocol for a resident-to-resident altercation. Facility documentation of 15-minute checks used as a nursing measure for both Resident #59 and Resident #117 were put into place and continued until the psychiatric evaluations were completed. A resident statement/interview form completed by Social Worker ( SW #2 )on 1/27/2026 at 11:00AM indicated Resident #59 said s/he was walking down the hallway and Resident #117 swung his/her cane at Resident #5 at which time s/he pushed Resident #117 and punched him/her in the face a couple of times while the other resident pushed during the interaction. A late entry psychosocial note dated effective date of 1/27/2026 at 2:35 PM indicated the social worker followed up with Resident #59 who indicated the two residents apologized and are on amical terms. The social worker documented subsequent follow-up visits on 1/28/2026 at 2:35 PM and 1/29/2026 at 2:37 PM with no issues or concerns. On 2/03/2026 the social worker note indicated s/he was following up regarding a room change but Resident #5 still declined a room change. Resident #59 had a psychiatric visit note dated 1/27/2026 signed at 4:09 PM indicating the resident was being evaluated due to a peer-to-peer incident. Resident #5 indicated there was no change in his/her mood, alternative ways to handle the situation were discussed, Resident #5 indicated feeling safe in the current environment with no latent psychological concerns from the incident. Resident #5 was found not a risk to others or danger to him or herself. On 1/27/2026 the psychotherapist visited Resident #59 with the visit note signed at 4:48PM indicating had followed up with Resident #59 regarding the recent altercation and discussed steps to take to help reduce escalation of an event in the future. Subsequent visit to Resident #59 occurred on 1/29/2026 with the note signed at 4:48 PM and on 2/03/2026 Signed at 1:40 PM both visits without any new concerns. 2. Resident #117's diagnosis includes depressive episodes. The annual MDS assessment dated [DATE] indicated Resident #117 was cognitively intact and had some depressive symptoms but no behavioral symptoms. The care plan dated 11/20/2025 indicted Resident #117 had a self-care deficit due to weakness and depression but was able to self-transfer with a walker. The care plan further indicated Resident #117 pursued his/her own leisure activities and enjoyed the coffee social and exhibits verbal aggression including yelling at staff during periods of frustration or emotional dysregulation. Interventions, in part, included for the social worker to meet weekly or as needed to discuss triggers, coping skills and emotional regulation, and reinforce expectations for respectful communication. The resident interview conducted by SW#2 on 1/27/2026 at 11:15 AM indicated Resident #117 was not forth coming with any information regarding the incident and only indicated Resident #59 was a thief. The social worker note indicated education and support was provided and the administrator and Director of Nursing Services (DNS) were updated. The psychosocial note written by SW #2 on 1/27/2026 at 2:38 PM indicated Resident #117 stated s/he was now on amical terms with Resident #5 further follow up visit notes by SW#2 were documented on 1/28/2026 at 2:41 PM and 1/29/2026 at 2:42 PM with no concerns noted. A psychiatric visit note dated 1/27/2026, signed at 4:22 PM, indicated visiting the resident on this day due to a peer-to-peer incident. The note indicated Resident #117 was not very engaging and did not want to provide any details about the event but affirmed feeling safe in the facility. The resident did indicate having increased anxiety and a medication adjustment was made with recommendations to continue psychotherapy. A psychotherapy visit note on 1/29/2026 signed at 5:16 PM indicated some conversation regarding Resident #117's perspective regarding the past incident. An interview with Resident #115 on 6/22/26 at 9:50 AM indicated she/he did recall the incident but no details. An interview, facility document and clinical record review with the Director of Nursing Services (DNS) on 6/22/26 at 9:51 AM indicated Resident #117 allegedly had a history of sharing his/her items with others and mistakenly accused and then approached Resident #59 of taking his/her coffee grounds. The resident witness (Resident # 115) had indicated in a statement Resident #117 had an open palm to the shoulder at Resident #5. The residents made up the next day, and it was identified the coffee grounds had been given by Resident #117 to another resident. The DNS indicated there were no staff in the dining room as they were transporting residents and providing care at the time per the statements when the incident occurred. However, when staff members heard Resident # 5 and Resident # 117 discussion escalate, they came in and separated the residents although the statements and incident reports did not indicate what staff separated the residents and no documentation of Resident #5's or Resident #117's statement of what occurred on that date. A full statement provided by Resident #5 to SW#2 on 1/27/2026 (upon return to work after the weekend off) indicated Resident # 117 had raised a cane at him/her and pushed the Resident # 59 then Resident # 59 punched Resident # 117 in the face a couple times. During the resident and witness statement inquiry the DNS indicated since there was a witness who said it was an open palm on a shoulder versus the incident described during SW#2's interview on 1/27/2026 ( 3 days later) with Resident #115 with Resident #117 not being forthcoming with any details they had to go with the witness statement. The DNS indicated RN #8 the supervisor on duty during the incident and the charge nurse on duty LPN #5 might have more information since no detailed interviews were taken and documented from Resident #59 or Resident #117 at the time of the incident which would have been most accurate, the DNS indicated RN #8 was on vacation through the week and weekend but would try to reach him/her. The DNS indicated psychiatric services followed up with both residents and they are given all the investigative documents before they see the residents. At 12:05 PM the DNS indicated s/he was unable to reach RN #8. On 6/22/26 at 10:59 AM an interview with SW#2 who no longer employed by the facility indicated she/he could not recall the written interview with Resident # 59. When surveyor read the interview to SW # 2 she/he still indicated she/he could not recall. SW#2 did indicate after the interview s/he did update the DNS and administrator. Interview with RN # 5 on 6/29/26 at 10:12 AM identified that when she entered the dining room after hearing commotion, she saw Resident # 117 on the floor and Resident # 59 told her when Resident # 117 attempted to hit Resident # 59 she/he grabbed the cane from Resident #117 and hit her/him. Interview with the DNS on 7/1/26 with the Administrator at 2:31 PM identified they were not made aware of RN # 5 statement Resident # 5 grabbed the cane from Resident # 117 and hit her/him. The DNS indicated she/he would have expected the licensed nurse to interview the residents involved in the incident at the time of the incident. Interview with the Administrator and the DNS on 7/2/26 at 2:30 PM identified they were not unaware that Resident # 59 grabbed the cane from Resident # 117 and hit Resident # 117 until today and when they spoke with the surveyor on 7/1/26 there was no mention about a cane. They also mention that when Resident # 117 was interviewed about the incident she/he did not want to discuss the incident. After inquiry, the DNS indicated that RN # 5 was educated on 7/1/26 to report statements given by residents during abuse resident to resident altercation and fall so the facility can conduct a thorough investigation. The facility policy labeled Abuse indicated in part notes residents will not be subjected to abuse (example- verbal or physical) by anyone including other residents. Allegations of abuse will be reported immediately and thoroughly investigated. The alleged abuser would be removed from the other residents, consultation with law enforcement, family physicians and the state agency as required. Social Work staff will assess the resident for psychological effects and provide supportive counseling as needed.

Based on review of the clinical record, facility policy and staff interviews for 1 of 2 residents (Resident #96) reviewed for pressure ulcers, the facility failed to develop a timely comprehensive, preventative care plan for a resident at risk for skin breakdown to prevent skin impairment on the heels that resulted in a pressure ulcer development. The findings Include: Resident #96's diagnosis included displaced fracture of the right femur (hip fracture), end stage renal disease, diabetes mellitus, and congestive heart failure. The Nursing admission assessment dated [DATE] at 8:37 PM indicated Resident #96 skin was warm and moist, had a surgical incision on the right hip and a bruise on the right iliac crest A Braden Scale of 18 ( 15-18 indicate mild risk) for predicting pressure ulcer risk evaluation was completed on 3/18/2026 at 6:26 PM indicating Resident #96 had no impairment in sensory perception, skin was occasionally moist, s/he was chair fast for activity, had no limitations in the ability make changes on position, had adequate nutrition and had a potential problem with friction and shear upon movement due to requiring assist during moves due to sliding on surfaces during movement. No focuses or interventions were documented. Another Braden scale for predicting pressure ulcer risk evaluation was completed on 3/25/2026 with the score of 19 ( 19-23 no risk). The baseline care plan dated 3/19/2026 indicated in the skin section Resident #96 required assistance to change positions with a goal to have skin remain intact through the next review. Intervention included to offer Resident #96 assistance to the bathroom and offering treatments as ordered. The care plan dated 3/19/2026 indicated Resident #96 had a self-care performance deficit in activities of daily living due to limited mobility. Interventions included assisting resident with toileting at bed level and transfers with 2 staff assisting with a mechanical lift. The Nurse Aide (NA) care card indicated Resident #96 needed monitoring, reminders, or assistance to turn and reposition more often as needed or requested and required a mechanical lift transfer with 2 staff person assistance The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #96 as cognitively intact and required substantial/ maximum assistance with rolling left and right, moving from sitting to standing going from lying to sitting on the side of the bed, going from sit to standing and was dependent for moving to and from the bed and chair. The assessment also noted no pressure ulcers but noted the resident was at risk for developing pressure ulcers. The MDS further indicated since Resident #96 was at risk for pressure ulcers the facility would proceed in developing an interdisciplinary care plan. The care plan did not address Resident #96's risk for skin breakdown/pressure ulcer development. An Advanced Practice Registered Nurse ( APRN) visit note dated effective 4/01/2026 at 1:00 PM (signed on 4/04/26 at 1:35:36 PM, 2 days 35 minutes after the evaluation and recommendation visit) identified Resident #96 was noted with a blister on the right heel after complaining of heel pain while on the specialized treatment chair ( outside of the facility). The APRN noted upon examination of the blister noted the area was open and asked the infection control nurse to follow up with applying skin prep now, providing pressure relieving boots, providing an air mattress due to decreased mobility and to have the wound physician see the resident The note did not indicate if the left heel was observed. No new physician orders were dated 4/01/2026. A nutrition/dietary note dated 4/02/2026 at 12:42 PM indicated Resident #96 had new deep tissue injuries (DTI's) to bilateral heels and his/her nutritional status was evaluated and the resident refused further changes to his/her current meals or supplements for wound healing. An APRN visit note dated 4/02/2026 at 1:00 PM signed on 4/05/2026at 8:14 AM, 2 days 19 hours after the visit) indicating Resident # 96's chief complaint was the right heel wound and constipation with the skin assessment indicating the right heel had a superficial open spot and to provide a boot and an air mattress for the right heel wound and to add MiraLAX 17 grams daily for the constipation. No documentation about the left-heel skin integrity was observed. 3 days and 2 hours after the right heel open blister was noticed, physician's orders dated 4/04/2026 at 3:00 PM directed to check the low air loss mattress setting to Resident #96's weight and to check functioning for appropriate inflation every shift. A physician's order dated 4/04/2026 at 3:00 PM directed to observe the dressing on the right heel to ensure it was clean, dry and intact and to observe the surrounding skin for signs of infection and evaluate for associate pain every shift. A physician's order dated 4/04/2026 at 7:08 PM directed to provide treatment to the open area on the right heel by cleansing with normal saline, pat dry then apply calcium alginate followed by a foam dressing daily and as needed, reporting any signs of infection to the physician. A physician's order dated 4/04/2026 at 7:10 PM directed to cleanse the left heel with normal saline then apply skin prep daily and leave open to air every day to start the treatment on 4/05/2026. No documentation of the left heel condition was found within the clinical record or having notified the physician. The lack of documentation had no clear timeline of the pressure ulcer development. A care plan dated 4/06/2026 (no time) indicated Resident #96 had a stage 2 pressure ulcer of the right and left heel and had potential to develop further pressure ulcers. Interventions included in part to administer treatments as ordered, monitor wound healing, obtaining wound measurements, follow facility protocols and policies regarding prevention and treatment of skin breakdown, pressure relieving devices to bed and chair. An additional care plan dated 4/06/2026 indicated Resident #96 had actual skin breakdown related to wounds of the heels. Interventions included to offer to assist with repositioning as tolerated, and to float heels as appropriate to relieve heel pressure. A care plan meeting note dated 4/06/2026 at 12:50 PM Indicated the resident family member and the interdisciplinary team were in attendance with Resident #96's care plan and advanced directives reviewed. A wound care specialist note dated 4/06/2026 at 3:34 PM indicated the resident was being seen for consultation for evaluation and management of Resident #96's wounds. The report indicated the following. Wound #1: the left heel, first evaluated on 4/06/2026 was a new stage 2 pressure ulcer (superficial layer of skin missing) with erythema (redness). Size of the wound was 4 Centimeter (cm) x 2 cm by 0.1 cm deep. Wound #2: A new Right heel stage 2 pressure ulcer( superficial layer of skin missing or a fluid filled blister) with no indicated measurements noted erythema surrounding the wound. Treatment recommendations included cleanse with normal saline then apply calcium alginate with silver to the base of the wound secured with a dry clean dressing to be changed daily. Further interventions included providing facility pressure ulcer prevention, a pressure relieving mattress, offloading heels per facility protocol and to offload pressure repositioning to Resident #96 every 2 hours. The evaluation indicated Resident #96 had decreased sensation of the lower extremities due to diabetes mellitus. Additionally noted the wound care orders were entered on this date. The first weekly skin observation tool completed since admission was documented on 4/08/2026 at 9:19 PM indicating Resident #96 had bilateral heel deep tissue injuries ( skin with purple discoloration) due to pressure. An interview and record review with the Director of Nursing Services (DNS) on 6/16/2026 2:06 PM identified no weekly skin assessments of Resident #96 were completed after admission on [DATE] until 4/08/2026 ( 3 weeks 1 day or 22 days after admission) and Resident #96 had developed 2 pressure ulcers. The DNS also indicated Resident # 96 was admitted without any pressure ulcers. An interview and record review on 6/16/2026 at 2:25 PM with Licensed Practical Nurse ( LPN #2), the nurse who completes the MDS assessment, found the admission MDS assessment had indicated Resident #96 was at risk for pressure ulcers and the Care Area Assessments(CAAs) indicated the facility was to proceed with care planning for risk for developing pressure ulcer. However, she was unable to locate a preventative care plan to prevent the development of a pressure ulcer or skin breakdown until after the pressure ulcers were found on 4/1/2026 (nurse practitioner note) right heel and the left heel but noted no documentation of date.The facility policy labeled pressure ulcer prevention revised on 12/26/2025 indicated the policy of the facility was to promote prevention of pressure injury development by identifying and providing needed care and services required by each resident. The facility would ensure that based on the results of a comprehensive assessment residents would receive care consistent with professional standards of practice. Upon admission and weekly thereafter, the nurse would conduct a complete head to toe skin check to identify any new or preexisting skin issues, any new alteration would be assessed by the Registered Nurse(RN) and treatment initiated per physician orders. Resident would be evaluated by the licensed nurse for risk of skin breakdown using the Braden scale on admission and weekly x 4 weeks. Interventions to minimize and/or eliminate contributing factors for pressure ulcer development would be included on the resident's individualized care plan and those residents at risk for pressure injury would receive routine repositioning and pressure relief based on the resident's condition, mobility, tolerance and care plan.

Based on clinical record reviews, review of facility policy and staff interviews for 1 resident (Resident # 5) reviewed for Continuous Positive Airway Pressure (CPAP) a non-invasive machine that uses air pressure to keep the airways open to treat periods of non-breathing during sleep with machine, the facility failed to revise the resident care plan to address the utilization of the CPAP. The findings included: Resident #5's diagnosis included Obstructive Sleep Apnea (OSA). The physician's order dated 2/09/2026 directed to apply a Continuous Positive Airway Pressure (CPAP) is a non-invasive machine that uses air pressure to keep the airways open to treat periods of non-breathing during sleep with machine settings set at 12:0 at bedtime and to remove in the morning. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was cognitively intact and did not receive noninvasive respiratory treatment of CPAP (Continuous Positive Airway Pressure). An interview and clinical record review on 06/18/2026 at 11:25 AM with the regional clinical reimbursement and case management nurse, RN #4, indicated a physician order was in place from 2/09/2026 (146 days or 4 months, 23 days ago) for Resident #5 to receive CPAP. During clinical record review RN #4 indicated Resident #5's care plan should have been revised when the order was received to accurately reflect the resident needs.The facility policy titled Care Plan Policy indicated in part the facility policy was to develop a comprehensive person-centered plan of care for its residents and update and revise.

