Every finding on record at Woodbury Health Care Center

Based on observation, interview, and document review, the facility failed to comprehensively assess, monitor, evaluate, and implement individualized interventions to prevent/treat pressure ulcers, including timely physician notification for 1 of 3 residents (R1) reviewed for pressure ulcers. The facility's failures resulted in harm when R1's moisture associated skin damage deteriorated to a stage 3 pressure ulcer.Findings include:Findings include:Moisture-Associated Skin Damage (MASD): Inflammation and erosion of the skin caused by prolonged or continuous exposure to moisture and chemical irritants, including urine, feces, sweat, or wound drainage. This exposure breaks down the skin's protective acid mantle and lipids, causing overhydration and maceration (softening and wrinkling of the tissue). Wounds are typically superficial, affecting the top layers of skin with diffuse, irregular edges, and are not classified by stages. Incontinence-associated dermatitis (IAD) is the most common form. While MASD involves partial-thickness skin loss, it can quickly convert to a pressure injury if underlying pressure or shearing forces are also presentStage 3 Pressure Ulcer: Full-thickness skin loss, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI (pressure ulcer/pressure injury). R1's Face sheet identified diagnoses of chronic kidney disease stage 4 (severe kidney damage where the organ can no longer filter waste properly), metabolic encephalopathy (brain dysfunction and confusion caused by severe chemical imbalances in the body), and nutritional deficiency (severe malnutrition from a lack of food and fluids).R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and was dependent with toileting, dressing and transfers. R1 did not have behaviors including no rejection of care. Further identified R1 was at risk for pressure ulcers and had one stage 2 pressure ulcer upon admission. R1 had a pressure reducing device for bed and chair, nutrition hydration intervention to manage skin problems, pressure injury care, and application of ointments/medications other than to feet.R1's care area assessment (CAA) dated 5/19/26, identified R1 was at an actual risk for developing pressure ulcers. The assessment identified R1 required staff assistance for bed movement, required a special mattress or seat cushion to relieve pressure, and required a regular turning schedule. The analysis concluded that the care plan would focus on pressure relief, repositioning, incontinence management, and daily skin monitoring.R1's care plan revised 5/22/26, identified a focus of potential or actual impairment to skin integrity related to incontinence, a need for staff assistance with position changes, diabetes, and a risk of malnutrition and obesity. Interventions dated 5/15/26, directed staff to attempt to reposition R1 off the area, encourage good nutrition and hydration to promote healthier skin, and keep linens dry and wrinkle-free. The plan further directed staff to observe skin during cares, report changes to the nurse, offer toilet assistance before meals and at bedtime, and utilize pressure-relieving support surfaces in his bed and chair. An intervention dated 5/22/26 directed staff to complete a weekly skin inspection and as needed.R1's progress note dated 6/14/26 at 2:29 p.m., identified a skin check was completed. The note showed R1's skin was warm and dry, skin color was within normal limits, and no skin issues were identified.R1's progress note dated 6/26/2026 10:34 p.m., identified a skin check was completed. The note showed R1's skin was warm and dry, skin color was within normal limits, and no skin issues were identified.R1's progress note dated 7/13/26 at 2:43 p.m., identified a new in-house acquired skin issue on the intergluteal cleft (the crack of the buttocks). The note identified the injury as moisture-associated skin damage (MASD) and incontinence-associated dermatitis (IAD)-(skin damage caused by prolonged exposure to urine or stool). The documentation showed that wound measurements were not recorded during this assessment.R1's progress note dated 7/17/26 at 9:59 p.m., identified a weekly skin check was completed. The note identified the in-house acquired skin issue on the intergluteal cleft was MASD and IAD.Review of R1's medical records failed to identify any phone calls, faxes, or notifications to the medical provider regarding the development of this in-house acquired skin injury. The documentation further failed to identify any measurements and characteristics of the wound, protective nursing interventions, or medical treatment orders put in place to manage the skin damage.R1's progress note dated 7/24/26 at 10:57 p.m., identified a weekly skin check was completed. The note identified the in-house acquired skin issue on the intergluteal cleft had transitioned to a pressure ulcer. The note documented that the wound was stable, but measurements were not recorded because the resident was uncooperative. Furthermore, did not identify what stage the pressure ulcer was. Review of R1's medical records failed to identify any phone calls, faxes, or notifications to the medical provider regarding the development of this in-house acquired pressure ulcer. The documentation further failed to identify any measurements and characteristics of the wound, protective nursing interventions, or medical treatment orders put in place to manage the pressure injury.R1's nutrition progress note dated 7/27/26 at 12:15 p.m., identified R1 was at high risk related to wound healing for a pressure area on the intergluteal cleft. The note identified R1 had increased nutritional needs, and the dietitian would follow up on oral supplements. The documentation showed R1's meal intakes ranged from 25 percent to 100 percent, his weight was 197 pounds, and no significant weight loss or weight gain was recorded.R1's hospital noted dated 7/28/26 at 8:58 a.m., identified a photographic review of R1's sacrum area showing a single wound pressure injury that was identified as a stage 3 pressure ulcer. The photograph reviewed showed a raw, red, open wound bed over the sacral and gluteal region with a fluid blister, extensive deep purple tissue discoloration, surrounding skin shearing, and widespread red mottling across both buttocks.R1's record reviewed which included Point of Care documentation and progress notes between 7/13/26 through 7/28/26 did not include any documentation of rejection/refusal of care behaviors. During a phone interview on 8/24/26 at 9:45 a.m., family member (FM)-A stated R1 originally entered the facility with a pressure ulcer that healed quickly, which placed him at a high risk for developing another one. FM-A stated R1 developed an ugly wound on his buttocks because staff left him lying in bed and sitting in wet briefs for long periods. FM-A stated the hospital took a picture of the pressure ulcer upon admission and noted the injury could have been prevented.During an interview on 8/25/26 at 10:57 a.m., nursing assistant (NA)-A stated she worked with R1 frequently on the day shift and checked him for wet briefs every two hours. NA-A stated R1 rarely wanted to get out of bed, and if he did, he wanted to lie back down fifteen minutes later. NA-A stated R1 would claim he was dry when he was actually wet, requiring significant encouragement to even check him, and he was always wet when changed. NA-A stated R1 developed an open area on his tailbone in the middle of July, approximately two weeks before his hospital transfer, and she reported this out-of-the-normal finding directly to the nurse on duty.During an interview on 8/25/26 at 2:23 p.m., registered nurse (RN) quality assurance director (QAD)-A, who was acting as the director of nursing (DON), verified R1 was bed-bound and dependent on staff for repositioning. QAD-A verified moisture-associated skin damage developed on R1's sacrum on 7/13/26 with no provider notification or treatment in place. QAD-A stated after R1's pressure ulcer developed on 7/24/26, the facility had no assessment, monitoring, treatment, or provider notification in place. QAD-A confirmed there were no treatment orders or person-centered prevention interventions in place for the pressure injury.During a phone interview on 8/26/26 at 1:04 p.m., nurse practitioner (NP)-A stated she was not notified of R1's MASD on 7/13/26 or the development of pressure ulcer on 7/24/26 and confirmed that standard practice requires immediate provider notification of condition changes as well as daily skin assessments. NP-A stated the facility could have implemented standing house orders until a provider was able to look at it. NP-a further stated had been notified of the MASD, she would have ordered immediate treatments, including moisture barrier creams, strict turning schedules, and frequent incontinence checks to protect the skin and prevent it from breaking down into a pressure ulcer.Facility policy, Lifespark Pressure Injury Prevention Guidelines, dated 4/2026, identified it was the policy of the facility to implement evidence-based interventions to prevent avoidable pressure injuries and promote healing. The policy identified individualized interventions must address specific factors including moisture management, impaired mobility, nutritional deficits, staging, and wound characteristics. The guidelines directed staff to keep the skin clean and dry, manage incontinence by checking the resident every 2 hours, and protect the skin from excessive moisture with barrier products. The policy further identified a routine repositioning schedule of every two hours, using both side-lying and back positions when a resident was in bed and out of bed. The guidelines mandated that in the absence of prevention orders, the licensed nurse must utilize nursing judgment and notify the physician to obtain orders.

Based on interview and document review the facility failed to notify the physician with change in condition who required prn medication for nausea and vomiting for 1 of 1 resident (R1) and for 1 of 1 resident (R3) who developed a non-pressure skin lesion. Findings include:R1's face sheet printed 8/26/26, identified diagnoses of chronic kidney disease stage 4 (severe kidney damage), metabolic encephalopathy (brain dysfunction causing confusion), and nutritional deficiency (severe malnutrition).R1's order summary dated 5/13/26, identified an order for sodium bicarbonate 650 mg (a medication used to balance high acid levels in the blood caused by kidney failure), two tablets twice a day. An additional order dated 6/15/26, directed staff to give ondansetron 4 mg (an anti-nausea medication used to prevent throwing up) every 4 hours as needed for nausea.R1's admission Minimum Data Set (MDS) assessment dated [DATE], identified R1 had moderate cognitive impairment and entered the facility with one stage 2 pressure ulcer.R1's progress note dated 6/4/26, identified R1 vomited after taking his morning medication and blamed the sodium bicarbonate tablets. An additional note at 4:47 p.m. identified R1 refused the medication until he could see his provider. The provider was notified and wanted R1 to continue the medication.R1's nurse practitioner (NP) visit note dated 6/8/26, identified R1 reported vomiting at breakfast and lunch most days and felt it was related to the sodium bicarbonate pill. New orders were received to discontinue (stop) the morning dose of sodium bicarbonate due to vomiting, but to continue the afternoon dose.R1's progress note dated 6/11/26 at 4:00 p.m., identified R1 refused to take his evening dose of sodium bicarbonate and stated that it made him sick and upset his stomach. R1's progress note dated 6/22/26 at 10:14 a.m., identified ondansetron 4 milligrams (mg) was given because R1 vomited that morning.R1's progress note dated 6/29/26 at 2:57 p.m., identified ondansetron 4 mg was given for nausea.R1's progress note dated 6/30/26 at 1:03 a.m., identified ondansetron 4 mg was given for nausea.R1's progress note dated 6/30/26 at 8:41 a.m., identified R1 reported feeling nauseous and received PRN (as-needed) ondansetron. The note further identified R1 was hungry but refused to eat solid foods, drinking only broth and sipping on water.R1's progress note dated 7/1/26 at 8:36 a.m., identified ondansetron 4 mg was given for nausea.R1's progress note dated 7/16/26 at 9:41 a.m., identified ondansetron 4 mg was given because R1 was nauseated after breakfast.R1's progress note dated 7/24/26 at 8:11 p.m., identified ondansetron 4 mg was given for nausea.R1's progress note dated 7/25/26 at 4:26 p.m., identified ondansetron 4 mg was given for nausea and vomiting his lunch.Review of R1's medical records identified that licensed nursing staff repeatedly identified ongoing nausea, vomiting, and food refusals requiring multiple administrations of anti-nausea medication throughout June and July 2026. The facility documentation failed to identify any phone calls, faxes, or notifications to the medical practitioner regarding these ongoing symptoms or his subsequent decrease in oral intake.During an interview on 8/25/26 at 10:57 a.m., nursing assistant (NA)-A identified that throughout July, R1 did not eat much, required significant encouragement to consume meals, and frequently threw up after eating. NA-A confirmed that she regularly reported these poor intakes and ongoing episodes of nausea and vomiting directly to the charge nurse.During a phone interview on 8/25/26 at 2:52 p.m., licensed practical nurse (LPN)-A stated R1 had a lot of nausea and received ondansetron for it. LPN-A further stated she monitored R1's eating because he did not eat as much and would only eat about one-quarter of his meals.During a phone interview on 8/26/26 at 1:04 p.m., nurse practitioner (NP)-A identified that nurses should be watching hydration status for a resident with kidney failure and notifying her if he was potentially becoming dehydrated. NP-A stated that if she had been told he was not eating and drinking, she would have conducted a visit. NP-A identified that had she been notified he was taking ondansetron and had ongoing nausea, she would have conducted an in-person visit and ordered a BMP (Basic Metabolic Panel, a blood test used to check kidney function). NP-A identified that staff did not call her about any issues until 5:45 p.m. on 7/27/26 regarding family concerns about confusion.R3R3's face sheet printed 8/26/26, identified diagnoses of rheumatoid arthritis (a chronic inflammatory disorder affecting joints), lymphedema (severe swelling caused by fluid buildup), nutritional deficiency (severe malnutrition), and dependence on supplemental oxygen.R3's annual minimum data set (MDS) dated [DATE], identified R3's cognition was intact. The assessment identified R3 used a walker for mobility and required setup assistance with dressing. The documentation further identified R3 was at risk for skin injuries and required the application of ointments or protective medications other than to feet.R3's medical doctor (MD) visit note dated 7/21/26, identified a visit for a long-term care review. The note identified R3's skin was warm and dry, with no rashes or lesions on exposed skin.R3's skin check document dated 8/16/26, identified a new in-house acquired skin tear on the right gluteal fold of unknown onset measuring 1 centimeter (cm) x 0.5 cm. The assessment failed to document any clinical suggestions, wound characteristics, or provider notification.R3's progress note dated 8/16/26 at 3:12 p.m., identified an in-house acquired skin tear on the right gluteal fold. The note identified the injury was a new wound with no skin loss and it was unknown how long the injury had been present. The documentation recorded the skin tear measured 1 cm x 0.5 cm and showed no signs or symptoms of infection.R3's order summary dated 8/16/26, did not identify a treatment plan for any skin alterations.Review of R3's medical records failed to identify any phone calls, faxes, or notifications to the medical provider regarding the development of this in-house acquired skin injury.R3's progress note dated 8/23/26 at 10:03 a.m., identified a weekly skin check was completed. The note documented that the in-house acquired skin tear on the right gluteal fold remained unevaluated, with no wound characteristics, measurements, or treatments identified.During an interview on 8/24/26 at 1:50 p.m., licensed practical nurse (LPN)-B identified that R3 reported needing a Mepilex (a protective foam dressing) for a sore on her buttocks. LPN-B stated she had never visualized the wound and noted there were no current orders for wounds or dressings on the treatment administration record (TAR).During an observation and interview on 8/24/26 at 1:52 p.m., R3 was seated on her bed and stated she had a very painful sore on her bottom for the past five days.During an interview on 8/24/26 at 1:55 p.m., licensed practical nurse (LPN)-B stated she visualized a nickel-sized area of red and irritated skin on the right-side midline by the intergluteal cleft (the crack of the buttocks). LPN-B reported that urine caused a burning sensation on the area. LPN-B confirmed there were no medical treatment orders in place for the sore, she had not been informed about the injury by previous shifts.Review of R3's medical records failed to identify any phone calls, faxes, or notifications to the medical provider regarding the ongoing presence of this skin injury.R3's progress note dated 8/24/26 at 2:19 p.m., identified R3 reported sustaining a rough area on her right inner buttock after applying a pull-up brief incorrectly and sitting on it. The note identified R3 requested a foam dressing for protection, and the area measured 1.7 cm by 2 cm with intact skin and dry tissue. The documentation showed a new physician order was received to apply a Mepilex (a protective foam dressing) every three days and as needed for skin protection.During an interview on 8/25/26 at 2:34 p.m., registered nurse (RN) quality assurance director (QAD)-A stated when the skin alteration was first discovered on 8/16/26, staff should have immediately notified the medical provider to ensure a treatment plan for healing was put in place.During a phone interview on 8/26/26 at 1:04 p.m., nurse practitioner (NP)-A stated that any change in skin condition should be reported to the provider immediately to ensure appropriate treatment was in place for healing and prevent further skin breakdown.Facility policy, Notification of Changes, dated 6/1/26, identified the purpose of the policy was to ensure the facility promptly informs the resident, consults the resident's physician, and notifies the resident's representative when there is a change requiring notification. The policy identified clinical complications included the development of a stage 2 pressure injury. The document defined a need to alter treatment significantly as a need to stop a form of treatment because of adverse consequences or commence a new form of treatment to deal with a problem. The compliance guidelines mandated that the facility must consult with the resident's physician and notify the resident's family member or legal representative when there is a significant change in the resident's physical, mental, or psychosocial condition, a deterioration in health, or a circumstance that requires a need to alter treatment. Facility policy for notifying the physician was requested and not received.

Based on interview and document review, the facility failed to notify the physician, assess, and monitor non-pressure-related skin injuries for changes until resolved for 1 of 1 (R3) residents reviewed for quality of care. Findings include R3's face sheet printed 8/26/26, identified diagnoses of rheumatoid arthritis (a chronic inflammatory disorder affecting joints), lymphedema (severe swelling caused by fluid buildup), nutritional deficiency (severe malnutrition), and dependence on supplemental oxygen.R3's annual Minimum Data Set (MDS) dated [DATE], identified R3's cognition was intact. The assessment identified R3 used a walker for mobility and required setup assistance with dressing. The documentation further identified R3 was at risk for skin injuries and required the application of ointments or protective medications other than to feet.R3's care area assessment (CAA) dated 1/20/26, identified R3 was at an actual high risk for impaired skin integrity. The assessment identified R3's risk factors included chronic obstructive pulmonary disease (COPD) with oxygen dependence, oxygen tubing use, edema, and malnutrition status. The analysis concluded that the care plan would focus on minimizing skin risks and avoiding complications.R3's care plan revised 7/6/26, identified a focus for a potential impairment to skin integrity related to a dependency on staff for cares and the use of assistive devices. Interventions dated 7/24/25, directed staff to observe R3's skin during cares and report changes to the nurse. The plan mandated staff to observe and document the location, size, and treatment of any skin injury, and to report any abnormalities or failures to heal directly to the medical practitioner.R3's medical doctor (MD) visit note dated 7/21/26, identified a visit for a long-term care review. The note identified R3's skin was warm and dry, with no rashes or lesions on exposed skin.R3's skin check document dated 8/16/26, identified a new in-house acquired skin tear on the right gluteal fold of unknown onset measuring 1 centimeter (cm) x 0.5 cm. The assessment failed to document any clinical suggestions, wound characteristics, or provider notification.R3's progress note dated 8/16/26 at 3:12 p.m., identified an in-house acquired skin tear on the right gluteal fold. The note identified the injury was a new wound with no skin loss and it was unknown how long the injury had been present. The documentation recorded the skin tear measured 1 cm x 0.5 cm and showed no signs or symptoms of infection. No other characteristics such as (but not limited to) color, drainage, and pain.R3's order summary dated 8/16/26, did not identify a treatment plan for any skin alterations.Review of R3's medical records failed to identify any phone calls, faxes, or notifications to the medical provider regarding the development of this in-house acquired skin injury. The documentation further failed to identify any specific wound characteristics, protective nursing interventions, or medical treatment orders put in place to manage the skin damage.R3's progress note dated 8/23/26 at 10:03 a.m., identified a weekly skin check was completed. The note documented that the in-house acquired skin tear on the right gluteal fold remained unevaluated, with no wound characteristics, measurements, or treatments identified.During an interview on 8/24/26 at 1:50 p.m., licensed practical nurse (LPN)-B identified that R3 reported needing a Mepilex (a protective foam dressing) for a sore on her buttocks. LPN-B stated she had never visualized the wound and noted there were no current orders for wounds or dressings on the treatment administration record (TAR). LPN-B identified she did not know if the resident had a pressure injury and stated she intended to assess the area and apply a dressing immediately.During an observation and interview on 8/24/26 at 1:52 p.m., R3 was seated on her bed and declined a request to observe her wound care due to privacy preferences. R3 stated she had a very painful sore on her bottom for the past five days. LPN-B then requested to examine R3's bottom to apply a Mepilex dressing.During an interview on 8/24/26 at 1:55 p.m., licensed practical nurse (LPN)-B stated she visualized a nickel-sized area of red and irritated skin on the right-side midline by the intergluteal cleft (the crack of the buttocks). LPN-B identified the skin was not open but R3 reported that urine caused a burning sensation on the area. LPN-B stated R3 had been applying a Mepilex dressing to the area herself and preferred privacy. LPN-B confirmed there were no medical treatment orders in place for the sore, she had not been informed about the injury by previous shifts, and she was unsure of the exact type of skin issue.Review of R3's medical records failed to identify any phone calls, faxes, or notifications to the medical provider regarding the ongoing presence of this skin injury. The documentation further failed to identify any measurements and characteristics of the wound, protective nursing interventions, or medical treatment orders put in place to manage the skin damage.R3's progress note dated 8/24/26 at 2:19 p.m., identified R3 reported sustaining a rough area on her right inner buttock after applying a pull-up brief incorrectly and sitting on it. The note identified R3 requested a foam dressing for protection, and the area measured 1.7 cm by 2 cm with intact skin and dry tissue. The documentation showed a new physician order was received to apply a Mepilex (a protective foam dressing) every three days and as needed for skin protection.During an interview on 8/25/26 at 2:34 p.m., registered nurse (RN) quality assurance director (QAD)-A stated the nurse manager examined R3's buttocks and reported the area looked like flaky, dry skin rather than a pressure injury. QAD-A stated that R3 reported sitting on her pull-up brief incorrectly, which caused the irritation. QAD-A confirmed that any skin alteration should be initially measured, the wound type identified and comprehensively assessed weekly in a weekly wound assessment until healed. QAD-A further stated that when the skin alteration was first discovered on 8/16/26, staff should have immediately notified the medical provider to ensure a treatment plan for healing was put in place.During a phone interview on 8/26/26 at 1:04 p.m., nurse practitioner (NP)-A stated that any change in skin condition should be reported to the provider immediately to ensure appropriate treatment was in place for healing and prevent further skin breakdown.R3's medical doctor (MD) visit dated 8/26/26, identified to monitor pressure sore in the coccygeal due to diaper per R3 advised to stay off pressure points. No new orders. Policy requested for non-pressure skin alterations was requested and not received.