Based on clinical record review, observation and staff interviews for 1 sampled resident (Resident # 11) reviewed for Hospice Care, the facility failed to ensure continuation and implementation of hospice directed medication as directed by the physican orders for comfort care. The findings include:ensure comfort measure during end of life. The findings include:Resident #11's diagnoses included chronic lung disease, dementia, muscle weakness, and depression.A physician's order dated [DATE] directed that Resident #11 be admitted to hospice.Review of a nurse's note dated [DATE] documented admission to routine hospice care and directed the following: to discontinue blood draws, discontinue rehabilitation therapies, discontinue Vitamin B12 and discontinue Vitamin D3 and start atropine drops for secretions. Additionally, the nurse's notes noted to start Lorazepam Intensol Oral Concentrate 2 MG/ML (Lorazepam) Controlled Drug Give 0.25 ml by mouth every 6 hours as needed for anxiety and restlessness for 30 Days will reevaluate as needed and to start Morphine Sulfate (Concentrate) Solution 20 MG/ML Controlled Drug Give 0.25 ml by mouth every 3 hours as needed for Pain/SOB for 30 Days Will reevaluate as needed.The Minimum Data Set assessment dated [DATE] identified the resident as moderately cognitively impaired, with a BIMS score of 11, requiring setup and cleanup assistance for eating, toileting, and personal hygiene.The Resident Care Plan dated [DATE] identified Do Not Resuscitate, Do Not Intubate, Do Not Hospitalize, and Nurse May Pronounce Death. The care plan did not identify Resident #11 as receiving hospice care, despite an active hospice admission.A review of the clinical record failed to identify that the Lorazepam Intensol Oral Concentrate 2 MG/ML (Lorazepam) Controlled Drug Give 0.25 ml by mouth every 6 hours as needed for anxiety and restlessness for 30 Days will reevaluate as needed and to start Morphine Sulfate (Concentrate) Solution 20 MG/ML Controlled Drug Give 0.25 ml by mouth every 3 hours as needed for Pain/SOB for 30 Days had been re-evaluated and reordered by the physician. A clinical record review and interview with the Assistant Director of Nursing Services (ADNS) on [DATE] at 11:35 AM identified the clinical record did not reflect active hospice comfort medication orders for lorazepam for anxiety or morphine for shortness of breath or pain. Review of hospice documentation indicated the plan of care should continue, and medications were not to be discontinued. Lorazepam and morphine orders expired on [DATE].The ADNS identified there was no documented reason for the discontinuation of these medications and no provider or hospice notes indicating a decision to discontinue. Inspection of the medication cart and narcotic log with the ADNS identified oral lorazepam present in the narcotic drawer with a narcotic log, indicating the medication remained available, despite discontinued orders. The ADNS stated there was no reason documented for discontinuation. An interview with the Director of Nursing (DNS) on [DATE] at 12:55 PM identified that Nursing Supervisors were responsible for reviewing, maintaining, and entering hospice orders. She stated hospice narcotic and benzodiazepine orders were written for 30 days and required review by the Nursing Supervisor and the provider. She also stated that hospice nurses and hospice providers did not have access to the electronic medical record and could not enter orders themselves.During an interview with the hospice nurse (RN #6), she stated hospice was unaware that physician's orders for lorazepam and morphine had been discontinued.A review of the Home Health and Hospice Contract dated [DATE] directed, in part, that hospice would make recommendations for the resident and the facility would honor and fulfill hospice requests on behalf of the resident. The contract further directed the facility to contact hospice for clarification when questions arose and to provide safe services for all residents in their care.After Surveyor inquiry, an physician's order was placed on [DATE] at 8:42 PM for Lorazepam and Morphine.

Based on review of the clinical record, facility policy review and interview for 1 of 2 residents for (Resident #96) reviewed for pressure ulcer, the facility failed to complete weekly skin checks, develop a preventative skin breakdown care plan for a resident at risk and when pressure ulcers were identified, physician's orders for treatment were delayed for 3 days. The findings include: Resident #96's diagnosis included displaced fracture of the right femur (hip fracture), end stage renal disease, diabetes mellitus, and congestive heart failure. The Nursing admission assessment dated [DATE] at 8:37 PM indicated Resident #96 skin was warm and moist, had a surgical incision on the right hip and a bruise on the right iliac crest A Braden Scale of 18 ( 15-18 indicate mild risk) for predicting pressure ulcer risk evaluation was completed on 3/18/2026 at 6:26 PM indicating Resident #96 had no impairment in sensory perception, skin was occasionally moist, s/he was chair fast for activity, had no limitations in the ability make changes on position, had adequate nutrition and had a potential problem with friction and shear upon movement due to requiring assist during moves due to sliding on surfaces during movement. No focuses or interventions were documented. Another Braden scale for predicting pressure ulcer risk evaluation was completed on 3/25/2026 with the score of 19 ( 19-23 no risk). The baseline care plan dated 3/19/2026 indicated in the skin section Resident #96 required assistance to change positions with a goal to have skin remain intact through the next review. Intervention included to offer Resident #96 assistance to the bathroom and offering treatments as ordered. The care plan dated 3/19/2026 indicated Resident #96 had a self-care performance deficit in activities of daily living due to limited mobility. Interventions included assisting resident with toileting at bed level and transfers with 2 staff assisting with a mechanical lift. The Nurse Aide (NA) care card indicated Resident #96 needed monitoring, reminders, or assistance to turn and reposition more often as needed or requested and required a mechanical lift transfer with 2 staff person assistance The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #96 as cognitively intact and required substantial/ maximum assistance with rolling left and right, moving from sitting to standing going from lying to sitting on the side of the bed, going from sit to standing and was dependent for moving to and from the bed and chair. The assessment also noted no pressure ulcers but noted the resident was at risk for developing pressure ulcers. The MDS further indicated since Resident #96 was at risk for pressure ulcers the facility would proceed in developing an interdisciplinary care plan. The care plan did not address Resident #96's risk for skin breakdown/pressure ulcer development. An Advanced Practice Registered Nurse ( APRN) visit note dated effective 4/01/2026 at 1:00 PM (signed on 4/04/26 at 1:35:36 PM, 2 days 35 minutes after the evaluation and recommendation visit) identified Resident #96 was noted with a blister on the right heel after complaining of heel pain while on the specialized treatment chair ( outside of the facility). The APRN noted upon examination of the blister noted the area was open and asked the infection control nurse to follow up with applying skin prep now, providing pressure relieving boots, providing an air mattress due to decreased mobility and to have the wound physician see the resident The note did not indicate if the left heel was observed. No new physician orders were dated 4/01/2026. A nutrition/dietary note dated 4/02/2026 at 12:42 PM indicated Resident #96 had new deep tissue injuries (DTI's) to bilateral heels and his/her nutritional status was evaluated and the resident refused further changes to his/her current meals or supplements for wound healing. An APRN visit note dated 4/02/2026 at 1:00 PM signed on 4/05/2026at 8:14 AM, 2 days 19 hours after the visit) indicating Resident # 96's chief complaint was the right heel wound and constipation with the skin assessment indicating the right heel had a superficial open spot and to provide a boot and an air mattress for the right heel wound and to add MiraLAX 17 grams daily for the constipation. No documentation about the left-heel skin integrity was observed. 3 days and 2 hours after the right heel open blister was noticed, physician's orders dated 4/04/2026 at 3:00 PM directed to check the low air loss mattress setting to Resident #96's weight and to check functioning for appropriate inflation every shift. A physician's order dated 4/04/2026 at 3:00 PM directed to observe the dressing on the right heel to ensure it was clean, dry and intact and to observe the surrounding skin for signs of infection and evaluate for associate pain every shift. A physician's order dated 4/04/2026 at 7:08 PM directed to provide treatment to the open area on the right heel by cleansing with normal saline, pat dry then apply calcium alginate followed by a foam dressing daily and as needed, reporting any signs of infection to the physician. A physician's order dated 4/04/2026 at 7:10 PM directed to cleanse the left heel with normal saline then apply skin prep daily and leave open to air every day to start the treatment on 4/05/2026. No documentation of the left heel condition was found within the clinical record or having notified the physician. The lack of documentation had no clear timeline of the pressure ulcer development. A care plan dated 4/06/2026 (no time) indicated Resident #96 had a stage 2 pressure ulcer of the right and left heel and had potential to develop further pressure ulcers. Interventions included in part to administer treatments as ordered, monitor wound healing, obtaining wound measurements, follow facility protocols and policies regarding prevention and treatment of skin breakdown, pressure relieving devices to bed and chair. An additional care plan dated 4/06/2026 indicated Resident #96 had actual skin breakdown related to wounds of the heels. Interventions included to offer to assist with repositioning as tolerated, and to float heels as appropriate to relieve heel pressure. A care plan meeting note dated 4/06/2026 at 12:50 PM Indicated the resident family member and the interdisciplinary team were in attendance with Resident #96's care plan and advanced directives reviewed. A wound care specialist note dated 4/06/2026 at 3:34 PM indicated the resident was being seen for consultation for evaluation and management of Resident #96's wounds. The report indicated the following. Wound #1: the left heel, first evaluated on 4/06/2026 was a new stage 2 pressure ulcer (superficial layer of skin missing) with erythema (redness). Size of the wound was 4 Centimeter (cm) x 2 cm by 0.1 cm deep. Wound #2: A new Right heel stage 2 pressure ulcer( superficial layer of skin missing or a fluid filled blister) with no indicated measurements noted erythema surrounding the wound. Treatment recommendations included cleanse with normal saline then apply calcium alginate with silver to the base of the wound secured with a dry clean dressing to be changed daily. Further interventions included providing facility pressure ulcer prevention, a pressure relieving mattress, offloading heels per facility protocol and to offload pressure repositioning to Resident #96 every 2 hours. The evaluation indicated Resident #96 had decreased sensation of the lower extremities due to diabetes mellitus. Additionally noted the wound care orders were entered on this date. The first weekly skin observation tool completed since admission was documented on 4/08/2026 at 9:19 PM indicating Resident #96 had bilateral heel deep tissue injuries ( skin with purple discoloration) due to pressure. An interview and record review with the Director of Nursing Services (DNS) on 6/16/2026 2:06 PM identified no weekly skin assessments of Resident #96 were completed after admission on [DATE] until 4/08/2026 ( 3 weeks 1 day or 22 days after admission) and Resident #96 had developed 2 pressure ulcers. The DNS also indicated Resident # 96 was admitted without any pressure ulcers. An interview and record review on 6/16/2026 at 2:25 PM with Licensed Practical Nurse ( LPN #2), the nurse who completes the MDS assessment, found the admission MDS assessment had indicated Resident #96 was at risk for pressure ulcers and the Care Area Assessments(CAAs) indicated the facility was to proceed with care planning for risk for developing pressure ulcer. However, she was unable to locate a preventative care plan to prevent the development of a pressure ulcer or skin breakdown until after the pressure ulcers were found on 4/1/2026 (nurse practitioner note) right heel and the left heel but noted no documentation of date. An interview with Medical Doctor (MD #2) the wound physician on 6/18/2026 at 2:56 PM indicated Resident #96's medical conditions being diabetic, requiring specialized treatments, recent surgery with limited mobility were some of the reasons Resident #96 was at risk for skin breakdown. MD#2 further indicated Resident #96's not having his/her heels offloaded while receiving specialized treatment out of the facility in addition to not having a preventative skin breakdown plan in place at the facility all contributed to the skin breakdown, but the facility was not the only cause. MD #2 indicated having preventative measures in place( in the facility and at specialized treatment ) may have prevented the breakdown. An interview with the regional Infection preventionist/wound nurse Registered Nurse (RN #1) and the DNS on 6/18/2026 at 2:45 PM indicated the wound tracking document the infection preventionist/wound nurses only consider the wound physician visits and does not track the initial date of the identification of the wounds. Since no nursing assessments, weekly skin assessments or notes were found in the clinical record, it was not clear when each pressure ulcer was first identified. The right heel was documented by the nurse practitioner on 4/01/2026 as a blister that had opened after the resident complained of pain while at the specialized treatment, and there was no documentation of the description of the left heel or the date it was identified. The DNS indicated s/he would have expected nursing to have made a note or complete the change of condition assessment in the electronic system including skin measurements. The DNS further indicated the resident or responsible party would be updated and Resident #96 was responsible for self. The facility policy labeled pressure ulcer prevention revised on 12/26/2025 notes the policy of the facility was to promote prevention of pressure injury development by identifying and providing needed care and services required by each resident. The facility would ensure that based on the results of a comprehensive assessment, residents would receive care consistent with professional standards of practice. Upon admission and weekly thereafter, the nurse would conduct a complete head to toe skin check to identify any new or preexisting skin issues, any new alteration would be assessed by the Registered Nurse(RN) and treatment initiated per physician orders. The resident would be evaluated by the licensed nurse for risk of skin breakdown using the Braden scale on admission and weekly x 4 weeks. Interventions to minimize and eliminate contributing factors for pressure ulcer development would be included on the resident's individualized care plan and those residents at risk for pressure injury would receive routine repositioning and pressure relief based on the resident's condition, mobility, tolerance and care plan.

Based on clinical record review, observations, facility documentation, review of policy and interviews for 1 of 2 residents ( Resident # 2), reviewed for dining observation, the facility failed to follow dietary guidelines and restrict the use of Styrofoam products during dining to prevent a potential accident. The findings include: Resident #2's diagnoses included dementia, speech disorder, restlessness, agitation, and bipolar disorder.The comprehensive Minimum Data Set assessment dated [DATE] identified Resident #2 was cognitively impaired and required set up assistance for eating and required substantial assistance for personal hygiene and toileting and noted independence with transfer and walking.The Resident Care Plan dated 6/2/26 identified Resident #2 would require assistance with activities of daily living related to dementia. Interventions included setting up for eating with no Styrofoam products.A physician's order dated 5/29/26 was directed to have no Styrofoam products for Resident #2.Observation on 6/15/26 at 11:55 AM identified a nurse's aide observed clearing Resident #2's lunch, which had been served in a Styrofoam box. The meal ticket had been discarded and was not available for inspection.Observation on 6/15/26 at 2:10 PM, the kitchen dishwasher was observed to be non functional, and dietary staff reported it had been broken since 12/25, resulting in the facility serving meals in disposable Styrofoam containers.Observation on 6/16/26 at 9:02 AM, the meal ticket for Resident #2 stated no Styrofoam products. No leftovers were present for inspection.Observation on 6/16/26 at 11:42 AM, four staff were noted wearing red shirts and protective hair and beard covers transporting Styrofoam lunch containers from the steam table to residents. Resident #2 was seated at a table with another resident as two nurse aides and the Assistant Director of Nursing assisted residents. Resident #2 was again served using Styrofoam products.During an interview with the Director of Dietary Services on 6/16/26 at 11:57 AM, she stated Resident #2's dietary slip indicated no Styrofoam. She confirmed the resident had been served in a Styrofoam container and plate. She stated that nursing and nurse aides were responsible for ensuring residents receive meals according to dietary interventions. She reported that Speech Therapy entered dietary orders into the medical record.During an interview with the Speech Language Pathologist on 6/18/26 at 11:19 AM, she stated she entered all dietary orders into the electronic medical record and completed a dietary slip for the kitchen. She stated she placed the no Styrofoam order on 5/29/26 after observing the resident chewing on Styrofoam. The Speech- Language Pathologist also stated she provided oral education to staff at that time.Although requested, a facility policy for Dietary to address no Styrofoam was not provided.