Based on interview and document review, the facility failed to ensure 1 of 1 resident (R1) maintained acceptable parameters of hydration status to prevent renal complication, reviewed for quality of care.Findings include:R1's Face sheet printed 8/19/26, identified diagnoses of chronic kidney disease stage 4 (severe kidney damage where the organ can no longer filter waste properly), metabolic encephalopathy (brain dysfunction and confusion caused by severe chemical imbalances in the body), and nutritional deficiency (severe malnutrition from a lack of food and fluids).R1's order summary dated 5/13/26, identified an order for sodium bicarbonate 650 mg (a medication used to balance high acid levels in the blood caused by kidney failure), two tablets twice a day. An additional order dated 6/15/26, directed staff to give ondansetron (an anti-nausea medication used to prevent throwing up) 4mg every 4 hours for nausea.R1's mini nutrition progress note dated 5/14/26, identified R1 has no decrease in food intake or weight loss in the last 3 months. Further identified R1 was at risk for malnutrition.R1's nutrition progress note dated 5/14/26 at 8:55 a.m., identified R1 was at risk for malnutrition related to a low assessment score. Risk factors included decreased mobility and severe illness. A malnutrition warning was completed and given to the floor nurse manager. The note stated staff would monitor weights and intakes.R1's admission minimum data set (MDS) assessment, dated 5/19/26, identified R1 had moderate cognitive impairment, required set up assist with eating and required a therapeutic diet. R1's care area assessment (CAA) dated 5/19/26, identified a need for special diet or altered consistency which might not appeal to R1. R1's care plan dated 5/19/26, identified a focus of potential for a nutritional problem related to a CSC (controlled carbohydrate) diet, metabolic encephalopathy, and CKD4 (stage 4 chronic kidney disease). Interventions dated 5/19/26 directed staff to provide and serve the diet as ordered. Staff were ordered to observe intake and record it every meal. An additional focus dated 5/22/26 identified a risk for malnutrition and directed staff to provide oral supplements between meals as needed.R1's care plan failed to address R1's high risk for dehydration due to his stage 4 chronic kidney disease, where damaged kidneys cannot properly balance fluids and waste. The care plan failed to include interventions to monitor fluid intake.R1's nutritional assessment dated [DATE], identified R1's estimated fluid requirement was 2708 cubic centimeters (CC's) per day and consumed greater than 2,000 cc of fluids per day. R1 explained appetite hasn't been the best but was starting to improve.R1's progress note dated 5/31/26, identified R1 refused his sodium bicarbonate 650 mg tablet due to making him vomit. R1's progress note dated 6/4/26 at 11:54 a.m., identified R1 vomited after taking his morning medication and blamed the sodium bicarbonate tablets. An additional note at 4:47 p.m. identified R1 refused the medication until he could see his provider. The provider was notified and wanted R1 to continue the medication.R1's nurse practitioner (NP) visit note dated 6/8/26, identified R1 was seen for a follow-up. R1 reported vomiting at breakfast and lunch most days and felt it was related to the sodium bicarbonate pill (medication used to balance blood acid levels caused by kidney failure). New orders were received to discontinue (stop) the morning dose of sodium bicarbonate due to vomiting, but to continue the afternoon dose.R1's progress note dated 6/10/26 at 1:28 p.m., identified R1 was sent to the hospital due to hypotension (dangerous low blood pressure). The note showed R1 was tired and sleepy, and staff pushed fluids before the transfer.R1's after-visit summary (AVS) dated 6/10/26, identified R1's history of dialysis earlier in the year and a solitary (single functioning) kidney. R1 was seen for hypotension (dangerous low blood pressure) and stage 4 kidney disease. R1 had instructions to continue previously prescribed medications, including midodrine (a medication used to raise low blood pressure). The summary included an additional instruction to drink plenty of fluids to stay hydrated (keeping enough water in the body).R1's progress note dated 6/11/26 at 4:00 p.m., identified an order for sodium bicarbonate 650 mg to be given in the evening. R1 refused to take this medication and stated that it made him sick and upset his stomach.R1's nurse practitioner (NP) recheck visit dated 6/15/26, identified R1 was seen for a hospital follow-up and was encouraged to ensure adequate oral hydration (drinking enough fluids). New orders were received to check a BMP (Basic Metabolic Panel, a blood test used to check kidney function and chemical balance) on 6/17/26.R1's progress note dated 6/22/26 at 10:14 a.m., identified ondansetron HCL 4mg tablet given due to R1 vomiting that morning. At 11:40 a.m., identified the medication was effective.R1's progress note dated 6/29/26 at 2:57 p.m., identified ondansetron 4mg was given for nausea and at 5:03 p.m., was noted to be effective.R1's progress note dated 6/30/26 at 1:03 a.m., identified ondansetron 4mg was given for nausea and at 3:11 a.m., was noted to be effective.R1's progress note dated 6/30/26 at 8:41 a.m., identified R1 reported feeling nauseous and received PRN (as-needed) ondansetron. The note further identified R1 was hungry but refused to eat solid foods, drinking only the broth from a can of soup and sipping on water.R1's progress note dated 7/1/26, at 8:36 a.m., identified ondansetron 4mg was given for nausea and at 1:07 p.m., was noted to be effective.R1's progress note dated 7/16/26, at 9:41 a.m., identified ondansetron 4mg was given due to R1 being nauseated after breakfast nausea and at 2:01 p.m., was noted to be effective.R1's progress note on 7/19/26, at 10:53 p.m., identified R1 had an episode of diarrhea shortly after eating food purchased by family and staff encouraged fluids. R1's progress note dated 7/24/26 at 8:11 p.m., identified ondansetron 4mg was given for nausea and at 8:42 p.m., was noted to be effective.R1's progress note dated 7/25/26 at 4:26 p.m., identified ondansetron 4mg was given for nausea and vomiting his lunch and at 8:39 p.m., was noted to be effective.Review of R1's medical record identified a failure to implement a fluid tracking system or record R1's actual daily fluid intake, despite administering multiple doses of anti-nausea medication for ongoing stomach distress.R1's progress note dated 7/27/26 at 5:33 p.m., identified a family member called and was very upset about R1's confusion since the previous day. The family member demanded an immediate assessment. The note identified that the family member rejected a basic lab test and demanded R1 be sent to the hospital for a thorough assessment. Staff called the provider and received an order to send R1 to the emergency room per the family's request.R1's progress note dated 7/28/26 at 5:39 p.m., identified R1 was sent to the emergency room on 7/27/26, and was treated for hypotension (dangerous low blood pressure) of 71/41, shock (a life-threatening drop in blood flow), hypoglycemia (dangerous low blood sugar) with a glucose level of 25, and acute on chronic renal failure (sudden kidney collapse). The note identified his creatinine (a waste product filtered by the kidneys) was at 8.39, proving severe kidney failure.R1's hospital notes dated 7/27/26, identified R1 arrived at the emergency room with a dangerous low blood pressure of 70/40. The notes showed R1 was severely acidotic with a blood pH of 7.18 (severe acid buildup in the blood) caused by worsening renal failure (kidney collapse). R1's creatinine had spiked from a baseline of 3.0 in June to an acute level of 8.0, and his GFR (kidney filtering rate) dropped to a near-deadly level of 7. The notes further identified R1 was profoundly hypoglycemic (dangerously low blood sugar) because he had a multi-week history of not really eating or drinking and had refused most oral intake at his care center. The hospital provider concluded that this fluid and food starvation was the direct cause of his acute kidney collapse, low blood pressure, and low blood sugar.R1's hospital Discharge summary dated [DATE], identified R1 was admitted from a long-term care facility on 7/27/26 for hypotension (dangerous low blood pressure), severe acute kidney injury (sudden kidney collapse), and metabolic acidosis (severe acid buildup in the blood). The summary identified the family decided to transition R1 to comfort care on 7/28/26, and he passed away on 7/30/26. The final synopsis listed the cause of death as renal failure (kidney collapse) due to septic shock (a life-threatening infection response) and cardiogenic shock (heart pump failure).Review of R1's medical record identified a failure to record fluid inputs or monitor R1's hydration status, allowing a multi-week fluid deficit to progress unmanaged until his single kidney completely collapsed.Review of the facility's active electronic treatment sheets throughout July 2026, identified that staff possessed active electronic tasks to track solid food intake. The documentation identified that the facility failed to initialize, activate, or assign a specific electronic tracking task within the PointClickCare system for staff to log R1's daily fluid inputs.During a phone interview on 8/24/26 at 9:45 a.m., family member (FM)-A identified she called R1 on 7/27/26. R1 stated to FM-A that he had not consumed fluids for days. FM-A called the nursing station and requested laboratory tests to be completed. Facility staff refused and stated they would not perform labs until Wednesday. FM-A demanded that the facility call 911 to get R1 evaluated.During an interview on 8/25/26 at 10:57 a.m., nursing assistant (NA)-A stated that staff did not document fluid intake because there was designated place in the electronic record system to record it. NA-A stated throughout July R1 did not eat much, requiring significant encouragement to consume meals, and frequently threw up after eating. NA-A further stated that R1 was adamant about not wanting his food or fluids so the left-over trays were thrown away. NA-A confirmed she regularly reported these poor intakes and ongoing episodes of nausea and vomiting directly to the nurse on duty.During an interview on 8/25/26 at 12:33 p.m., the certified food production manager (CFPM)-A stated R1 had renal failure and required monitoring for hypovolemia (low blood fluid levels). (CFPM)-A verified there were no medical orders or electronic point-of-care tasks put in place for fluid monitoring, noting that the facility only monitored fluids if a doctor specifically ordered it. (CFPM)-A confirmed that neither nursing nor social services ever submitted a formal dietary consult or notified the dietary department that R1 was persistently nauseated, refused regular meals, or relied on outside liquids, and stated that the department would have assessed R1 immediately had they been notified.During a phone interview on 8/25/26 at 2:52 p.m., licensed practical nurse (LPN)-A identified R1 ate only about one-quarter of his meals. LPN-A stated R1 had a lot of nausea and received ondansetron prn. LPN-A identified she was not sure if R1 had kidney disease. LPN-A further stated that if there was no task to document fluids in the electronic system, she was unable to monitor his fluid intake.During a phone interview on 8/25/26 at 3:05 p.m., registered nurse (RN)-A identified that R1 would not finish the small cup of water given with his medications and was not drinking much. RN-A stated that because fluid intake was not documented in the electronic system, staff had no way to review fluid logs or check if R1 met his hydration targets. RN-A identified he was unaware that R1 had a history of dialysis or kidney disease. RN-A further stated that when FM-A called on 7/27/26 regarding R1's confusion, he told her that routine blood work would take two days to process because of when the lab company visited the facility, leading to the decision to transfer R1 to the hospital.During an interview on 8/25/26 at 2:23 p.m., registered nurse (RN) quality assurance director (QAD)-A, who was acting as the director of nursing (DON), identified the facility did not have a policy for monitoring fluids. QAD-A stated that staff found no documentation regarding R1's fluid intake. QAD-A identified that the facility only monitors fluid intake if a doctor explicitly orders it. QAD-A confirmed that a resident who is care-planned to be monitored for a fluid deficit (severe dehydration) or overload due to kidney disease should have documentation of fluid intake so the provider can be notified of a change for ongoing direction.During a phone interview on 8/26/26 at 1:04 p.m., nurse practitioner (NP)-A stated that nurses managing residents with kidney failure should actively monitor hydration and report signs of dehydration or decreased oral intake. The practitioner noted that had she been informed of ongoing nausea, she would have conducted an in-person assessment and ordered a basic metabolic panel.Facility policy for hydration/fluid monitoring was requested and not received.

Based on interview and document review, the facility failed to ensure consumed fluid intake was appropriately tracked and monitored to help reduce the risk of dehydration for 1 of 3 residents (R1) reviewed for hydration. R1 had not been consuming her recommended fluid intakes according to the charted intakes, and the medical record lacked evidence that these totals were being routinely checked to ensure R1 didn't develop acute dehydration.Findings include:R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had intact cognition and multiple medical conditions including heart failure and malnutrition. R1 had no weight loss or weight gain and did not consume an altered or therapeutic diet.On 8/13/26 at 11:44 a.m., R1's family member (FM)-C was interviewed and expressed multiple concerns about the care provided to R1 while at the care center including concerns about R1 getting enough fluid while she had been there. R1 had repeated urinary tract infections (UTI) while there which also led them to feel R1 wasn't getting enough fluids. FM-C stated they didn't even think the staff were monitoring how much R1 ate or drank most of the time, as they would visit and find old meal trays left in the room or hallway from the day prior. FM-C questioned how that was being accurately recorded if it was being left in the room for that long of a period and stated they felt R1 had major problems with hydration while she was at the care center. Further, R1 had been taken to the hospital on 7/24/26 with a stroke and would not be returning to the campus.R1's Nutritional Assessment 10-14-V2, dated 5/29/26, identified a quarterly review was completed and R1 had a stable BMI (Body Mass Index) with no weight changes. R1's past medical history was listed which included dysphagia (trouble swallowing). R1 was on a regular diet with regular textures and was not on a fluid restriction. The section labeled, Oral Intake Fluids, identified R1 needed an estimated fluid intake of 1980 ml/day and the subsection labeled, Fluid Intake, identified R1 as consuming approximately 1500-2000 ml/day of offered fluids. The section labeled, Summary identified care plan approaches to be checked by the assessor. The checked interventions included Observe fluid intake, and Provide, serve diet as ordered. Observe intake and record q [every] meal. R1's care plan, last reviewed 6/11/26, identified R1 required set-up assistance with eating and should be upright for all oral intakes. The plan identified R1 had potential for nutritional complication due to multiple medical conditions and history of malnutrition. The care plan listed several interventions to help R1 maintain her weight and remain able to feed herself. The interventions included: - Observe fluid intake, with an initiation date recorded, 03/03/2026. - Utilize smaller water jug for daily hydration needs ., with an initiation date recorded, 06/23/2026. - Provide, serve diet as ordered. Observe intake and record q meal, with an initiation date recorded, 03/03/2026.When interviewed on 8/13/26 at 12:33 p.m., nursing assistant (NA)-E stated the NA staff were responsible for checking how much food and fluid was consumed for each meal by each resident and recording it in the POC charting. It should be charted for every meal (at least three times/day), and it could be charted in real-time using the I-Pad devices they had been provided. NA-E stated they were unsure how it was tracked or monitored after it was entered into the POC system, or who, if anyone, ever checked it to ensure residents were consistently getting enough fluid intake in accordance with their assessment adding further, I can't tell you that. NA-E recalled working with R1 while at the care center and described her as picky with eating and using a little mug for water. NA-E stated they filled that mug once a shift but were unsure how often other shifts did that. NA-E stated water consumed between meals, such as from the little mug, should also be recorded in the system by the NA staff.However, R1's POC (Point of Care) Response History, dated 7/15/26 to 8/3/26, identified R1's recorded fluid intakes as completed by the NA staff members. These were: 7/15/26 - Two (2) fluid intakes were recorded for the day. These were 100 milliliters (ml)(6:34 a.m.) and 200 ml (9:32 p.m.) for a total of 300 ml of fluid intake recorded. 7/16/26 - Three (3) fluid intakes were recorded for the day including 200 ml (6:12 a.m.), 350 ml (8:51 p.m.), and one entry recorded as Not Applicable [2:59 p.m.]. The total fluid intake recorded was 550 ml. 7/17/26 - Three (3) fluid intakes were recorded for the day including 100 ml (3:35 a.m.), 680 ml (1:41 p.m.), and 240 ml (8:30 p.m.). The total fluid intake recorded was 1120 ml. 7/18/26 - Three (3) fluid intakes were recorded for the day including 200 ml (6:31 a.m.), 350 ml (2:59 p.m.), and one entry recorded as Not Applicable [7:39 p.m.]. The total fluid intake recorded was 340 ml.7/19/26 - One (1) fluid intake was recorded for the day which just marked, Resident Refused [6:04 a.m.] There was no fluid intake recorded that day. 7/20/26 - Three (3) fluid intakes were recorded for the day including 540 ml (1:32 p.m.), 8 ml (8:52 p.m.) and one entry recorded as Resident Refused [1:29 a.m.]. The total fluid intake recorded was 548 ml. 7/21/26 - Three (3) fluid intakes were recorded for the day including 100 ml (5:29 a.m.), 270 ml (2:21 p.m.), and 120 ml (6:13 p.m.). The total fluid intake recorded was 490 ml. 7/22/26 - Two (2) fluid intakes were recorded for the day including 1 ml (6:07 a.m.) and 120 ml (8:08 p.m.). The total fluid intake recorded was 121 ml. 7/23/26 - Two (2) fluid intakes were recorded for the day including 200 ml (2:18 p.m.) and 120 ml (8:15 p.m.). The total fluid intake recorded was 320 ml. 7/24/26 - Three (3) fluid intakes were recorded for the day including 70 ml (6:59 a.m.), 540 ml (9:32 a.m.) and the last was recorded (9:00 p.m.) as, Resident Not Available [sent to hospital]. R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 7/2026, identified R1's completed medication administrations and treatments. This document lacked any recorded data for R1's fluid intake. Further, R1's entire medical record lacked evidence that R1's fluid intake was being observed and recorded for each meal (or in-between) as directed by her care plan to help ensure accurate assessment and evaluation to prevent dehydration despite having a history of malnutrition.On 8/13/26 at 1:26 p.m., registered nurse managers (RN)-A and RN-B were interviewed. RN-A stated both the meal and fluid intakes were expected to be tracked in the POC charting, and the water mug(s) in the rooms should be filled every shift. RN-A stated they thought the night shift then reviewed and did a 24-hour total of fluid intake. RN-B reviewed R1's recorded POC charting for the fluid intake and verified the multiple spaces with no data recorded or refused marked adding, There's a very slim chance she refused. RN-A stated the care plan intervention for recording meal intakes meant that staff should record both food and fluid intakes. RN-A stated they were unsure why someone would chart the fluid intake as not applicable and would have to follow-up with the staff who charted that to know more. RN-A stated they recalled R1's family having concerns about R1 getting enough fluid intake and R1 having multiple UTIs, so they had been trying to go in R1's room often and ensure the water mug was filled. RN-A stated it would be the dietician's responsibility to monitor fluid intakes to ensure the resident was hydrated well and getting their recommended fluid intakes. Further, RN-A stated it was important to ensure the fluid intake was adequately monitored and recorded so they had a good understanding of how much fluid was being consumed adding, Fluid is important.When interviewed on 8/13/26 at 2:47 p.m., registered dietitian (RD)-A explained they were the only RD on the campus and that most residents would trigger potential malnutrition risk solely from having been hospitalized . RD-A recalled R1 as having weight loss while at the care center and not always having good intake due to her dislike of some of the food items. The family had been involved with R1's care and helping her complete menus to help promote more intake. R1 was also on some oral supplements to help boost her caloric intakes. RD-A reviewed and verified R1's care plan interventions listed to observe fluid intake and record meal intakes. RD-A explained they were more concerned with fluid intake monitoring and recording if the person was on a fluid restriction and staff were maybe not recording R1's fluid intake well in the record. RD-A stated they were more involved with R1 for her weight loss and that her fluid consumption wasn't something I was looking at. RD-A stated they believed the nursing department would track that more and reach out if they had concerns about poor fluid intake. RD-A stated they only routinely reviewed a resident's fluid intake if they were on a fluid restriction or on dialysis since there was a risk of holding onto too much fluid there. RD-A acknowledged adequate hydration was important and expressed that someone who was dehydrated could have more infections (i.e., UTI) and poor kidney function. RD-A added it was good to be generally aware of someone's fluid intake for their general well-being.On 8/13/26 at 3:26 p.m., a group interview was held with the administrator, director of nursing (DON), social services director (SSD), and RN-A present. DON explained the NA staff members should be recording the fluid intakes with each shift, and the goal was to get the total intake for a 24-hour period recorded and tracked. They typically did not record the little sips in between meals such as with medication pass. DON stated they felt R1's recorded fluid intakes were way under what she had been provided and consumed, and R1 was never dehydrated as her laboratory values didn't reflect that. DON stated the tracking and monitoring of fluid intake should be a collaborative thing between all departments like nursing and dietary. DON verified the medical record lacked consistent evidence of the fluid tracking being done every shift as it should have been, and expressed it was important to ensure fluid intakes were tracked and monitored to help prevent dehydration and to reflect what's really happening.

Based on interview and document review, the facility failed to ensure choices and preferences for bathing were clarified and, if needed, then implemented for 1 of 1 resident (R1) reviewed for choices. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had intact cognition and multiple medical conditions including heart failure and malnutrition.On 8/13/26 at 11:44 a.m., R1's family member (FM)-C was interviewed and expressed multiple concerns with R1's care while she had been admitted . FM-C explained they felt R1's bathing and grooming while there to be not consistent at all, and staff would often approach R1 in a manner to elicit a 'no' response from her when she was asked about bathing (i.e., You don't want that [bath] still do you?) FM-C stated nobody from the care center had ever asked them what, if any, preferences for bathing frequency R1 had or wanted. FM-C stated they were unsure if R1 had ever been asked or not, but FM-C recalled having been told by someone there earlier that once-a-week bathing was all they'll give. R1's Care Conference Summary Resident Profile V2-V11, dated 2/27/26, identified a 72-hour care conference was held for R1. It listed several sections to record R1's preferences for daily care which included, 2d. Frequency of bathing (daily, twice weekly, weekly etc.), and this was answered with, Twice weekly. The medical record had four (4) total of these summaries recorded, however, none of the subsequent ones (dated 3/5/26, 5/21/26, and 6/2/26) had the preference information recorded on them and most of them were left nearly blank with multiple sections being incomplete. R1's Comprehensive Nursing Data Collection 2025-V5, also dated 2/27/26, identified R1 admitted from the hospital and was oriented to her room. The form included a question labeled, 1e. Describe any resident specific preferences in routine, which was answered with, No preference. An additional section labeled, F. Preferences, identified R1 preferred an evening (PM) bath along with a response written, Weekly. R1's Follow-Up Question Report, dated 7/1/26 to 8/13/26, identified the recorded episodes of care R1 received for bathing assistance during the period. This identified R1 received help or was offered bathing only weekly on 7/1/26, 7/8/26, 7/15/26, 7/22/26. R1's medical record lacked evidence these conflicting responses were clarified with R1 or their family member to ensure R1's preferences for frequency of bathing were correctly implemented while she was admitted to the care center. When interviewed on 8/13/26 at 1:14 p.m., licensed practical nurse (LPN)-D stated that typically the admission nurse was responsible to ask residents for their preferences with bathing and record that. LPN-D stated, We try to get to know them right away. LPN-D stated they thought this was re-visited with them again, too, at some point but were not sure when or how often. On 8/13/26 at 1:26 p.m., registered nurse unit managers (RN)-A and RN-B were interviewed. It was explained that the Nursing Data Collection reviewed the preferences for bathing and everyone, by default, was given a weekly bath or shower. If a resident wanted more than one, then the schedule could be modified to accommodate that. RN-A reviewed R1's Care Conference Summary which directed two baths a week listed as the preference along with the subsequent ones which were nearly blank. RN-A verified R1 had only been on a weekly shower/bath rotation while at the care center on the long-term unit and questioned if the person who completed the form didn't communicate R1's preferences with the nursing staff. RN-A added, It might have [been missed]. On 8/13/26 at 3:26 p.m., a group interview was held with the administrator, director of nursing (DON), social services director (SSD), and RN-A present. DON verified they had reviewed R1's medical record and the form which directed twice weekly bathing was completed by a staff member who no longer worked at the care center. DON acknowledged that the forms completed for R1 were conflicting and stated they felt it was an issue of collaboration and communication. The desire for more than one bath a week had never been communicated to them, from their understanding, from either R1 or the family members involved with her care. SSD stated the care plan, which listed a weekly bath only, had been given to the family and no objections or errors were ever mentioned. However, DON stated if R1 desired more than one bath a week and they had known about it, then that would have been done adding it was important to ensure preferences were honored as, We want to meet their needs the best we can. A facility policy on choices and preferences was requested; however, none was received.

Based on interview and document review, the facility failed to ensure that care plan interventions for toileting and/or check-and-change were completed and recorded in the medical record to ensure a complete and accurate medical record was maintained for 1 of 3 residents (R1) reviewed for ADL care. Findings include: On 8/13/26 at 11:44 a.m., R1's family member (FM)-C was interviewed and expressed multiple concerns about the care provided to R1 while at the care center. Family members, including themselves, visited often and questioned how much, if any, routine hygiene care such as bathing or toileting were being provided. On 7/22/26, they had visited R1 and recalled her (R1) as being in bed where R1 had been laying in an awkward position. FM-C returned the next day (on 7/23/26) to find R1 lying in the same position in bed which FM-C then questioned how anyone could have provided care to her overnight. R1's ADL care plan, dated 6/8/26, identified R1 had an ADL self-care deficit due to a hip fracture and traumatic brain injury (TBI) and limited physical mobility. R1 was non-ambulatory and required assistance with bed mobility. R1 was at risk for incontinence and wore briefs. Further, an intervention dated 2/27/26 directed, Check and change every 2-3 hours.R1's Urinary Continence POC (Point of Care) Response History, dated 7/15/26 to 7/25/26, identified staff recorded entries for when R1 was continent, incontinent, or did not void. The data recorded: On 7/22/26 at 4:25 p.m., R1 was assisted and incontinent of bladder. On 7/23/26 at 2:16 p.m., R1 was assisted and incontinent of bladder. There was no recorded data between those entries to demonstrate R1 had been checked or changed every two to three hours as directed by the care plan. There were no checks placed next to the option, Did Not Void. R1's corresponding Size of BM (bowel movement) POC Response History, dated 7/15/26 to 7/25/26, identified staff recorded entries for when R1 had a BM. The data recorded: On 7/22/26 at 4:26 p.m., the staff marked, Response Not Required. On 7/23/26 at 2:16 p.m., the staff marked again, Response Not Required. There was no recorded data on the BM tracking to demonstrate R1 had been assisted with being checked and changed every two to three hours. R1's progress notes, dated 7/15/26 to 7/25/26, identified a single note recorded during the period of 7/22/26 at 4:25 p.m. to 7/23/26 at 2:16 p.m. This was on 7/22/26 at 11:10 p.m. which was by the nurse and recorded, Skin warm & dry, skin color WNL [within normal limits] and turgor is normal. No skin issues identified. The note lacked evidence of what, if any, hygiene or toileting cares were completed with R1 for the shift. Further, R1's medical record was reviewed and lacked evidence that R1 had been assisted with hygiene or toileting cares between 7/22/26 at 4:25 p.m. and 7/23/26 at 2:16 p.m. (nearly 22 hours later).On 8/13/26 at 1:26 p.m., registered nurse unit manager (RN)-A and RN-B were interviewed. R1 had been on a check-and-change program and did not use the toilet until the very last week of her admission to the care center. The assistance with toileting was tracked in the POC charting and the NA staff should be doing it in real time. RN-B stated they questioned if the NA staff understood the importance of doing the charting in real time but reiterated the staff are educated to do it then adding, It's forever a teaching thing. RN-A and RN-B both verified that the data recorded lacked evidence that R1 had been assisted with toileting or incontinence care during the period and wondered if maybe the night shift forgot to record it. It should be charted so it doesn't look like there's gaps of care like that.On 8/13/26 at 3:26 p.m., a group interview was held with the administrator, director of nursing (DON), social services director (SSD) and RN-A present. The administrator explained there had been communication from R1's family about concerns with a lack of care provided from 7/22/26 into 7/23/26. This was investigated using the camera system where it seemed R1 had been checked on but not changed. They further identified the morning shift (7/23) NA did not help R1 with toileting cares, so they addressed it with a formal warning to the employee. However, the group acknowledged there was no documentation to demonstrate any follow-up to this incident with the night shift staff despite that shift also not recording any care provided. DON verified the lack of any recorded data in the record to demonstrate the care had been provided expressed the NA staff were likely not recording care in real time despite being trained to do that using the I-pads provided. DON stated it was important to ensure the care was charted in the record as it reflects the care and what's happening with residents.

Based on observation, interview, and document review, the facility failed to ensure food items were labeled, dated when opened, and stored at the proper temperatures to prevent foodborne illness. In addition, the facility failed to ensure dishware was cleaned and sanitized and failed to ensure cups and pans were dry prior to stacking and storage. This had the potential to affect all residents who consumed food from the main production kitchen. Furthermore, the facility failed to ensure nursing and dietary staff followed appropriate infection control practices while handling plate covers during 1 of 1 meal service. This had the potential to affect residents residing on the second floor who received room tray.Findings include: Food Storage and Labeling During the initial tour of the kitchen on 7/13/26 at 10:44 a.m., an undated bag of red grapes was in the refrigerator portion of a refrigerator/freezer unit in a small storeroom. The temperature gauge read 45 degrees Fahrenheit (F). The lower freezer portion of the unit contained four containers of sherbet and did not appear to have a working temperature gauge. A sign on the door indicated Do not leave sherbet or ice cream in here. The food service director (FSD) joined the tour and stated during interview the sign was there because items melted in that freezer, and nobody likes melted ice cream. He indicated the grapes had not yet been washed and was not sure how long they had been in the refrigerator. Upon review of the sandwich bar refrigeration unit, an undated metal container of egg salad approximately 2/3 full was seated in a refrigeration well. The top was dry and congealed, with a watery liquid approximately 1/2 inch deep around the edges. FSD stated lunch had already been served, verified it was undated, and stated, that looks pretty gross, it's going in the garbage. A large metal pan of sliced ham was also undated. The lower refrigerator compartment of the sandwich bar area contained two metal cubical containers on the far-left side in the back of the unit, one full of applesauce and another approximately 30% full of a white yogurt-like substance, both covered in plastic and undated. A large undated metal container of cut mixed fruit covered in plastic wrap with watery juices at the bottom and another undated container of grapes were also in the unit. FSD confirmed all items were undated, and he unsure how long they had been there, although suspected they were placed there sometime over the weekend. During a subsequent interview and tour of the kitchen with FSD on 7/15/2026 at 10:38 a.m., a large rack containing two large trays of gelatin cups was stored in the walk-in cooler and covered with a semi-transparent plastic garbage bag with a label indicating they were made on 7/14 for dinner on 7/15. The inside of the bag was dripping wet with moisture. FSD stated it was from the steam from the hot gelatin and staff probably did not let it cool down before covering which was not a good thing. During interview on 7/16/26 at 12;03 p.m., dietary district manager (DDM) stated refrigerator temperatures should be under 41 degrees F and freezer temperatures should be under -10 degrees F. DDM stated the facility put sherbet in the one freezer, but things disappeared once they had been placed there. DDM stated most items should be dated upon opening, and the items in the deli cooler all should have a label and date. The facility New Horizon Foods Skilled Nursing Facility Food and Beverage Policy dated 1/1/26, indicated all items related to food and drink must be labeled in a way what supports safety and quality standards. Labels should be clear and include basic identifying information. Items should generally include what the item is, when it was prepared or opened, and when it should be used or discarded (if need be). The facility Refrigerator and Freezer Temperature Monitoring Policy dated 1/1/26, indicated refrigerators shall be maintained at 41 degrees F or below. Freezers shall be maintained at 0 degrees F or below. Each unit shall have an accurate, easily visible thermometer or continuous temperature monitoring device. Dish storageDuring observation of the clean dish storage area on 7/13/26 at 11:01 a.m., a group of metal shelving units contained a stack of food service trays, the top tray being soiled with an egg-like drippy substance and a one-inch by one-inch large piece of solid crusty dessert-like food. The shelves also contained a beverage pitcher with a light brown film and dark brown pepper-like specks inside. Thirty-three plastic cups were stacked upside down on another tray, each with droplets of water on top and between each cup. During observation and interview on 7/13/26 at 11:03 a.m., dietary aide (DA)-B was washing pans using the dish machine. He took large metal serving pan from exit area of dishwasher, looked inside the pan, and stacked it in storage area upside down on top of five other pans while still wet. DA-B stated he looked at the pan for anything the dish machine may have missed so it could be re-washed if needed and then put them on the shelf, but every now and then they were damp. He observed the cups on the shelf, verified they were wet, and stated he usually let them sit out and air dry before stacking them, because if they were put away wet it could cause mold and stuff. During observation and interview on 7/13/26 at 11:08 a.m., FSD stated staff should wait for dishes to dry before putting them away. He observed and confirmed the wet pan and the wet stacked cups, stating they shouldn't be that way, bacteria builds up, and brought them back to be re-washed. FSD also verified the pitcher was not clean and returned it to be re-washed. During a subsequent tour of the kitchen on 7/15/26 at 11:09 a.m., Six plastic beverage pitchers were upside down on the metal dish storage racks, each covered with a light brown film and dark brown specks on the inside. During interview on 7/15/2026 at 11:17 a.m., kitchen production manager (KPM) viewed the six pitchers, confirmed they appeared soiled, and indicated they looked like there was coffee or juice splashed up in them. During interview on 7/16/26 at 11:47 a.m., registered dietician (RD) stated she did not know anything about stacking wet dishes or opening and dating packages of food and referred to the FSM. During interview on 7/16/2026 at 12:03 p.m., DDM stated dishes should be air dried before they were put away to prevent bacterial growth. Regarding the pitchers, DDM stated she thought it was residue from cranberry juice and staff needed to do a better job soaking them before washing. Meal Service During observation on 7/15/26 at 7:43 a.m., breakfast was being served on the second floor. At this time, there were 10 residents in the dining room. After the residents in the dining room received their meals, the dietary aid started to plate meals for residents in their rooms. All the plates were covered with a plastic cover. At 7:53 a.m., the plates were put on a metal cart, and a nursing assistant (NA)-A took 5 meals to the residents' rooms. At 8:09 a.m., NA-A returned to the dining room with the plastic plate covers down, one cover on top of the other. NA-A took the covers and with her fingers touched the inside part of the covers and placed them one by one on top of clean plate covers. At 8:11 a.m., another nursing assistant took plates served with breakfast items and grabbed the used covers and placed over the food. At the same time, another NA returned with an empty cart and plate covers. The NA placed the used plate covers on back on top of the same stack of plate covers. During interview at 8:13 a.m., NA-A stated they always re-used the plate covers. NA-A stated they knocked on the residents' door, opened the door and brought the covered meals to the residents' rooms. CN-A stated some residents needed assistance to set up their meals. The plate covers were removed from the rooms and placed on the food cart. During interview on 7/15/26 at 8:15 a.m., food service manager (FSM) stated reusing the plate covers was concerning due to the risk of cross contamination. FSM stated the plate covers shouldn't be re-used. During interview on 7/16/26 at 2:10 p.m., director of nursing (DON) stated reusing plate covers was an infection control issue, due to potential cross contamination and foodborne illnesses. The facility Dishwashing and Clean Dish Storage Policy dated 1/1/26, indicated all dishes, utensils, trays, cookware, and food-contact equipment shall be cleaned and sanitized after each use. All items shall be allowed to air dry completely before storage. Clean items shall not be stacked while still wet as moisture could prevent proper drying. If this is observed, these items need to be immediately removed and rewashed. All dishware should be properly inspected before use. If wet or soiled. Itemed need to immediately be brought back to the dishwasher along with items it had been in contact with. Facility's policy titled Food Handling and Food Safety Policy dated 1/1/26, indicated the policy's purpose was to ensure all food served to residents, patients, visitors, and staff was received, stored, prepared, transported, served, and discarded in a manner that prevents foodborne illness and maintains food quality.

Based on interview and document review, the facility failed to ensure binding arbitration agreements for 3 of 3 residents (R63, R5, R120) were clearly explained in a form and manner that they understood prior to entering into the binding arbitration agreements. Findings include: R63's comprehensive Minimum Data Set (MDS) dated [DATE], identified R63 was admitted to facility on 6/30/26 and had intact cognition. R63 signed [NAME] Senior Living Arbitration Agreement on 7/1/26. During interview on 7/16/26 at 12:40 p.m., R63 stated he knew what an arbitration agreement was, but he was unable to remember signing an arbitration agreement with the facility. R63 said he didn't remember talking about it when he signed a bunch of admission documents. R5's comprehensive MDS dated [DATE], identified R5 was admitted to the facility on [DATE] and had intact short- and long-term memory. R4 signed [NAME] Senior Living Arbitration Agreement on 6/30/26. During interview on 7/16/26 at 12:45 p.m., R5 stated she didn't remember signing an arbitration agreement. R5' s husband was present when she signed the admission papers, and he was present during this interview. R5 and her husband stated that they didn't know what an arbitration agreement meant. R120's comprehensive MDS dated [DATE], identified R120 was admitted to the facility on [DATE] and had intact cognition. R120 signed [NAME] Senior Living Arbitration Agreement on 6/30/26. During interview on 7/16/26 at 12:55 p.m., R120 stated she didn't remember what documents she signed on admission. R120 stated she was heavily medicated and believed legal documents should not been signed when somebody was heavily medicated with pain medications. During interview on 7/15/26 at 1:51 p.m., social service designee (SS)-A stated she presented and reviewed all the admission papers with new residents, including the arbitration agreement. SS-A stated some residents asked questions and others did not. SS-A stated she explained the arbitration agreement as follows, If they [new resident] felt there was a concern with the facility and was not resolved, arbitration was a step forward if they choose to sign the agreement. SS-A stated nobody had asked questions about what a concern referred to. SS-A added if a new resident asked, she would explain it meant meeting with a third party instead of using a lawyer. During interview on 7/15/26 at 2:03 p.m., director of social services/licensed social worker (SS)-C stated the new residents should understand what an arbitration agreement meant before they sign one on admission. SS-C stated it needed to be explained in a way they understand they are waiving the right to hire a lawyer and instead they choose to use an arbitrator to act as a mediator between the facility and themselves. Requested the policy regarding the facility's arbitration agreement but it was not provided.

Based on observation, interview, and document review, the facility failed to ensure food was served in a timely manner and at palatable temperatures for 1 of 1 residents (R102) who expressed concerns about food temperatures and palatability.Findings include:R102's quarterly Minimum Data Set (MDS) dated [DATE], indicated R102 was cognitively intact, had diagnoses of malnutrition and heart failure, and required set-up or clean-up assistance with eating. R102's room was on the second floor of the building.During interview on 7/13/26 at 3:08 p.m., R102 stated she received cold scrambled eggs the previous day. R102's family member who was present also indicated they were ice cold.During interview on 7/14/26 at 2:49 p.m., R102 stated again that the food was cold, and the lasagna served the previous evening was cold and she could not eat it.During observation on 7/15/2026 at 11:03 a.m., three containers of sliced carrots and one large container of stuffing were open, uncovered on the steam table in the main kitchen. One large container of turkey was also present and covered with clear plastic. Additional covered containers of each food item were sitting on top of unheated metal three-tiered carts for transport to other floors for serving.During observation on 7/15/2026 from 11:30 a.m. through 11:47 a.m., kitchen staff plated and delivered meals for the first-floor residents.During observation in the second-floor dining area on 7/15/26 at 12:08 p.m., uncovered metal containers of food were sitting on top of a flat surface on a serving cart. Staff reviewed resident menu forms and dished out one plate at a time, placing the plates on top of a three-tiered cart. Once three plates were completed, the food sat on top of the cart until a staff person arrived to take the cart and deliver the meals to the appropriate residents. Another empty cart was brought to the area, and three more plates were dished and left on top until staff returned to distribute them.During interview on 7/15/26 at 12:08 p.m., KPM stated staff completed three meals at a time and then needed to find an aide to take them to the residents, and that's why the food got cold. At 12:15 p.m., KPM stated two hallways were completed and there was still one left.During observation on 7/15/26 at 12:28 p.m., KPM used a thermometer to take the temperature of the food on the last (test) tray, plated nearly 90 minutes after the food was brought to the floor from the kitchen. Results were as follows in degrees F:Carrots - 125.5Stuffing - 139.6Turkey 113.6Gravy 105.0During interview on 7/15/26 at 12:30 p.m., KPM stated the hot items should be at 135 degrees F or higher and cold items should be at 40 degrees F or lower to prevent foodborne illness.During interview on 7/16/26 at 12:03 p.m., dietary district manager (DDM) stated all hot foods should be above 140 degrees F and can be held at 120 degrees, and all cold items should be at 40 degrees or below. She stated meat needed to be higher than 110 degrees F to keep bacteria from growing and for palatability.The facility Food Temperature Control Policy dated 1/1/26, indicated hot foods shall be maintained at 135 degrees F or above during holding and service.

Based on interview and document review, the facility failed to ensure residents had the appropriate indications for use for 1 of 1 resident (R11) who was receiving antipsychotic medications. Findings include: R11's annual Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of dementia and Schizophrenia (severe mental illness that often leads to hallucinations and delusions). It further indicated R11 received an antipsychotic medication (medication to treat Schizophrenia) on a routine basis. Furthermore, a gradual dose reduction (GDR) for the antipsychotic medication was attempted on 10/24/24, and the physician documented GDR as clinically contraindicated on 11/24/25. R11's physician's orders dated 3/27/25, indicated Zyprexa (Olanzapine) oral tablet 2.5 milligrams (an antipsychotic medication). Give 1 tablet by mouth once a day related to Schizophrenia. R11's pharmacist recommendations for 8/28/25 and 10/6/25, indicated R11 had been taking the following antipsychotic medication: Olanzapine tab 2.5 mg. Take 1 tablet by mouth daily for dementia related agitation. According to 8/28/25, psych meeting, R11 was not a candidate for a gradual dose reduction. When she was off this medication, she yelled and cursed having an increase in behaviors. It further indicated the following recommendation to update diagnosis to schizophrenia and add it to her medical diagnosis list. R11's care planned dated 6/10/26, lacked documentation R11 had a diagnosis of Schizophrenia. R11's nursing progress notes dated October of 2025 to 7/15/26, lacked documentation R11 had been diagnosed with Schizophrenia. During interview on 7/16/26 at 9:08 a.m., registered nurse (RN)-A stated a diagnosis of Schizophrenia was added to R11's medical chart due to a pharmacy recommendation dated 8/28/25, which indicated to update diagnosis to Schizophrenia. During interview on 7/16/26 at 12:23 p.m., the pharmacist stated they had interdisciplinary team (IDT) meetings on a regular basis to discuss residents on antipsychotics to discuss resident GDR. The IDT meetings included the medical director, director of nursing (DON), assistant director of nursing (ADON), nurse managers, nursing staff, and the administrator. The pharmacist further stated it was decided at one of those meetings (on 8/8/25) to add Schizophrenia to R11's diagnosis list. The pharmacist further stated the former medical director (MD)-A was the one who made that determination. During interview on 7/16/26 at 1:17 p.m., the director of nursing (DON) stated she didn't know the basis for R16's Schizophrenia diagnosis and didn't remember having a conversation about it. During interview on 7/16/26 at 1:50 p.m., MD-A verified they were the medical director for the facility at the time R11's diagnoses of Schizophrenia was added to her medical record (on 10/6/25). MD-A further stated they were not aware the diagnosis had been added and they never gave the okay to add it. The reason R11 was being prescribed Zyprexa (Olanzapine) was for vascular dementia stating R11 does not have Schizophrenia. A facility policy regarding psychotropic medications was requested and received but did not address the indications for use.

Based on interview and document review the facility failed to report an allegation of physical abuse to the state agency (SA) for 1 of 1 residents (R1) reviewed for abuse. Findings IncludeR1's admission Minimum Data Set, dated [DATE], indicated R1 was cognitively intact. Diagnoses included heart failure, post-traumatic stress disorder (PTSD), depression, and anxiety disorder.R1's care plan dated 4/20/26, indicated R1 was a vulnerable adult and interventions included investigating any suspicions of abuse and report as necessary. R1's care plan dated 5/14/26, also indicated R1 had a history of experienced trauma and PTSD.R1's Trauma Informed Care Screening dated 6/6/26, indicated R1 had a history or experienced trauma with a goal to feel secure in the environment.In email correspondence received 7/15/26 at 1:04 p.m. family member (FM)-C indicated R1 had complained about abuse from staff on two different occasions. The first one involved a staff member shaking R1. The second incident involved a staff member physically threatened R1 by raising a fist to R1 as if the staff member was going to hit R1. FM-C indicated the director of nursing and registered nurse (RN)-B had been notified of the abuse concerns by email shortly after the occurrences.In email correspondence received 7/15/26 at 4:10 p.m., FM-C forwarded the email that was sent to the DON on 6/30/26 at 3:12 British standard time (BST). In the email FM-C reported a formal complaint of abuse against R1. A staff member who worked on the transitional care unit raised their arm and hand at R1 and threatened to hit R1. FM-C indicated R1 had been afraid of the staff member after that occurrence.In email correspondence received 7/15/26 at 4:24 p.m., FM-C forwarded the email that was sent to the RN-B on 6/26/26 at 12:54 a.m., BST. The email indicated FM-C reported to the RN-B on Wednesday night R1 reported to FM-C a nurse aide had physically shook R1.During an interview on 7/16/26 at 9:33 a.m., RN-B stated FM-C had sent an email to her that reported a concern of abuse between a staff member that had allegedly shook R1. As soon as the email was read, the email was forwarded to the DON and confirmed the DON had received the forwarded email. RN-B stated she was not sure how much investigating had been done or if a report was filed with the SA because the DON and/or administrator took care of those steps.During an interview on 7/16/26 at 10:53 a.m., the DON stated she had received a copy of both emails sent by FM-C and both emails had concerns of abuse. R1 was talked with and there were no concerns of abuse, so they were not reported to the SA.Facility policy Abuse, Neglect and Exploitation dated 25, indicated an alleged violation related to abuse or serious bodily injury would be reported to the SA immediately, but no later than 2 hours after the allegation is made.

Based on interview and document review the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 residents (R1) reviewed for physical and mental abuse.Findings IncludeR1's admission Minimum Data Set, dated [DATE], indicated R1 was cognitively intact. Diagnoses included heart failure, post-traumatic stress disorder (PTSD), depression, and anxiety disorder.R1's care plan dated 4/20/26, indicated R1 was a vulnerable adult and interventions included investigating any suspicions of abuse and report as necessary. R1's care plan dated 5/14/26, also indicated R1 had a history of experienced trauma and PTSD.R1's Trauma Informed Care Screening dated 6/6/26, indicated R1 had a history or experienced trauma with a goal to feel secure in the environment.In email correspondence received 7/15/26 at 1:04 p.m. family member (FM)-C indicated R1 had complained about abuse from staff on two different occasions. The first one involved a staff member shaking R1. The second incident involved a staff member physically threatened R1 by raising a fist to R1 as if the staff member was going to hit R1. FM-C indicated the director of nursing and registered nurse (RN)-B had been notified of the abuse concerns by email shortly after the occurrences.In email correspondence received 7/15/26 at 4:10 p.m., FM-C forwarded the email that was sent to the DON on 6/30/26 at 3:12 British standard time (BST). In the email FM-C reported a formal complaint of abuse against R1. A staff member who worked on the transitional care unit raised their arm and hand at R1 and threatened to hit R1. FM-C indicated R1 had been afraid of the staff member after that occurrence.In email correspondence received 7/15/26 at 4:24 p.m., FM-C forwarded the email that was sent to the RN-B on 6/26/26 at 12:54 a.m., BST. The email indicated FM-C reported to the RN-B on Wednesday night R1 reported to FM-C a nurse aide had physically shook R1.During an interview on 7/16/26 at 9:33 a.m., RN-B stated FM-C had sent an email to her that reported a concern of abuse between a staff member that had allegedly shook R1. As soon as the email was read, the email was forwarded to the DON and confirmed the DON had received the forwarded email. RN-B stated she was not sure how much investigating had been done or if a report was filed with the SA because the DON and/or administrator took care of those steps.During an interview on 7/16/26 at 10:53 a.m., the DON stated she had received a copy of both emails sent by FM-C and both emails had concerns of abuse. R1 was talked with during the first allegation of abuse. R1 and the alleged perpetrator were talked with related to the accusation. Nobody in the facility talked with anybody else, staff or resident, related to the concerns and accusations made about the staff member. The staff member was removed from R1's care but was allowed to provide care for all the other residents in the facility.Facility policy Abuse, Neglect and Exploitation dated 25, indicated the facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.

Based on interview and document review, the facility failed to ensure written bed hold/transfer notices were give upon transfer to the hospital for 2 of 2 residents (R32, R9) reviewed for hospitalization. Findings include: R32 R32's admission Minimum Data Set (MDS) dated [DATE], indicated R32 was cognitively intact, had diagnoses of anemia, irregular heartbeat, high blood pressure, liver disease, kidney failure, and diabetes. R32 was non-ambulatory, used a wheelchair, and was dependent on staff for toileting, transfers, and showering. R32's profile reviewed 7/16/26, indicated R32 was her own responsible party and did not have a guardian or power of attorney (POA). R32's progress note dated 6/30/26 at 12:04 p.m., indicated R32 was sent to the hospital for altered mental status at 10:50 a.m. and R32's emergency contact was informed. R32's progress note dated 6/30/26 at 2:48 p.m., indicated bed hold was given via telephone to resident representative/POA. The note included Bed Hold determination by resident and/or resident representative/POA is Yes, I want my bed held and agree to pay privately. R32's Transfer, Discharge, Bed Hold Notification -V3 dated 6/30/26, indicated R32's emergency contact person was reached via phone and chose to hold the bed and pay privately. A field labeled A written copy of the bed hold was provided (explain if faxed, mailed, in person, etc.) was blank. R32's progress note 7/1/26 at 8:00 p.m., indicated R32 was admitted with right internal carotid artery (ICA) narrowing. R32's Interagency Transfer Form – Physician Orders signed by the provider on 7/4/26 at 10:28 a.m., indicated R32 was being discharged from the hospital. R32's progress notes lacked indication R32 transferred back to the facility. R32's progress note dated 7/4/26 at 4:19 p.m., indicated R32 had a nosebleed at 2:50 p.m. which could not be controlled. Provider was called and R32 was sent to the hospital at 3:53 p.m. for evaluation and treatment. The note indicated R32's friend was updated. Bed hold information was identified in the note. R32's progress note dated 7/7/26 at 2:43 p.m., indicated R32 was sent to hospital for evaluation of continued vaginal bleeding, lethargy, and weakness. R32's medical record lacked evidence that a bed hold and/or transfer notice was given to R32 for hospital transfers on 7/4/26 and 7/7/26. During interview on 7/13/26 at 3:11 p.m., R32 stated she had to go to the hospital twice recently, back-to-back, for bleeding. She did not recall receiving information regarding bed hold. R9 R9's admission MDS dated [DATE], identified R9 was cognitively intact. R9's diagnoses included diabetes, neurogenic bladder (condition affecting the nerves between bladder and brain causing under or over-active bladder), and kidney disease. R9's census list printed 7/16/26, indicated R9 transferred out of the facility to the hospital on 7/11/26. R9's electronic medical record (EMR) lacked evidence of a bed hold. R9's progress noted dated 7/11/26 at 11:19 a.m., indicated (R9) complained of lower abdominal pain and thought she could be passing a kidney stone. The on-call provider was notified and order given to send (R9) to the hospital. R9's progress notes 7/11/26 through 7/16/26, lacked evidence of discussion or written notice provided regarding bed hold. During interview on 7/16/26 at 11:49 a.m., R9 stated she went to the hospital with symptoms of kidney stones and that it was not under emergent conditions. R9 remembered having a conversation regarding a bed hold but was not provided anything in writing. During interview on 7/16/26 at 10:27 p.m., licensed practical nurse (LPN)-A stated when she sent a resident to the hospital, she contacted the provider, prepared paperwork including a face sheet, medication list, and code status forms. Depending on the resident's level of orientation, she contacted the family listed in the medical record. LPN-A indicated for each transfer to the hospital, she verbally explained what a bed hold was and completed a transfer/bed hold assessment form on the computer, however, they did not usually print one out to give to the resident or family. During interview on 7/16/2026 at 10:54 a.m., social services designee (SSD)-A stated when a resident was sent to the hospital the nurse was responsible for completing the bed hold assessment in the computer, however, did not think it was needed if the resident was not gone overnight. She stated if it was not completed, she would address it the next day. When asked how the resident and/or family would receive the information regarding their bed hold rights, she stated she would print it out and they could receive it when they returned. She indicated it was important for residents to know they have a right to come back to the same room and indicated they could have it as long as they wanted it and could cancel any time. During interview on 7/16/26 at 10:59 a.m., registered nurse (RN)-B who was also the nurse manager stated the facility bed hold process changed a few months prior. She stated nursing used to complete a paper bed hold/transfer notice form and staff would try to get a signature from the resident before they left for the hospital and give a copy to the resident. RN-B stated social services recently took ownership of the process, and now the resident or POA would be called and the assessment form would be completed afterward. Regarding R32, RN-B indicated she called her emergency contact to ask him if he wanted to hold the bed, although she was unsure if he could make decisions regarding her care since she was her own responsible party. During interview on 7/16/2026 at 1:05 p.m., director of nursing (DON) stated she expected staff to get a bed hold upon transfer of the resident, or as soon as possible if the resident needed to be sent to the hospital urgently. She indicated there was a form in the electronic record to fill out and it should be printed and given to the resident so they have the information. The facility Bedhold Notice Policy dated 7/21/25, indicated: 1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or the resident representative written information that specifies: The duration of the State bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; The reserve bed payment policy in the state plan policy, if any. The facility policies regarding bed-hold periods include allowing a resident to return to the next available bed. Conditions upon which the resident would return to the facility: The resident requires the services which the facility provides; The resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record.

Based on observation, interview, and document review the facility failed to ensure pressure ulcer interventions were implemented for 1 of 1 resident (R16) reviewed for pressure ulcers. R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of chronic kidney disease, congestive heart failure (CHF), and diabetes. It further indicated R16 was dependent on staff for most activities of daily living (ADL) and mobility, was at risk for and had (1) unstageable facility acquired pressure ulcer and moisture associated skin damage (MASD).R16's physicians orders dated 6/10/26, indicated R16 required pressure reducing boots on at all times, every shift for deep tissue injury (DTI) to left heel. R16's care plan dated 6/8/26, indicated R16 had potential/actual impairment to skin integrity related to MASD, current lower extremity venous wound, unstageable pressure injury (blood blister) on toe, and a history of removing dressing despite education not to do so. R16's care plan indicated the following interventions: -Attempt to reposition off area and/or not position on area when possible -Educate, cue and assist with repositioning -Elevate lower extremities if resident is wanting to be up in her wheelchair without rest periods with repositioning. -Encourage good nutrition and hydration to promote healthier skin-Float/off load heels -Keep linens dry, wrinkle free-Keep skin clean and dry. Apply lotion to dry skin during cares. Do not apply lotion between toes or to open areas or rashes. -Mattress replacement system: Air mattress -Observe skin during cares. Report any changes to nurse -Observe/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration, etc. to medical practitioner-Position body with pillows/supportive devices, protect bony prominences -Pressure relieving support surfaces in bed and chair: Standard reduction necessary to reduce pressure and to improve comfort level in relation to positioning/repositioning in bed and chair.-Reposition/position changes every 2-3 hours -See skin/wound tab for current skin measurements and interventions-Treatment as ordered. Notify medical practitioner if skin alteration worsening, shows signs of infection or no improvement x 14 days-Treatment to venous ulcer on LLE as ordered-Weekly skin inspection and prnR16's care plan lacked documentation of a DTI to her left heel or the intervention to wear pressure reducing boots at all times. R16's treatment administration record (TAR) dated 7/2026, indicated the nurse documented R16 was wearing her pressure reducing boots. No refusals were documented. R16's nursing progress note dated 6/10/26 indicated a new area of skin impairment noted to left heel when resident complained of pain in that area during weekly wound rounds. The wound nurse was present and gave a diagnosis of DTI with orders for skin prep twice a day and to wear pressure reducing boots at all times. During observation on 7/14/26 at 2:25 p.m., R16 was sitting in her wheelchair in her room. She was not wearing pressure reducing boots. R16's pressure reducing boots were sitting at the end of her bed. During interview on 7/14/26 at 2:53 p.m., registered nurse (RN)-A verified R16 wasn't wearing her heel protectors but should be at all times. If R16 refused to wear them, it should be documented. During observation on 7/16/26 at 7:53 a.m., R16 was in bed sleeping without the pressure reducing boots in place. R16's pressure reducing boots were on a card table in front of the window. During interview on 7/16/26 at 7:48 a.m., licensed practical nurse (LPN)-B stated nursing assistants (NA) were primarily responsible for putting on resident's pressure reducing boots and the nurses were responsible for charting it. LPN-B further stated the NAs should report resident refusals to the nurse, and it should be documented.During interview on 7/16/26 at 1:17 p.m., the director of nursing (DON) stated she expected nursing staff to be following doctor's orders for pressure reducing boots and if a resident refused care, they should be documenting refusals. A facility policy regarding pressure ulcer prevention dated April of 2026, directed staff to prevent the formation of avoidable pressure injuries and to promote the healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present.

Based on observation, interview, and document review the facility failed to ensure perimeter mattress were assessed for safety for 2 of 2 residents (R11, R16) reviewed for falls. Findings include: R11's annual Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of dementia, muscle weakness, and failure to thrive. It further indicated R11 was dependent on staff for all activities of daily living (ADL) and mobility.R11's physician's orders lacked orders for a perimeter mattress. R11's care plan dated 6/10/26, indicated R11 was at risk for falls related to poor safety judgment, non-ambulatory at this time, overestimates own abilities, was not aware of her own limitations, and had a history of a fall with left hip fracture. It further indicated the following interventions:-Bed adjusted to appropriate height -Call light and personal belongings within reach -Contour/defined perimeter mattress. -Coordinate with appropriate staff to ensure a safe environment: floors even and free from spills or clutter, adequate, glare-free light,call light, bed at appropriate height, grab bar/U-bar as ordered, handrails on walls, personal items within reach.-Get up into chair as soon as she is dressed in the morning.-Gripper stockings or shoes at all times -Place in commons area for observation when unsteady/unsafe or involve in structured activity of her choice-Removed foot pedals from wheelchair to prevent from tripping over if she attempts to stand.R11's progress notes indicated the following:- On 6/13/2026, R11's roommate went to the nurse's station to report that R11 was on the floor. R11 was on the floor, on her back, next to her bed.-On 6/15/2026, interdisciplinary team (IDT) met to review R11's fall. Incident was from bed and a perimeter mattress had been placed for edge of bed awareness.R11's medical record lacked evidence a physical device safety assessment was completed when R11 had a perimeter mattress placed. During observation on 7/13/26 at 3:51 p.m., R11 was in bed sleeping. R11's bed had a perimeter mattress in place. During observation on 7/14/2026 at 1:42 p.m., R11 was in bed sleeping. R11's bed had a perimeter mattress in place. R16R16's quarterly MDS dated [DATE], indicated severely impaired cognition and diagnoses of chronic kidney disease, congestive heart failure (CHF), and diabetes. It further indicated R16 was dependent on staff for most ADL's and mobility.R16's physician's orders lacked an order for a perimeter mattress. R16's care plan dated 6/8/26, indicated R16 was at risk for falls and included the following interventions:-Bed adjusted to appropriate height -Call light and personal belongings within reach-Gripper stockings or shoes at all times -Monitor for mattress overlays and remove as needed (PRN).-Offer to get up for the day before 10:00 am per preference. -Provide reacher in room if requesting it -Touch pad call lightR16's care plan lacked indication R16 required a perimeter mattress. R16's physical device assessment dated [DATE], lacked documentation of an assessment for a perimeter mattress. During observation on 7/15/26 at 8:15 a.m., R16 was in bed, awake, and had a perimeter mattress.During interview on 7/16/26 at 9:08 a.m. registered nurse (RN)-A verified R11 and R16 had perimeter mattresses but didn't know who was responsible for assessing them. RN-A also verified R11 and R16 did not have an assessment for a perimeter mattress. During interview on 7/16/26 at 7:48 a.m., licensed practical nurse (LPN)-B stated residents who have a perimeter mattress need to be assessed for safety and therapy was responsible for assessing them.During interview on 7/16/26 at 8:13 a.m., RN-E stated residents who have a perimeter mattress need to be assessed for safety and the nurses were responsible for assessing them. During interview on 7/16/26 at 1:17 p.m., the director of nursing (DON) stated they talk about interventions such as perimeter mattresses at IDT meetings. Their goal was to make sure they aren't inhibiting the residents from getting up. They only used the perimeter mattress as an intervention for awareness of the edge of the bed because the beds were so small. The DON further stated the residents were required to have an assessment in order to have a perimeter mattress, and the assessments didn't reflect that very well. There was not a spot to assess it (perimeter mattress), therefore there was no documentation that those residents were being assessed. A facility policy regarding physical device assessments was requested but not received.