Based on observations, review of facility documentation facility policy and staff interviews for 1 of 5 residents (Resident # 5) reviewed for Infection control, the facility failed to ensure staff served food items on a resident table where no urinary items were stored, the facility failed to ensure CPAP machine, bedside table were not kept clean and mask stored in a clean bag. The facility also failed to ensure staff handled resident food appropriately when peeling a hard-boiled egg while preparing a resident breakfast tray to serve. The findings include: Resident #5's diagnosis included spinal stenosis(narrowing of the nerve pathway in the spine) and paraplegia (partial or complete loss of motor and sensory function of on half of the body. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact. The care plan dated 2/03/2026 revised on 5/07/2026 indicated Resident #5 required extensive 2 staff person assistance for bed mobility, was dependent and required 2 staff person assistance with dressing and toileting and was independent for eating once meal tray was set up. a.An observation on 6/16/2026 at 8:40 AM of Resident #5's room including the over the bed table identified 2 empty urinals on the over the bed table and other items including an open bag of snacks. While talking with Resident #5 NA#1 came into the room with breakfast and started to place it onto the over bed table next to the 2 urinals when Resident #5 had asked if instead it could be placed on his/her lap. NA#1 indicated s/he could squeeze the breakfast meal containers next to the urinal and after placed on the table left the room. An observation and interview with RN #3 on 08/16/2026 a9:05 AM in Resident #5's room the nursing supervisor indicated the urinal should not have been on the table with the breakfast and s/he would get another table to place the urinal and towel on. She/he would, with Resident #5's permission, wipe off the table with breakfast. RN #3 further indicated that education would be provided to staff to prevent this from happening again.b.Observation and interview on 6/16/2026 at 08:46 AM with Resident #5 after observation of medication administration identified Resident #5 was wearing the CPAP mask and had removed it when the medication nurse woke him/her for medication administration. Further observation identified the CPAP machine on bedside table was uncovered with a dust-like substance.An interview and clinical record review with RN #3 at 10:53 AM and review of Resident #5's physician orders for the CPAP directed the CPAP mask to be wiped clean with soap and water and bagged after use. Upon observation of the CPAP machine, mask and table it was on inside Resident #5's room, RN #5 ran a finger on the bedside table and noted accumulated dust like material. RN# 5 further it was housekeeping's responsibility to keep the machine and table clean, and she/he would contact them to come clean. RN #3 further indicated s/he would find a clean bag to place the mask in and it was the 11PM-7:00 AM shift nurses' responsibility to change the tubing and bags. RN # 5 also indicated education would be provided to staff . Facility policy titled CPAP BiPAP revised 3/03/2026 indicated in part the CPAP unit will be cleaned weekly by using slightly dampened cloth with water and mild detergent to wipe the outside of the case. The mask would be cleaned daily and as needed for soiling using water and mild detergent and after thorough rinsing, allowing the mask to dry air.c.After going to get the supervisor and going back to the unit to see Resident #5 an observation on 6/16/2026 at 9:00 AM identified Nurse Aide NA#1 standing at the nurse's station with a small food cart peeling a hardboiled egg within a Styrofoam food plate for a resident with his/her bare hands and very long nails well past the finger tips. The Nursing Supervisor RN #3 was standing near NA#1 and the surveyor. RN #3 after inquiry indicated NA #1 should not have been handling the egg and peeling it with bare hand and her/his nails that were too long. After further inquiry with RN #3 RN #3 she/he indicated NA#1 should have donned gloves when handling the egg then instructed NA #1 to don gloves at which she/he proceeded to do without the benefit of washing his/her hands first ,then after prompting RN #3 s/he asked NA#1 to wash hands then apply new gloves. RN #3 also indicated after inquiry, staff should not serve the egg peeled by NA#1 and indicates she/he would call the kitchen for a new hardboiled egg for the resident.Although a facility policy was requested regarding handling of food one was not provided.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for ADL care, the facility failed to ensure a resident was treated with respect and dignity when they failed to ensure privacy was maintained when providing personal care to a resident. The findings include: Resident #1's diagnoses included Alzheimer's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicative of severe cognitive impairment, had no behaviors, and was dependent for toileting, bed mobility and personal hygiene, and was 5 feet 6 inches tall and weighed 128 pounds. The Resident Care Plan (RCP) dated 1/30/2026 directed Resident #2 had an ADL self-care performance deficit. Interventions directed assistance of one (1) with bed mobility, assistance of one for personal hygiene, sensitive skin - avoid scrubbing and pat dry, and totally dependent on one (1) staff for brief change at bed level. Review of the NA care list dated 2/2026 indicated Resident #2 required assistance with personal care. Observation on 3/19/2026 at 8:38 AM as surveyor was passing by Resident #2's room, observation identified NA #1 was in Resident #2's room at the bedside. The door to the room was open and the bedside curtain was open to the hallway. Resident #2 was fully visible from the hallway and was observed to be undressed laying supine (flat on back) while NA #2 was providing ADL care. Resident #2 was not wearing a shirt or pants, his/her chest was exposed, and the NA's body was blocking the view of the resident's hips/groin area. Further, Resident #2 was not covered with a sheet, blanket, towel or bath blanket. Surveyor returned to the doorway on 3/19/2026 at 8:39 AM and observed the door and curtain remained open and Resident #2 remained fully visible from hallway lying supine in bed and exposed. Observation identified NA #1 was pulling and tugging an adult brief out from under Resident #2's hips. The brief appeared to be moderately to heavily saturated with a pale yellow color observed. NA #1 was not heard to ask Resident #2 to roll over, or to lift his/her buttocks during the removal of adult brief. Interview and observation on 3/19/2026 at 8:40 AM with NA #1 at doorway to Resident #1's room as NA #1 approached a cart in the hall near the doorway entrance identified NA #1 should have closed Resident #2's door and/or curtain when providing resident care. Interview failed to identify if an adult brief should be pulled/tugged out from under a resident when providing care or if the resident should be turned to remove the brief. Interview on 3/19/2026 at 8:42 AM with LPN #1, informed LPN #1 that NA #1 requested her assistance with providing care for Resident #2. LPN #1 stated privacy should be provided for resident care, and privacy is a resident right. LPN #1 indicated the brief should not be pulled out from under a resident; gentle care of resident's skin was important. Interview and documentation review with LPN #1 on 3/19/2026 at 9:05 AM identified Resident #2's care card indicated he/she required the assistance of one with ADL care, and to protect a resident's skin, a brief should not be pulled out from under a resident. On 3/19/2026 at 9:09 AM interview with the ADNS indicated a resident's door and/or curtain should be closed when personal care/hygiene care is being provided. The ADNS stated an adult brief should not be pulled out from under a resident who is lying flat on their back in bed. Interview and record review on 3/19/2026 at with Administrator and DNS identified when a NA is providing resident care, the door or the privacy curtain should be closed. The DNS stated a brief should not be pulled and or tugged out from under a resident. Review of facility Residents' [NAME] of Rights directed in part, residents had a right to privacy, including in receiving personal and medical care and treatment.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to notify responsible party timely of a change in condition. The findings include:Resident #1's diagnoses included dementia and restlessness/agitation. The Resident Care Plan (RCP) dated 11/11/2024 identified at risk of falls. Interventions directed transfer and ambulate per MD order, observe closely for side of medications, and to check often to ensure grippy socks are on at night/resident removes grippy socks. A physician order dated 1/31/2025 directed ambulation: independent. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen, indicative of severe cognitive impairment, and was independent with bed mobility, transfers, and ambulation without adaptive equipment. Further review identified RCP updated 3/15/2025 to include grippy socks on at all times. Review of aide care card/Kardex dated 3/18/2025 directed ensure that resident is wearing appropriate footwear when ambulating. Review of facility reportable event dated 3/19/2025 identified a Nurse Aide (NA) witnessed Resident #1 fall at 3:55 AM in the hallway. RN assessment identified Resident #1 was observed lying supine (face up) on the floor with blood and a laceration noted on the head. A call was made to 911, resident remained on the floor until EMS arrival and Resident #1 was transferred to the hospital. Further, the reportable event identified the APRN and family were notified. Review of facility Change of Condition Evaluation dated 3/19/2025 indicated Resident #1 had a fall with a change in level of consciousness and a laceration to the back of the head. Further, the Evaluation form identified the provider was notified at 5:15 AM and family/resident representative notification was via voicemail on 3/19/2025 at 9 AM. Although clinical record review identified RN #1 left a voice mail message for the responsible party at 9 AM, additional record review failed to identify any additional attempts were made to contact the responsible party. Interview, clinical record review, and facility documentation review with RN #1 (RN supervisor) on 12/1/2025 at 11:47 AM identified he worked on 3/19/2025 from 12 AM (midnight) to 8 AM. RN #1 stated he notified Resident #1's responsible party by leaving a voice mail message at about 9 AM. Further, RN #1 stated he believed he notified the family around 5 AM but he did not document a call was made at 5 AM. RN #1 stated if he made a call at 5 AM, he would have written a nursing note, and his usual routine is to write a note whenever he makes a call. Interview on 12/1/2025 at 1:00 PM with LPN #3 identified she was the charge nurse working on the 7 AM to 3 PM shift on 3/19/2025, she did not place any calls to the responsible party to notify them that Resident #1 was transferred to the hospital after a fall. LPN #3 stated she did not make any calls because Resident #2 was no longer in the facility. Interview on 12/1/2025 at 1:27 PM with LPN #4 identified she was the charge nurse on 3/19/2025 on the 11 PM to 7 AM shift (ending at 7 AM on 3/19/2025) when Resident #1 fell. LPN #4 stated she did not call the family/responsible party to notify of Resident #1's fall or transfer to the hospital as the RN supervisor (RN #1) had stated he would notify them. LPN #4 stated a follow up call should have been made after the voice mail message was left, and it should have been documented in the medical record if it was done. Interview and record review with the Administrator and RN #2 (Regional Clinical Director) on 12/1/2025 at 2:10 PM identified a resident's responsible party should be notified timely of a change in condition, especially when a serious injury has occurred. If a responsible party is not reached, additional attempts should be made, as well as documentation of all attempts, including the initial attempt in the nursing notes. Although interview identified additional attempts to notify the responsible party should have been made after the voice mail message was left, interview failed to identify why additional attempts were not made. Additional interview with RN #1 on 12/3/2025 at 10:26 AM identified his usual routine is to follow up with the responsible party if he did not reach them (left a voice mail message), however he was unsure if he had placed any additional calls, and was unable to provide documentation of additional calls beyond the voicemail message at 9 AM. Review of facility Physician Notification - Change of Condition Policy directed in part, the responsible party will be notified of a change in condition. The nurse will document in the nurse's notes regarding responsible party notification. Review of facility Fall Management Program Policy directed in part, notify the family/responsible party (of a fall).

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1), reviewed for accidents, the facility failed to ensure adequate supervision for a resident while at an outpatient dental appointment. The findings include: Resident #1 was admitted to the facility with diagnoses that included dementia, diabetes mellitus and stroke. The Resident Care Plan (RCP) dated 3/26/2025 identified Resident #1 was at risk for impaired communication with demonstrated verbal and physical behaviors to express frustration and anger. Interventions directed to allow adequate time for Resident #1 to respond and anticipate needs. An exit seeking risk assessment dated [DATE] identified Resident #1 had no known risk factors for exit seeking behaviors but had disorientation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and independent for bed mobility, transfers, and ambulation. A facility reportable event dated 6/11/2025 at 3:06 PM identified a missing resident. Resident #1 was accompanied by NA #1 to a scheduled dental appointment at 11:00 AM. At 3:06 PM, the facility was notified by NA #1 that Resident #1 wandered off and was unable to be located. Resident #1's description of clothes, height and weight were disclosed. Resident #1 was located at 5:30 PM and transported to the hospital emergency department (ED). Interview and review of NA #1's facility interview with NA #1 on 6/16/2025 at 12:15 PM identified she accompanied Resident #1 to a hospital dental appointment (clinic) on 6/11/25. The appointment concluded at 11:30 AM and NA #1 notified the facility to arrange a return ride. She exited the clinic building and sat with Resident #1 on a nearby bench. She received a call around noon to let her know that a problem occurred with return transport arrangements. She continued to wait outside with Resident #1. She identified that Resident #1 used the bathroom twice while waiting and began to stand rather than sit with her on the bench or sat on a wall near her. At 2:30 PM, Resident #1 was about 10 feet away from her by the door to the clinic when she received a call that the return transport ride was 5 minutes away. She turned away from Resident #1 while continuing to talk on the phone and collected her belongings. She hung up and turned back to observe that Resident #1 was no longer in sight. She immediately went inside the clinic to check to see if Resident #1 had gone in alone to use the bathroom again. She determined Resident #1 was not in the bathroom and began to look throughout the lobby area requesting assistance from the clinic security. She contacted the receptionist at the facility at approximately 3:00 PM to report that she could not locate Resident #1. The receptionist reported the information to the Administrator. NA #1 indicated she should not have taken her eyes off Resident #1 as she needed to keep him/her in line of sight at all times. She identified that the ride notification call took longer than she thought and there may have been a total of 5 minutes where Resident #1 was not supervised by her line of sight. She identified she was re-educated by the facility that under no circumstances should a resident be left alone or be outside of the staff's line of sight when they are being escorted to an appointment. Interview with the ADNS on 6/11/2025 at 11:15 AM identified she was with the Administrator when the receptionist reported that NA #1 could not find Resident #1 after a dental appointment at the clinic. The Administrator contacted NA #1 and directed NA #1 to notify the police. The ADNS left to meet NA #1 outside the clinic that was about 15 minutes away by car. When she arrived, the police were on the scene and had begun to search for Resident #1. Staff was mobilized from the facility and other corporate resources/facilities to fan out across the area to search for Resident #1. At 5:30 PM, Resident #1 was found at a gas station (2 miles from the clinic) and was transported to the ED for evaluation. Resident #1 was unharmed and returned to the facility on 6/12/2025. Interview with the DON on 6/16/2025 at 1:05 PM identified NA #1 should have maintained line of sight supervision at all times while out at the appointment with Resident #1 and while waiting for the transportation back to the facility, and the report of not observing Resident #1 for 5 minutes was not appropriate. He continued that NA #1 had since been re-educated. The facility document Rules and Standards for Working Transport Shifts dated 10/15/2019 directed in part, that the staff member who accompanied a resident on an appointment must stay alert and within a close distance to the resident at all times The staff member should not get distracted and should keep the resident in sight at all times. Facility documentation review identified education was initiated on 6/11/2025 for facility staff who have the potential to accompany a dementia residents to appointments within the community. The education included that staff maintained a close proximity to the resident who they are accompanying and that the resident always remained within their line of sight. Education was completed on 6/12/2025. Audits were initiated and a QAPI meeting was held on 6/12/2024. Review identified the facility met the requirements for past non-compliance

Based on review of clinical records, interviews, and facility documentation for one (1) of three (3) residents (Resident #3) reviewed for pain management, the facility failed to ensure that the physician was notified when the resident's prescribed pain medication was unavailable and an alternate pain medication that was administered was ineffective. Resident #3 had diagnoses of acute osteomyelitis of the left ankle and foot. Review of Resident #3's Care Plan dated 11/1/24 identified the resident was on pain medication therapy with interventions directed to administer analgesic medications as ordered by the physician, and to monitor and document the side effects and effectiveness. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of severe cognitive impairment. The MDS further identified Resident #3 was independent with Activities of Daily Living. A physician's order dated 12/6/24 directed acetaminophen 325 milligram tablets, two (2) tablets by mouth every six (6) hours as needed for pain. A physician's order dated 12/9/24 directed Oxycodone APAP, 5-325 milligrams by mouth, one (1) tablet every six (6) hours as needed (PRN) for moderate pain and two (2) tablets every six (6) hours as needed (PRN) for severe pain (a narcotic pain reliever). Review of Resident #3's Controlled Substance Disposition Record identified one (1) tablet of Oxycodone 5-325 milligrams was administered on 12/15/24 at 9:00 AM, which left zero (0) available for future administrations. Review of Resident #3's Medication Administration Record (MAR) for December 2024 identified Resident #3's pain level had ranged from five (5) to ten (10) (on a scale from one (1) to ten (10), (one (1) being the least amount of pain and ten (10) being the most pain). Review of the Resident #3's Medication Administration Record (MAR) dated 12/16/24 identified a pain level of nine (9) and 650 milligrams of acetaminophen was administered at 11:39 AM by LPN #1 ( location of pain not identified) . Review of LPN #1's nursing note dated 12/16/24 at 12:32 PM identified Resident #3 reported a pain level of eight (8) and that the acetaminophen was ineffective at relieving his/her pain. Review of the Controlled Substance Disposition Record identified Resident #3 received his/her next dose of Oxycodone 5-325 milligrams on 12/16/24 at 5:35 PM, thirty-two (32) hours and thirty-five (35) minutes after his last dose. Interview with LPN #1 on 2/18/25 at 1:51 PM identified that he/she did not inform the supervisor that Resident #3 was out of his/her Oxycodone 5-325 milligram pain medication on 12/16/24 and that the back-up emergency supply of Oxycodone 5-325 milligram was also not available on 12/16/24. LPN #1 further indicated at 2:40 PM on 2/16/25 that the charge nurse was aware that there was no Oxycodone available and the pain was unrelieved by acetaminophen. (although he/she was unable to identify who that was) further, the practioner was not contacted to request an alternate pain medication to help relieve the resident's pain. Interview with RN #1 (Nurse Supervisor on 7:00 AM to 3:00 PM shift on 12/16/24) on 2/19/25 at 11:41 AM identified that h/she was not informed that Resident #3 had reported the acetaminophen was ineffective in relieving his/her pain or that Resident #3 reported a pain level of eight (8) following administration of acetaminophen on 12/16/24. RN #1 further identified that he/she did not recall being informed the resident was out of his/her Oxycodone 5-325 milligram medication, if he/she had been informed he/she would have informed the provider of the resident's pain, and that the resident was out of his/her Oxycodone 5-325 milligram medication, checked the availability of the medication in the emergency box/PIXUS (dispenses emergency medication), and inquired about an alternative that could have been given in the meantime until the Oxycodone came in from the pharmacy. Interview with the Assistant Director of Nurses (ADNS) on 2/19/25 at 11:48 AM identified that he/she was not notified Resident #3 was still in pain after being administered 650 milligrams of Acetaminophen on 12/16/24. Interview with the Medical Director on 2/19/25 at 2:10 PM identified he/she would expect the facility to notify him/her or the provider of the resident's unresolved pain and inquire about an alternative medication that could be offered. The Medical Director indicated he/she would have given the resident a one-time dose of an alternate medication to relieve his/her pain and would expect a call back if the resident's pain persisted. Interview with the DON on 2/19/25 at 12:02 PM identified when Resident #3's pain was not relieved following the administration of pain medication, the nurse supervisor should have been notified, and provider informed of the resident's unrelieved pain. The DON further indicated he/she would have reviewed Resident #3's orders for an alternate medication that could have provided pain relief. Review of the change in condition policy identified that a change in condition is a significant clinical development that requires assessment and intervention. The RN supervisor will do an assessment and report findings to the physician.