Based on interview and document review, the facility failed to provide in writing a transfer of room notice. This effected 2 of 2 residents (R1, R102) reviewed for room change. Findings Include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. Diagnoses included heart failure, post-traumatic stress disorder (PTSD), depression, and anxiety disorder. R1 was admitted on [DATE], to a transitional care unit (TCU) bed. R1's census report undated indicated R1 move to a long-term care (LTC), semiprivate bed on 5/5/26. R1's Transfer, Discharge, Bed Hold Notification form dated 5/5/26 at 3:38 p.m., indicated R1 was transferred from TCU to LTC on 5/5/26, because TCU was for rehabilitation and R1 was staying long term. The form lacked a signature or indication R1 refused to sign. R1's medical record lacked evidence of a signed copy of the Room Transfer Form with explanation for transfer. On 7/15/26 at 10:38 a.m., R1 was called but no answer. No voicemail available. An email correspondence received 7/15/26 at 1:04 p.m., family member (FM)-C indicated R1 had been told during the care conference on 4/22/26, R1 might need to move to a room on the LTC unit. R1 did not really want to move and did vocalize not wanting a roommate. Staff reported at that time, more conversations would come. On 5/5/26 R1 was moved to the second floor. there was no paperwork given to R1 that explained the reasons for the move or for her to sign related to the move. R102's admission MDS dated [DATE], indicated R102 was admitted to the facility 2/26/26 into a TCU room, and had intact cognition. R102's census list printed 7/16/26, identified R102 moved to a long-term care room on 3/14/26. R102's electronic medical record (EMR) lacked evidence of a room transfer notice. R102's progress notes dated 2/27/26 through 6/17/26, lacked evidence of any discussion or notice of room change with R102 or R102's family. During interview on 7/14/26 at 2:49 p.m., family member (FM)-A stated no one provided a room transfer notice. FM-A stated all of a sudden, they were moving R102 and did not provide anything in writing. During interview on 7/14/26 at 2:55 p.m., R102 stated did not feel like she was not informed of what was going on and did not receive anything in writing regarding room transfer.During interview on 7/14/26 at 3:18 p.m., (FM)-B stated R102 was abruptly moved to the LTC room without any advanced written notice. During an interview on 7/16/26 at 9:51 a.m., licensed social worker (LSW)-B stated all residents who would be transferred from the TCU to the LTC units would be given the Room Transfer Form 7 days prior to the actual change of rooms. The form explains why the room change was occurring and when the change would occur. LSW-B could not remember if R1 was given a Room Transfer Form prior to the transfer of rooms. During an interview on 7/16/26 at 10:07a.m., licensed social worker (LSW)-C confirmed all residents were to be given the Room Transfer Form at least 7 days prior to transfer. The 7 days allowed the resident to ask questions related to the move, see the new room, and meet the possible roommate. LSW-C reviewed R1 medical record and confirmed there was no Room Transfer Form in the chart. During an interview on 7/16/26 at 12:26 p.m., the administrator stated all residents should be given the Room Transfer Form, which explains why the move occurs and the timeframe for the move, at least 7 days prior to the move. The room change policy was not received.

Based on interview and document review, the facility failed to ensure orders were carried out for a urinary analysis and urine culture (UA/UC) in a timely manner for 1 of 1 resident (R76) reviewed for urinary tract infection (UTI). Findings include: R76's quarterly Minimum Data Set (MDS) dated [DATE], indicated R76 had moderate cognitive impairment, was always incontinent of urine, and needed maximal assistance with toileting hygiene. Further, the MDS indicated R76 did not have a current or previous UTI within the last 30 days. R76's care plan dated 7/16/26, indicated R76 was incontinent of bladder, required assistance with toileting hygiene, and directed staff to monitor and report to the medical practitioner any signs and symptoms of UTI including urinary frequency, burning, foul smelling urine, cloudy urine, hematuria, fever, chills, and altered mental status. R76's progress note dated 7/12/16 at 10:13 p.m., indicated UA/UC one time only for 2 days, discontinue when done. Progress note indicated a straight catheterization was attempted and was able to get a little urine, but not enough. R76's treatment administration record (TAR) for the month of July 2026, identified a UA/UC order to straight catheterization one time for 2 days and discontinue when done. The TAR order directed staff to collect a sample on 7/12, 7/13, and 7/14. The TAR only included the failed attempt to obtain the urine sample on 7/12/26. Nothing was documented on 7/13/26 or 7/14/2026. R76's medical record lacked documentation of UA/UC laboratory results and/or updates to primary provider from 7/12/26 through 7/15/26. During observation and interview on 7/14/26 at 8:54 a.m., R76 was awake in bed but kept her eyes closed for most of the interview. R76 stated she was tired, didn't feel well and was not going to eat breakfast because after she drank cranberry juice and she felt nauseous. R76 stated the staff thought she had a UTI. During observation on 7/15/26 at 10:03 a.m., R76 was in bed, she didn't open her eyes or answer any questions. During interview on 7/15/26 at 11:43 a.m., registered nurse (RN)- C stated R76 was very weak, she refused breakfast and wanted to be left alone. RN-C verified a urine sample was not collected. RN-C stated when a nurse was unable to obtain a urine sample during their shift it was reported to the next shift, and so on. RN-C stated the provider needed to be updated if the nurses were unable to collect a sample. RN-C stated the previous nurse did not report anything about it. RN-C added he needed to update the provider and obtain new orders. RN-C added, I am concerned the sample was not collected. During interview on 7/16/26 at 11:43 a.m., nurse manager/registered nurse (RN)-D stated he was not aware of R76's orders for an UA/UC. RN-D stated two days ago he was informed R76 was not eating well. RN-D stated he expected the nurses to collect a sample according to the doctor's order. RN-D expected the nurses to report to next shifts, and he added the order is open until the sample was collected. RN-D verified R76's medical record lacked documentation why the sample was not collected. During interview on 7/16/26 at 2:10 p.m., director of nursing (DON) stated the provider needed to be updated if the staff was unable to obtain a sample. DON stated if R76 had an UTI, it needed to be treated without delay. A policy regarding following doctors' order was requested but not received.

Based on interview and document review the facility failed to assess and monitor a change in condition for 3 of 4 residents (R1, R2, R4) reviewed for wound care. The lack of assessment and monitoring for R1 resulted in harm for R1 when R1 appeared to be sleeping in bed but instead had a change in responsiveness and mentation, was not assessed timely for the change, and was hospitalized . The lack of thorough assessment and monitoring for R2 resulted in delay in treatment for wounds related to moisture associated skin damage (MASD). Wound care staff identified wounds on 4/28/26, but were not evaluated until 5/11/26. The wounds were open and R2 reported pain associated with the wounds. The lack of assessment and monitoring for R4 resulted in harm when R4 was noted to have a change in condition, staff did not perform ongoing assessments and monitoring, the provider was not notified of the changing and deteriorating condition, and R4 was found unresponsive in bed two days after becoming ill and was subsequently transferred to the hospital. Findings include: R1 R1's admission Minimum Data Set (MDS) dated [DATE] indicated intact cognition, dependence upon staff for assistance with activities of daily living (ADLs), no behaviors including refusals of care, and diagnoses that included kidney insufficiency, urinary tract infection (UTI) in the previous 30 days, liver disease, and hypertension. R1's provider progress note dated 4/29/26 indicated the provider reviewed the resident with the facility nursing staff and nurse manager to watch R1 carefully as she may need further hospitalization for diuresis (pass increased amount of urine), and to watch vital signs (VS). R1's provider orders dated 4/29/26 indicated Lasix (diuretic - medication used to promote the production of urine by the kidneys used to flush out excess salt and water) 40 milligrams (mg) one time a day at 8:00 a.m., and 20 mg one time a day at 1:00 p.m., for edema. The provider orders lacked indication staff were to monitor R1's carefully for indication she may need further hospitalization for diuresis per the provider's progress note on 4/29/26. R1's care plan lacked mention R1 was taking a diuretic or needed careful monitoring for the need for further diuresis at the hospital. R1's progress notes indicated the following:5/2/26 at 10:01 p.m., vital signs (VS) were checked at 10:22 p.m.: blood pressure (BP) 101/55, pulse (P) 79, respirations (R) 18, temperature (T), 96.9 Fahrenheit (F), oxygen saturation (O2 sats) 99% on room air (RA). Resident was alert and oriented and coherent, with clear speech. 5/2/26 at 10:20 p.m., vital signs stable, pedal pulse on left ankle not palpable. 5/2/26 at 10:43 p.m., R1 was taken to the hospital. R1's After Visit Summary from the hospital dated 5/2/26 indicated R1 had a diagnosis of cellulitis (bacterial infection of the skin and underlying tissue) and was started on an antibiotic. R1's diagnosis list dated 5/3/26 indicated a diagnosis of cellulitis of the left lower limb. R1's progress notes after the hospitalization indicated the following: 5/3/26 at 6:40 a.m., returned from hospital with new orders and diagnosis. 5/3/26 at 10:50 a.m., VS were assessed at 7:48 a.m. and were BP 100/58, P 94, R 16, T 97.4 F, O2 sats 96% on RA, resident followed commands, was alert and oriented. 5/3/26 at 6:09 p.m., VS BP 118/60, P 84, R 18, T 96.9 F, O2 sats 98% on RA, alert and oriented, coherent with clear speech. 5/4/26 at 2:26 p.m., VS T 97.6 F assessed at 12:49 p.m., P 85 and R 18 assessed at 2:28 p.m. Resident was alert and oriented, and able to follow commands. The progress note lacked indication BP and O2 sats were assessed. 5/4/26 at 9:42 p.m., VS T 97.7 F assessed at 9:09 p.m., P 87 and R 17 assessed at 9:43 p.m. Resident was alert and oriented and able to follow commands. The progress note lacked indication BP and O2 sats were assessed. 5/5/26 at 12:29 p.m., VS BP 92/53, P 114, R 18, T 97.0 F. Resident complained of hip and left calf pain at 12:00 p.m.; Tylenol was given. The progress note lacked indication O2 sats were assessed and lacked further mention of the low BP and elevated P, lacked later reassessment of the VS, and lacked indication the VS were reported to the provider. 5/5/26 at 3:15 p.m., VS P 85, R18, T 97.7 F. Resident is alert and oriented, followed commands. The progress note lacked indication BP or O2 sats were assessed. 5/6/26 at 3:29 p.m., VS BP 45/26, P 66, R 22, T 97.0 F, O2 sats 98% on RA. Resident had very low BP and was alert knew her first and last name but did not know where she was and was lethargic.5/6/26 at 4:16 p.m., VS 50/26, pulse 66, R 22, T 97.0 F. Resident follows commands, has not been eating any of her food, especially this shift. 5/6/26 at 4:27 p.m., when caregivers offered to do cares, R1's family would tell staff to come back because R1 was sleeping. At 2:30 p.m. during medication pass, the trained medication aide (TMA) came to pass meds, and was told to come back later. The licensed practical nurse (LPN)-A went to check on R1 and BP was noted to be very low; the provider was updated and gave orders to send R1 to the emergency room (ER). The progress note lacked indication staff assessed R1 even though it was unusual for her to sleep during the day. R1's death certificate dated 5/7/26 at 12:27 p.m., indicated R1 died of multiorgan failure due to septic and hemorrhagic shock, acute renal (kidney) failure, and acute respiratory failure. During an interview on 5/19/26 at 11:33 a.m., social worker (SW)-A stated when R1 was intubated shortly after she arrived at the hospital on 5/6/26, and family reported R1 was not acting like herself and didn't want to talk to her husband that day which was not normal for R1. The SW-A stated R1's family reported being very concerned about the care R1 received at the facility. During an interview on 5/21/26 at 2:46 p.m. the family member (FM)-A stated the day after R1 died, she visited the facility to discuss with a registered nurse (RN) how R1 was fine one day, and on lift support the next day. The FM-A stated FM-B and FM-C had seen R1 the morning R1 was transferred to the hospital. R1 complained of a headache the morning of 5/6/26, and was sleeping a lot, which was unusual for her; her baseline was lively and talkative. The FM-A stated FM-C visited R1 in the morning on 5/6/26, and FM-B visited around 10:00 a.m., and R1 slept through both visits. FM-A stated it was after lunchtime when staff checked on R1, but FM-C asked staff to let R1 sleep. A nurse came in later, and assessed R1, and then rushed to send R1 to the hospital. During an interview on 5/21/26 at 3:27 p.m., the FM-C stated on 5/6/26 R1 was sleeping a lot which was not normal. A nurse came to R1's room at approximately 10:00 a.m., physical therapy and occupational therapy staff came and left when I sent them away. The FM-C stated she looked for a wound care nurse in the facility because the wounds on R1's legs were weeping. A nursing assistant (NA) entered R1's room around 2:00 p.m., and wanted to give R1 some medication, but because R1 had complained about that NA previously, the FM-C asked them to leave. The NA sent a nurse back in to give the medication but didn't give the medication and instead called emergency medical services to send R1 to the hospital. She had just been in the hospital with sepsis the Thursday or Friday after Easter. The day before she went to the hospital on 5/6/26, R1 kept saying she wanted her mom and didn't seem real energized but was usually more alert than she was that week. She seemed to be declining all week. During an interview on 5/21/26 at 4:04 p.m., the nurse practitioner (NP)-A stated she was not informed R1 had an UTI, and a urine test had not been ordered for R1 after her hospitalization in April. R1 was very ill and had been declining. Staff had to monitor R1 closely because she was immobile, at risk for infection, and had so many contributing co-morbidities. During an interview on 5/22/26 at 10:14 a.m., the FM-C stated when R1 went to the hospital on 5/6/26, hospital staff told the FM-C R1 was very sick may not make it through the night. They put a tube down her throat, and when they pulled that out, R1 died about 30 minutes later. The FM-C stated he visited R1 on 5/6/26 at the facility, and stated staff looked at R1 in her room, and walked away, but did not assess her. During an interview on 5/22/26 at 2:54 p.m., the RN-A stated after R1 returned from the hospital in April 2026, the care provided included checking R1's blood pressure, wounds care for the wounds on R1's legs, and catheter care. During an interview on 5/26/26 at 11:39 a.m., the licensed practical nurse (LPN)-A stated she took R1's VS on 5/6/26 and was very concerned. R1 was conscious and speaking but didn't know where she was. She was sleepy all day and hadn't felt well. The DON didn't want me to send R1 to the hospital again, but we did send her in later in the day. During a subsequent interview on 5/26/26 at 12:29 p.m., the NP-A stated any resident required assessment when they were sick and the provider should be updated any time a resident had a change in condition. During an interview on 5/26/26 at approximately 1:30 p.m., the RN-B stated R1 was assessed on 5/6/26 right before she was sent to the hospital but did not appear to have any assessment on 5/6/26 that day prior to that because the family wanted her to sleep. If the nurse was concerned, she should have awakened her to assess her. When nurses do a set of VS, they should include a blood pressure, pulse, respirations, temperature, and oxygen saturations, and usually pain. Staff would not know R1's condition if they didn't assess her. During an interview on 5/26/26 at 2:46 p.m., the medical director (MD)-A stated R1 was very frail and compromised and should have been assessing for signs of infection and fever. During an interview on 5/26/26 at 3:31 p.m., the director of nursing (DON) stated the expectation was if R1 or her family refused care, the expectation was for nursing staff to educate the resident or the family about the need for care, and then document in a progress note that care was refused and education was provided about the risks and benefits of refusing the care. If R1's BP was low, staff should recheck the BP, and if it is still low, report it to the provider. R2 R2's annual MDS dated [DATE], indicated severe cognitive impairment, R2 was always incontinent of bowel and bladder, was at risk for developing pressure ulcers (PU), and had diagnoses that included dementia and arthritis. R2's grievance log entry dated 3/31/26, indicated R2's was supposed to be added to wound rounds but had not been. R2's grievance log entry dated 5/11/26, indicated R2's FM-D was concerned about R2's wound. R2's care plan indicated the following:5/14/22, revised 6/22/22, indicated R2 wore incontinence products daily, apply barrier cream/protective ointment after each incontinent episode. 5/14/22, revised 4/21/25, reposition every 2-3 hours and as needed10/28/25, check and change for incontinence every 2-3 hours5/14/22, revised 5/20/26, indicated R2 had potential impairment to skin integrity related to incontinence, immobility, and medication use with current MASD with treatment with an ointment. Interventions were added 5/18/26 including see the Skin/Wound tab in the medical record for current skin measurements and interventions, treatment as ordered and notify provider if the skin alteration was worsening or shows signs and symptoms of infection or no improvement in fourteen days. R2's progress notes indicated the following:4/1/26 at 11:27 a.m., new skin issue, MASD on the intergluteal cleft (the deep vertical groove that runs between the buttocks) 3.99 centimeters (cm) x 4.25 cm, 100% granulation tissue, no drainage, cleaned with generic wound cleaner, treated with Calmoseptine Ointment used to prevent and soothe skin irritations), to be treated daily and as needed (PRN). The progress notes lacked mention the provider was notified. 4/7/26 at 9:36 a.m., MASD on the intergluteal cleft was healed. 4/7/26 at 3:38 p.m., MASD, in-house acquired, on intergluteal cleft that had not been evaluated by a provider. The note lacked mention of treatment, clinical treatment suggestions, or notification to the provider. 4/14/26 at 3:20 p.m., MASD in the intergluteal cleft, in-house acquired with a clinical suggestion to apply barrier cream to the skin, that had not been evaluated by a provider. The progress note lacked mention of notification to the provider. 4/17/26 at 6:10 p.m., Calmoseptine External Ointment 0.44020.6% was ordered, apply to buttocks two times a day for wound care to buttocks twice a day (BID) and PRN4/28/26 at 3:13 p.m., MASD, in-house acquired on the left gluteal fold that had not been evaluated by a provider; barrier cream was applied. The progress note lacked mention of notification to the provider. 5/5/26 at 12:26 p.m., MASD, in-house acquired on the intergluteal cleft that had not been evaluated by a provider. The progress note lacked mention of treatment, clinical suggestions, or notification to the provider. 5/5/26 at 10:01 p.m., a Braden Evaluation (assessment tool used to predict risk of developing pressure ulcers) was completed with a score of 12, which indicated a high risk of developing PU. 5/9/26 at 11:35 p.m., resident's daughter indicated R2 might have a wound on her bottom she was not informed about. The LPN-B performed an assessment that revealed on-going MASD and a Stage 1 PU(skin is not broken but is red and discolored or may show hardness or temperature change compared to the skin around it) about 1 cm to 2 cm on R2's coccyx. The LPN-B informed the nurse on-coming nurse for the subsequent shift and advised that nurse to inform the resident provider on Monday, 5/11/26, so they can possibly prescribe a topical ointment for the resident coccyx. The progress note lacked evidence the LPN-B notified the provider of the PU. 5/11/26 at 2:01 p.m., MASD on the gluteal cleft that had been evaluated by a provider, noted as an in-house acquired new wound that measured 1.36 cm in width (W) x 1.45 cm in depth (D), with 100% granulation tissue (new pink connective tissue that fills the base of a wound), with orders to clean the wound with generic wound cleaner and cover it with Calmoseptine Ointment daily and PRN. R2's Skin Issues/ Skin Checks notes indicated the following:4/1/26 at 11:27 a.m., Skin Issues: new issue, intergluteal cleft, MASD, 3.99 cm x 4.34 cm, 100% granulation tissue, no drainage. The care planning and clinical suggestions sections were not completed. 4/7/26 at 9:36 a.m., Skin Issue: in-house acquired MASD on intergluteal cleft, resolved. 4/7/26 at 3:38 p.m., Skin Check: skin issue needs review, in-house acquired MASD on intergluteal cleft, with no education provided, no provider/family notifications or clinical suggestions noted. 4/14/26 at 3:20 p.m., Skin Check: skin issue needs review, in-house acquired MASD on intergluteal cleft, no education provided, no provider/family notifications noted. Clinical suggestion indicated apply barrier cream to skin. 4/22/26 at 9:59 a.m., Skin Issues: in-house acquired MASD on intergluteal cleft, resolved. 4/28/26 at 3:13 p.m., Skin Check: skin issue needs review, in-house acquired MASD on intergluteal cleft, no provider/family notifications or clinical suggestions noted. 5/5/26 at 12:26 p.m., Skin Check: skin issue needs review, in-house acquired MASD on intergluteal cleft, no provider/family notifications or clinical suggestions noted. 5/11/26 at 2:01 p.m., Skin Issues: evaluated, in-house acquired MASD on intergluteal cleft, new wound, 1.36 cm x 1.45 cm, 100% granulation tissue, none exudated noted, but has exudate noted to be serosanguinous (mixture of serous - clear pale watery fluid and sanguinous fluid-contains fresh blood or has a blood-like appearance), with a pink wound bed, and minimal dressing saturation, treated with Calmoseptine ointment daily and PRN, with no care plan or wound interventions noted.The skin assessments lacked indication a skin check was performed on R2 the week of 4/21/26. R2's provider orders indicated the following:2/3/26 Calmoseptine Ointment .44-20.6% ointment, apply to buttock topically two times a day (BID) for wound cares to buttock and PRN During an interview on 5/20/26 at 3:56 p.m., the FM-D stated R2 had a wound on her bottom for the 3rd or 4th time, because facility staff didn't change R2's incontinence brief frequency enough and R2 lays on her backside in bed for hours in a row. The FM-D stated for the last six months, she requested R2 be put to bed after 9:00 p.m., and to be gotten up on the morning before 10:00 a.m. The FM-D stated she visits R2 almost daily, and leaves the facility around 7:00 p.m. or 7:30 p.m. nightly, and the video camera footage in the room revealed staff putting R2 to bed around 7:45 p.m., nightly after the FM-D leaves for the day. The video camera footage revealed staff gets R2 up in the morning between 11:00 a.m. and 11:30 a.m., and then don't change R2's incontinence brief again util they put her to bed at night. The FM-D further stated she has talked to staff about it daily for about three weeks because the routine had not changed, but not R2 at least gets checked and changed at the end of first shift and is them up in her chair again until bedtime. The FM-D stated she discovered R2 has a wound on her bottom when she saw a soiled incontinence wipe and undergarment in the garbage that had blood on them on 5/2/26. The FM-A stated she asked the facility DON to have a wound nurse assess the wound, and was told it happened, but when she reviewed camera footage, discovered no wound rounds occurred for R2. The FM-A then spoke to the DON, stated she had been lied to about the wound care team seeing R2, and asked again for the wound care team to see R2. The DON assessed the wound, ordered a product from the pharmacy called butt goop, and told the FM-D the wound should have been assessed long before it was. Now, as seen by the FM-D on video footage, the wound care team visits R2 weekly on Wednesdays. The FM-A stated she just wants the wound treated, was concerned about infection, and the wound looked really raw and red the last tine she saw it, approximately two weeks prior to the interview. Additionally, the FM-D stated she had video footage of staff wiping R2's wounds and R2 hollered out in pain during the care. The FM-D stated, if the wounds had been found before they were open, they might not be so painful to clean. During an interview on 5/26 26 at 10:09 a.m., the LPN-B stated R2 had ongoing MASD, and it was possible the treatment was not working because it kept returning. The treatment was to apply a barrier cream and reposition R2 every two to three hours. The LPN-B stated weekly skin checks were performed each week during the resident's bath time, and if it was not completed weekly, skin deterioration could be missed that wasn't identified previously. During an interview on 5/26/26 at 12:29 p.m., the NP-A stated if R2 did not get the wound checks and assessments as ordered, new wounds could be missed, or the wounds could get worse. During an interview on 5/26/26 at approximately 1:30 p.m., the RN-B stated staff told the wound team about wounds on R2's bottom, but during assessment, the wound team did not locate the wounds. Twice, staff sent pictures to the wound team, and the wound team did not find the wounds. After R2's family got upset with the DON, the wound team looked a third time, and moved skin folds around more, and discovered two wounds on R2's perineum (region of the body located between the thighs between the anus and vaginal opening). The RN-B stated the wound did not likely recur but were likely present each time. The RN-B stated she didn't think repositioning in a wheelchair would make a difference, but instead it was the sitting on the area that was likely causing the issue. The RN-B stated she was unsure if that education was provided to the family and did not find any documentation indicating education to the family about not sitting on the wounds had occurred. The RN-B acknowledged R2 did not have a skin check the week of 4/21/26 and stated the facility could miss new wounds when the assessments were not done weekly. During an interview on 5/26/26 at 2:32 p.m., the nursing assistant (NA)-A stated she thought R2 had pain with the wounds on her bottom and sometimes hollered out during checks and changes for incontinence. During an interview on 5/26/26 at 3:31 p.m., the DON stated R2 had previous MASD wounds, and then recently staff found them again. Ensuring skin checks are completed timely, education about refusals of care, and keeping R2 as dry as possible were keys to ensure MASD didn't occur. The DON acknowledged R2 did not have a skin check on 4/21/26 but should have and acknowledged skin checks were utilized to discover new skin issues, and skin issues forms were utilized to assess current skin issues, and stated It could have potentially made a difference if that skin check had been done. I wish we had noticed the wounds sooner. R4 R4's Medicare 5-Day MDS dated [DATE] indicated R4 had intact cognition, was dependent upon staff for applying footwear, had a pressure ulcer, and was at risk of developing additional pressure ulcers. R4's diagnoses included an unstageable pressure ulcer, diabetes, and diabetic foot ulcers. R4's care plan indicated the following:5/4/23 difficulty sleeping 6/13/23 type II Diabetes 6/13/23 altered cardiac status related to congestive heart failure (chronic progressive condition in which the heart cannot pump blood efficiently enough to meet the body's needs) and hypertension (high blood pressure)7/24/23 peripheral vascular disease (slow progressive circulatory disorder characterized by the narrowing, blockage, or spasms of blood vessels, most commonly reducing blood flow to the arms, legs, and feet5/12/25 impaired vision6/30/25 incontinence of bowel12/12/25 encephalopathy (broad term for any disease, damage, or malfunction that affects the brain's function, with an altered mental state that may include confusion, memory loss, or personality changes)12/18/25 kidney failure related to Type II diabetes4/2/26 actual and potential impairment to skin integrity related to immobility, diabetes, obesity, incontinence, chronic moisture associated skin damage (MASD), and lymphedema (chronic condition of build-up of fluid from the lymphatic system (network of tissues, organs, and vessels that maintain fluid balance, absorbs dietary fats, and defends the body against infections and circulates lymph fluid (colorless, watery fluid) throughout the body) in the body's soft tissues, usually in the arms or legs often started with swelling in the hands or feet). Interventions included protecting bony areas with pillows and supportive devices initiated 1/6/22, and pressure relief ankle foot orthosis (PRAFO, used to stabilize the ankle, prevent foot drop, and eliminate pressure on the heels) boots on at all times, initiated 5/4/23. R4's orders included the following:4/17/26 Novolog ( a short-acting insulin given before meals, often given in combination with a long-acting insulin) Flex Pen 100 units/milliliter (unit/ml), inject 20 units subcutaneously (subq) before meals 4/18/26 Novolog Flex Pen 100 unit/ml sliding scale, inject subq before meals: if blood glucose (BG):150-199 give 3 units200-249 give 6 units250-299 give 9 units300-349 give 12 units250-399 give 15 units400+ give 18 units and call physician4/17/26 oxycodone hydrochloride (HCl - narcotic pain medication administered for moderate to severe pain) 5 milligrams (mg), give 5 mg by mouth as needed for pain one time daily in the morning, in the evening, and PRN for pain one time daily. 4/17/26 Sildenafil citrate 20 mg, give 20 mg three times daily related to pulmonary hypertension (high blood pressure in the arteries that carry blood from the heart to the lungs)5/11/26 UA/UC for cloudy urine and chills R4's diagnoses list dated 5/20/26, included diagnosis of sepsis dated 5/19/26. R4's care timeline provided by email by the facility after the survey exit as supplemental documentation on 5/28/26 at 5:55 p.m., indicated the timeline was developed using nursing documentation and review of video footage from the facility, revealed the following:5/12/26 at 7:38 a.m., not feeling well, provider ordered UA/UC, observed vomiting, resident declined going to the Emergency Department. The timeline lacked indication a nursing assessment was completed, or VS were taken. 5/12/26 at 8:00 a.m., NA entered the room, daily weight taken. The timeline lacked indication VS were taken, what care was provided, or the condition of the resident. 5/12/26 at 8:53 a.m., a nurse entered the room. The timeline lacked indication a nursing assessment was performed, VS were taken, or the condition of the resident. 5/12/26 at 9:02 a.m., a nurse entered the room to administer medication. The timeline lacked indication a nursing assessment was performed, or VS were taken. 5/12/26 at 10:27 a.m., a nurse and trainee were observed entering the room briefly to monitor. The timeline lacked mention of what monitoring occurred, nor what was observed. 5/12/26 at 11:34 a.m., a nurse entered the room. The timeline lacked indication a nursing assessment was performed, VS were taken, or the condition of the resident. 5/12/26 at 11:41 a.m., a NA entered the room. The timeline lacked indication VS were taken, what care was provided, or the condition of the resident. 5/12/26 at 12:21 p.m., a NA brought lunch to the room. The timeline lacked information about the condition of the resident. 5/12/26 at 1:04 p.m., the timeline indicated, Oxygen tank with no further reference. 5/12/26 at 2:10 p.m., a NA entered the room. The timeline lacked indication VS were taken, what care was provided, or the condition of the resident. 5/12/26 at 3:33 p.m., a NA entered the room. The timeline lacked indication VS were taken, what care was provided, or the condition of the resident. 5/12/26 at 2:24 p.m. a nurse and trainee entered the room. The timeline lacked indication a nursing assessment was performed, VS were taken, or the condition of the resident. 5/12/26 at 4:20 p.m., the NP was notified the UA was back. No further assessment details were included. 5/12/26 at 5:30 p.m., a nurse entered the room. The timeline lacked indication a nursing assessment was performed, VS were taken, or the condition of the resident.5/12/26 at 6:08 p.m., a NA entered the room. The timeline lacked indication VS were taken, what care was provided, or the condition of the resident. 5/12/26 at 6:22 p.m., a nurse took R2's temperature. The timeline lacked indication a nursing assessment was performed, additional VS were taken, or the condition of the resident.5/12/26 at 7:49 p.m., a NA entered the room. The timeline lacked indication a nursing assessment was performed, VS were taken, or the condition of the resident.5/12/26 at 8:15 p.m., a NA entered the room. The timeline lacked indication a nursing assessment was performed, VS were taken, or the condition of the resident.5/12/26 at 8:44 p.m., a nurse entered the room. The timeline lacked indication a nursing assessment was performed, VS were taken, or the condition of the resident.5/12/26 at 10:21 p.m., a nurse documented lethargy all shift, and indicated her note she was frequently monitoring from 2:30 p.m., to 10:30 p.m. The timeline lacked indication a nursing assessment was performed (other that indicating lethargy), VS were taken, or the condition of the resident.5/12/26 at 10:47 p.m. a nurse entered the room. The timeline lacked indication a nursing assessment was performed, VS were taken, or the condition of the resident.5/13/26 at 12:53 a.m., assessed by nurse and sent to ER. The timeline included 18 opportunities for staff to take VS, 11 opportunities for a nurse to perform an assessment including taking VS and reporting on the condition of the resident. The timeline lacked mention R4 started feeling ill on 5/11/26, lacked mention of any VS other than one temperature, and lacked an update on R4's condition to the provider other than to report the UA was back. R4's progress notes indicated:5/11/26 at 2:01 p.m., oxycodone Hcl 5 mg was administered for back pain5/11/26 at 3:55 p.m., urine was cloudy this shift and temperature was 99.3 [Fahrenheit (F)]. The nurse practitioner was notified and an order was given for UA/UC (urinalysis - a urine test and urine culture - to test for bacteria). Report given to p.m. shift nurse. 5/11/26 at 4:59 p.m., urine specimen collected this evening. Lab has been called for collection. 5/11/26 at 5:11 p.m., refused scheduled Novolog injection but allowed the Novolog sliding scale injection, and did not want to eat dinner. 5/12/26 at 6:40 a.m., indicated R2 was not feeling well, a UA/UC were collected, resident was weak and had vomited, R2's VS were P-83, O2 sats 91 %, on 5 liters (L) O2 per his baseline, with a temperature of 101.1. The nurse offered to send R4 to the ER, but R4 declined to go. R4 requested PRN Tylenol 1000 mg which he took. The VS lacked assessment of BP and respirations. The nurse reported R4's condition to on-coming staff. The note lacked mention of an update to the resident's provider or family. 5/12/26 at 7:46 a.m. resident's current condition inhibited any leg treatments. The progress note lacked mention of a nursing assessment or VS taken. 5/12/26 at 11:15 a.m., resident refused to eat. The progress note did not indicate why, a nursing assessment, or VS.5/12/26 at 2:14 p.m., Tylenol 1000 mg given for pain. The resident had a temperature of 100.5 F. The progress note lacked mention of the location of the pain, other VS, or additional nursing assessments. 5/12/26 at 2:20 p.m., oxycodone HCl 5 mg administered for back pain5/12/26 at 3:27 p.m., Tylenol effective was rated as ineffective with pain rated as 5/10. R4 also had oxycodone HCl 5 mg at 2:20 p.m. The progress note lacked an update to the provider about unmanaged pain or that an extra oxycodone HCl was required or administered. 5/12/26 at 3:28 p.m., refused Novolog 20 units insulin. The note lacked indication that the provider was notified of insulin refusals on 5/11/26 and 5/12/26 or education about the risks and benefits of refusing the medication. 5/12/26 at 4:20 p.m., the provider was notified of resident change in condition. 5/12/26 at 9:49 p.m., resident refused Sildenafil Citrate 20 mg, resident if very lethargic. The progress note lacked mention of notification to the provider the resident refused the medication or education about the risks and benefits of refusing the medication. 5/12/26 at 10:16 p.m., resident lethargic all shift, waiting for culture results from UA, brother was present and will be back 5/13/26, resident refused some of his meds, did not eat or drink and needed help holding a cup. The progress notes lacked VS, a nursing assessment, or indication the provider was aware of R4's current condition. 5/13/26 at 1:15 a.m., R4 was found unresponsive in his bed, O2 sats 77% on 5 L O2 at 12:50 a.m. Provider notified at 12:53 a.m., and order received to send R4 to the ER for further evaluation and treatment. The progress notes lacked an assessment of VS other than O2 sats. 5/13/26 at 3:30 a.m., R4 admitted to hospital, noted with temperature of 103.3F. The progress notes lack evidence of nursing assessments including full vital signs, pain assessment, changes in cognition and speech, lung sounds, changes in mobility or elimination, and lacked evidence of education provided to either the resident or the resident's family member about the risks and benefits of medication refusals, delay in care and hospitalization, or palliative care options. R4's vital signs records lacked indication a blood pressure was assessed after 5/1/26 at 3:47 p.m., a pulse was assessed between 5/1/26 at 3:47 p.m., and 5/12/26 at 9:55 p.m., or a temperature was taken between 5/1/26 at 3:47 p.m., and 5/12/26 at 6:28 p.m., other than the two mentioned in the progress notes. During an interview on 5/20/26 at 11:58 a.m., R4 stated he had returned from the hospital the day prior for an infection in his blood. During an interview on 5/22/26 at 9:57 a.m., the FM-E stated R4 had many hospitalizations, seemingly related to his catheter and UTIs. The FM-E stated he was concerned about R4's recent hospitalization because it seemed like a del

Based on interview, observation, and document review the facility failed to promote dignity for 1 of 4 residents (R4) when his call light was not answered timely, staff did not honor a request to don R4's protective heel boots, and did not provide a blanket to cover his body. Findings include: R4's Medicare 5-Day Minimum Data Set (MDS) dated [DATE] indicated R4 had intact cognition, was dependent upon staff for activities of daily living (ADLs) including applying footwear, had a pressure ulcer, and was at risk of developing additional pressure ulcers. R4's diagnoses included an unstageable pressure ulcer, diabetes, and diabetic foot ulcers. R4's care plan indicated the following:11/15/23- dependent on staff to put on/take off shoes4/2/26- indicated R4 had potential and actual skin impairment, admitted to the facility on [DATE] with an unstageable right heel venous ulcer (sores that typically occur on the legs due to poor blood circulation), left medial malleolus (bony prominence on the inner side of ankle) diabetic ulcer, a left plantar (foot) ulcer, and right medial calf (inner side of the lower leg).4/2/26- actual and potential impairment to skin integrity related to immobility, diabetes, obesity, incontinence, chronic moisture associated skin damage (MASD), and lymphedema (chronic condition of build-up of fluid from the lymphatic system (network of tissues, organs, and vessels that maintain fluid balance, absorbs dietary fats, and defends the body against infections and circulates lymph fluid (colorless, watery fluid) throughout the body) in the body's soft tissues, usually in the arms or legs often started with swelling in the hands or feet). Interventions included protecting bony areas with pillows and supportive devices initiated 1/6/22, and pressure relief ankle foot orthosis (PRAFO, used to stabilize the ankle, prevent foot drop, and eliminate pressure on the heels) boots on at all time initiated 5/4/23. During continuous observation on 5/22/26, starting at 1:13 p.m., R4 was lying in bed covered in a white sheet, his protective boots were sitting in his recliner out of reach. R4's call light was activated. At 1:51 p.m., the nursing assistant (NA)-D responded to R4's call light. R4 told the NA-D he would like his boots on and asked the NA-D to tell the nurse he was waiting for his wound care. The NA-D responded to R4, Right now? R4 told the NA-D his boots were supposed to have been on since after his morning bath. The NA-D shut R4's door, and when it was opened again at 1:54 p.m., R4's protective boots were on his feet. R4 was covered with a sheet. During an interview on 5/22/26 at 1:13 p.m., R4 stated he had been trying to get a blanket after his morning bath but was told the facility did not have a blanket to give him. R4 was covered in a white sheet but wanted a blanket because he had visitors coming and didn't want just a see-through sheet, so his visitors didn't see his wounds. It was R4's birthday, and he just wanted to be covered properly for his guests. R4 stated he had asked his NA about what was in his recliner several times and was told only a pillow was in the recliner. The NA did not tell R4 his boots were also in the recliner. Because R4 didn't have feeling in his lower extremities, and had poor vision, R4 stated that he could not see what was in the chair and did not know his boots were not on his feet. During an interview on 5/22/26 at 1:54 p.m., the nursing assistant (NA)-C stated he was not R4's NA that day but just came to answer R4's call light. The NA-C stated staff was supposed to answer call lights within five minutes, NA-C stated R4 would likely be upset about having to wait to get assistance from staff and would be embarrassed if he was not able to cover his body with a blanket as requested. During an interview on 5/22/26 at 2:05 p.m., the registered nurse (RN)-C stated all staff were responsible for answering call lights. RN-C hadn't seen R4's call light because she was not able to see the banner which displayed the activated call lights. Further, the RN-C stated R4 would not feel important to staff if he had to wait all morning to get a blanket or his protective boots and further stated the NA should have looked for a blanket for R4 on another floor. During an interview on 5/22/26 at 2:25 p.m., the NA-D stated he was R4's assigned NA for the shift, and stated R4's boots were supposed to go on in the morning. The NA-D stated he informed NA-C he was going on break and NA-C should have answered R4's call light. The NA-D acknowledged R4 wanted his protective boots, a blanket, and staff didn't answer R4's call light timely. The NA-D stated R4 would be sad, disappointed, and not well cared for when his needs weren't met. During an interview on 5/26/26 at 3:31 p.m., the director of nursing (DON) stated waiting 38 minutes for a call light response was too long, and staff were expected to answer call lights as quickly as possible, Thirty-eight minutes sitting there waiting feels like a lifetime. Further, the DON stated R4 would feel terrible waiting for his protective boots, and when residents asked for help, staff was expected to help meet their needs. The Promoting/Maintaining Dignity policy dated 4/1/26 indicated it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance guidelines included: During interactions with residents, staff must report, document and act upon information regarding resident preferences.Respond to requests for assistance in a timely manner. The Call Lights Accessibility and Timely Response policy dated 4/2025 indicated that all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on interview and document review the facility failed to accurately transcribe a medication order correctly for Bumex (diuretic medication used to remove fluid) for 1 of 1 resident (R1) which resulted in an 18-pound (lb.) weight loss in 12 days, critical labs, vomiting and a hospitalization. In addition, the facility had two additional medication errors and failed to implement appropriate corrective actions to prevent the significant medication error for R1. The facility failure resulted in an immediate jeopardy (IJ) for R1.The IJ began on 11/07/25, when R1 was ordered Bumex (diuretic) 2 milligrams (mg) by mouth (po) QD (daily) x three days. The order was transcribed as Bumex 2 mg po TID (three times daily) with no stop date indicated. As a result, R1 received (36) 2 mg doses from 11/7/25 to 11/18/25 versus the 3 doses he should have been administered. R1 was admitted to the hospital with acute kidney injury and infection on 11/18/25. The administrator and director of nursing (DON) were notified of the IJ on 11/26/25 at 3:05 p.m. The IJ was removed on 11/28/25, at 1:45 p.m., but non-compliance remained at the lower scope and severity of level D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact had cellulitis of left lower limb, atrial fibrillation, renal insufficiency (kidneys are not functioning as well as they should, leading to waste products and fluid buildup in the body) and cardiomyopathy (heart disease that affects the heart muscle's ability to pump blood efficiently). The MDS also indicated he was frequently incontinent of bladder, required partial assist with toileting had one diabetic foot ulcer with infection and received an antibiotic medication. The MDS further indicated his weight was 179 lbs. and no weight loss or unknown weight loss.R1's Care Plan dated 11/05/25, indicated he had renal failure/insufficiency related to chronic kidney disease and directed staff to provide fluids as ordered, give medications as ordered by medical practitioner, observe for changes in mental status: lethargy, somnolence, fatigue tremors and seizures. Observe for signs of fluid loss or fluid overload, observe lab reports of electrolytes and report to medical practitioner.R1's Medical Diagnosis List undated, indicated he had chronic kidney disease and failure and Type II Diabetes. On 11/6/25, R1 was order Bumex (diuretic) 2mg po QD (daily) x three days. The order was transcribed as Bumex 2mg po TID (three times daily) with no stop date indicated. As a result, R1 received (36) 2mg doses from 11/7/25 to 11/18/25 versus the 3 doses he should have been administered.R1's Lab results indicated the following: On 11/18/25:BUN- 99 H (high) (8-23) (evaluates kidney function.)Creatinine 3.4 H (0.67-1.7) (checks kidney function.)GFR 19 L (low) >60 (measures how well kidneys are filtering waste from your blood.) WBC 13.33 H (4.0 to 0.11) (shows if you have an infection.) Weight on 11/6/25 was 182.2, 11/18/25 was 163.4, a loss of 18.8 pounds. Additionally, between 11/6-11/18, a weight was to be recorded weekly and was missed the week of 11/10/25.Progress Note dated 11/17/25 at 11:55 p.m., indicated R1 reported not feeling well during day shift and evening shift, vital signs stable on this shift, but patient refused to go to the hospital to be evaluated. MD (medical doctor) notified and ordered BMP (basic metabolic panel, CBC (complete blood count) and thyroid stimulating hormone (TSH) to be drawn tomorrow. Progress notes on 11/18/25 at 2:38 p.m., indicated MD called with lab results and to talk to family to see if they want him transferred to the emergency department (ED) for further evaluation and treatment. Labs indicate resident is dehydrated, this writer talked to family resident will be transferred to hospital and 911 called all paperwork sent with emergency medical services (EMS). Family would like to hold the bed. R1's Emergency Department Encounter dated 11/18/2025 at 4:06 p.m., indicated he presented to the ED department by emergency medical services (EMS) for evaluation of generalized weakness. The transitional care unit (TCU) he was at had been administering 2 mg of Bumex TID since 11/07 or 11/10 (staff unsure) instead of how it was prescribed which was 2mg of Bumex daily for three days. The ED note indicated the final Impression was Acute Kidney Injury (AKI) superimposed on CKD (chronic kidney disease).R1's Hospital admission Encounter dated 11/18/25, indicated noted to have miscommunication regarding his Bumex dose and had been taking TID (since 11/6) instead of daily x 3 days. Holding Bumex this admission, renal function gradually improving, continue oral bicarbonate and received IV fluids after angiogram yesterday, has colitis (C.diff)(clostridioides difficile bacterium that causes an infection of the colon, the longest part of the large intestine) developed abdominal pain, diarrhea and elevated WBC (white blood cell count) this stay. Placed on oral Vancomycin (used to treat serious infections) QID (four times a day) (starting 11/20) and probiotic. In addition, has Chronic left foot wound. Weight listed was 165 lbs.During interview on 11/25/25 at 10:21 a.m., director of nursing (DON) stated the provider wrote a written order for the Bumex and the health unit coordinator (HUC) transcribed the order. The DON stated the HUC was new to her position and did not have a medical background, but the nurse manager licensed practical nurse (LPN)-A was to complete a second check to make sure the order was transcribed correctly which was missed and resulted in the medication given incorrectly for eight days. LPN-B noted R1 was not feeling well, was vomiting, and noticed redness on R1's wound on his left leg on 11/17/25. LPN-B notified the on-call physician and later that afternoon labs were ordered. On 11/18/25, R1's physician's triage team notified us R1's Bumex order was only supposed to be given once daily for three days not three times daily with no stop date. It was then decided to send R1 to the emergency department and he was hospitalized . The DON stated he was admitted with acute kidney injury, wound infection in soft tissue. And after the medication error was found they immediately started a review of all orders to cross check to make sure they were accurate starting that day. In addition, they added a triple check the nurse managers were to start daily. During interview on 11/25/25 at 2:50 p.m., health unit coordinator (HUC)-A stated she is the HUC for the Transitional Care Unit (TCU) and is new to the facility. She was trained by the second floor HUC for a week and received computer training from the facility. HUC-A stated she does not have a background in the medical field except for working in a group home in the past. HUC-A stated she did not know the terminology for QD, TID and QID but is learning from being at the facility and asking questions from the nurses and the staff. She stated after each medication error HUC-B would explain to her how the transcription error occurred, corrected her and for R1 she also explained how dangerous that was. During interview on 11/26/25 at 12:05 p.m., DON stated they have started to have the nurse managers run a report on all new orders for the day and then go back and have them recheck them as a triple check three times a week, in addition to herself reviewing all new orders to make sure they were audited correctly and nothing was missed. In addition, the DON stated R1 was never a complainer and never did complain of having a need to go to the bathroom at night and was surprised none of the nurses realized they were giving a diuretic in the evening. DON stated the staff were supposed to be weighing R1 weekly and noticed he did have a significant weight loss, and he did have one weekly weight missed. She also stated from her review of the hospital records R1's hospital admission was the result of many medical complications which included the medication error of Bumex.During interview on 12/01/25 at 1:20 p.m., R1's medical provider (MP) stated R1 had underlying kidney failure prior to his hospitalization on 11/28/25 and was ordered diuretics (Bumex) short term due to his swelling and blisters in his left leg wound. The MP stated she did not want to give him long term diuretics due to his kidney issues and felt the staff should have clarified the order. MP stated R1 had c-diff, was also suffering from diarrhea and diuresis (condition in which the kidneys filter too much bodily fluid. That increases your urine production and the frequency with which you need to use the bathroom), which could be the contributing factors for his acute kidney injury. In addition, the MP stated the nursing staff also should have caught the error when giving a diuretic in the evening and because TID is a high rate to give Bumex. MP stated she felt the medication error contributed to an unnecessary hospitalization. Review of the facility's medication errors indicated the following:On 11/3/25, two medication errors were discovered by the facility pharmacy due to a transcription error.R3's Medical Diagnosis List undated, indicated she had delusional disorders, bipolar disorder, and overactive bladder.-R3's admission orders dated 10/31/25, revealed an error as to she received 50 milligrams (mg) of Quetiapine (antipsychotic) BID (twice daily) when the order was to be written as two times daily as needed (PRN). As a result, the resident received 6 doses of Quetiapine scheduled in error.-The same resident received 2mg of Tolterodine (for overactive bladder) twice a day when the order was written to be once daily. As a result, the resident received double the dose for three days.In response, the facility retrained the Health Unit Coordinator (HUC), who transcribed the medication orders incorrectly and the nurse who was responsible for the second check to ensure the transcriptions were correct. No audits of other recently transcribed orders were conducted.During interview on 11/26/25 at 10:04 a.m., LPN-D stated she saw a fax from the pharmacy and called the physician right away to inform of the transcription and medication error. R2's Hospitalist Discharge summary dated [DATE] at 4:51 p.m., indicated he was to receive furosemide 20 mg tablet, take one tablet (20 mg) by mouth and two tablets (40 mg) by mouth daily alternating for Coronary artery disease (CAD the arteries supplying blood to the heart become narrowed by a buildup of plaque) involving native coronary of native heart without angina pectoris (chest pain).On 11/17/25, a transcription error was found for R2's Furosemide (diuretic to reduce fluid), ordered by the provider to take 20mg and 40mg alternating every other day but transcribed to administer both doses the same day. This error was caught by the facility before any incorrect administration of the medication. The HUC was again retrained. No audits of other recently transcribed orders were conducted.The immediate jeopardy that began on 11/07/25, was removed on11/28/25, when it was verified, the facility implemented the following:Determined the root cause for transcription/medication errors and put in place additional safeguards.-review and revise policy and procedures as needed-educated staff on new procedures before the start of next shift worked.Medication Reconciliation Policy revised 11/26/25, indicated the facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent. Medication reconciliation refers to the process of verify that the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident at all points throughout his or her stay.