Based on clinical record reviews, facility documentation, facility policies, and interviews for one (1) of two (2) sampled residents (Resident #1) who were reviewed for an allegation of resident to resident abuse, the facility failed to ensure Resident #1 was free from physical abuse. The findings include: 1. Resident #1's diagnoses included bipolar disorder and anxiety. The Resident Care Plan (RCP) dated 1/3/25 identified Resident #1 had behavioral problems. Interventions directed to administer medications as ordered, monitor and document for side effects and effectiveness, anticipate and meet the resident's needs, and provide opportunities for positive interaction. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #1 was alert and oriented to date, time and place and ambulated independently with a cane. 2. Resident #2's diagnoses included anxiety, adjustment disorder, and depression. The quarterly MDS dated [DATE] identified Resident #2 had a BIMS score of 11 indicating Resident #2 had some memory recall deficits, was independent with transfers and utilized a motorized wheelchair. The RCP dated 1/16/25 identified Resident #2 had a mood problem related to anxiety, insomnia and depression. Interventions directed to administer medications as ordered, monitor and document for side effects and effectiveness, behavioral health consults as needed, and monitor, record and report to physician if the resident was at risk for harming others, had increased anger, labile mood or agitation. The nurse's note dated 2/4/25 at 1:46 PM identified Resident #1 was observed sitting on his/her buttocks on the floor and a large laceration was noted to the right side of the forehead. The note identified Emergency Medical Services (EMS) was called and Resident #1 was transferred to the Emergency Department (ED) for treatment. The nurse's note dated 2/4/25 at 7:36 PM identified Resident #1 returned from the hospital and seven (7) sutures were noted to the right lateral aspect of the head. The nurse's note dated 2/4/25 at 2:03 PM identified Resident #2 was involved in a resident-to-resident altercation with Resident #1. The note identified witnesses reported Resident #2 hit Resident #1 in the forehead with a cane. The note identified Resident #2 was sent to the ED for evaluation and treatment to ensure no further harm would be done. The nurse's note dated 2/5/25 at 2:40 AM identified Resident #2 returned from the hospital at 12:15 AM with a no harm letter. The facility's investigational summary report dated 2/7/25 at 12:00 PM identified Resident #1 and Resident #2 had a verbal altercation in the dining room. Resident #2 then drove his/her motorized wheelchair towards Resident #1 causing Resident #1 to stumble and fall. Resident #2 then picked up Resident #1's cane, struck Resident #1 in the head and Resident #1 sustained a laceration to the right side of the forehead. Interview with the Social Worker (SW) #1 on 2/20/25 at 11:47 AM identified she arrived on the unit while the altercation in the dining room was occurring. SW #1 explained that Resident #2 reported to her that he/she had sugar packets on the table and Resident #2 told Resident #1 not to touch the condiments, but Resident #1 did touch the sugar. Resident #2 reported to her that it was then he/she wheeled towards Resident #1 in his/her motorized wheelchair causing Resident #1 to fall to the ground. Resident #2 identified while on the floor Resident #1 attempted to swing his/her cane at Resident #2 who then grabbed the cane and struck Resident #1 with it. Interview with the Physical Therapy Assistant (PTA) #1, on 2/20/25 at 12:03 PM identified at the time of the incident, he was in the hallway on the unit and observed Resident #1 on the ground in the dining room swinging his/her cane at Resident #2. PTA #1 indicated Resident #2 grabbed the cane from Resident #1 and hit Resident #1 on the head. PTA #1 identified he then took the cane away from Resident #2. Interview with the Certified Occupational Therapy Assistant (COTA) #1 on 2/20/25 at 1:23 PM identified on 2/4/25 she observed Resident #1 being a bit irritated while in the dining room. COTA #1 identified she heard a tussle, and when she turned around she saw Resident #2 going towards Resident #1 with his/her motorized wheelchair, bump into Resident #1 and Resident #1 fell to the floor. COTA #1 indicated Resident #2 continued to move towards Resident #1, and she observed what appeared to be Resident #1 attempting to get Resident #2 to stop by using his/her cane. COTA #1 identified at that time, Resident #2 grabbed the cane from Resident #1 and began to hit Resident #1. COTA #1 indicated she called for help and attempted to redirect the residents away from each other. Interview with the Director of Nursing (DON) on 2/20/25 at 2:01 PM identified on 2/4/25, she responded to the unit when she heard the page overhead and arrived at the dining room. The DON identified both residents were separated, the provider was notified, police were called, and an investigation was immediately initiated. The DON identified the facility policy on abuse is that all residents are to be free from abuse of any type from anybody. Review of the facility policy titled Abuse, last reviewed 3/20/24, directed, in part, abuse, neglect, exploitation, and/or mistreatment of residents is prohibited. The policy further directed, in part, residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies service the residents, family members or legal guardians, friends or other individuals. Review of the facility policy titled Nursing Facility Residents' [NAME] of Rights directed, in part, each resident has the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion.

Based on review of clinical records, interviews, and review of facility policy and documentation for two (2) of three (3) residents (Resident #4, and #5) reviewed for medication administration, the facility failed to administer resident's medications in accordance with facility policy. The findings included: 1. Resident #5 had diagnoses that included schizoaffective disorder, major depressive disorder, and Crohn's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition. The MDS further identified Resident #5 was independent with oral, toileting and personal hygiene. Review of Resident #5's Care Plan dated 12/18/24 identified an alteration in gastro-intestinal status related to Crohn's, use of antidepressant medication related to depression, chronic pain and arthritis, and for staff to be alert for the efficacy of his/her pain medication with interventions that directed to administer medications as ordered by the physician and to monitor for side effects and effectiveness. Review of the physician's orders dated 2/1/25 and the Medication Administration Record dated 2/19/25 identified the following medication orders: -Hydroxyzine (Antihistamine), 25 milligram tablet, three (3) tablets to be given twice daily at 8:00 AM and 5:00 PM. -Omega-3 Acid (Supplement), 1 gram capsule, twice daily at 8:00 AM and 5:00 PM. -GuaFENesin (Expectorant), 400 milligram tablet, twice daily at 8:00 AM and 5:00 PM. -Morphine Sulfate Extended Release (Narcotic Pain Reliever), 15 milligram tablet, twice daily at 9:00 AM and 9:00 PM. -Furosemide (Diuretic), 40 milligram tablet daily at 9:00 AM. -Loratadine (Antihistamine), 10 milligram tablet daily at 9:00 AM. -Multivitamin Tablet (Supplement), one (1) daily at 9:00 AM. -Senna with Docusate (Laxative), 8.6-50 milligram tablet, two tablets twice daily at 9:00 AM and 5:00 PM. -Lisinopril (Antihypertensive), 20 milligram tablet, one tablet daily at 9:00 AM. -Gabapentin (Anticonvulsant), 400 milligram tablet three (3) times daily at 9:00 AM, 1:00 PM, and 5:00 PM. -Potassium Chloride (Supplement), 10 milliequivalent tablet, daily at 9:00 AM. -Metoprolol Succinate (Antihypertensive), 100 milligram Extended Release tablet daily at 9:00 AM. -Sertraline (Antidepressant), 100 milligram tablet, two tablets daily at 9:00 AM. -Metamucil Powder (Laxative), one serving daily at 9:00 AM. Review of the time the aforementioned medications were administered was recorded as 10:53 AM and 11:17 AM, one (1) hour and fifty-three (53) minutes and two (2) hours and seventeen (17) minutes after their scheduled administration times. 2. Resident #4 had diagnoses that included metabolic encephalopathy, diffuse traumatic brain injury, and adjustment disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition. The MDS further identified Resident #4 was dependent with toileting hygiene, bathing, dressing, and mobility. Review of Resident #4's Care Plan dated 1/6/25 identified a nutritional problem or potential nutritional problems related to diabetes mellitus, hypertension, congestive heart failure, dysphagia/shortness of breath, and obesity with interventions that directed to administer medications as ordered and provide and serve supplements as ordered. Observation of LPN #1 on 2/19/25 at 10:20 AM identified he/she was administering morning medications. Review of the Physician's orders dated 2/1/25 and the Medication Administration Record dated 2/19/25 identified the following medication orders: -Prosource Protein Liquid (Supplement), 30 milliliters to be administered daily at 8:00 AM -Prednisone (Anti-Inflammatory), 2.5 milligram tablet to be administered daily at 9:00 AM -Eliquis (Anticoagulant), 5 milligram tablet, to be administered twice daily at 9:00 AM and 9:00 PM. -Incruse Ellipta Inhalation Aerosol Powder (Bronchodilator), 62.2 micrograms to be given daily at 9:00 AM. -Suboxone Sublingual Film (Substance Addiction), 12-3 milligrams to be administered daily at 9:00 AM. -Ferrous Sulfate (Supplement), 325 milligrams to be administered daily at 9:00 AM. -Ascorbic Acid Tablet (Supplement) 250 milligrams to be administered daily at 9:00 AM. -Allopurinol Tablet (Uric Acid Depletion), 100 milligrams daily to be administered daily at 9:00 AM. -Metoprolol Tartrate Oral Tablet (Antihypertensive), 25 milligrams given twice daily at 9:00 AM and 6:00 PM. Review of the time the medications were administered was recorded in the electronic medical record system as administered at 11:29 AM and 11:30 AM, two (2) and one-half (1/2) to three (3) and one-half (1/2) hours past their scheduled times. Interview with LPN #1 on 2/19/25 at 1:55 PM identified he/she did not communicate to the supervisor that he/she was running late in administering medication because he/she was running late was due to a heavy resident assignment (thirty (30) to thirty-one (31) residents) with multiple medications to administer. LPN #1 further identified that the late medication administrations is not something new and that the facility was aware that this was happening. Interview with RN #1 on 2/19/25 at 2:00 PM identified he/she was not aware that resident's medications were being administered late and had he/she known, he/she would have discussed the issue with the Director of Nursing Services (DNS) to resolve the issue so that medications were administered timely. Interview with the DNS on 2/19/25 at 4:00 PM identified resident medications could be administered up to one (1) hour before and one (1) hour after the scheduled time and that staff should notify the nursing supervisor that medications were being administered late in order for the issue to be attended to and resolved. Review of the Medication Administration policy directed medications were to be administered within sixty (60) minutes of the scheduled administration time and that unless otherwise specified by a prescriber, routine medications were administered according to the established medication administration schedule for the facility.

Based on review of clinical records, interviews, and facility documentation for one (1) of three (3) residents (Resident #3) reviewed for pain management, the facility failed to ensure medications were available to and treat a resident's unrelieved pain. The findings included: Resident #3 had diagnoses of acute osteomyelitis of the left ankle and foot. Review of Resident #3's Care Plan dated 11/1/24 identified the resident was on pain medication therapy with interventions directed to administer analgesic medications as ordered by the physician, and to monitor and document the side effects and effectiveness. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of severe cognitive impairment. The MDS further identified Resident #3 was independent with Activities of Daily Living. A physician's order dated 12/6/24 directed acetaminophen 325 milligram tablets, two (2) tablets by mouth every six (6) hours as needed for pain. A physician's order dated 12/9/24 directed Oxycodone - APAP, 5-325 milligrams by mouth, one (1) tablet every six (6) hours as needed (PRN) for moderate pain and two (2) tablets every six (6) hours as needed (PRN) for severe pain (a narcotic pain reliever). Review of Resident #3's Controlled Substance Disposition Record identified one (1) tablet of Oxycodone 5-325 milligrams was administered on 12/15/24 at 9:00 AM, which left zero (0) available for future administrations. Interview with RN #2 on 2/19/25 at 12:35 PM identified he/she had approached Resident #3 in the hallway during second shift (3:00 PM to 11:00 PM) on 12/15/24 as the resident had appeared frustrated. RN #2 identified that Resident #3 had informed him/her that the facility had run out of h/her Oxycodone 5-325 milligrams pain medication. RN#1 identified the facility was also out of the emergency supply of Oxycodone 5-325 milligrams so she contacted the APRN to request a prescription be sent to the pharmacy. A Nurse's note written by (RN) #2 dated 12/15/24 at 7:32 PM identified the facility was out of Resident #3's PRN (as needed) Oxycodone 5-325 milligram medication, a call was made to the on-call Advanced Practice Registered Nurse (APRN) who informed a script would be called into the pharmacy, a substitute medication was requested until the resident's pain medication was delivered, however, APRN stated the medication should be in the facility sometime today, and to continue to offer Tylenol to the resident. Review of Resident #3's Medication Administration Record (MAR) for December 2024 identified Resident #3's pain level had ranged from five (5) to ten (10) (on a scale from one (1) to ten (10), one (1) being the least amount of pain and ten (10) being the most pain). Review of the Resident #3's Medication Administration Record (MAR) dated 12/16/24 identified a pain level of nine (9) and the administration of 650 milligrams of acetaminophen at 11:39 AM by LPN #1. Review of LPN #1's nursing note dated 12/16/24 at 12:32 PM identified Resident #3 reported a pain level of eight (8) and that the tylenol was ineffective at relieving his/her pain. Review of the Controlled Substance Disposition Record identified Resident #3 received his/her next dose of Oxycodone 5-325 milligrams on 12/16/24 at 5:35 PM, thirty-two (32) hours and thirty-five (35) minutes after his last dose. Interview with LPN #1 on 2/18/25 at 1:51 PM identified that he/she did not inform the supervisor that Resident #3 was out of his/her Oxycodone 5-325 milligram pain medication on 12/16/24 and that the back-up emergency supply of Oxycodone 5-325 milligram was also not available on 12/16/24. LPN #1 further indicated at 2:40 PM on 2/16/25 that the charge nurse was aware that there was no Oxycodone available and the pain was unrelieved by tylenol. (although he/she was unable to identify who that was) further, the APRN was not contacted to request an alternate pain medication to help relieve the resident's pain. Interview with RN #1 (Nurse Supervisor on 7:00 AM to 3:00 PM shift on 12/16/24) on 2/19/25 at 11:41 AM identified that h/she was not informed that Resident #3 had reported the acetaminophen was ineffective in relieving his/her pain or that Resident #3 reported a pain level of eight (8) following administration of acetaminophen on 12/16/24. RN #1 further indicated he/she did not recall being informed the resident was out of his/her Oxycodone 5-325 milligram medication, if he/she had been informed he/she would have informed the provider of the resident's pain, and that the resident was out of his/her Oxycodone 5-325 milligram medication, checked the availability of the medication in the emergency box/PIXUS, and inquired abot an alternative that could have been given in the meantime unitl the Oxycodone came in from the pharmacy. Interview with the Assistant Director of Nurses (ADNS) on 2/19/25 at 11:48 AM identified that he/she was not notified Resident #3 was still in pain after being administered 650 milligrams of Acetaminophen on 12/16/24. Interview with the DON on 2/19/25 at 12:02 PM identified when Resident #3's pain was not relieved following the administration of pain medication, the nurse supervisor should have been notified, and provider informed of the resident's unrelieved pain. The DON further indicated he/she would have reviewed Resident #3's orders for an alternate medication that could have provided pain relief. Interview with the Clinical Service Manager (CSM) of the On-Call Nurse Practitioner Service) on 2/20/25 at 12:03 PM identified a call was received on 12/15/24 at 5:34 PM from the facility requesting a new script for Oxycodone 5-325 milligrams be placed for Resident #3 as the resident had run out of his prescription and the facility did not have any of the medication on hand. The CSM further indicated the caller had inquired about substituting the Oxycodone 5-325 mg with Tramadol and indicated the facility was giving the resident Acetaminophen, 650 milligrams, for his/her pain in between administration of his/her Oxycodone. RN #1 did not indicate the resident was experiencing any pain during the call and that APRN #1 did not direct the facility to use Acetaminophen for the resident's pain in the meantime. An order for eight (8) tablets of Oxycodone 5-325 milligrams was electronically submitted to the pharmacy immediately following the call, however was not placed as a stat order (to be filled and delivered immediately). The CSM identifed that no additional calls were received into the on-call service following the prescription refill request through to 8:00 AM the following day (12/16/24) for Resident #3. Interview with the Medical Director on 2/19/25 at 2:10 PM identified he/she would expect the facility to notify him/her or the provider of the resident's unresolved pain and inquire about an alternative medication that could be offered. The Medical Director indicated he/she would have given the resident a one-time dose of an alternate medication to relieve his/her pain and would expect a call back if the resident's pain persisted. Review of the Pain Management policy directed pain strategies to include as applicable, pharmacologic, and non-pharmacologic interventions.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (2) of two (2) residents (Resident #1 and #2) reviewed for resident-to-resident abuse, the facility failed to ensure residents were free from physical and verbal abuse. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included fibromyalgia and mood disorder. A psychiatric note dated 10/14/24 identified Resident #1 was tolerating his/her medications well and maintaining a stable mood. The quarterly MDS dated [DATE] identified Resident #1 had a BIMS of fifteen (15) indicative of intact cognition, no physical behavioral symptoms and verbal behavior symptoms that occurred one to three days out of a seven-day period. A physician's order dated November 2024 directed independent mobility with a power wheelchair. The care plan dated 10/23/24 identified on 5/0/24 Resident #1 yelled at others, called others names and tended to threaten others when upset with interventions that included to have Resident #1 see the psychiatric team for therapy and medication management, offer 1:1 visits by the social workers so that Resident #1 could express concerns/issues about others, facility- contracted behavioral health services available as needed and to keep Resident #1 separated from residents if bothered by their presence. A psychotherapy note dated 11/5/24 identified one of Resident #1's treatment goals was to decrease conflict dynamics and reduce his/her conflicts with peers and others. Resident #1 expressed difficulty in managing intense emotions during stressful situations, which sometimes lead to conflict dynamics with others. Resident #1 had no current conflict with others reported by Resident #1 or staff. Resident #1 continued to implement coping strategies discussed in previous sessions, including deep breathing and mindfulness techniques. Resident #1 was assessed to be at no harm to self or others. A nursing note written by RN #1 dated 11/6/24 at 11:41 AM identified she was notified by the supervisor of an alleged resident to resident altercation in the first floor dining room. Resident #2 was sitting at a table coloring when Resident #1 approached the table yelling at Resident #2 that he/she was not allowed to sit at that table ever again. Resident #2 started to gather his/her things to leave when Resident #1 punched Resident #2 on the left side of his/her face. Resident #2 placed Resident #1 in a head lock to prevent him/her from further punches to his/her face. The residents were immediately separated and placed on 1:1. Psychiatry evaluated both residents, discontinued 1:1 and initiated every 15-minute checks. A psychiatry note dated 11/6/24 at 11:59 PM identified Resident #1 was seen for a peer-to-peer altercation. Resident #2 recalled the events, affirmed feeling safe. He recommended every 15-minute checks. Resident #1's care plan was updated on 11/6/24 with the intervention that Resident #1 was re-educated to not have physical altercations with other staff or residents and to notify staff of any issues. 2. Resident #2 was admitted to the facility with diagnoses that included fracture of the sternum, Tourette's disorder and attention deficit disorder (ADD). The nursing admission assessment dated [DATE] identified Resident #2 was alert and oriented, had no behaviors and ambulated with a manual wheelchair. The five-day MDS dated [DATE] identified Resident #2 had a BIMS of fifteen (15) indicative of intact cognition and had no behavioral symptoms. A physician's order dated November 2024 directed ambulation with assistance of one. The care plan dated 11/5/24 identified Resident #2 had a mood problem related to obsessive compulsive disorder (OCD), ADD, and Tourette's disorder. Interventions included to administer medications as ordered, assist Resident #2 to identify strengths and positive coping skills and behavioral consults as needed. A nurse's note dated 11/6/24 at 11:50 AM written by RN #identified she was notified by the supervisor of an alleged resident to resident altercation on the first-floor dining room. Resident #2 was sitting at a table coloring when Resident #1 approached the table yelling at Resident #2 that he/she was not allowed to sit at that table ever again. Resident #2 started to gather his/her things to leave when Resident #1 punched Resident #2 on the left side of his/her face. Resident #2 placed Resident #1 in a head lock to prevent him/her from further punches to his/her face. The residents were immediately separated and placed on 1:1. Psychiatry evaluated both residents, discontinued 1:1 and initiated every 15-minute checks. Resident #2 was provided a room change. A nurse's note dated 11/6/24 at 6:49 PM identified Resident #2 verbalized he/she would not be able to sleep tonight. The room change was completed, in-house APRN was notified and ordered Trazodone 25 mg at bedtime for five days for sleep. A Psychiatric note dated 11/6/24 at 11:59 PM identified Resident #2 was seen for a peer-to-peer altercation. Resident #2 recalled the events and affirmed feeling safe. He recommended every 15-minute checks. Resident #2's care plan was updated on 11/6/24 with the intervention that Resident #2's room was changed to a different wing to avoid interactions with Resident #1. a. Review of the accident and incident form dated 11/6/24 identified Resident #2 was punched by Resident #1 in the head in the dining room. The residents were placed on 1:1, evaluated by psychiatry and then placed on every 15-minute checks. Resident #2's room was changed. The summary identified the allegation was substantiated related to the fact that the statements from the witnesses were consistent. Review pf RN #2's statement dated 11/6/24 identified RN #2 heard noise in the dining room and rushed over. He identified Resident #1 and Resident #2 were observed fighting and Resident #2 had Resident #1 in a headlock. The residents were immediately separated. Resident #2 reported he/she was sitting at the table when Resident #1 approached him/her and asked him/her to leave. Resident #2 stated he/she was leaving but Resident #1 told Resident #2 he/she could not use the table anymore and punched Resident #2. Resident #1 stated he/she had to protect him/herself by putting Resident #1 in a headlock. Upon assessment, Resident #2 had no injuries. Interview with Resident #2 on 11/26/24 at 2:10 PM identified he/she was able to recall the event that occurred on 11/6/24. Resident #2 identified he/she was in the dining room working on a craft when Resident #1 rolled up in his/her wheelchair and stated that was his/her table. Resident #2 started to pack up his/her belongings and leave the table when Resident #1 then ran into Resident #2 with his/her wheelchair at full force and punched Resident #2 three times. Resident #2 stated he/she put Resident #1 in a head lock to stop Resident #1 from punching him/her. Resident #2 identified Resident #1 stated I will kill you. Interview with LPN #1 on 11/26/24 at 2:35 PM identified he was assigned Resident #1 and Resident #2's unit on 11/6/24. He identified Resident #1's behavior that day was calm, friendly and did not identify any concerns. He identified he last saw Resident #1 in the common room in his/her power wheelchair and Resident #2 in the common room sitting at the table where Resident #1 usually sat around 11:20 AM. He identified he was passing through the common room at that time. He identified he was in the supervisor's office when he heard yelling and went to the common room where Resident #1 and Resident #2 were already separated. Interview with NA #1 on 11/26/24 at 2:40 PM (identified on the staffing for 11/6/24 as working in Resident #1 and Resident #2's unit) identified on 11/6/24 she heard he/she's hitting in the common room and ran over. Resident #2 was at a table gathering his/her supplies and Resident #1 was yelling at Resident #2 close to the table. Interview with the DNS and Administrator on 11/26/24 at 3:00 PM identified that the facility has no tolerance for abuse. He identified subsequent to the event; recreation was notified to ensure when Resident #2 comes to the common room after activities to clear a spot for Resident #2 and continue education on handling his/her emotions. He identified this is the first event where Resident #2 was territorial about his/her table in the common area. Attempts to interview RN #1 were unsuccessful. Review of the abuse policy directed that abuse, exploitation and/or mistreatment of residents is prohibited. It further directed residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #2) reviewed for resident-to-resident abuse, the facility failed to complete and document 1:1 and every fifteen minute (Q 15) checks subsequent to a resident-to-resident abuse event per facility policy. The findings include: physical altercations with other staff or residents and to notify staff of any issues. 2. Resident #2 had diagnoses that included fracture of the sternum, Tourette's disorder and attention deficit disorder (ADD). The nursing admission assessment dated [DATE] identified Resident #2 was alert and oriented, had no behaviors and ambulated with a manual wheelchair. The five-day MDS dated [DATE] identified Resident #2 had a BIMS of fifteen (15) indicative of intact cognition and had no behavioral symptoms. A physician's order dated November 2024 directed ambulation with assistance of one. The care plan dated 11/5/24 identified Resident #2 had a mood problem related to obsessive compulsive disorder (OCD), ADD, and Tourette's disorder. Interventions included to administer medications as ordered, assist Resident #2 to identify strengths and positive coping skills and behavioral consults as needed. A nurse's note dated 11/6/24 at 11:50 AM written by RN #identified she was notified by the supervisor of an alleged resident to resident altercation on the first-floor dining room. Resident #2 was sitting at a table coloring when Resident #1 approached the table yelling at Resident #2 that he/she was not allowed to sit at that table ever again. Resident #2 started to gather his/her things to leave when Resident #1 punched Resident #2 on the left side of his/her face. Resident #2 placed Resident #1 in a head lock to prevent him/her from further punches to his/her face. The residents were immediately separated and placed on 1:1. Psychiatry evaluated both residents, discontinued 1:1 and initiated every 15-minute checks. Resident #2 was provided a room change. A nurse's note dated 11/6/24 at 6:49 PM identified Resident #2 verbalized he/she would not be able to sleep tonight. The room change was completed, in-house APRN was notified and ordered Trazodone 25 mg at bedtime for five days for sleep. A Psychiatric note dated 11/6/24 at 11:59 PM identified Resident #2 was seen for a peer-to-peer altercation. Resident #2 recalled the events and affirmed feeling safe. He recommended every 15-minute checks. Resident #2's care plan was updated on 11/6/24 with the intervention that Resident #2's room was changed to a different wing to avoid interactions with Resident #1. Review of the accident and incident form dated 11/6/24 identified Resident #2 was punched by Resident #1 in the head in the dining room. The residents were placed on 1:1, evaluated by psychiatry and then placed on every 15-minute checks. Resident #2's room was changed. The summary identified the allegation was substantiated related to the fact that the statements from the witnesses were consistent. Interview with the DNS and Administrator on 11/26/24 at 3:00 PM identified he could not locate Resident #2's 1:1 or Q15 minute monitoring flowsheet for 11/6/24. He identified he would expect staff to document in a nursing note or the 1:1 or Q15 minute monitoring flowsheet when a patient is on increased monitoring. He further identified that he was not aware of when Resident #2 was taken off of fifteen-minute checks. He identified the process for taking a patient off Q15 checks is usually based on psychiatry feedback, discussion during morning rounds and/or during behavior rounds every Monday. Review of the close observation policy identified that residents are placed on close observation when the physician, nursing supervisor or the interdisciplinary team deem it necessary to ensure their safety or the safety of others. The policy directed that if an observation level is ordered by a physician, PA or APRN, it must be entered into the physician order sheets in the clinical record and must be discontinued by a physician, PA or APRN order. It directed the initiation of checks must be documented in an appropriate location in the clinical record. Documentation of staff monitoring of any resident on observation should be entered on either a Q15 or Q30 minute flowsheet. Documentation of 1:1 monitoring should be entered on a Q15 minute flowsheet.

Based on observation, review of the clinical record, facility documentation, facility policy, job descriptions, and interviews, for 2 of 4 units, the facility failed to ensure the environment was maintained in good repair and in a homelike manner and for 1 resident, (Resident #95) the facility failed to ensure a homelike environment. The findings include: Observation on 11/5/24 at 8:35 AM through 11:00 AM, and on 11/5/24 at 11:49 AM with the Regional Maintenance Director and the Administrator identified the following: a. Damaged, chipped, stains and/or marred bedroom walls on A wing in rooms 102, 103, 105, 106, 109, 110, 114, 115, 116, and 117. B wing in rooms [ROOM NUMBER]. b. Damaged, chipped, stains and/or marred bedroom radiators on A wing in rooms [ROOM NUMBER]. B wing in room [ROOM NUMBER]. c. Damaged, chipped and/or marred bathroom radiators on A wing in rooms [ROOM NUMBER], 107, and 108. B wing in room [ROOM NUMBER]. d. Damaged, bent, and/or missing window blind in bedroom on A wing in room [ROOM NUMBER]. e. Damaged, broken, and/or missing nightstand, closet, and dresser drawer knobs on A wing in rooms 101, 102, 110, 111, and 119. B wing in room [ROOM NUMBER]. f. Damaged, broken, and/or missing nightstand, dresser drawer and/or door on A wing in room [ROOM NUMBER]. B wing in room [ROOM NUMBER], and 137. g. Damaged, bent, and/or missing window blind in bedroom on A wing in room [ROOM NUMBER]. h. Damaged, cracked, and/or stained ceiling in the bathroom on A wing in rooms 102, 105, 112, 117, and 118. B wing in rooms 122, 123, 124, 125, 126, 128, 129, 131, 132, 133,134, 135, 136, 137, and 138. i. Damaged, broken, and/or peeling nightstand, closet, and dresser drawer on A wing in rooms 102, 105, 110, and 119. B wing in room [ROOM NUMBER]. j. Damaged and/or missing bathroom wall tile on wing in room [ROOM NUMBER]. k. Damaged, broken, and/or cracked floor tile in bedroom and/or bathroom on A wing in rooms 102, 105, 109, 112, 114, and 116. B wing in rooms 121, 122, 124, 127, 136, and 137. l. Damaged, loose, and/or off-wall bedroom sink on A wing in rooms 105, 108, 115, and 117. B wing in room [ROOM NUMBER]. m. Damaged, broken, missing, peeling and/or dirty cove base in the bedroom on A wing in rooms [ROOM NUMBER]. B wing in room [ROOM NUMBER]. n. Damaged, dirty, dusty, and/or black stains on window air conditioner on A wing in room [ROOM NUMBER]. Interview on 11/5/24 at 11:54 AM with the Regional Maintenance Director identified he was not aware of the issues. The Regional Maintenance Director indicated that maintenance of the facility is ongoing. The Regional Maintenance Director indicated that the facility is going through the process of changing the maintenance log onto a computer system log. The Regional Maintenance Director indicated that the staff are responsible for calling the maintenance department with any maintenance problems/issue that require repair and if there is an emergency or safety related concern, the staff members are responsible for calling maintenance department immediately. The Regional Maintenance Director indicated he will have a meeting with the Administrator, Interim DNS, Infection Preventionist, housekeeping department and the maintenance department. Interview on 11/5/24 at 11:56 AM with the Administrator identified she was not aware of the issues. The Administrator indicated it is the responsibility of the maintenance department to oversee the repairs of the facility. The Administrator indicated that she will in-service the maintenance department. Interview on 11/5/24 at 12:24 PM with the Interim DNS identified he was not aware of the issues. The Interim DNS indicated he will have an in-service with the maintenance department, and the Infection Preventionist. Review of the maintenance director job description identified the primary purpose of position is to direct and conduct physical plant maintenance and grounds upkeep at a designated facility and oversee these functions at other facilities/building. Such maintenance includes building improvements, grounds, utilities, and mechanical/electrical systems. Review of the maintenance assistance job description identified the purpose of this position is to maintain the facility grounds, and building in a safe and efficient manner. This position will also repair faulty and broken equipment.