Based on interview and document review, the facility failed to accurately assess and implement interventions to prevent hypoglycemia (low blood sugar) for 1 of 1 resident who was diabetic, had a blood sugar of 30 mg/dl (milligrams per deciliter; normal range is 80-130 mg/dl) and was unresponsive at dialysis. This resulted in an immediate jeopardy for R1 who was hospitalized with hypogylcemia. The IJ began on 3/1/25 at 5:00 p.m. when R1 was admitted to the facility with orders for insulin but lacked orders to check blood sugars. The facility did not implement standing orders or request orders to monitor R1's blood glucose levels, resulting in a severe drop in R1's blood sugar level and hospitalization . The administrator, director of nursing (DON), and regional nurse were notified of the IJ on 3/7/25 at 11:50 a.m. The facility had implemented immediate corrective action on 3/4/25 to prevent recurrence prior to the survey, therefore, the IJ was issued at past none compliance. Findings include: R1 admitted to the facility on [DATE] with a diagnoses of dependence on renal dialysis, pleural effusion, Type 2 Diabetes Mellitus (DM) with diabetic chronic kidney disease, acute respiratory failure with hypoxia, chronic atrial fibrillation, and chronic systolic congestive heart failure. R1's physician admission orders indicated that he was to receive 35 units Lantus (insulin) once daily at bedtime, and to use nursing home standing orders. Admission orders lack direction for blood sugar checks. A facility document, Standing Orders for Skilled Nursing Facilities dated 2023, directed to initiate four times daily blood glucose monitoring upon admission for three days for all diabetic patients unless ordered otherwise. R1's hospital discharge summary, dated 3/1/25, indicated he was hospitalized from 1/21/25 through 3/1/25 and his insulin requirements had been decreasing and he started having hypoglycemia episodes after being started on hemodialysis on 2/13/25. The discharge summary also directed R1 to have a continuous Dexcom 7 sensor (a continuous glucose monitoring system that provides real-time glucose readings, alerts for highs and lows) to be changed every ten days. R1's care plan indicated R1 had a diagnosis of diabetes and took hypoglycemic medication (insulin). R1's progress note dated 3/3/25 at 7:45 a.m., indicated writer received call from Fresenius dialysis clinic regarding R1, who was found unresponsive upon arrival at the dialysis clinic and sent to the hospital. R1's hospital note, dated, 3/3/25, indicated he was admitted for hypoglycemia, tachypnea (rapid breathing) and tachycardia (fast heart rate) with the plan to remain hospitalized for at least two additional days to monitor and stabilize. R1's progress notes lacked any blood sugar readings from 3/1/25 through 3/3/25. R1's MAR (medication administration record)/TAR (treatment administration record) lacked instruction for blood sugar monitoring. On 3/6/25, registered nurse (RN)-A (dialysis nurse) stated R1 was dropped off at the dialysis clinic at 7:50 a.m., on 3/3/25. RN-A stated R1 was very weak and could not answer questions. R1 was not responding to verbal cues, his head was tilted to the side, and his mouth was wide open. She called for help right away and checked his blood sugar which was 30 mg/dl (normal range is 80-130 mg/dl, per the American Diabetes Association). Emergency medical services (EMS) called. EMS transported R1 to the hospital for evaluation. RN-A also stated R1 was not provided a lunch in anticipation of dialysis. On 3/6/25, at 12:28 p.m., RN-B (RN nurse manager) stated at admission, nurses should initiate standing orders for blood sugar checks for three days for any diabetic residents who did not have a physician order to check blood sugars and notify the provider to request orders. RN-B stated nurses should check blood sugar and vital signs for any diabetic residents before sending them to dialysis treatment. On 3/6/25, at 1:24 p.m., the director of nursing (DON) stated she expected nursing staff to ensure residents received breakfast, checked blood sugar and vital signs for diabetic residents before sending them to dialysis. On 3/6/25, at 2:18 p.m., licensed practical nurse (LPN)-A, an agency nurse assigned to R1 the morning of 3/3/25, stated he did not check R1's blood sugar and vital signs prior to his dialysis appointment. LPN-A stated he did not give R1 breakfast before R1 left for dialysis. LPN-A did not know R1 had diabetes at the time and no report was given to him about R1's diabetic status. On 3/6/25 at 3:24 p.m., medical provider (MD)-A stated she expected nursing staff to check the blood sugar of diabetic residents, even if they do not have order from the hospital, before sending them to the dialysis treatment. On 3/7/25, at 1:29 p.m., LPN-A stated R1 was brought to the lobby of the facility around 6:30 a.m. on 3/3/25. LPN-A stated transportation was scheduled for 7:00 a.m. to pick R1 up for dialysis. LPN-A stated he wasn't sure why R1 didn't receive breakfast. On 3/7/25, at 1:36 p.m., RN-C stated he and another nurse entered R1's orders on 3/1/25. RN-C stated he was aware diabetic residents should have blood sugar checks for the first few days, per the standing orders. RN-C confirmed this was missed. On 3/7/25, at 1:40 p.m., RN-D stated she and RN-C worked together to enter R1's orders on 3/1/25. RN-D stated she would expect blood sugar checks for a diabetic resident on insulin. RN-D stated they should have called to clarify R1's orders. On 3/7/25, at 2:15 p.m. family member (FM)-A stated R1 remained hospitalized but his status was improving. A facility policy regarding caring for diabetic residents was requested, but not received. The facility implemented corrective action prior to the start of survey. The IJ is issued at past noncompliance. IJ began on 3/1/25 and was corrected by 3/4/25. Facility action included: The facility identified like residents and ensured appropriate blood glucose monitoring was in place. Education was provided to all nursing staff on standing orders and when to implement standing orders, specifically to diabetic care. Reviewed and educated nursing staff regarding the importance of nutrition for vulnerable residents including those with diabetes or on dialysis. Re-educated staff who provide diabetic care to the dialysis residents on these policies and procedures. Orientation training package to be provided to all agency staff with competencies test.

Based on observation, interview and document review, the facility failed to implement care plan interventions, including providing required supervision, which resulted in a fall for 1 of 1 residents (R68) reviewed for accidents. This resulted in actual harm when R68 required hospitalization for pain control and sustained a fractured left tibia and fibula (lower leg bones). The facility had implemented and completed corrective action prior to the start of the survey, and the deficient practice is being issued at past non-compliance. Findings include: R68's annual Minimum Data Set (MDS), dated [DATE], indicated R68 was admitted to the facility on [DATE], was cognitively intact and required substantial or maximum assistance with toileting and dressing and partial to moderate assistance with bed mobility. R68's care plan, dated 3/22/23, indicated R68 had an activities of daily living (ADL) self-care performance deficit related to failure to thrive, osteoarthritis (inflammation of one or more joints) of the right knee and generalized weakness. Interventions included assistance of two staff for bathing and bed mobility and to ensure two staff were in the room when receiving daily cares due to a history of false accusations. R68's care plan, dated 6/6/24, also indicated R68 had limited physical mobility r/t [related to] ., which lacked information on what the limited mobility was related to in the blank space on the care plan form, with an additional intervention of contour/defined perimeter mattress or bed bolsters. R68's care sheets (used by the nursing assistants to know what cares to provide the residents), dated 6/24/24, indicated R68 was incontinent of bowel and bladder and required assistance of two staff for toileting in bed and bed mobility. During an interview on 6/25/24 at 12:35 p.m., nursing assistant (NA)-J stated the NAs used the care sheets to know what cares, and how to provide cares, to residents, stating the care sheets should be checked every shift in case there had been a change. NA-J stated R68 required two staff members for cares in bed and they had recently received education on cares in pairs for residents who received cares in bed for safety, so the resident does not fall out of bed. R68's progress notes indicated on 6/6/24, at approximately 1:30 p.m., R68 was found on the floor, on the left side of her bed and had complaints of left ankle pain and left side rib pain. R68 was assessed for injury and transferred back to bed. R68's progress notes further indicated a change in condition on 6/7/24 at 8:56 p.m., indicating R68 had continued pain and a recieved a provider recommendation to transfer to the hospital for evaluation. During an interview on 6/25/24 at 1:42 p.m., NA-B stated on 6/6/24, she went into R68's room to help NA-A with cares. NA-B stated R68 was very particular so NA-B told NA-A he could leave, and she would call him back into the room when she needed him. NA-B stated she tried to call NA-A back into the room, but he did not answer the walkie talkie. NA-B stated R68 was on her left side, having a bowel movement, when NA-B noticed she was out of barrier cream. NA-B did not want to lay R68 on her back so her sheets would not be soiled. NA-B then left R68 laying on her left side in bed unsupervised and unassisted in order to go get barrier cream. When NA-B returned, approximately 2-3 minutes later, she found R68 laying on the floor. NA-B stated she called the nurse and NA-A back to the room and R68 was transferred to bed via a hoyer lift. NA-B stated at that time R68 was complaining of left ankle and rib pain and stated she felt herself falling over the left side of the bed but could not stop herself. NA-B stated she was aware at the time of the fall that R68 was to receive cares with two staff members and stated she checked the care sheets daily. NA-B also stated she received education on the importance of always following a resident's care plan, stating R68 would not have fallen if two staff members were in the room providing cares. During an interview on 6/25/24 at 1:27 p.m., NA-A stated on 6/6/24, he went into R68's room with NA-B because R68 required two staff members for cares for safety. NA-A stated NA-B told him she could handle it and R68 did not want him there so he left the room. NA-A stated he did not notify the nurse or another NA to help because NA-B s stated she could handle it. NA-A stated he had received education since R68's fall that all residents who received cares in bed needed two staff members for safety. R68's physician order, dated 6/6/24, indicated an order for a left ankle and chest x-ray to rule out fractures. R68's medication administration record (MAR) indicated the x-ray was completed 6/7/24. R68's after visit summary (AVS) from Woodwinds Hospital, dated 6/10/24, indicated R68 was admitted to the hospital on 6/7/24 due to left ankle pain. The AVS indicated on 6/6/24, facility staff left R68's room after she was placed on the edge of the bed resulting in a fall to the floor. The AVS confirmed R68 sustained a fracture to her left tibia and fibula. R68's hospital discharge orders, dated 6/10/24, indicated a new medication order for hydromorphone (a narcotic used to treat moderate to severe pain) 2 milligrams (mg) by mouth every four hours as needed for severe pain. R68's physician orders indicated an order, dated 6/17/24, for Oxycodone (a narcotic used to treat moderate to severe pain) 5 mg every four hours as needed for pain. R68's medication adminsitration record (MAR), dated 6/24, indicated R68 received hydromorphone 13 times on 6/10/24, 6/11/24 x 2, 6/12/24 x 4, 6/13/24 x 4, 6/16/24 and 6/20/24. The MAR also indicated R68 received oxycodone 14 times on 6/17/24, 6/18/24, 6/19/24 x 2, 6/21/24 x 4, 6/22/24 x 2, 6/23/24, 6/24/24 x 2, and 6/25/24 x 2. R68's Associated Clinic of Psychology (ACP) note, dated 6/11/24, indicated R68 was calm and lethargic likely due to receiving narcotic pain medication. R68's fall from bed was reviewed and how distressing it was for her. R68 indicated she was nervous for facility staff to provide incontinent cares in bed since her return from the hospital and how it will take time for her to regain trust in the facility staff. R68's ACP note, dated 6/18/24, indicated R68 updated the ACP practitioner on her post fall experience and how angry she was at the situation and not able to understand how staff walked out of her room allowing her to fall. The ACP note indicated R68 was very averse to pain and complained of the weight of her left leg cast. R68 continued to be anxious when staff provided incontinent cares in bed, stating they have not done anything to help her feel safer about the process. The note explained how R68 was also concerned about how this incident set her back in her rehabilitation process as she was not able to get out of bed due to pain. During an interview on 6/25/24 at 12:49 p.m., the director of nursing (DON) stated he was made aware of the 6/6/24 incident with R68 the day it happened. The DON stated NA-B had told NA-A he could leave R68's room while providing cares and R68 was ultimately left alone, laying on her left side which resulted in R68 falling from bed. The DON stated due to R68's complaints of left ankle and rib pain post fall an x-ray was ordered that same evening but did not get completed until the following day, 6/7/24. The evening of 6/7/24 the X-ray confirmed a fractured left ankle and R68 was sent to the hospital for evaluation. The DON confirmed at the time of the fall R68 was an assist of two staff members for bed mobility and incontinent cares and that the care plan was not followed. The DON stated another resident at the facility had a similar fall out of bed on 5/2/24 and at that time all residents who received cares in bed were reviewed and it was determined that R68 required assistance of two staff members for bed mobility and incontinent cares in bed for safety to prevent falls. The DON further stated R68 did not have a perimeter mattress but an air mattress currently in place on her bed, stating after IDM review they believed this was a better option after the incident for her due to her fractures and current bed bound status. The DON stated if stay were providing cares in pairs for R68 she would be safe in an air mattress since she did not roll ut of bed on her own, but was left up on her side by staff causing her to fall out of bed. The DON stated interventions for R68's fall revolved around education to the entire staff on care in pairs for residents who received cares in bed and the importance of following the care plan. The DON stated even though NA-A was not in the room at the time of the fall he was also coached on the incident because even if NA-B told him to leave, he should have stayed for R68's safety. The DON stated if a second staff member had been in the room with R68 and NA-B, R68 would not have fallen out of bed stating, she (R68) would not have rolled out of bed on her own, it was because she was left on her side alone. The past non-compliance that began on 6/6/24 and was verified, and found to be corrected, during the current recertification survey from 6/24/24 - 6/27/24. Verification of corrective action was confirmed by observation of cares, interview with staff on education received and document review of the all nursing staff education and coaching provided to NA-A and NA-B. Interviews above with NA-A and NA-B indicated they received coaching and education on the importance of following the care plan and cares in pairs for all bed bound residents for safety. During observation on 6/27/24 at 7:47 a.m., R26, a bed bound resident was observed to receive incontinent care in bed with two staff members present. The nursing staff education given to all nursing staff after the 6/6/24 incident and was completed by 6/21/24 and the recertification survey began on 6/24/24. During survey education documentation was reviewed and indicated nursing staff were educated on Two Assist and Why it Matters. Topics included why do some NAR sheet tasks (care sheets) say A-2 (assist of 2)?, who decides who is A-2 or not?, why do assistance levels matter?, and what of the resident tells the 2nd aide to leave?. The form had the following statement on the bottom and was signed by the employee receiving the training; This education was produced as a part of the mitigation action plan. I acknowledge that I have read and understand the contents of this training. If I have any further questions, I will ask either my floor nurse, care coordinator, assistant director of nursing, or the director of nursing. A facility policy on falls was requested but not received.

Based on observation, interview, and document review, the facility failed to comprehensively assess fall risk and implement immediate fall interventions upon admission for 3 of 3 residents (R1, R2, R6) who had history of falling with major injury and failed to identify probable root causal factors to determine reason for fall for R2. R1 had a history of falls with fractures and was hospitalized with a head injury and hip pain after a fall within the facility. R2 had a history of falls with fractures and sustained a left hip fracture after a fall within the facility. R6 had a history of falls with fractures and was hospitalized for a lip laceration and facial bruising after a fall within the facility. These deficient practices resulted in immediate jeopardy (IJ) for R1, R2, and R6. In addition, to the residents in the immediate jeopardy the facility failed to comprehensively assess and identify probable root cause factors to determine reason for fall and and implement individualized immediate interventions to decrease risk for falls for 2 of 5 residents (R3,R5) The IJ began on 5/31/22, when R1 fell and was hospitalized with head injury and hip pain after the facility failed to comprehensively assess R1's risk for falls, implement immediate fall interventions, and adequately educate and supervise direct care staff to ensure concise documentation was completed. The administrator and director of nursing (DON) were notified of the IJ at 4:50 p.m. on 6/10/22. The IJ was removed on 6/14/22 at 11:00 a.m. after it was verified the facility had implemented an acceptable removal plan. However, non-compliance remained at E, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R1's pre-admission screen (undated) included hospital documentation which indicated R1 was hospitalized from 5/13/22-5/19/22, due to a fall, had a surgical procedure to repair a right hip fracture on 5/15/22, had a subsequent fall on 5/21/22, and was hospitalized again from 5/23/22-5/27/22. In addition, R1's hospital records included R1 was at high risk for falls and contained interventions of alarms and check in on resident frequently. R1's hospital discharge orders dated 5/27/22, included an order for fall precautions. R1's discharge Minimum Data Set (MDS) dated [DATE], indicated R1 required extensive assistance of one staff for bed mobility, toileting, and extensive assistance of two staff for transfers. The MDS indicated R1 was unsteady and required partial to moderate assistance with ambulation but did not walk in room or corridor during the assessment period. The MDS indicated R1 was always continent of bowel, occasionally incontinent of bladder, and not on a toileting program to manage urinary incontinence. R1's Admission Record dated 6/14/22, indicated R1 was admitted to the facility on [DATE], with diagnoses of pain in right hip and leg related to right hip fracture and Alzheimer's disease. R1's Nursing Assessment Admission/Readmission + Care Plan dated 5/27/22, indicated R1 was able to use the call light, make self-understood and was oriented to person, place, time and situation. The assessment indicated R1 had a fall with a fracture in the past 6 months, was receiving opioid and psychoactive medications and had unknown modifiable external risk factors for falls. R1's baseline care plan for falls dated 5/27/22, identified R1 required assistance with activities of daily living (ADL's), however, did not identify extent. The care plan indicated R1 was non-ambulatory (unable to walk) and included an incomplete focus area of [Preferred Name] has Limited physical mobility [SPECIFY: Fall risk] r/t [related to] which included reposition changes (with frequency left blank). R1's care plan lacked personalized interventions to prevent and/or minimize fall risk. R1's adverse event report dated 5/31/22, indicated R1 was walking by herself using a walker in the hallway outside of her room at 3:00 p.m. She reportedly let go of her walker to reach her head, lowered her hands, and fell to the floor. The nurse attempted to do an assessment but was unable as resident was distressed and screaming and refused assessment or discussion with staff. The report indicated R1 was inconsolable, had a pain score of 8 out of 10, and no injuries were observed. R1's nurse practitioner was notified and R1 was sent to the hospital emergency department for follow-up. The report identified CP [care plan] followed. A progress note dated 5/31/22, at 3:36 p.m. indicated R1 was walking by herself and fell to the floor. The note identified the nurse tried to do range of motion and take vital signs and resident would holler out loud and scream. The note indicated the NP gave an order to send R1 to the hospital and staff called 911. R1's record did not include a comprehensive assessment/analysis that identified defined causal factors/root cause and appropriate individualized interventions. The Post Fall Data Collection -V1 was not completed until 6/9/22, which identified R1 fell due to loss of balance/weakness and had unknown injuries. The form identified a root cause of Mood or mental status (did not specify) with intervention of OT/PT (occupational therapy and physical therapy) referral. The form indicated both the nursing assistant care sheets and the care plan were reviewed and no changes were indicated. R1's progress note dated 6/1/22, at 8:58 a.m. indicated R1 did not return to the facility. During interview on 6/8/22, at 11:12 a.m. family member (FM)-A stated R1 fractured her hip a few weeks prior, went to the hospital for surgery, transferred to another long-term care facility where she fell a second time, returned to the hospital for pain control, and was admitted to this facility on 5/27/22. She stated R1 put her call light on because she needed to use the bathroom and nobody came for over an hour, so R1 tried to get up on her own with her walker. She stated R1 had a bump on her head from the fall was still at the hospital. R1's Device Activity Report (call light log) reviewed on 6/9/22, indicated R1 used her call light six times on 5/31/22, with an average response time of 58 minutes. The record identified the light was turned on at 1:43:44 p.m. and was on for 103 minutes. During interview on 6/9/22, at 8:47 a.m. NA-E indicated she knew someone was at risk for falls when residents attempted to self-transfer when they required assistance; often times this would happen when residents needed to use the bathroom. During interview on 6/10/22, at 9:18 a.m. licensed practical nurse (LPN)-A stated R1 was found lying on her left side on the floor in the hallway by her doorway on 5/31/22 at approximately 2:50 p.m. LPN-A stated R1 was not ambulatory but must have gotten up by herself and gotten out to the hallway. She was not aware of any staff walking with her and did not recall any fall prevention interventions that were utilized prior to the fall- is this accurate? During interview on 6/10/22, at 3:34 p.m. NA-C did not recall R1 but stated when residents were admitted there was not much to go by on the NA care sheets. NA-C stated sometimes the nurse communicated if new resident was a fall risk, but they didn't usually say why the resident was a fall risk. She stated if a resident were restless, they were brought out in the open area so they could be watched, and if they were in bed the best we can do is keep them [bed] in a low position. During interview on 6/10/22, at 10:11 a.m. DON indicated R1 was at risk for falls due to history of falls, Alzheimer's disease, and recent right hip surgical repair. DON stated she watched the video of the event and when R1 fell the call light was on but review of the camera footage revealed the nurse entered and exited the room without turning off the light at 2:25 p.m. DON stated call light response time goal was ten minutes. The DON indicated the video showed R1 walked alone to the doorway of her room with her walker at 2:59 p.m. and stood in the doorway. DON indicated at 3:00 p.m. R1 let go of her walker, touched her hair with both hands, put her hands back down a few seconds later and missed one side which caused R1 to fall to the left next to the wall, hitting her head on the hallway railing. DON stated staff were following the care plan at the time, because R1 was receiving physical therapy. DON stated she and the admissions nurse reviewed the hospital prescreening information to ensure they could manage resident care, including the resident's history of falls, however, fall interventions used in the hospital, such as bed alarms and side rails, were not utilized by the facility for fall prevention measures. DON stated R1's admitting nurse did not complete the documentation, and R1's care plan lacked fall prevention interventions and expected that to be completed. DON reviewed R1's record and confirmed the Post Fall Data Collection for R1's fall on 5/31/22, was not completed until 6/9/22. She stated they did not put an intervention in place because R1 was sent to the hospital, but she was already getting OT and PT services. Upon review of R1's Post Fall Data Collection dated 6/9/22, DON verified the root cause was identified as Mood or mental status but could not identify what interventions would be appropriate for that root cause. DON reviewed her documentation and confirmed R1's fall was not discussed at IDT. R2's pre-admission screen (undated) indicated R2 had a fall with right hip fracture and surgical repair. The screening included a hospital Nursing Shift Care Plan Summary Note which identified R2 was on fall precautions, had a bed alarm, and attempted to get out of bed during the night on 5/19/22. R2's Admission Record dated 6/14/22, indicated R2 was admitted to the facility on [DATE], with diagnoses of right hip fracture, Alzheimer's disease, and history of falling. R2's admission MDS dated [DATE], indicated he was rarely or never understood, moderately cognitively impaired and required extensive assist of two staff for bed mobility, transfers, and toilet use. R2 was non-ambulatory, always incontinent of bowel, and used a urinary catheter. R2's Nursing Assessment Admission/Readmission + Care Plan dated 5/24/22, indicated R2 was alert, unable to use a call light, and unable to respond to questions pertaining to orientation. The assessment indicated R2 had a fall with fracture in the past six months, was receiving psychoactive medications, and identified modifiable external risk factor as room location and lighting/night light. The assessment indicated the Fall Care Plan focus was not selected for initiation. R2's baseline care plan for falls dated 5/26/22, indicated R2 was non-ambulatory and included an incomplete focus area of (Preferred Name) has Limited physical mobility (SPECIFY: Fall risk) r/t [related to]. R2's baseline care plan lacked personalized interventions to prevent and/or minimize fall risk. R2's adverse event report dated 6/1/22, indicated R2 was found lying on the floor on the right side of his bed, and had three abrasions on his left elbow with no other injuries noted. The report included a note dated 6/2/22, which identified the fall was reviewed by the interdisciplinary team (IDT) who determined the care plan was followed at the time of the fall. R2's Post Fall Data Collection - V1 dated 6/1/22, indicated R2 had an unwitnessed fall on 6/1/22, at 3:20 a.m. The report indicated he slipped/rolled out of bed, was incontinent of bowel, and wearing gripper socks at the time. Injuries included abrasions to left elbow. The potential root cause of the fall was determined to be Medical status/Physical condition/Diagnosis (did not specify) and identified no changes to the NA care sheet and care plan were indicated. R2's Post Fall Data Collection - V1 dated 6/2/22, indicated R2 rolled out of bed on 6/1/22 at 3:20 a.m. while attempting to self-transfer. The potential root cause of the fall was determined to be Medical status/Physical condition/Diagnosis and identified no changes to the NA care sheet and care plan were indicated. R2's progress note dated 6/2/22, at 2:42 a.m. R1 complained of pain in his left hip, lateral left torso, and back, and was given pain medication. A progress note at 6:04 a.m. indicated R2 stated he cannot take it and described his pain as like a nail being pounded into his hip. The note indicated pain medications had no effect. A provider progress note dated 6/2/22, indicated R2 was seen by the nurse practitioner on 6/2/22. The note identified R2 had fallen two days prior and was reporting excruciating pain in his left hip and would not get out of bed. The note indicated R2 had a large lump on the side of his hip, and he yelled out in pain when he was touched. NP indicated she sent R2 to the hospital for evaluation due to high propensity for hip fracture due to deformity. R2's progress note dated 6/2/22, at 2:48 p.m. indicated R2 was admitted to the hospital with a left hip fracture and a progress note dated 6/6/22, at 8:28 a.m. indicated R2 did not return to the facility. During interview on 6/8/22, at 9:58 a.m. hospital social worker (SW)-A stated R2 was brought to the hospital after falling and was yelling out with any movement in the emergency department. She stated nursing staff indicated there was something obviously wrong with his hip prior to obtaining x-ray results. X-rays confirmed he had a fractured and R2 had a surgical repair the following day. During interview on 6/10/22, at 12:23 p.m. RN-C stated a NA called her and reported R2 was on the floor next to the bed, and when she responded the bed was in low position. She completed an assessment, and R2 did not complain of pain at that time. RN-C stated R2 laid on his back most of the time and did not have the ability to self-transfer and must have somehow slipped since that was all he was capable of. During interview on 6/10/22, at 10:11 a.m. DON reviewed R2's admission assessment and verified R2 was at risk for falls due to history of falls and diagnosis of Alzheimer's disease. DON confirmed R2's initial assessment was incomplete, and the falls care plan was not selected. She stated she expected interventions to have been added to the care plan and the NA care sheets immediately to communicate new interventions to the staff. DON confirmed R2's baseline care plan lacked personalized fall prevention interventions. DON reviewed R2's Post Fall Data Collection and stated root cause was determined through adequate completion of the post fall data collection. She disagreed with the root cause, identified as Mental status/Physical condition/Diagnosis. DON confirmed lighting was selected as an intervention on the form and stated she did not know how lighting related to Mental status/Physical condition/Diagnosis and could not identify what intervention would be appropriate for the selected root cause. DON stated normally R2's fall would have been reviewed in IDT, but there was no IDT meeting on 6/1/22, and upon review of her documentation, verified it was not reviewed on 6/2/22. DON stated R2 fell at 3:20 a.m. on 6/1/22. She stated she reviewed the cameras and could see R2's room at the end of the South hallway on the left. She stated staff were in the room shortly after 1:00 a.m. to provide cares, and the NA found R2 during rounds between 3:00 p.m. and 4:00 p.m. R6's pre-admission screen dated 6/2/22, indicated R6 had a left femur fracture, fall, recurrent [CONDITION(S)], dementia and falls. The checklist lacked evidence the admission screen was sent to the nursing staff for review. R6's hospital discharge orders dated 6/3/22, indicated R6 was able to resume activities as tolerated with a walker and could place full weight as tolerated on the left leg. R6's face sheet reviewed 6/13/22, indicated R6 had diagnoses of left femur fracture, encounter for orthopedic aftercare, [CONDITION(S)] and collapse, history of falling, and dementia. R6's admission entry MDS dated [DATE], indicated R3 was admitted to the facility on [DATE]. R6's Nursing Assessment Admission/Readmission + Care plan dated 6/3/22, indicated R3 was orientated to person, place, time, and situation and had a history of falls, and had a fracture related to a fall in the past 6 months. R6's functional and safe handling review dated 6/3/22, indicated R6 had a history of falls with major injury within the past 3 months. R6 was not assessed for balance during transitions and walking or surface to surface transfers and indicated R6 was non weight bearing. The review further indicated R6 was unpredictable with behaviors and ability to cooperate or comprehend simple commands. R6's baseline care plan dated 3/3/22, indicated R6 was a fall risk, but did not identify why R6 was fall risk and lacked individualized fall interventions. R6's adverse event report dated 6/6/22, indicated R6 had an unwitnessed fall that resulted in bruising R6's left cheek and some blood around R6's mouth. At the time of fall R6 was oriented to person and was confused. The report further identified no environmental factors related to the fall and R6 was sent to the emergency room for evaluation per family request. R6's Post Fall Data Collection dated 6/6/22, indicated R6 had an unwitnessed fall after attempting to self-transfer. The potential root cause for the fall was due to mood/mental status (did not specify mood/mental status). The data collection did not address fall interventions. R6's progress note dated 6/7/22, at 1:01 a.m. indicated R6 sustained no fractures, but was admitted to the hospital. During an interview on 6/14/22, at 10:25 a.m. registered nurse (RN)-B had not remembered R6 and stated sometimes information was received from the hospital that would indicate if a resident can get up or what the weight bearing status would be to help us understand a resident's fall risk. RN-B stated during the admission assessment, staff try to understand a resident's mobility status, diagnoses, and limits and what they can do. During an interview on 6/14/22, at 11:28 p.m. the DON verified R6's admission assessment section mobility and fall risk was not completed entirely and fall interventions had not been included on the care plan. DON further verified R6's post fall data collection was not completed in its entirety as it had not indicated any care plan review. DON further stated it was her expectation for the assessment, care plan and post fall data collection to be accurate and complete. R3's significant change MDS dated [DATE], indicated R3 had mild cognitive impairment, one fall since admission with no injury and had diagnoses of anxiety and history of falling. R3's fall Care Area Assessment (CAA) dated 4/16/22, indicated R3 was at risk for falls due to need for staff assistance to stabilize with all balance situations, a fall since last assessment. Furthermore, the assessment stated R3 was at risk for falls and had interventions in place. R3's care plan revised 4/27/22, indicated R3 was a fall risk related to weakness and limited physical mobility. R3's care plan lacked individualized fall interventions to minimize the risk of R3 falling. R3's post fall data collection dated 5/12/22, indicated R3 had an unwitnessed fall on 5/12/22, at 7:30 p.m. when going to the bathroom without assistance. There was not a possible root cause identified for R3's fall. However, interventions of physical therapy/occupational therapy referral and a medication review were indicated. R3's care plan and nursing assistant (NA) care plan were reviewed with no changes indicated. R3's record lacked evidence of a comprehensive fall assessment/analysis, care plan review/revision, and IDT involvement. During an interview on 6/8/22, at 2:27 p.m. NA-A did not recall R3's fall. NA-A stated residents were rounded on in the morning before and after breakfast. NA-A stated NA care sheets were reviewed and that tells us what to do. Furthermore, NA-A stated many residents fall trying to transfer themselves. I try to keep an eye on them and answer call light. NA-A verified R3's NA care sheet section titled fall prevention listed fall risk, utilize grab bars for transfer assistance, and able to demonstrate use of recliner. NA-A stated there was not a lot of information and was not aware of other interventions in place to prevent falls. R5's significant change MDS dated [DATE], indicated R5 was cognitively intact and had diagnoses of anxiety and a history of falls. R5's fall CAA dated 3/2/22, indicated R5 was at increased risk for falls related to decline in functional mobility. R5's CAA indicated falls was addressed on the care plan to avoid complications. R5's care plan dated 1/26/22, indicated R5 had limited physical mobility and was at fall risk related to weakness and pain. R5's care plan lacked individualized fall interventions to decrease R5's risk of falling. A facility document titled Adverse Event Log indicated R5 had fallen on 5/20/22 and 6/4/22. R5's post fall data collection dated 5/20/22, indicated R5 had an unwitnessed fall when walking with her walker. The report had not identified a potential root cause and identified intervention was a therapy referral. R5's corresponding adverse event report dated 5/20/22, R5 lost her balance with the walker. R5's record lacked a comprehensive fall assessment/analysis, care plan review/revision, and IDT involvement for the fall that happened on 5/20/22. R5's falls adverse event report dated 6/4/22, R5 had an unwitnessed fall and was found on the floor and was returned to bed safely. The report did not identify a root cause and did not address review/revision of fall interventions. R5's record lacked a comprehensive fall assessment/analysis and IDT review for the fall that happened on 6/4/22. R5's falls adverse event report dated 6/9/22, indicated R5 self-reported a fall that occurred on 6/8/22. The report was reviewed by IDT on 6/9/22 and therapy orders were received. R5's post fall data collection dated 6/9/22, indicated resident reported low back pain and right ankle pain at an unknown date and time. The report indicated R5 had just completed therapy prior to fall. A potential root cause of the fall was marked other with X-ray and pain medications specified. Interventions initiated was therapy evaluation and a review of R5's care plan was completed, however, did not address outcome of the review. R5's record lacked a comprehensive fall assessment/analysis for root cause. R5's care plan revised on 6/11/22, (after SA entrance) directed staff to ensure R5 had a safe environment, adequate lighting and had call light and personal items within reach. The care plan further instructed staff to and to educate R5 with safety reminders and what to do if a fall occurs and encourage rest periods mid-morning and afternoon. An observation on 6/9/22, at 8:57 a.m. NA-B entered R5's room to help with morning cares. R5's walker was folded and placed next to the dresser across the room. R5's bedside table was also across the room and not in reach. R5 told NA-B was not able to get up and was confined to the bed due to recent falls. R5 further stated, I am decompensated I guess. R5 declined to use bathroom or the bedside commode and requested NA-B to help change her brief. After completion of brief change, NA-B placed wheelchair next to R5's bed. R5 was able to get to the edge of the bed and transfer self into the wheelchair with assistance of NA-B. No transfer belt or walker was used for support. NA-B changed linens and R5 transferred back to bed with the same assistance used to get into the chair. NA-B moved table closer to resident and walker was left folded across the room. During an interview on 6/9/22, at 9:24 a.m. R5 stated she fell maybe 4 days ago and then again maybe 2 days ago. R5 recalled the fall 2 days ago and R5 stated she just collapsed down. R5 added, It was like my knees buckled under me and I just kind of collapsed down. R5 further explained she was not able to get up from her knees but was able to put her bed all the way down and crawl back onto the bed. R5 stated the fall 4 days ago was during the night when attempting to get back to the bed from the bathroom. R5 stated she fell back against the dresser, but not hard. R5 confirmed staff were not present for either fall. R5 feels weak and further stated the facility was going to try to get more therapy but was unsure if that was going to happen as R5 was supposed to discharge next week. R5 feared falling and that was why she declined to get to the commode or bathroom today. During an interview on 6/9/22, at 10:45 a.m. RN-D stated she recalled R5 had not had her call light at the time of the fall and could not remember other details. RN-D stated some interventions are not on resident's care plan but are just known like the call light in reach or bed low. During an interview on 6/9/22, at 10:16 a.m. NA-B stated the NA care sheets were reviewed each morning for instruction on resident needs. NA-B stated R5 usually walked into the bathroom. NA was not sure about any specific fall interventions for R5 but stated a transfer belt was needed when assisting R5 NA-B acknowledged was not used when transferring R5 to the wheelchair this morning. NA-B reviewed the NA care sheet and verified it didn't really list anything about preventing falls for R5. NA-further sated R5 moves quick and need to be attentive to the call light. During an interview on 6/9/22, at 10:45 a.m. RN-D stated R5 was known to self-transfer. When reviewing R5's care plan, RN- verified mobility interventions had been placed, but acknowledged fall interventions specific to R5's falls were not included. During an interview on 6/10/22, at 10:11 a.m. DON stated R5's individualized fall risk interventions were not incorporated into R5's care plan. DON further acknowledged the care plan was not individualized and there could be more. DON verified R5's post fall data collection dated 5/20/22, had no root cause identified and identified therapy consult as the intervention. DON verified R5 had been in therapy currently at the time of the fall and stated if it was most appropriate for continuation of therapy, that was fine and there doesn't need to be an intervention after each fall. DON further stated her expectation was for a root cause of the fall be determined and was needed to determine an appropriate intervention. DON stated it was unknown if therapy was an appropriate intervention without identification of a root cause. DON verified R5's fall was not reviewed by IDT. DON verified a post fall data collection for R5's fall on 6/4 was not completed. DON stated she was unsure if it happened but acknowledged the adverse event report was completed. DON further stated with no manager on the unit, it was hard to determine what happened. DON confirmed this fall was not reviewed by IDT. DON stated R5 had self-reported a fall on 6/9/22, that occurred after her appointment on 6/8/22. DON was unsure if the fall occurred as R5 could not get herself up without assistance and staff had not assisted her. DON further stated event was treated like a fall and she expected the process to be the same and an immediate intervention should be in place. DON confirmed this fall was not reviewed by IDT. During an interview on 6/10/22 at 3:41 p.m. DON stated the hospital is not doing anything to actively decrease those, and hospitals are held to a different standard for alarms and restraints. She stated the facility did not use alarms, and instead, went through the records and got a feel for the person. DON stated upon admission the admitting nurse completed the nursing head-to-toe assessment, including falls risk, and DON expected the nurses to put fall interventions in place. DON indicated the expectation to have personalized base-line care plan within a short period of time was not realistic, however, there should be enough in the care plan to care for resident safely and effectively. She stated staff would have a better understanding of the resident within a couple of days and nurses would update the care plan when changes were needed, however, the DON did not identify what constituted a change. DON stated interventions may or may not be different for residents who had a previous history of falls compared to those who did not, but all residents received gripper socks, call light instruction, and grab bars if appropriate. The IJ was removed on 6/14/22, at 11:00 a.m. when it could be verified the acceptable plan of correction was implemented which included: -Applicable policies were reviewed -Residents admitted in the past seven days were reviewed for completion of Nursing Assessment Admission/readmission, fall risk factors identified, and ensuring appropriate interventions implemented and updated to resident care plans. -Residents with recurring falls within the past 90 days or a fall within the past 30 days were reviewed to ensure post fall assessments were completed and appropriate fall interventions are accurate and in place in resident care plan and NA care sheets. -All nursing staff mandatory re-education was created and implemented. -An auditing system was developed and implemented. A facility policy titled, Fall Risk and Prevention Guidelines, revised 2/2022, directed staff to evaluate records from referring institution and/or family resident interview to determine history of falls and fall risk factors. Upon admission, the care plan should be ready for incorporation of fall prevention measures based on this information. Intervention and prevention measures may include history of falls, resident risk areas consistent with resident specific behaviors, needs, and preferences and efforts to seek alternatives if resident refuses or resists interventions. Post fall, the nurse reviews the information collected, determines the potential root cause, and initiates a plan based on the information. The plan of care is reviewed and revised with changes as indicated. Further post fall follow up required is to update the resident care plan, NA care sheets, and complete an IDT discussion for review. A facility document titled Documentation guide (no date) directed staff to complete a Morse Fall Scale upon admission, hospital return/readmission, quarterly, annually, significant change, and post fall. This was an essential document to assess resident risk factors including history of falls and to document appropriate safety interventions. A facility policy titled Person Centered Care Plan Guideline revised 10/2017, directed staff to develop a baseline care plan that included instructions on how to provide effective and person-centered care of the resident. Further the baseline care plan will be generated with the completion of the Nursing Admission Assessment. The overall person-centered care plan should be orientated towards preventing avoidable declines and managing risk factors, building on resident strengths and respecting person preferences and rights.

Based on interview and document review, the facility failed to administer insulin as prescribed by the physician for 1 of 1 resident (R1) reviewed for significant medication errors. This deficient practice resulted in an immediate jeopardy (IJ) for R1 when 90 units of short-acting insulin was erroneously injected into her abdomen, rather than being infused by an insulin pump. R1's blood sugar decreased, required emergency treatment, and was hospitalized . The IJ began on 4/16/21, when 90 units of insulin was injected into R1's abdomen rather than being infused via an insulin pump as directed by the physician. The director of nursing (DON) was notified of the IJ on 4/21/21, at 11:52 a.m. The facility had implemented immediate corrective action on 4/17/21, therefore the deficiency is being cited at past-non-compliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified she was cognitively intact, had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Order Summary Report dated 4/15/21, indicated, R1's [MEDICATION(S)] KwikPen Solution Pen-injector 100 Unit/ML (Insulin [MEDICATION(S)] (1 unit Dial). Inject 90 units subcutaneously one time a day related to type 1 Diabetes Mellitus with diabetic [CONDITION(S)]. Inject 90-100 units via insulin pump every day. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility incident report dated 4/16/21, identified R1 had orders for insulin to be administered via her insulin pump even though the insulin pump was turned off. Staff did not clarify orders (with the physician) and a nurse injected 90 units of short-acting insulin (in R1's abdomen) using orders written for a insulin pump. The nurse did not have the insulin verified by second nurse, per policy. R1 later stated she felt her blood sugar was low. The nurse practioner (NP) was onsite and the medication error (wrong route of administration) was noted. R1 was given two [MEDICATION(S)] tablets (sugar tablets used to treat low blood sugar), but was still not feeling well. The NP evaluated the resident, and she was sent to emergency room (ER) for further evaluation. R1's progress note dated 4/16/21, at 10:27 a.m. included, R1 was sent to the emergency department for [CONDITION(S)] (low blood sugar). R1's medication incident report form dated 4/19/21, identified, administered 90 units of [MEDICATION(S)] subcutaneously (fat tissue) nurse did not review order @ [at] full. Resident sent to emergency department [ED] for further evaluation, resident remains in hospital. When interviewed on 4/20/21, at 9:45 a.m. R1 stated LPN-A came into her room with two syringes of insulin. R1 asked LPN-A how much insulin she was getting. LPN-A told R1 there was 60 units in one syringe and 30 units in the other. R1 stated LPN-A injected both syringes of insulin in her abdomen. R1 stated, after a while, she started to feel shaky, sweaty, freezing, and could not think straight. R1 stated those were, classic signs her blood sugar was low. R1 stated she was transported to the hospital, by ambulance, and hospitalized from 4/16/21, to 4/19/21. R1 stated when she arrived at the hospital her blood sugar was in the 20's (normal range 80 - 130 for a person with diabetes). When interviewed on 4/20/21, at 12:13 p.m. LPN-A stated R1's blood sugar was 141 (when she checked it on 4/16/21). LPN-A stated R1 told her she did not have her insulin pump anymore so she told R1 she would go check the insulin order and come back. LPN-A stated she returned to R1's room and had two blue insulin pens. LPN-A stated R1 asked how much insulin she was getting. LPN-A stated she told R1 the order called for 90 units. R1 told her, that's more then I get in the pump, but I don't have the pump anymore. LPN-A stated she then injected the insulin into R1's abdomen. LPN-A stated about 30 minutes later, R1 told her she felt like her blood sugar was low and requested it to be checked. LPN-A stated she checked R1's blood sugar and it was 72. LPN-A stated, after a while, R1 told her, I really feel like it's [blood sugar] tanking [decreasing blood sugar]. LPN-A stated she told the doctor at the facility R1 felt like her blood sugar was dropping and she had administered, quite a bit of insulin per the order because R1 no longer had her insulin pump. LPN-A stated she never saw the doctor after that and she didn't realize she had made an error at that time. LPN-A explained, when viewing R1's electronic MAR (EMAR) the order read to inject 90 units of [MEDICATION(S)] insulin subcutaneously. LPN-A stated in order to visualize a complete order, she needed to click, or hover (hold mouse cursor over a word), on the word more. LPN-A confirmed she did not visualize R1's complete insulin order. LPN-A stated had she done so, she would had seen the rest of the order which directed to infuse insulin using an insulin pump. When interviewed on 4/21/21, at 9:01 a.m. RN-A stated health unit coordinator (HUC)-A entered R1's insulin order in the computer before R1 arrived at the facility. RN-A stated she compared R1's new orders (sent with R1 upon being admitted to the facility) with the orders the HUC-A entered previously. RN-A stated she may have missed something because she was stressed that day from dealing with an issue with another resident. When interviewed on 4/21/21, at 12:00 p.m. the director of nursing (DON) stated she would not expect staff to call the on-call physician and clarify orders at 10:00 p.m. at night, they should wait until the next morning. The DON stated, it was the nurse administering the medication's [LPN-A] responsibility to clarify the order, not the person transcribing it. The DON also stated LPN-A told her she was aware insulin orders required a co-signature and LPN-A did not have another nurse verify the insulin order. The DON stated LPN-A put the initials of the other nurse on duty [RN-D] in the co-signature box without her knowledge. When interviewed on 4/21/21, at 10:49 a.m. the pharmacist stated injecting insulin into R1's abdomen, rather using an insulin pump, delivered 90 units of insulin all at once; therefore R1's blood sugar to dropped quickly. The pharmacist stated if R1's insulin was administered using an insulin pump, the insulin would had been spread out in small doses throughout the day. R1's hospital discharge summary dated 4/19/21, at 9:48 p.m. identified emergency medical services (EMS) gave 15 grams dextrose (sugar) gel on arrival for a blood sugar in the 20's (critical low). R1 was administered 25 cc (cubic centimeters) of apple juice and intravenous (IV) dextrose. R1's hospital discharge summary further indicated R1 was placed on a D10 drip (sugar solution given by IV, used to treat extremely low blood sugar) and continued to have [CONDITION(S)]. R1 was admitted to intensive care unit (ICU). The facility's medication administration policy revised 6/24/18, directed carefully check medication record (eMAR) as to name, room, name of drug, dosage, frequency, time and route of administration. If any questions, refer to the resident's chart to check the original physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . That individual will verify the amount drawn up is correct and initial as the co-signer on the EMAR. Further, if the insulin order seems questionable DO NOT proceed with further administration preparation and investigate the order: check paper chart for the most current order, check with RN supervisor/clinical manager, check with another nurse, and /or call the residents medical doctor (MD). The past non-compliance IJ began on 4/16/21. The IJ was removed and the deficient practice was corrected by 4/17/21, after the facility had implemented a systemic plan which included: - Reviewing policies and procedures related to medication orders, order processing, and insulin administration on 4/16/21. - Staff was retrained on policies and procedures which included insulin pen administration competencies beginning 4/16/21. Remaining nurses and trained medication assistants (TMA)'s were trained prior to the start of their next shift. - All insulin orders were reviewed on 4/16/21, and again on 4/17/21, by the DON and LPN-D. No medication or insulin errors noted for the past three months. - No other residents had an insulin pump. - R1 will self-manage her insulin pump, if she returns with it, per history of self-management. - LPN-A was suspended immediately and terminated on 4/16/21, for failure to follow policy and falsification of documentation. .

Based on interview and document review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (R1) reviewed for abuse. This deficient practice resulted in an immediate jeopardy (IJ) when R2 was found in R1's room touching her bare breasts and rubbing her thighs and the facility failed to provide immediate interventions to protect other residents. The facility immediately implemented appropriate interventions and corrected the deficient practice on 2/23/21 and is being issued as past noncompliance at Immediate Jeopardy (IJ). The IJ that began on 2/23/21, was corrected on 2/25/21, when the facility implemented interventions to prevent reoccurrence. The administrator and director of nursing (DON) were notified of the IJ past noncompliance on 3/1/21, at 6:00 p.m. as a result of the immediate corrective action taken by the facility. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 as severely cognitively impaired. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan revised 5/16/20, indicated R1 was considered a vulnerable adult and instructed staff to report any incidents of abuse immediately and ensure a safe environment before leaving alone. R1's care plan further indicated R1 had cognitive loss or alteration in thought processes affecting her judgement and decision-making process. R2's admission MDS dated [DATE], identified R2 as moderately cognitively impaired. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's care plan revised on 2/19/21, indicated R2 had cognitive loss or alteration in thought processes affecting his judgement, decision making and thought processes. R2 will occasionally make sexually inappropriate comments as a result of his cognitive impairments. R2's care plan instructed staff to cue and supervise as needed. R2's care plan further indicated R2 was a wander risk. R1's progress note dated 2/23/21, at 9:02 a.m. indicated, This resident was sleeping and staff came to call writer to observe a male resident sitting beside her and trying to put hands on the upper part of her body. Resident was deeply sleeping and do not recollect exactly what was happening. Staff provided 1:1 supervision for the two affected residents to make sure that they are safe for the rest of the night and that episode will not repeat again. Will continue to monitor resident status due to this incidence. When interviewed on 3/1/21, at 9:55 a.m. R1 stated she remembered a man was in her room and lying next to her in her bed. R1 stated he touched her breasts but could not remember if he touched her bottom area. R1 stated, He was really having fun with my uppers. What on earth protects you from something like that. R1 further stated the man was on top of me so fast I had no opportunity to stop him. It was happening so fast. It was rather traumatic because I did not expect it. R1 further stated she made it clear she did not want to have any relations. R1 did not know his name and stated she had not seen him in this facility prior to that night. R1 further stated no staff came in to interrupt this event. When interviewed on 3/1/21, at 10:27 a.m. social worker (SW)-A stated she was informed of the incident by licensed practical nurse (LPN)-A when she arrived at the facility on the morning of 2/23/21. SW-A stated upon admission, R2 was known to be a wandering risk but was not aware of any previous sexually inappropriate behavior. SW-A stated they were aware R2 had wandered while on the transitional care unit (TCU) prior to his transfer to the long-term care (LTC) unit. When interviewed on 3/1/21, at 12:01 p.m. nursing assistant (NA)-A stated during the night shift on 2/23/21, around 2:10 a.m. she noticed R2 was not in his bed, so she immediately went across the hall and found R1 in R2's room. NA-A stated, I saw [R2] in the room sitting on the edge of the bed, feet on floor and his body facing privacy curtain. NA-A further stated she saw R2's hands on R1's body. NA-A stated R2 did not notice her so she backed out of the room and went to get a coworker. NA-A stated she left the room because she went to get a witness. NA-A stated she got NA-B and licensed practical nurse (LPN)-A to returned to R1's room with her. They turned on the light and saw R2 sitting on R1's bed with his hands on R1. NA-A stated R1's night gown had buttons down the front which were all unbuttoned with her breasts exposed. NA-A stated R2 was directed back to his room, but he came out again at which time registered nurse (RN)-A then escorted him back to his room. NA-A stated RN-A instructed them to provide 1:1 supervision. NA-A stated 1:1 supervision means that someone would sit with the resident in their room all the time. NA-A further stated that 1:1 supervision was not possible that night due to staffing. NA-A stated she watched R2's room instead from the hallway so she could watch for other residents that tend to wander at night as well. NA-A stated R2 fell asleep and did not come out of his room until later in the shift during rounds when she heard voices in the hall and saw R2 in the hallway walking back into his room. When interviewed on 3/1/21, at 12:35 p.m. LPN-A stated the nursing assistants asked him to go to R1's room on 2/23/21 around 2:12 a.m. When he arrived at her room, he saw R2 sitting on the edge of R1's bed and had R1's leg up over R2's leg. LPN-A stated R2 had his hands on R1's breast area and that there was a lot of touching. LPN-A further stated, We just got [R2] off and explained to him that it was not appropriate. LPN-A stated that there was touching of R1's bottom part but her brief had not been removed. LPN-A stated he reported the incident to RN-A. LPN-A stated RN-A instructed them to put R2 back to bed and place on 1:1 supervision. LPN-A stated he instructed nursing assistant (NA)-A to monitor R1 and R2 very closely, since their two rooms faced each other, NA-A could watch to make sure nothing like that would happen again. LPN-A stated he thought R2 stayed in his room the rest of that night as he did not receive any reports from NA-A of R2 leaving his room. LPN-A stated he told social worker (SW)-A about the incident as soon as he saw her in the morning. LPN-A stated SW-A then notified the director of nursing (DON) about the incident. When interviewed on 3/1/21, at 2:16 p.m. RN-A stated she was notified by LPN-A on 2/23/21 around 2:20 a.m. that staff had to pull R2 out of a female resident's room (R1). RN-A stated LPN-A did not provide details about the incident. RN-A stated she assisted R2 back to his room and then told staff to provide 1:1 supervision. RN-A stated 1:1 supervision meant that someone should be close to the room to see if he came out and if so redirect back to his room. RN-A further stated when she talked to LPN-A later, he reported that R2 was sleeping. RN-A further stated that she did not report the incident to the DON because she was not aware of any sexual inappropriateness that night. RN-A stated she was familiar with R2 when he was on the TCU and that R2 would come out of his room naked almost every night. RN-A stated one night R2 grabbed her breasts. When interviewed on 3/1/21, at 2:51 p.m. RN-B stated she heard about the incident on the morning of 2/23/21. RN-B stated staff provided 1:1 supervision for R2 from that morning until he was discharged on [DATE]. RN-B stated that 1:1 supervision meant that there was a dedicated staff member with the resident at all times. RN-B further stated that 1:1 supervision would not have been possible on the shift that the incident occurred since there was not any extra staff member available. RN-B stated staff reported to her that morning that they were keeping a close eye on R2 during that night and that he had no further incidents of wandering. When interviewed on 3/1/21, at 10:46 a.m. NA-C stated 1:1 supervision meant someone would stay with the resident all the time and watched them very closely. Stay with them right by their side. When interviewed on 3/1/21, at 10:52 a.m. LPN-B stated 1:1 supervision meant that you have staff with the resident at all times. When interviewed on 3/1/21, at 1:48 p.m. family member (FM)-B stated R2 had an incident of groping a female resident while residing in a different facility. FM-B stated told this facility about his prior hypersexuality behaviors but could not recall using the term groping. FM-B further stated she had been told of an incident on the TCU when R2 had inappropriate language and behaviors to a female staff member. We really need to have him under close supervision. When interviewed on 3/1/21, at 9:07 a.m. DON stated two staff were currently on suspension because the camera footage from the night of the incident indicated staff did not provide 1:1 supervision for R2 and did not notify her about the incident that night as was her expectation. DON stated R2 was eventually placed on 1:1 supervision which continued until he was discharged on [DATE]. When interviewed on 3/1/21, at 3:03 p.m. DON stated having no knowledge of prior sexual behavior or wandering upon admit. DON stated R2 started wandering while on the TCU but was not intrusive. DON further stated that the TCU staff could easily redirect R2 when he wandered. DON stated R2 was transferred to LTC after TCU because of his wandering and there would be more eyes on him being on LTC. There are more staff out and rounding and others [residents] wandering at night. DON stated LPN-A continually changed his story about the incident when interviewed. DON stated LPN-A told NA-A to be attached by the hip to R2 and then LPN-A kept coming out of the office to check that this was being done. DON stated according to the video surveillance, NA-A did not provide 1:1 supervision to R2 and LPN-A did not come out of the nurse's office to check on the 1:1 supervision DON further stated that per the video surveillance no staff intervened when R2 came out of his room and entered those other two rooms. DON stated there were two NAs and one nurse on that unit that night and that there were several options for safely providing 1:1 supervision to R2 for the remainder of that shift. R1's progress note dated 2/23/21, at 9:10 a.m. indicated, Per nursing report, staff walked into resident's room and found resident [R2] touching her breasts and genital area. Previous progress note revealed: -R2's progress note dated, 2/16/21, at 2:41 p.m. indicated, Writer placed phone call to FM-B to inform her of events occurring on NOC [night] shift as well as few comments that were sexually inappropriate that were directed at staff. -R2's progress note dated 2/19/21, at 11:47 p.m. indicated, MOOD AND BEHAVIOR: Patient wandering throughout the unit. Sexually inappropriate with female staff including inappropriate touching. -R2's progress note dated 2/22/21, at 11:15 a.m. indicated, Pt transferred up to [LTC] @1100. R2's progress note dated 2/23/21, at 3:01 a.m. indicated, A behavior note was completed for [R2] due to the following behavior: Nar [nursing assistant registered] reported to this writer about the verbal sexual behavior from the part of this resident asking her to come and lay by his side on top of his bed. 2 [second] Nar called this writer to [R1's room] to see this resident committing physical sexual action on female resident [R1] by the window. Resident was observed touching the breast and the private part of the female resident. Review of the facility incident investigation report indicated camera footage timeline for 2/23/21: 1:58 a.m. Resident [R2] observed on the [LTC] hallway shirtless with shoes/socks on and a gown wrapped around his waste [sic]. Resident just walking the hallway. 1:59:57 a.m. [NA-A] approached [R2] and returns him to his room. 2:03 a.m. [R2] leaves his room and enters [R1's room]. 2:10:31 a.m. [NA-A] looks into [R2's] room and then turns around and sees [R2] in [R1's room] and enters [R1's room]. 2:10:45 a.m. [NA-A] leaves [R2's room] and runs down the hallway. 2:11:19 a.m. [NA-A] returns with [NA-B]-one enters the room while the other stands in doorway. NA in doorway then enters [R1's room] as well. 2:11:47 a.m. [NA-A and NA-B] leave the room and walk back towards the nurse station. 2:12:36 a.m. [NA-A and NA-B] return with [LPN-A]. 2:17:22 a.m. Staff return [R2] to his room. 2:32:20 a.m. [R2] leaves his room and enters [R4's room] 2:33:13 a.m. [R2] exits [R4's room]. 4:41:14 a.m. [R2] leaves his room and enters [R1's room]. 4:45:00 a.m. [R2] exits [R1's room], walks in the hallway briefly and returns to his room. Review of facility policy Vulnerable Adult/Maltreatment - Communication, Prevention, and Reporting, last revised 8/19, indicated, It is the facility's responsibility to ensure the resident is free from abuse, neglect mistreatment, misappropriation of resident property and exploitation. The policy further indicated, Sexual abuse is non-consensual sexual contact of any type with a resident. The past noncompliance immediate jeopardy began on 2/23/21, was corrected on 2/25/21. When the DON and administrative staff was made aware of the incident on 2/23/21, the facility placed R2 on 1:1 supervision until he was discharged on [DATE]. Review of the training sheets dated 2/23/21, 2/24/21 and 2/25/21, identified all staff were trained in regards to the Vulnerable Adult Abuse and Reporting policy. The facility initiated a process for nurse managers and DON to review the 24 hour communication report daily and ensure appropriate interventions were immediately implemented including reporting appropriately. An audit process was established through risk management to ensure this review process was completed timely. On 3/1/21 and 3/2/21, this audit process was reviewed and confirmed through interviews with the DON and nurse manager. During interviews on 3/1/21, from 10:45 a.m. to 3:00 p.m. and again on 3/2/21, from 10:30 a.m. to 12:00 p.m. licensed and unlicensed staff verbalized understanding of training on the Vulnerable Adult Abuse and Reporting policy. Staff interviews confirmed the facility implemented corrective action prior to the survey and therefore this will be cited at past noncompliance.