Based on clinical record review, facility documentation, facility policy, police reports, ambulance run sheets, and interviews, for one (1) of seven (7) residents, reviewed for a change in condition, (Resident #5), the facility failed to ensure that a baseline substance abuse care plan was put into place upon admission, supervised visits were put into place timely, a supervised visit conducted on [DATE] was in accordance with facility process for Resident #5, who was admitted with a recent history of substance abuse, had a history of possession of an illegal substance within the facility. As a result of this failure, Resident #5 was able to access to an illegal substance which was hidden in a ceiling of tile of Resident#5's bathroom by a visitor, resulting in Resident #5 overdosing on the substance requiring Narcan and Cardio-Pulmonary Resuscitation. The facility further failed to ensure that allegations on [DATE] of a resident who might be in possession of illegal substances was addressed by the facility, with subsequent overdoses that occurred during the time period of [DATE] through [DATE] resulting in a finding of Immediate Jeopardy. The findings include: 1. Resident #5's diagnoses included right acetabulum (hip) fracture and history of substance abuse. A hospital urine toxicology report dated [DATE] identified the resident had a positive urine screen for cocaine and Fentanyl (a highly potent synthetic opioid). Further review of the hospital discharge paperwork dated [DATE] identified that the resident had tested positive for cocaine and Fentanyl upon admission to the hospital. Review of an undated pre-admission basic assessment for Resident #5 completed by the facility admission liaison identified poly-substance abuse. A nursing admission assessment dated [DATE] identified Resident #5 required limited assistance with Activities of Daily Living and had no cognitive impairment. A physician progress note dated [DATE] identified Resident #5 had a history of substance abuse. Review of the Care Plan policy directed upon admission, licensed nursing personnel conduct a general assessment to identify resident's immediate needs and complete care plan within 48 hours of admission. Review of the clinical record failed to identify a substance abuse care plan was put into place upon admission although the facility pre-admission paperwork identified a history of substance abuse (a care plan was not placed for history of an opioid disorder until the resident overdosed on [DATE]). The Visitor Risk assessment dated [DATE] for Resident #5 identified a question that asked if the resident had a history of using in the hospital or 30 days prior to hospitalization , the response was checked off as no. The bottom of the assessment identified that any questions answered yes may necessitate supervised visits (the question should have been answered as yes, due to the resident's recent history of substance abuse which would have placed h/her on supervised visits). A nurse's note dated [DATE] at 10:16 AM identified Resident #5 was upset, and fifteen (15) minute checks had been implemented for Resident #5 due to reports of Resident #5 distributing drugs to other residents. Resident #5 became increasingly threatening and was sent to the hospital for evaluation. A nurse's note dated [DATE] at 2:45 AM identified that the resident returned from the hospital with no new orders, and every 15 minute checks continued. A nurse's note dated [DATE] at 2:34 AM identified Resident #5 was noted to be in Resident #3's room who had possibly overdosed. The DON was notified, a two (2) person room search was done, and one empty bag of Heroin/Fentanyl and an unidentified white pill were found. Resident #5 was placed on one-to-one observation subsequent to the incident. A psychiatric note [DATE] identified per nursing staff and administration Resident #5 stated he/she provided other residents with Fentanyl but denied using the drugs on [DATE]. Resident #5 was currently on one-to-one supervision, making the resident upset and agitated. One to one supervision was discontinued, because of the agitation and fifteen (15) minute checks initiated on [DATE] A nurse's note dated [DATE] at 1:02 PM identified that the Interdisciplinary Team (IDT) had met for weekly behavior rounds and the every 15 minute checks were discontinued. The visitor Risk assessment dated [DATE] identified that Resident #5 had been found with contraband, and a hazardous material/substance on [DATE]. Resident #5 was placed on one-to-one observation for safety due to possession of hazardous substance, and the assessment further identified that the resident may only have visitors with supervision. Interview with the DON on [DATE] at 10:00 AM identified it is the responsibility of the facility liaison to gather information on substance abuse prior to admission. The liaison sends the facility a pre-admission screening which would include a history of substance abuse that would decide if the resident will have a care plan for substance abuse and supervised visits. Any resident with a history of substance abuse within the past 30 days will be placed on supervised visits. The DON stated Resident #5 was not placed on supervised visits on admission because the facility was unaware of the resident's history of substance abuse (although the discharge summary dated [DATE] obtained from Resident #5's clinical record at the facility identified that the resident tested positive for Fentanyl an cocaine upon admission to the hospital on [DATE]). The DON identified that when the resident was found with drugs and drug paraphernalia on [DATE] the resident was placed on supervised visits. The DON further identified that the every fifteen minute checks were discontinued in an IDT meeting on [DATE] for Resident #5 because there were not further issues with the resident with drugs or paraphernalia. Interview with the [NAME] President of Business Development (VPBD) on [DATE] at 1:53 PM identified he oversees the admission team, the admission liaison completes the preadmission basic assessment with access to the hospital record, including toxicology screens. The VPBD identified Resident #5's history of drug use, positive Fentanyl and cocaine upon admission was listed in the preadmission and discharge documentation, however Resident #5's pre-admission evaluation was not sent electronically to the facility and was an omission by the liaison. Interview with the Administrator on [DATE] at 3:00 PM identified the facility does not keep copies of the visitor logs and they are discarded after a certain amount of time. The facility did not have any logs for Resident #5 from admission on [DATE] through when the resident was assessed to need supervised visits on [DATE], so it was unclear if the resident had unsupervised visits during this time frame (however, during this time frame the resident was alleged to be distributing and being in possession of illicit substances). A nurse's note dated [DATE] at 11:59 PM identified at 8:20 PM Resident #5 was found to lying on bed unresponsive to verbal and tactile stimuli, a sternal rub was performed without effect. Resident #5 had no pulse, no respirations, eyes were rolled back, the skin was pale and diaphoretic. CPR was initiated and 911 called. The resident was administered Narcan without effect, and a second dose of Narcan administered with positive effect. Resident #5 began to gurgle, positive pulse and respirations were noted, and CPR was stopped due to positive pulse and respirations. Resident #5 become alert, responsive, vomited twice, and was then transported to the hospital for evaluation. An ambulance run sheet dated [DATE] at 8:22 PM identified the staff had found the resident with agonal respirations (gasping for air) and pulselessness, with empty bags of street packaged Fentanyl on the floor. The staff had administered Narcan and briefly performed chest compressions, the Narcan was effective and pulses returned. The resident regained consciousness and had multiple episodes of projectile vomiting and was transported to the hospital. A Police Case/Incident Report dated [DATE] at 9:14 PM identified on [DATE] at approximately 8:21 PM police were dispatched to the facility for an overdose. The staff identified that they found Resident #5 not breathing, with no pulse, and administered Narcan with effect. The nurse stated she found wax folds by the resident's hands and had suspected Resident #5 had overdosed. Ten (10) white wax fold bags that had a white powdery substance consistent with Fentanyl were received from the nurse. Although it was verified that Resident #5 went to Hospital #1, Hospital #1 had only had laboratory values (Complete Blood Count) for the resident and no records of services provided. A nurse's note dated [DATE] at 8:05 AM identified that Resident #5 returned from the Emergency Department via stretcher at 7:20 AM with a diagnosis of an overdose with new orders for Zofran ( a medication used to treat nausea). The resident was alert and oriented and verbal upon return to the facility. Interview with Resident #5 on [DATE] at 10:15 AM identified he/she had a supervised visit that occurred in his/her room on [DATE], the visitor asked to use the resident's bathroom and the visitor hid the Fentanyl in the ceiling tile. When the resident's visitor left, Resident #6 went into Resident #5's bathroom and took the Fentanyl from the ceiling tiles in the bathroom and gave Resident #5 five (5) bags of Fentanyl. Resident #5 indicated he/she took two (2) bags of Fentanyl and then overdosed. Interview with the Director of Nurses (DON) on [DATE] at 3:00 PM identified on [DATE] Resident #5 had a visitor at 4:15 PM. The DON indicated the visit was not appropriately supervised, meaning, the visitor was allowed to go to resident #5's room instead of visiting in a designated area. The DON identified Resident #5 received the Fentanyl from the visitor on [DATE], and subsequently overdosed. Interview with Security Guard #2 on [DATE] at 3:37 PM identified that on [DATE] the visitor, Resident #5 and himself went to Resident #5's room, while in Resident #5's room, the visitor asked if he could use the resident's bathroom, the visitor used the bathroom, and after the visitor used the bathroom he/she was escorted downstairs and left the facility. Security Guard #2 identified although the supervised visits were usually held in the room behind the receptionist area, or the conference room located on the first floor, he had allowed the visit to happen in the resident's room because the visitor needed to retrieve some information written on a piece of paper in Resident #5's room Security guard #2 identified that he was not educated on supervised visit process upon hire and he was not aware that supervised visits should not occur in the resident's room, however, he was educated after the incident on [DATE]. Interview with the Administrator on [DATE] at 1:30 PM identified he was unsure when Security Guard #2 was hired, but it was previous to [DATE], he did not have any of the security guards education upon hire, as he may have been trained at a sister facility. The Administrator further identified that during supervised visits, the visitors are only allowed in the specified visiting area, and visitors are only to use the bathroom by the Administrators office because no residents have access to that bathroom. A memo dated [DATE] from the Administrator to the security and receptionist staff entitled procedure review identified that it was of tremendous importance to keep illicit substances out of the facility. The vast majority enter the facility either through visitors or packages. The procedures reviewed in the memo included the process of supervised visits (see below). The Supervised Visit Process dated [DATE] directed that the procedure for supervised visits identified that the visits will occur in either the conference room, or the room behind the receptionist area, no exceptions unless specifically approved by the Administrator or Director of Nursing on individual visit basis. Once the resident was in the visit specified location (conference room or Aging room), the visitor will be escorted into the visit room. Security will remain in the room for the entire visit, no exceptions will be made. There will be no physical contact between visitor and resident, no passing of food or substances during the visit, and if a visitor requests to use the bathroom, the bathroom next to the Administrator's office will be the only bathroom used, no exceptions. 2. Review of the security/receptionist shift to shift report dated [DATE] between 8:00 AM and 2:00 PM written by Receptionist #1 identified Resident #5 came downstairs and advised the security guard that he/she had an overdose that past weekend, the illegal substance brought in was for Resident #6, and Resident #6 still had drugs on him/her. Receptionist #1 called up and advised the Nursing Supervisor, RN #2, and RN #2 stated Resident #5 did not always tell the truth and she could not go by the word of another resident so there was nothing she could do. Receptionist #1 documented that she wanted to let RN #2 know so she could keep an eye out. Interview with Receptionist #1 on [DATE] at 1:18 PM identified what she documented in the security/receptionist shift to shift report on [DATE] was exactly what happened. Receptionist #1 indicated she only notified RN #2 because there was nobody else to notify, RN #2 was the only administrative staff on duty on that day. Interview with Nursing Supervisor, Registered Nurse (RN) #2 on [DATE] at 11:30 AM she could not recall the conversation with Receptionist #1 on [DATE]. Interview with the Administrator on [DATE] at 1:00 PM identified receptionist and security were under his supervision, however he was unaware of the Receptionist #1's note from [DATE], if he was aware he would have ensured the issue was investigated. Review of ambulance run sheets identified that there were 4 subsequent overdoses that occurred between [DATE] and [DATE], one fatal. Interview with the Office of Medical Examiner on [DATE] at 1:30 PM identified the resident who had the fatal overdose died of acute Fentanyl intoxication. On [DATE] the facility provided education to the security personal and receptionists regarding the process for supervised visits, audits were conducted and the incident was reviewed in QAPI. However, the facility administration was unaware of the allegation of Resident #6 being in possession of an illegal substance, although the RN supervisor was aware of the allegation, the facility failed to investigate the allegation. The facility submitted a removal plan on [DATE] at 4:15 PM which was accepted by the State Agency. The removal plan included all residents were being reviewed to confirm supervised visit status and all staff will be educated on the importance of visits occurring in designated areas whenever possible. Nursing supervisors will be educated on the importance of modifying supervision levels when security has identified potential drugs in the facility, and security staff will be educated to notify the administrator or designee if they do not receive a prompt response to the allegation. Daily Audits of supervised visits and locations will be conducted. The results of these audits will be forwarded to the QAPI committee for review. The compliance date for this action plan is [DATE] at 11:45 PM.

Based on review of the clinical record, facility documentation, facility policy, and interview for 2 residents (Resident #3 and 2) reviewed for [MEDICATION(S)] administration, the facility failed to administer [MEDICATION(S)] according to professional standards which resulted in a medication error in which Resident #2 received almost 3 times the ordered dose of [MEDICATION(S)] and required hospitalization in the ICU to be stabilized, and for 1 resident (Resident #1) reviewed for death, the facility failed to ensure the physician's order for an RN may pronounce death was transcribed according to professional standards. The findings include: 1. Resident #3 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS dated [DATE] identified Resident #3 had intact cognition and required limited assistance with personal hygiene. The care plan dated [DATE] identified Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to provide Resident #3 with [MEDICATION(S)] as directed. Prepare the [MEDICATION(S)] and ensure Resident #3 is able to take it without staff assistance. The reportable event form dated [DATE] at 5:30 AM identified Resident #3 received [MEDICATION(S)] 120mg instead of [MEDICATION(S)] 43mg at 5:30 AM (almost 3 times the ordered dose). Resident #3 was alert and oriented, walking and transferring independently. The APRN was notified and ordered to monitor Resident #3's vital signs every 4 hours. Accident & Incident protocol for medication error initiated. The medication error report dated [DATE] identified at 6:00 AM, although Resident #3 had physician's orders for [MEDICATION(S)] 43mg, the resident received [MEDICATION(S)] 120mg in error. The wrong dose of [MEDICATION(S)] was administered. The nurse failed to identify the resident. The nurse's note dated [DATE] at 8:00 AM identified RN #5 was asked to assess Resident #3 due to a change in baseline mentation. Resident #3 was observed lying in bed with unclear speech and couldn't verbalized his/her name or location. The APRN was notified and ordered Resident #3 to be sent to the hospital. Review of the facility inter-agency patient referral report dated [DATE] identified Resident #3 was transferred to the hospital for evaluation due to receiving [MEDICATION(S)] 120mg instead of [MEDICATION(S)] 43mg. Review of the hospital in-patient registration dated [DATE] at 2:43 PM identified Resident #3 was at the hospital for an overdose. Review of the hospital discharge summary dated [DATE] identified Resident #3 was admitted to the hospital on [DATE]. Resident #3 who resides at the facility was given the wrong dose of [MEDICATION(S)] at the facility in an apparent medication error. Resident #3 was reportedly given [MEDICATION(S)] 120mg instead of his/her regular [MEDICATION(S)] 43mg at 7:00 AM. According to facility nurse she noticed Resident #3 began to exhibit altered mental status around 9:00 AM and was talking gibberish and walking into the wrong doors. At 10:00 AM Resident #3's symptoms began to deteriorate even more, and she called Emergency Medical Service (EMS). EMS gave Resident #3 an unknown dose of [MEDICATION(S)], which caused the resident to become much more responsive. According to emergency room staff, Resident #3 was extraordinarily agitated upon arrival and required IV [MEDICATION(S)] and [MEDICATION(S)] for sedation. Resident #3 was treated with [MEDICATION(S)], IV fluids, and monitored on telemetry in the ICU. Resident #3 improved over the course of hospitalization , and was able to restart on his/her typical dose of [MEDICATION(S)]. At time of discharge, Resident #3 is clinically stable. Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note dated [DATE] at 8:00 PM identified Resident #3 was readmitted to the facility at 3:00 PM from the hospital for an accidental [MEDICATION(S)] overdose. Resident #3 had been admitted to the Intensive Care Unit (ICU) for observation overnight and was given morning dose of [MEDICATION(S)] at hospital today. The physician's order dated [DATE] at 3:00 PM directed to administer [MEDICATION(S)] 10mg/ml give 43mg by mouth daily for 14 doses. Review of the [MEDICATION(S)] administration audit dated [DATE] identified 3 residents were audited with no issues identified. Review of the facility documentation, undated identified Resident #2 continues to receive care in the facility. Resident #3 has had no physical or psycho-social effects from the incident. All residents and their roommates who both receive [MEDICATION(S)] have the potential to be affected by this alleged deficient practice. All nursing supervisors will be in-serviced on the importance of the five rights of medication administration. To ensure compliance, random weekly audits of [MEDICATION(S)] administration will be conducted. Audits will continue for 90 days or until substantial compliance is achieved. Results of these audits will be forwarded to the facility QAPI Committee for review. The DNS is responsible for this plan of correction. Interview with RN #1 on [DATE] at 10:10 AM identified he went to Resident #3 at around 5:35 AM and handed Resident #3 the wrong [MEDICATION(S)] control sheet and Resident #3 initialed the sheet. RN #1 indicated he handed the [MEDICATION(S)] bottle to Resident #3 who took the medication and then Resident #3 read the bottle and said that is not mine it belongs to my roommate pointing at the roommate. RN #3 took the [MEDICATION(S)] bottle back to the supervisors office and read it and realized he made a mistake. RN #1 indicated he reviewed the [MEDICATION(S)] control sheet and noticed that both residents initialed the wrong sheets. RN #1 indicated he failed to check Resident #3 identification bracelet. RN #1 indicated he notified the 7:00 AM - 3:00 PM supervisor regarding the [MEDICATION(S)] medication error. He indicated he notified the Acting DNS who gave him instructions to fill out a reportable event form for both residents. RN #1 indicated he did not assess Resident #3 after the incident. RN #1 indicated he never dealt with residents receiving [MEDICATION(S)] and this was his first-time administering [MEDICATION(S)]. RN #1 indicated after the medication error he was nervous. Interview with the Acting DNS on [DATE] at 1:30 PM identified she was aware that Resident #2 and Resident #3 received the wrong dose of [MEDICATION(S)]. The Acting DNS indicated a reportable event form was completed and she indicated she followed the policy of the facility which did not tell her to report the incident. The Acting DNS indicated an in-service was given to the RN #1 and the facility had a plan of correction in progress and audits are being performed. Interview with the Acting DNS on [DATE] at 3:06 PM identified she was aware of the [MEDICATION(S)] error the morning of [DATE] and indicated RN #5 notified her of the medication error that took place with RN #1 involvement. The Acting DNS indicated she directed RN #5 to contact the [MEDICATION(S)] Clinic who directed RN #5 to administer dose 13 to Resident #2. The Acting DNS indicated she came to the facility and investigated the medication error and RN #1 was in-serviced regarding the 5 rights of medication administration. Review of the facility [MEDICATION(S)] protocol policy identified residents on [MEDICATION(S)] Therapy due to a substance use disorder will have an assigned [MEDICATION(S)] Clinic. The care center will follow their specific clinic's policy & procedure for [MEDICATION(S)] pick up/delivery under licensed staff supervision. The RN supervisor or designee will be assigned to sign the accuracy of the Chain of Custody Record. The charge nurse is responsible for the storage of the [MEDICATION(S)] and distributing to resident for self-administration under close supervision. The LPN/RN will verify the correct date on the vial, have the patient sign the administration acceptance sheet, and return the empty bottle to the bag. All residents will have a self-administration of [MEDICATION(S)] completed and Chain of Custody form in place. Review of the facility medication administration and documentation-general policy identified medication administration and documentation occurs in a timely and accurate manner. Identify resident before administering medications. This can be accompanied by a) checking identification band and/or b) checking photograph attached to administration record, c) asking resident their name or d) asking another staff member to identify the resident. Ensure the 5 rights: Compare the medication name, strength, route, dosage schedule on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Although Resident #3 had physician's orders for [MEDICATION(S)] 43mg daily, on [DATE], the resident was given [MEDICATION(S)] 120mg in error (almost 3 times the ordered dose). Subsequently, Resident #3 exhibited a change in mentation, was sent to the hospital, required [MEDICATION(S)], IV [MEDICATION(S)] and [MEDICATION(S)], IV fluids, and monitoring on telemetry in the ICU. 2. Resident #2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] identified Resident #2 had intact cognition and was independent with personal hygiene. The care plan dated [DATE] identified Resident #2 was on [MEDICATION(S)] therapy due to a history of substance use disorder to prevent cravings and withdrawal symptoms. Interventions included to provide Resident #2 with [MEDICATION(S)] as directed. Prepare the [MEDICATION(S)] and ensure that the resident is able to take the medication without staff assistance. Review of the [MEDICATION(S)] - Chain of Custody Record dated [DATE] identified Resident #2 receives [MEDICATION(S)] 10mg/ml (concentration) dose: 120mg. Number of doses 14. Medication provided from [DATE] through [DATE]. Signature of Resident #2 and RN #3 signature. A reportable event form dated [DATE] at 7:15 AM identified Resident #2 received the wrong dose of [MEDICATION(S)], (Resident #2 received [MEDICATION(S)] 43mg). Review of the [MEDICATION(S)] form identified on [DATE], Resident #2's initials were not on the form, however, Resident #3's initials were on the form, as the person who received [MEDICATION(S)] 120mg. Further, RN #1 initialed as the nurse. Review of the medication error report dated [DATE] identified at 6:00 AM, Resident #2 received [MEDICATION(S)] 43mg. Resident #2 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was given Resident #3's [MEDICATION(S)](43mg dose). The nurse's note dated [DATE] at 9:00 AM identified Resident #2 reported he/she did not receive the correct dose of [MEDICATION(S)] (120mg). No signs or symptoms of withdrawal shaking, nausea, vomiting, diarrhea, anxiety, or body aches. Resident #2 stated he/she feels fine. Blood pressure ,d+[DATE], pulse 74, respiration rate 18, temperature 97.4, oxygen saturation 98%. APRN was notified with new order to give [MEDICATION(S)] 10mg by mouth 3 hours after the last dose of [MEDICATION(S)] given time one dose only. Resident #2 was notified of new order A physician's order dated [DATE] directed to administer [MEDICATION(S)] 10mg by mouth 3 hours after last as needed dose of [MEDICATION(S)] 10mg by mouth time one dose. Review of the nurse's note failed to reflect documentation on [DATE] on the 3:00 PM - 11:00 PM shift, and the 11:00 PM - 7:00 AM shift regarding the medication error and monitoring of Resident #2's condition. Review of the nurse's notes on [DATE] for the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and the 11:00 PM - 7:00 AM failed to reflect documentation regarding the medication error and ongoing monitoring of Resident #2 condition. Interview with RN #1 on [DATE] at 10:00 AM identified he was the supervisor that administered the wrong dose of [MEDICATION(S)] to Resident #2. RN #1 indicated on [DATE] at 5:30 AM he went to Resident #2 with Resident #3's [MEDICATION(S)] control sheet and spoke to Resident #2 who answered to Resident #3's name, and initialed Resident #3's [MEDICATION(S)] control sheet and he handed the [MEDICATION(S)] bottle to Resident #2 who then took the medication. RN #1 indicated he failed to check Resident #2's identification bracelet or picture for verification. RN #1 indicated he failed to review the [MEDICATION(S)] control sheet to verify the initials. RN #1 indicated he performed an assessment on Resident #2 but failed to document in the clinical record. 3. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician's orders dated [DATE] directed in the event of cardiopulmonary arrest, Do Not Resuscitate (DNR). Physician's order dated [DATE] directed to recommend hospice services. Review of the hospice admission consent form identified Resident #1 was admitted to hospice care on [DATE]. A physician's order sheet dated [DATE] directed to call hospice with change of condition and at time of death, DNR, and death may be pronounced by RN. Further, Do Not Hospitalize. The care plan dated [DATE] identified Resident #1 has cancer and is on hospice. Interventions included to provide pain medications and evaluate the effectiveness. Additionally, the care plan identified Resident #1 has decided not to have further measures to prolong his/her life. Interventions included to offer other measures as to maintain comfort and dignity. The significant change MDS dated [DATE] identified Resident #1 had intact cognition, required total assistance with personal hygiene. Review of the care plan signature sheet dated [DATE] identified Resident #1 has chosen to be on hospice due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Physician's orders for the month of [DATE] directed to DNR. The physician's orders failed to reflect death may be pronounced by RN. Interview with RN #4 on [DATE] at 5:30 PM identified she had assessed Resident #1 on [DATE] at 6:00 AM and he/she had expired, but she was unable to pronounce the resident because Resident #1 did not have a physician's order for an RN to pronounce. RN #4 indicated she left a voice message, and a text message for the Medical Director that Resident #1 had expired and there was no physician's order for an RN to pronounced. RN #4 indicated she received a text message from the Medical Director indicating he would be at the facility that morning. Interview with the Acting DNS on [DATE] at 1:30 PM identified she was not aware that the order dated [DATE] directing RN may pronounce death was not transcribed and indicated it is the responsibility of the editing licensed nurse to transcribe any new physician's order from the previous month to the upcoming month. Although requested, a facility policy on medication transcribing was not provided.

Based on clinical record reviews, review of facility documentation and interviews for two of five residents with a history of substance use (Resident# 25 and Resident# 201), the facility failed to ensure a safe environment and/or supervise the environmentt to prevent residents from engaging in risky behaviors and/ or for two residents' rooms observed, the facility failed to maintain a hazard free environment . The findings included: 1 a. Resident# 25's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified the resident with intact cognitive skills, total dependence for transfers, independent for locomotion on and off the unit, and extensive assistance for personal hygiene. A care plan dated 5/9/18 identified a risk for substance and [MEDICAL CONDITION] with interventions which included to provide education regarding facility policy on alcohol/substance abuse, counseling regarding negative psychosocial effects, mental health services as needed and directed staff to contact the physician for observed signs and symptoms of alcohol or substance abuse related impairments. The nurse's notes dated 6/21/18 at 7:30 P.M. identified the resident was observed unresponsive in bed with a tourniquet on the left arm and a needle resting on the right hand. Immediately after [MEDICATION NAME] was administered by the Nursing Supervisor (RN#4) the resident was noted with increased responsiveness. The APRN was notified and directed to transfer the resident to the emergency room for an evaluation. The hospital discharge summary dated 6/21/18 identified the resident was alert, awake and oriented to person, time and place and no evidence of needle marks on either arm. The resident further indicated to having obtained drugs but denied actual use and indicated he/she has not used drugs in the past two years. The resident was then discharged back to the facility. However, review of the neurological assessment dated [DATE] from the emergency response team identified the resident originally denied heroin use but then stated injecting one bag into his/her arm. Clinical record review and interview with the DNS and Administrator on 7/26/18 at 9:55 A.M. identified the DNS was notified of the incident involving Resident # 25 via text message. The DNS then called the Administrator to update him/her of the incident. The DNS identified instructions were then given to the Nursing Supervisor ( RN # 4) which included: notify the physician, notify the police department , conduct a room search and to initiate every 15 minute checks/ monitoring . Interview with RN# 4 on 7/26/18 at 2:00 P.M. indicated she gave instructions to LPN# 7 to complete the room search for Resident# 25 because she was busy doing room searches on two other resident rooms at that time. Multiple attempts were made to contact LPN# 7 but were unsuccessful. The facility failed to provide documentation of the room search for Resident # 25 on 6/21/18 in accordance with facility practice. b. Further review of nurse notes dated 6/22/18 indicated Resident# 25 returned to the facility on [DATE] at 11:15 P.M. with no complaints and the physician's orders directed to continue every 15 minute checks and room searches for safety. The nurse notes dated 6/22/18 at 3:58 A.M. identified the resident was observed lying in bed, unresponsive to verbal or painful stimuli and with decreased respirations. Additionally, the nurse's notes indicated this was Resident # 25's second incidence of unresponsiveness. [MEDICATION NAME] 0.4mg/ml was administered Intramuscular (IM) to the left deltoid. The resident was semi-responsive after 4 minutes stating huh then closed his/her eyes and relapsed into two periods of unresponsiveness. A second dose of [MEDICATION NAME] 0.4mg/ml IM to the right deltoid was then administered with good effect. The resident became agitated when told he/she was unresponsive and would be transferred to the hospital. However when the police and emergency medical services staff arrived the resident calmed down and was notified a room search would be conducted. The room search conducted on 6/22/18 after Resident # 25's second unresponsive episode identified a syringe inside the resident's eyeglass case. A review of the Reportable Event dated 6/22/18 with LPN#6 on 7/26/18 at 2:30 P.M. indicated when the resident returned from the hospital, the previous shift nurse (LPN# 7) instructed her to do a body audit of Resident# 25 upon arrival. A body audit was completed at 11:35 P.M. and no contraband was found. At around 3:30 A.M. the resident was alert and verbal, apologized for what happened and requested a pain pill. LPN# 6 indicated after verifying the physician's orders and noting the absence of a hold order on [MEDICATION NAME] 2mg by mouth, Resident#25 was given the medication. Further interview with LPN # 6 indicated later in the shift the nurse aide reported Resident # 25 was asking for something to eat when he/she suddenly rolled his/her eyes and became unresponsive despite staff efforts at waking him/her up. LPN# 6 then notified the RN Supervisor and [MEDICATION NAME] was administered. Review of the hospital discharge summary dated 6/22/18 identified Resident # 25 indicated he/she obtained heroin from a friend that visited the previous morning (Resident # 201 who resided in the facility). The resident reported he/she shot up and then was sent out to an acute care facility and returned to the facility, slept and woke with staff all around me. Clinical record review and facility documentation review with the DNS and Administrator on 7/26/18 at 9:55 A.M. identified the Administrator instructed staff on 6/22/18 to initiate one to one over the weekend until an evaluation was completed on 6/25/18, no visitors, and no personal food items from the outside could enter the facility. Review of facility documentation provided by the Administrator on 7/26/18 identified that the syringe found on Resident# 25's right hand on 6/21/18 was not a facility used syringe and Resident# 25 identified the drugs were received from Resident # 201. In addition, review of the every-15 minute monitoring flow sheets with the DNS on 7/26/18 at 9:55 A.M. failed to indicate the actual location of Resident # 25. The every 15 monitoring sheet for 6/21/18 identified the resident was in the hospital from 4:15 A.M. until 12:15 P.M. and was in the facility from 3:00 P.M. through 11:00 P.M. (The resident was noted leaving the building via ambulance at 7:30 P.M. and returned to the facility at 11: 15 P.M.). Additionally, the 6/22/18 1:1 monitoring shift indicated that the resident was in the facility the whole day when actual events identified the resident was in the hospital from 4:00 A.M.on 6/22/18 through 1:00 P.M. on 6/22/18. The DNS indicated the every fifteen minute monitoring documentation was done in error. 2. Resident# 201's [DIAGNOSES REDACTED]. An admission history and physical completed on 6/2/18 identified a history of heroin and cocaine use that he/she injects in his/her hands/feet. The resident indicated during the admission assessment that he/she used heroin last 3 or 4 days prior to an earlier admission in (MONTH) (YEAR). An admission MDS assessment dated [DATE] identified intact cognitive skills, independent for all activities of daily living, daily use of antibiotics and opioids. The (MONTH) (YEAR) care plan identified endocarditis with interventions which included risk for skin breakdown due to an IV peripherally inserted central venous catheter (PICC) line on the left upper arm, to monitor the site for bleeding, infiltration and swelling and to ensure the dressing was intact. The care plan further identified polysubstance use disorder with past overdoses. Interventions include to conduct room searches as indicated for removal of contraband items, involve mother in care, supportive and addiction counseling and supervised visits with the exception of certain family members. The APRN notes dated 6/7/18 identified Resident# 201 was lethargic the previous day and a urine sample for toxicity screen was obtained. The result of the 6/6/18 urine toxicity screening was negative despite the administration of [MEDICATION NAME] 50 mg three times a day. Resident # 201 admitted to giving urine that was not his/hers for the test. The APRN on 6/14/18 directed staff to initiate room searches twice a day on the 7:00-3:00 P.M. and 3:00-11:00 P.M. shift. The nurse's notes dated 6/19/18 identified Resident # 201's PICC line insertion site was slightly red and also a few red areas were noted surrounding the PICC line. The APRN directed staff to obtain urine sample for toxicity screen and the IV nurse to access the PICC line. The resident refused to give urine sample three times. Resident # 201 was again re-approached to obtain urine sample the following day without success. Every 15 minute checks were then initiated. On 6/21/18, the resident was observed to be sleepy and then became unresponsive during a group session. [MEDICATION NAME] was administered as ordered and the resident was then transferred to the emergency room for an evaluation. The hospital discharge summary dated 6/21/18 identified Resident # 201 was evaluated for suspected heroin overdose and was given [MEDICATION NAME]. Additionally, the summary noted the resident was awake and stable in the emergency department. Resident# 201 returned to the facility on [DATE] at 11:30 P.M. with orders to hold all opiates, every 15 minute checks and room searches twice a day. On 6/22/18 at 12:00PM the resident was discharged against medical advice (AMA) accompanied by paramedics to the hospital for PICC line removal. Interview with the Administrator on 7/26/18 at 1:40 P.M. identified that there had been no previous incidents of drug overdose in the past 1.5 years since his employment. The Administrator identified that drug dealing was suspected when Resident# 201 was admitted to the facility due to rumors circulating around the facility. The Administrator further indicated although he/she had rumors of drug circulating around the facility there was no concrete evidence. The Administrator further indicated that once one to one was initiated , Resident# 201 discharged himself/herself Against Medical Advice (AMA) and no drug overdose incidents has recurred. Interview with the Administrator and DNS on 7/26/18 at 5:00 P.M. and review of the behavior rounds sheet dated 6/6/18 identified that every 15 minute checks and room searches were initiated prior to 6/6/18 and continued until 6/22/18 when one to one monitoring (1:1) was initiated. The Administrator indicated that Resident# 201 was dissatisfied with the 1:1 monitoring and decided to be discharged AMA. However the clinical record failed to provide documentation of the room searches. Review of the facility documentation of room searches for Resident # 201 lacked evidence that room searches were conducted from 6/1/18, 6/2/18, 6/4/18 through 6/13/18, 6/15/18, 6/21/18 and 6/22/18 in accordance to the facility contraband policy. The facility administration was unable to explain why the room searches were not conducted in accordance to the plan of care/ practice and /or how drugs were able to entered the facility on 6/21/18 and 6/22/18. Review of the facility policy on contraband items identified that in the event of contraband items that included illegal drugs, any sharps item (items considered to be potentially dangerous or may pose a significant health risk) was detected by staff, the staff will immediately facilitate by whatever means possible to isolation and/or remove risk to others and immediately inform the Supervisor. In addition the policy on contraband items indicated that if contraband items are suspected to be present, the staff will immediately notify the Supervisor. At that time the determination, will be made as to whether it is appropriate to utilize the facility approved Room Search and/or Non-Intrusive Search procedures and protocol. 3. Observation on 7/25/18 at 11:43 A.M. with the DON identified that a window air conditioner in room [ROOM NUMBER] on the second floor was affixed on one side with an accordion type seal and with tapes on the other side covering a gap of about 8 inches. The DOM indicated that during the start of the summer season, the facility hired inexperienced young workers to help out with seasonal work. Upon surveyor inquiry, the tapes were replaced with a solid board. The DOM indicated that he was unaware that an accordion seal and/or a more permanent barrier was not utilized for the window to prevent accidents. 4. a. Resident #29's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #29 had both long and short term memory problems and required limited assistance with transfers, supervision with walking and extensive assistance with toilet use. Additionally, the resident was always incontinent of bladder. The Resident Care Plan (RCP) dated 6/12/18 identified at risk for deficit in self-care, transfer with assist, ambulate independently, observed on the floor. Interventions directed to assist with ADL's as indicated, place on every 15 minute checks to observe whereabouts. A physician's order dated 6/1/18 directed to transfer with assist of 1, ambulate with staff hand hold assist. The nurse's note dated 6/12/18 on the 7-3 P.M. shift identified the resident was observed on the floor. The Reportable Event dated 6/12/18 identified the resident had an unwitnessed fall, walks on the unit frequently and may have been tired, was placed on every 15 minute checks. Review of the fall scene investigation report identified the resident was found on the floor in the resident's room, the resident was non-verbal, vital signs were normal. The remainder of the investigation report was blank, including the root cause. b. Resident #29's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #29 had both long and short term memory problems and required limited assistance with transfers, supervision with walking and extensive assistance with toilet use. The Resident Care Plan (RCP) dated 7/10/18 identified observed lying on back, may have been trying to go to the bathroom. Interventions directed to toilet on last rounds 7-3 shift. The nurse's note dated 7/10/18 on the 3-11 P.M. shift identified the resident was observed lying on the floor. The Reportable Event dated 7/10/18 identified the resident had an unwitnessed fall and may have been trying to go to the bathroom. Review of the fall scene investigation report identified that, although the fall was unwitnessed, the resident lost his/her balance, the resident was in bed and indicated the facility was unaware what the resident was doing prior to the fall. The remainder of the investigation report was blank. An interview and review of the clinical record with RN #3 and the DNS on 7/25/18 at 3:45 PM identified the ADNS is responsible for Reportable events with the exception of frequent fallers and submitting Reportable Events to DPH. An interview with RN #3 on 07/27/18 at 1:01 PM identified that the facility was unable to provide documentation to reflect the 15 minute checks for the resident from 6/12/18 through 6/18/18, the care plan intervention for the fall that occurred on 6/12/18. A review of the facility policy identified, in part, fall management plan will be initiated on all resident who are at a high risk of falling and in the event a fall occurs, a root cause analysis will be conducted to determine the factors that may have contributed to the fall.

Based on review of the clinical record, facility documentation and interviews for one resident reviewed for hospitalization (Resident #142), the facility failed to ensure care and/or services were provided in accordance with the physician orders [REDACTED].#70), the facility failed to ensure the resident was appropriately positioned during dining. The findings include: 1. Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].The quarterly MDS assessment dated [DATE] identified severely impaired cognition, total assistance for bed mobility, transfers, and dressing and impaired range of motion on both upper and lower extremities. The care plan dated 8/16/16 identified Resident #142 was totally dependent on staff for care and utilized a customized wheelchair.The physician's orders [REDACTED]. The treatment administration record from 9/19/16 through 10/22/16 failed to reflect an order to apply bilateral elbow splints and bilateral hand splints 2-4 hours before bedtime and to conduct skin checks before and after use of the splints. The treatment administration record did identify the application of a right leader grip splint and left resting hand splint on after am care and off after lunch, however, failed to identify any documentation that daily skin checks were completed before and after use of the hand splints with exception of standard weekly body checks conducted on shower day Saturday on the 7:00AM-3:00PM shift. Review of the weekly skin report dated 10/22/16 signed by NA#7 and LPN#6 identified Resident #142 received a bed bath on the 7:00 AM-3:00 PM shift and no skin abnormalities were identified.The nurse's note dated 10/23/16 at 12:00 PM identified the resident wrapped hair around his/her left thumb and the thumb was red. Upon further assessment, the left thumb was noted with a deep laceration at the circumference of the left thumb. Hair was removed from the base of the thumb, however, more hair was noted deeper and was unable to be removed. The thumb was swollen and red with mild purple discoloration and purulent drainage noted from the wound. Resident #142 was transferred to the emergency room for an evaluation. The hospital discharge summary dated 10/29/16 identified hair was wrapped around the left thumb which caused a tourniquet effect to the thumb which led to an open wound. Further review of the Discharge Summary identified a culture of the wound was conducted that identified positive Staphylococcus Aureus, [DIAGNOSES REDACTED] pneumoniae and diptheroids +3. Subsequent consultation with Infectious Disease recommended a PICC line to administer antibiotics for 10 days. Interview with NA#7 on 6/28/17 at 3:30 PM identified he/she was assigned to provide care to Resident #142 on 10/23/16 on the 7:00 AM-3:00 PM shift. NA#7 identified that after the resident was transferred to the w/c late morning, she/he went to clip the resident's nails and noticed the left thumb was very red and swollen. There was a hair wrapped tightly around the base of the thumb. NA#7 further identified the area was noted when the splints were about to be applied and had not noticed the area earlier that morning. NA#7 identified that Resident #142 had very long hair in front of her/his face if she/he didn't pull it back. NA#7 identified that he/she does not recall Resident #142 ever twirling her/his hair, however, the resident did have a habit of gagging at times due to putting fingers in her/his mouth. Interview with LPN#6 on 6/29/17 at 8:43 AM identified he/she was the charge nurse on duty 10/23/16 during the 7:00 AM-3:00 PM shift. LPN#6 identified sometime in the late morning on 10/23/16, NA#7 reported Resident #142 had something on her/his thumb. Upon observation, LPN #6 identified Resident #142's left thumb was pink/red and swollen and a piece of dark hair was wrapped around the thumb. LPN#6 tried to remove the hair but was unsuccessful because it was embedded deeply into the left thumb. LPN #6 notified RN#3 and the resident was transferred to the emergency room for an evaluation. Further interview with LPN#6 identified Resident #142's thumbs/fingers are always moist from the resident sucking on them and the residents hair may have gotten caught around the thumb as the resident has been observed twirling his/her hair. LPN#6 identified Resident #142's skin is checked daily before and after splint applications and would have seen the area if it was there any length of time. Interview with MD#1, the Chief emergency room Physician (who treated Resident #142) on 6/29/17 at 9:45 AM identified Resident #142 was admitted on [DATE] due to an infected wound on the left thumb apparently caused by hair being wrapped around the finger which imbedded into the skin. MD#1 identified that due to the soft tissue damage, leukocytosis and an infection was identified during assessment. MD#1 indicated the hair on the left thumb had to have been there for at least 24 hours or longer to cause such damage. Interview with the DNS on 6/29/17 at 11:00 AM identified the investigation identified the injury to the thumb was caused by the resident's constant hair twirling. Review of the facility Splint Policy and Procedure identified staff are to check skin integrity before splint/immobilizer application, note any skin color, changes, indentations, [MEDICAL CONDITION], ecchymosis, lacerations, etc. and to check skin integrity after splint removal and report any changes in the resident to the nurse. 2. Resident #70's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified severely impaired cognition, required extensive assistance with transfers, total assistance with locomotion and limited assistance with eating. The physician orders [REDACTED]. The physician orders [REDACTED]. The care plan dated 5/9/17 identified a risk for alteration in nutrition and had swallowing problems with an intervention which included to monitor self-feeding skills/set up and assist with feeding. The assessment further identified the resident required a customized wheelchair due to poor postural control and alignment while sitting.Observation on 6/26/17 at 1:00 PM identified Resident #70 seated in a wheelchair at a table with two other residents who were being fed by nurse aides. The resident was positioned in the upright position in the wheelchair however the resident's mouth was level with the height of the table as he/she was eating. The resident was noted to drop food onto his/her lap during the course of the meal. In order to feed himself/herself, the resident had to lift his/her arms above the height of the table and then angle his/her arm/hand in a downward motion in order to scoop food onto his/her utensil and then bring the food to his/her mouth. Interview with the COTA#1 on 6/26/17 at 1:20PM identified Resident #70 was not seated in a position conducive for optimal self-feeding indicating the resident needed to be seated at a table with a lower height for the resident to be better accommodated. COTA #1 further identified it is the responsibility of the nursing staff to communicate positioning concerns to therapy and/or change the seating arrangement as there are other tables in the dining room which are shorter and would better meet the needs of the resident. Subsequent to surveyor inquiry an Occupational Therapy note dated 6/28/17 identified on 6/26/17 the resident was observed with decreased positioning during the lunch meal related to resident being seated at improper table height in an adaptive wheelchair to carry out self-feeding task. The note further identified Resident #70 was moved to a lower height table with the table height around mid-torso and staff education provided on proper positioning for the resident.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #2) who had sustained a head injury of unknown origin, the facility failed to conduct neurological assessments and/or monitor the resident for a change in condition which resulted in immediate jeopardy corrected and/or for one sampled resident (Resident #1) who had behavioral symptoms, the facility failed to ensure that the resident was free from mistreatment. The findings include: 1. Resident #2's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had short and long term memory deficits, severe cognitive impairments, difficulty focusing attention, disorganized thinking, required extensive one person assistance with transfers in and/or out of the bed and chair and was unsteady with surface to surface transfers requiring staff assistance. The resident care plan dated 5/22/15 identified the resident was at risk for falls and had a history of [REDACTED]. Interventions directed to remind the resident to call for assistance, anticipate the resident's needs for assistance with transfers, back and front anti-tippers to wheelchair, dycem cushion to the wheelchair and two one-half side rails up when in bed to promote safety and mobility. The nurse's note dated 5/24/15 at 1:30 PM identified Resident #2 had self-transferred back to bed after smoking. The note at 4:00 PM identified a purple bruise was noted around the outer edge of Resident #2's right eye. Review of the Registered Nurse (RN) assessment-behavior sheet dated 5/24/15 identified that Resident #2 had a 1.5 by 1 inch purple bruise to the right outer edge of the eye with a slight opening, vital signs were obtained and the resident was reminded to call for assistance with transfers. The assessment failed to reflect documentation that a neurological assessment had been conducted. A revision to the care plan dated 5/24/15 identified a possible fall, discoloration to right eye/ shoulder. Interventions directed to remind the resident to call for assistance with transfers and anticipate needs. Review of the Reportable Event Form dated 5/24/15 at 3:15 PM identified the resident was observed to have discoloration to the right eye and right shoulder. The investigation identified the injury was of unknown origin. Review of the seventy-two (72) hour nursing notes dated 5/24/15 for the 7-3 shift identified Resident #2 was alert, verbal and the right brow had discoloration. The 3-11 shift note identified the resident was alert, verbal, out of bed to the wheelchair and the discoloration remained to right eyebrow. The notes failed to reflect documentation that Resident #2 had been assessed on the 11-7 shift. Review of the clinical record from 5/24/15 through 5/25/15 failed to reflect documentation that neurological assessments had been conducted after an injury of unknown origin was identified. The note dated 5/25/15 identified that Resident #2 had minimal verbal response, complained of not feeling well, bruising was observed to the right eye and face and right shoulder. The nurse's note dated 5/25/15 identified that at 9:15 am Resident #2 stated I'm sick, the resident did not eat breakfast, slight [MEDICAL CONDITION] was noted in front of the right ear, right side facial droop was noted and the resident was nauseous. The Advanced Practice Registered Nurse (APRN) was notified and ordered [MEDICATION NAME] 25 mg now for nausea. The note indicated a consideration of sending Resident #2 to the hospital but needed clarification from the Conservator and waiting to hear back from the APRN. The note at 10:50 AM identified that the APRN was called and an order to transfer to the hospital was obtained. Resident #2 was transferred to the hospital at 11:00 AM. The nurse's note dated 5/25/15 identified that Resident #2 returned to the facility at 3:05 PM and was placed on Comfort Measure Only per the Conservator's wishes. Review of the Medication Administration Record [REDACTED]. Review of the clinical record and the twenty-four (24) shift hour reports sheets failed to reflect documentation that neurological assessments were completed after the injury of unknown was discovered. The facility policy and procedure for Neurological Checks identified that residents with suspected head injury will have neurological signs monitored and recorded for forty-eight (48) hours per policy unless otherwise ordered by a physician. Interview with the 7-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 7/29/15 at 12:00 PM identified that she saw Resident #2 on 5/24/15 at 1:00 PM lying sideways in bed and the half side rails were up. LPN #1 stated she saw a small scab on the resident's forehead and the discoloration around the right eye at that time but did not report the findings until shift report when the 3-11 shift nurse stated she had to complete a Reportable Event Form. LPN #1 identified that she did not conduct any type of assessment because the resident had a history of [REDACTED]. Interview with the 3-11 PM charge nurse, LPN #2, on 7/29/15 at 1:20 PM identified that LPN #1 reported to her that the resident had a bruise on the right eye and thought that it might have been from picking at his/her face. Interview with the 7-3PM Nursing Supervisor, Registered Nurse (RN) #1, on 7/29/15 at 2:05 PM identified that the purple bruise and a small scratch around Resident #2's right eye and discoloration to the right shoulder was reported to her. RN #1 stated she did not initiate neurological assessments and/or conduct a complete assessment because she assumed the bruising was from the resident being on anticoagulant therapy and not from a fall. RN #1 stated that she did not speak to the resident and/or the nurse aides to ask if they saw what happened. Interview with the 11-7AM charge nurse, LPN #3, on 7/29/15 at 1:30 PM identified that although the bruising was reported to her at the start of shift, she did not question why neurological assessments were not being done. LPN #3 stated that at the beginning of the shift she does a quick check on all the residents and she did not assess Resident #2 at that time. LPN #3 identified that at 6:00 AM when she went to administer medications to Resident #2 she saw the bruise on the resident's eye but did not assess the resident at that time. Interview with the 7-3PM charge nurse, LPN #4, on 7/29/15 at 12:30 PM identified that on 5/25/15 she was asked to look at the resident. LPN #4 stated that when she assessed the resident bruising around the right eye and the right shoulder in the scapula area, swelling from the right cheek area down the neck, right side facial drooping and little use the right arm were noted. LPN #4 stated the hospital notified her that Resident #2 had a large subdural hemorrhage to the right side of head and the resident would be returning to facility on comfort measure only care. Interview with the Director of Nursing (DON) on 7/30/15 at 10:15 AM identified that during the investigation it was identified that no neurological assessment was completed as per the facility's policy. The DON stated that upon discovery of the bruise the assessment should have started and the resident monitored. Subsequent to the incident with Resident #2 licensed staff were re-educated on neurological assessment and injuries of unknown origin. 2. Resident #1's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified that Resident #1 had severe cognitive impairment, was easily distracted, had disorganized thinking, delusions, exhibited verbal and physical behaviors directed towards others, wandered, and was independent with mobility. The resident care plan dated 1/29/15 identified impaired cognition and continues to wander. Interventions included one to one supervision between 5:00 PM-9:00 PM, to monitor the behaviors and redirect. The nurse's note dated 4/19/15 at 7:45 PM identified Resident #1 was dragged by Nurse Aide (NA) #1 and a small abrasion was noted to the left cheek. The Reportable Event Form dated 4/19/15 at 6:30 PM identified Resident #1 was dragged and scratched by NA #1. Staff had reported the nurse aide had the resident by the collar. The investigation identified that NA #1 was overheard by NA #2 saying to Resident #1 you should not hit me in the stomach. Get up! Get up. NA #2 indicated that NA #1 had the resident by the collar, NA #1 was angry and yelling at Resident #1. NA #2 went over to assist and noted blood on the resident's left cheek. The investigation identified that NA #3 witnessed NA #1 holding Resident #1 by the collar and indicated that NA #1 was very mad. In a written statement the 3-11 PM charge nurse, Licensed Practical Nurse (LPN) #5, identified that the incident was reported to her NA #2 and #3, upon assessment blood was noted on the left side of the resident's face and red marks on the neck and the supervisor was notified. The statement indicated that Resident #1 stated I was dragged and scratched by a woman. At the conclusion of the investigation NA #1 was terminated for physical abuse towards a resident. Interview with NA #2 on 7/28/15 at 1:45 PM identified that she observed NA #1 pull Resident #1 by the collar and yell at the resident. NA #2 stated that NA #3 went over to the resident to assist him/her to the room and notified the nurse of what they observed. Interview with NA #3 on 7/28/15 at 2:00 PM, NA #3 identified that she was at the nurse's station and witnessed NA #1 dragging Resident #1 down the hall. NA #3 stated she got up and went to assist with the resident and at that time NA #1 removed her hands from the resident's collar and ambulated the resident back to his/her room. NA #3 identified that she noted a scratch on the resident's cheek and red marks on the neck and she reported it to the nurse. Interview with Registered Nurse (RN) #1 on 7/28/15 at 2:15 PM identified that three nurse aides came to her and reported that Resident #1 was dragged by the collar by NA #1 in the hallway. RN #1 stated the nurse aides reported that NA #1 was upset and yelling at the resident. RN #1 identified that she sent NA #1 home and assessed the resident and the resident was found to have red marks on each side of the neck and a scratch to the left cheek. Interview with the Director of Nursing (DON) on 7/28/15 at 2:30 PM identified that the NA #1 was terminated for mistreatment of [REDACTED].#1 were unsuccessful.