Based on observation, interview and document review, the facility failed to provide the necessary treatment and services to minimize, prevent or promote healing of pressure ulcers for 3 of 4 residents (R123, R48, R191) in the sample with identified pressure ulcers. R123's pressure area was not adequately monitored per facility protocol and R123 was not provided positioning services to promote healing for 4 hours, resulting in harm. R48 had a new or recurrent pressure area that was not adequately assessed, resulting in harm. Findings include: R123 did not have a position change for four hours on 3/27/17, and had an unstageable pressure ulcer on the sacrum. On 3/27/17, at 7:00 p.m. nursing assistants (NA)-A and NA-B entered the resident's room, transferred R123 to bed and began to provide bedtime cares. During observation of the care, NA-A and NA-B expressed surprise upon seeing the pressure ulcer to R123's sacrum. At 7:15 p.m. NA-A and NA-B both verified during interview that neither had provided or offered care for R123 that shift until the bedtime cares. Both stated they thought R123 took care of self. In addition, NA-A and NA-B verified they did not know R123 had a pressure ulcer to the sacrum, but would call and inform the nurse. Document review of a facility form titled, Nursing Assistant Care Plan, updated 3/27/17, indicated R123 required assist of 2 staff for transfers and was to be repositioned every 2 hours. There was no mention that R123 had a pressure ulcer on the sacrum. Document review of a facility form titled Admission Record dated 3/29/17, indicated R123 had an initial admission date of [DATE]. A document titled Progress Notes indicated R123 had been transported to the hospital on [DATE], at 11:34 a.m. and had been admitted for shortness of breath which turned into acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (oxygen deprivation). Progress Notes indicated on 3/16/17 at 11:40 a.m., R123 had been readmitted to the facility. Review of R123's most recent cognitive assessment dated [DATE], indicated R123 had moderate cognitive impairment. A form titled Braden Scale for Predicting Pressure Sore Risk dated 3/29/17, indicated R123 had mild risk for developing pressure ulcers. Review of a hospital progress note for R123, dated 3/2/17 indicated: Pressure ulcer sacrum, Stage suspected deep tissue injury. Potential for impaired healing related to chronic [MEDICAL CONDITION] and DM (diabetes mellitus) type 2. Length: 4.5 cm (centimeter) Width: 2 cm. wound bed 100% Agranular. Exudate: Yes, Serosanguineous small. treatment plan: [REDACTED] A nursing home form titled Nursing Admission Screening History dated 3/16/17, indicated R123 had a wound on the coccyx; Length 3.5, Width 6, and Depth 0.8. There was no other documentation available regarding this wound. When the surveyor brought this to the attention of management, it was acknowledged that the facility failed to monitor and assess the wound from readmission until 3/29/17, at 2:06 p.m. A form titled Wound Assessment Details Report dated 3/29/17 indicated: wound: Sacrum Pressure ulceration Present on (re)admission unstageable Slough Loosely Adherent=100% size, 3.00 length, 1.5 Width, unknown depth and the area is measured at 4.50 cm. Review of R123's facility form titled, Daily Wound Monitoring was blank and had not been completed. Document review of an undated facility policy Documenting Pressure Ulcers, directed weekly wound rounds and weekly wound documentation along with a comprehensive skin risk evaluation weekly. The policy further indicated that when an ulcer is present, daily monitoring with accompanying documentation using the Daily skin/wound monitoring sheet would be done. When interviewed on 3/29/17, at 9:48 a.m. registered nurse (RN)-A and RN-B stated they were unaware of when R123's pressure ulcer had developed and did not know the staging but would evaluate, provide interventions and explained that R123 was in the re-admission assessment minimum data set (MDS) period. RN-A stated, Staff should have followed the facility policies for daily wound monitoring. When interviewed on 3/29/17 at 10:05 a.m., RN-D verified having documented on the Nursing Admission Screening History on 3/16/16, at 12:18 p.m. that R123 had a coccyx wound that was 3.5 length, 6 width, and 0.8 depth. RN-D verified the measurements were in centimeters, and that the pressure ulcer was a Stage 3. During an interview on 3/29/17, at 2:00 p.m. licensed practical nurse (LPN)-B stated she had not been aware R123 had a sacral pressure ulcer until 3/27/17. LPN-B verified having documented, Yes pressure ulcers on 3/27/17 in the progress notes after having been informed of the pressure ulcer by NA-A and NA-B. LPN-B further verified no other assessment had been conducted or documented by her on 3/27/17 related to R123's pressure ulcer. The facility's 9/2010 policy titled, Guidelines for Pressure Ulcer Prevention, indicated interventions for prevention and intervention of pressure ulcers were individually selected and holistic in approach. Revisions to the prevention plan were to occur when assessments were scheduled, when there was a change in condition, when a new risk factor became known or when an intervention was determined to be ineffective. The interventions were to be determined by an analysis of risk factors. R48 was admitted to the facility on [DATE], with hospital discharge physician orders [REDACTED]. Although the resident had an order for [REDACTED]. An 11/30/16, Nursing Admission Screening History document indicated R48 had a pressure ulcer on the coccyx, but no other assessment of the area was documented. physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. A review of Progress Notes dated 12/5/16-1/5/17 revealed there had been no continued assessment of the resident's skin for maintained healing, or development of any new open areas on the coccyx. On 12/21/16, LPN-A documented R48 had a pressure ulcer that was being treated with non-surgical dressing change, ointments/cream/medications. However, there was no documentation found indicating the location or size of the open pressure ulcer. A comprehensive pressure ulcer assessment of the open area on R48's coccyx was not completed until 1/6/17. According to a document titled Wound Summary dated 1/9/17, a Stage 3 pressure ulcer, measuring 3 centimeters (cm) long, by 1.5 cm wide and 0.60 cm deep, was noted on R48's coccyx. On 3/28/17, at 12:42 p.m. RN-E stated she was unable to find anything in the Wound Rounds computer program regarding pressure ulcers at the time of R48's admission to the facility or prior to the assessment dated [DATE]. On 3/30/17, RN-E again stated she was unable to find an admission comprehensive pressure ulcer assessment for R48. RN-E verified the Nursing Admission Screening History completed on 11/30/16, was not a complete assessment and did not include measurements of the pressure area on the resident's coccyx. R191 was observed during wound care on 3/29/17, at 10:07 a.m. Licensed practical nurse (LPN)-A was observed to complete a dressing change to a pressure ulcer on R191's coccyx. During the observation an open area was noted on the back of R191's upper thigh, near the gluteal fold. At 10:09 a.m., LPN-A was interviewed and stated when she had observed the area on R191's thigh on 3/27/17 it had not been open. LPN-A then stated she would inform the unit's registered nurse about the open thigh wound. Nursing assistant (NA)-E, also present during the interview, stated the area on R191's thigh had been observed to be open on 3/28/17, and that information had been reported to a nurse that same date. Following observation of the 3/29/17 dressing change, two staff assisted R191 to transfer to the wheelchair using a mechanical lift. At 11:15 a.m., R191 was observed sitting by the nursing offices. R191 remained in this area until 11:54 a.m. when she was taken outside to smoke. At 12:26 p.m. on 3/29/17, R191 was observed back in her room. At that time R191 was interviewed and asked when she had last been repositioned. R191 stated she had not been repositioned since she'd gotten up after her dressing change earlier that morning. At 12:51 p.m. R191 received lunch in her room. At 1:04 p.m. a nursing assistant went into the room to speak with the resident however did not offer or provide repositioning for R191. At 1:11 p.m. a nursing assistant entered R191's room and removed the lunch tray, but R191 was not repositioned. At 1:25 p.m. R191 was transferred back into bed via the mechanical lift with assistance of two nursing assistants. At that point, R191 had not been positioned for approximately three hours since transferring into the wheelchair after the wound dressing change that morning. R191 had been assessed by the facility on 12/29/16 to be cognitively intact. During interview on 3/29/17, at 11:31 a.m. NA-E stated R191 was supposed to be turned and repositioned every two hours. However, an undated document titled Nursing Assistant Care Plan, directed staff to reposition R191 every hour. R191's care plan revised on 3/23/17, revealed there was a new skin breakdown on the left thigh and directed staff to turn and reposition R191 at least every hour or more often as requested. A review of a Wound Summary document dated 3/23/17, indicated skin on the back of the left thigh was superficially excoriated and measured 3 centimeters (cm) by 1 cm, with no depth. There was no documentation found in the Wound Summary document, or in progress notes, to indicate a nurse had assessed the wound on 3/28/17 or on 3/29/17, despite NA-E and LPN-A stating they had reported the change in condition of R191's back left thigh. On 3/31/17, at 8:42 a.m. registered nurse (RN)-D stated she was aware of the open area on the back of R191's thigh on 3/29/17, but had been too busy to assess the open area on 3/29/17. RN-D stated the area on the back of the left thigh at one time was thought to be excoriation, due to pulling an incontinent product up between R191's legs. However, at 8:52 a.m. RN-D stated she had determined on 3/30/17, the back of the left thigh was now a Stage 2 pressure ulcer measuring 4.5 cm by 1 cm, and was 0.2 cm in depth, which was a decline in skin condition from 3/23/17.

Based on interview and record review the facility failed to ensure transfer equipment was used in accordance with manufacturer's guidelines and facility policy for one of four residents (R1) reviewed for falls. R1 had left sided facial bruising and generalized body pain on the right side. Findings include: R1's medical record was reviewed. R1 had dementia and kyphosis (a curving of the spine that caused a rounding of the back, which leads to a slouching posture). R1's care plan, dated 3/31/2014, indicated R1 required a mechanical lift for transfers. R1 was assessed to require a sling with two leg straps that crossed over the opposite thigh and attached to the mechanical lift. A review of a facility incident report dated 11/5/2016 indicated at 5:40 p.m. R1 fell out of a sling when transferred from the bed to his/her wheelchair. R1 fell four feet to the floor. R1 landed on the floor hitting the right side of his/her body and the left side of his/her face. R1 complained of pain and sustained a black eye. At 8:00 p.m. x-rays of R1's right shoulder, arm, elbow, wrist, pelvic region, hip, knee, and ankle were taken. X-rays indicated R1 did not have any fractures. An interview was conducted on 12/30/2016 at 1:20 p.m. with nursing assistant (NA)-B who stated on the day of the incident, s/he went to R1's room to bring R1 to the dining room for dinner. NA-B stated s/he put the sling under R1 while R1 was in bed and had looked for a second staff to help with the transfer. NA-B asked NA-C to assist with the transfer. NA-B brought the lift into R1's room, positioning it on the left side of the bed, and operated the controls of the lift. NA-B stated NA-C was on the right side of the bed and attached the right sling hooks to the right side of the lift. NA-B attached the left sling hooks to the left side of the lift. NA-B raised R1 up while NA-C was moving the wheelchair toward R1. NA-B stated R1 was about four feet from the floor when R1 slipped out of the front of the sling, landing on the floor. NA-B stated that when R1 fell to the ground, the sling was still attached to the mechanical lift. The sling's two leg straps were not crossed over the opposite thigh of R1 when attached to the mechanical lift. An interview was conducted on 1/11/2017, at 2:39 p.m. with NA-C who stated s/he assisted NA-B to transfer R1. NA-C stated the sling was already under R1 when s/he entered R1's room and the lift was placed on the left side R1's bed. NA-C stated s/he attached the right side of the sling to the right side of lift and NA-B attached the left side of the sling to the left side of the lift. NA-B was operating the lift equipment and started to raise R1 up. NA-C stated while s/he was on the right side of the bed, s/he realized the wheelchair was not positioned near the resident. NA-C left the right side of the bed to move the wheelchair near R1, who was now on the left side of the bed. NA-C stated R1 slipped forward out of the sling. NA-C did not have hands on R1 when R1 fell to the floor. An interview was conducted on 1/11/2017 at 3:17 p.m. with the nurse practitioner (NP)-E who stated R1's kyphosis and contracted muscles made spontaneous movement impossible, and R1 could not have contributed to the fall. The Volaro mechanical lift manufacturer's manual dated 11/1/12 provided instructions for lifting a resident from a bed to a chair. It directed staff to place the sling under the resident, cross the leg straps, bring the lift to the bed, place the hanger near the center of the resident, hook the straps, raise the resident up until there is no tension, and double check the hooks. The facility policy and procedure titled Full Mechanical Lift dated June 2016 included instructions for use of a sling for transfer of a resident from a bed to a wheelchair. It directed staff to place the leg straps under the resident's thighs, cross the straps over, move the lift into position, lower the hanger bar, hook the straps to the lift, raise the lift until the resident is slightly above the bed, stop, check the straps, and resume the lift.

Based on observation, documentation and interviews, the facility failed to thoroughly investigate allegations of abuse and neglect, and report alleged violations to the State agency, in 8 of 9 residents reviewed (residents #1, #2, #3, #4, #5, #6, #8 and #9). As a result of the facility's failure to thoroughly investigate allegations of abuse and neglect, and injuries of unknown origin, it was determined that there is an immediate and serious threat to resident health and safety. The administrator was notified of the immediate jeopardy on 01/28/11 at 4:55 p.m. The immediate jeopardy was not removed prior to the investigator's exit on 01/28/11 at 7:00 p.m. The immediate jeopardy was removed on February 1, 2011 at 11:22 a.m., at which time employee (A) and (B) administrative staff were informed of the immediate jeopardy removal. Removal of the immediate jeopardy reduces the scope and severity to a pattern of actual harm that is not immediate jeopardy. Eleven residents were interviewed related to the care they receive at the facility and no concerns were identified related to maltreatment. Seven staff were interviewed related to the facility ' s policy and procedure for the grievance process and related to reporting maltreatment and what constitutes maltreatment. Three grievances were identified by the facility during their audit and monitoring process. These three grievances and the investigative process to conclude the grievances were reviewed and the facility was immediately reporting the allegations to administration, initiating internal investigations and in one example suspended an employee pending the outcome of the investigation. Findings include: The facility failed to thoroughly investigate injuries of unknown origin and resident allegations of abuse and neglect, to determine if mistreatment had occurred. The facility also failed to report such allegations to the State agency. As a result, resident allegations of rough and inappropriate treatment by staff went unresolved since at least 11/09/10. There was no evidence that facility staff tracked and trended allegations to determine common factors such as the employees involved in the allegations, the care unit identified, and/or the shift/time that mistreatment allegedly occurred. Although the facility frequently documented that staff education was completed in connection with a resident complaint about care or treatment by staff, the facility acknowledged that the content of the education was not recorded. In addition, the facility acknowledged that they did not always keep education records pertaining to the employees that they re-educated in connection with resident allegations of abuse and neglect. Nurse managers, on three of four care units where resident mistreatment had been alleged, all stated that there were no employees on their respective units, whose performance was being monitored, as a result of resident complaints about staff care. Although allegations of neglect and rough treatment by staff was an ongoing problem, there was inadequate evidence of administrative follow-up, to indicate that the facility was evaluating staff practice during resident care, including on the evening and night shift. There were no care audits. Resident feedback was limited to the specific concern date. There was no mechanism to ensure sustained compliance, as evidenced by: An incident report, dated 01/18/11 at 10:30 a.m., indicated that a bruise of unknown origin was discovered on Resident #2's left arm. The bruise measured 8.0 x 8.0 and was various shades of purple in color. The incident report, completed by administrative nurse (C)/RN, noted that the immediate intervention implemented was padding the resident's grab bars. The incident report also noted that the resident told staff that no one hurt her. The facility concluded that "no maltreatment"occurred. The facility did not report the unexplained injury to the State agency. Observations on 01/26/11 at 10:30 a.m. revealed that the above bruise had dissipated into the skin and was no longer measurable. The bruise was located on the resident's left inner arm, near the antecubital space, and was yellowish-green in color. Below the bruise on Resident #2's left forearm were three additional bruises, also yellowish-green in color. These bruises were linear and resembled fingerprints. Resident #2 was interviewed on 01/26/11 at 10:30 a.m. She stated that she needs staff assistance with her care, including repositioning in bed. She stated that some staff are rough when performing her care. She pointed to the bruises on her forearm and said that staff grabbed her there, when helping to re-position her. She stated it "hurt"when the staff pulled on her that way. She said she reported that staff were rough when doing care, when a facility nurse (name unknown) asked her about the origin of the bruises. She said she told the facility nurse that a female nursing assistant on the day shift and a male nursing assistant on the night shift are often rough when they help her with care, especially if the care involves repositioning or transferring. Family member (H) was interviewed on 01/27/11 at 3:30 p.m. She visits at the facility at least two to three times a week. She was informed by facility staff that Resident #2's bruises were caused by the grab bar, even though she and the resident told staff that the bruises resulted from staff grabbing the resident. Family member (H) stated that the resident has voiced concern to her several times about being handled roughly by the night shift staff. Medical record review established that Resident #3 was discharged from the facility on 01/25/11, to an assisted living setting. A Concern/Suggestion form, dated 11/09/10, indicated that during Resident #3's facility stay, Family member (I) reported that staff "treat her rough and that they plop her, when transferring her." Staff asked Resident #3 when this happened and the resident stated "all the time/every day." The Concern form, completed by Nurse Manager (D)/RN, noted that staff education was completed and a different transfer sling was tried. Other than the notation on the Concern form that staff education was done, there was no documented evidence regarding which specific staff were re-educated or what the content of the training was. In addition, there was no evidence of any follow-up to indicate that the facility was evaluating staff practice during resident care or that the performance of specific staff was being monitored. The facility did not report Resident #3's allegation of abuse to the State agency. Medical record review established that Resident #9 was discharged from the facility on 12/17/10. A Concern/Suggestion form, dated 12/07/10, indicated that during Resident #9's facility stay, he reported that three women were in his room to do care between midnight and 1:00 a.m. The women (names unknown) were "rough" with him and "tossed" him from side to side. The concern form noted that Administrative nurse (C)/RN provided education to staff, but there was no documented evidence regarding which staff were re-educated. The concern form noted that Nurse (C) checked back with the resident two days later, on 12/09/10, and the resident had no further complaints or concerns regarding rough care. The facility did not report Resident #9's allegation of abuse to the State agency. Although facility documentation reflected that after 12/09/10, Resident #9 had no further problems with rough care by staff, Resident #4 filed a concern on 12/09/10 that staff physically mistreated her during the night of 12/09/10. Medical record review established that Resident #4 was discharged from the facility on 12/21/10, to a local hospital. A Concern/Suggestion form, dated 12/09/10, indicated that during Resident #4's facility stay, she reported that staff were rude when they came to assist her with care at 12:05 a.m. on 12/09/10. The resident reported that staff walked into her room and said, "Oh, you!" The staff then came to her bedside and just grabbed her, when turning her from side to side. The resident told staff, "That hurts." The Concern form, completed by Nurse Manager (D)/RN, noted that the resident cried when she was asked to recall the events of the incident. Although the Concern form noted that education was given to the staff, there was no documented evidence regarding which staff were re-educated. There was no evidence that the facility was evaluating staff practice during resident care or that the performance of specific staff was being monitored. The facility did not report Resident #4's allegation of abuse to the State agency. Medical record review established that Resident #5 was discharged from the facility on 01/14/11. A Concern/Suggestion form, dated 12/01/10, indicated that during Resident #5's facility stay, she reported that her call light remained unanswered for approximately thirty minutes, while she sat on the toilet, sometime between 6:30 and 7:30 p.m. on 12/01/10. The resident reported that she sat on the toilet so long her left leg went numb. Nurse Manager (D)/RN documented that she checked the call light report data (retrievable from the facility's automated system) and "talked to staff about the results." There was no documented evidence regarding which staff were re-educated. There was no plan for any follow-up monitoring of employee performance. The facility did not report Resident #5's allegation of neglect to the State agency. A Concern/Suggestion form, dated 12/17/10 at 4:00 a.m., indicated that Resident #5 reported an additional concern during her facility stay regarding the behavior of a male night shift employee. The resident reported that when she activated her call light on 12/17/10 at approximately 4:00 a.m., the male employee peered at her from behind the privacy curtain, in a stance with his arms folded. The male employee didn't interact with her or acknowledge her request. The male employee's mannerisms made her "nervous" and left her with "unsettling" feelings, so she reported his behavior to facility staff. The Concern form, completed by Nurse Manager (D)/RN, indicated that Nurse Manager (D) reported the resident's concern to the night supervisor for follow-up. The night supervisor documented that she spoke to Nursing Assistant (K) about his behavior. There was no evidence that this employee's performance was subsequently monitored or that supervisory staff audited his care of residents. Nursing Assistant (K)'s personnel file reflected that he received a "satisfactory" performance review on 12/29/10. The performance review was signed by Nurse (L)/LPN/Night Supervisor and Administrative nurse (B)/RN. The performance review did indicate that Nursing Assistant (K) did not always respect the rights of residents and that he had received education in the areas of using gentle touch when providing care and explaining all care to the resident prior to providing care. The personnel file also indicated that Nursing Assistant (K) was counseled on 04/06/10 regarding "unsatisfactory work," in response to a resident complaint of "rough handling during morning care." There was no evidence of any supervisory follow-up between 04/06/10, when he was counseled, and 12/29/10, when his annual performance evaluation was completed. During the OHFC investigation on 01/26/11, two additional residents reported concerns regarding the behavior of a male night shift employee. Resident #6 stated that a male employee (name unknown) on the night shift does as little as possible to assist her, when she needs help to go to the toilet. He rushes through care and handles her in a rough manner, as if she were an inanimate object. On one occasion, he pulled a chair out from behind her too soon, when he was assisting her to the toilet, causing her to stumble and lose her balance. She is fearful of this employee. The employee is rude. He never talks to her or acknowledges her requests. When she asks him something, he doesn't answer. He told her once that he does not like her. She has reported his behavior several times to the nurse (name unknown) but nothing ever changes. Resident #7 stated that some of the night shift staff make her uncomfortable because they are not friendly and are abrupt in their approach to her. A Concern/Suggestion form, dated 11/19/10, indicated that Resident #8 reported that she waited over an hour for her call light to be answered on 11/19/10, between 11:15 p.m. and 12:15 a.m. When the nursing assistant finally responded to her call light, she made a comment about waiting so long. The nursing assistant was rude and told her, "Well I am not going to answer your light on my break." The Concern form noted that the call light log was reviewed with the resident and staff, and staff were re-educated. There was no documented evidence regarding which staff were re-educated. There was no plan for any follow-up monitoring of employee performance. Family member (J) was interviewed on 01/25/11 at 2:15 p.m. She stated that Resident #1 no longer resides in the facility because she was unhappy with the care provided by staff. On several occasions, she advocated for Resident #1 and tried to improve the resident's service by identifying obstacles to care, such as impersonal approaches with Resident #1. For example, staff would often enter Resident #1's room to do care and not explain what they were doing. Staff would come to the bedside and begin manipulating the resident, without saying anything to her. On one occasion, staff twisted Resident #1's arm during care, causing her pain. Afterward, Resident #1 was fearful that she would be physically injured by staff during care. Family member (J) stated she reported these issues to the head nurse (name not recalled) but nothing seemed to change. Nurse Managers (D, E, and F)/RNs were interviewed on 1/28/11 at 11:28 a.m., 10:50 a.m., and 9:50 a.m., respectively. All of the nurse managers acknowledged that the the staff education, noted on the Concern forms, is not formally documented in another place and none of the nurse managers recalled the identity of the employees involved in the above allegations, for which they had done training. None of the nurse managers were trending allegations of abuse and neglect, identified by the residents. All of the nurse managers stated that there were no employees on their units whose performance was being monitored, despite ongoing allegations of rough and inappropriate treatment by staff, that went unresolved since at least 11/09/10.

Based on observation, documentation, and interviews, the facility failed to promote each resident's care in a manner that preserved the resident's dignity, in 11 of 22 residents reviewed (#'s 5, 6, 7, 8, 10, 11, 12, 13, 15, 19, and 20). Findings include: Care-related concerns have been voiced by residents since 10/31/10, without sufficient evidence of administrative follow-up to remedy the problem. Residents have identified ongoing issues with staff response time to call lights, the manner in which staff physically manipulate them during care (like inanimate objects), staff rushing through care and performing care without talking to them (explaining what care was going to be done). Improper staff actions have compromised resident dignity and resulted in disrespect to facility residents. For example: Resident #12's medical record indicated that she is incontinent of bladder daily, but does have some control present. She is able to identify and respond to the need to toilet. Her toileting plan was to have the assistance of one staff for toileting, when she requested to use the toilet, to ensure safety because she is also at risk for falls, due to her bilateral amputations. Resident #12 was interviewed on 01/27/11 at 10:00 a.m. She was alert, oriented, and friendly. She was seated in a recliner in her room, which had an odor of urine. She had no bed in her room. She sleeps in the recliner because she suffers from chronic back pain and she is more comfortable sleeping in the recliner. She recognized that her room smelled of urine and stated that she didn't like it either. She stated her incontinence had increasingly become a problem because the staff don't assist her to the toilet "in time." Sometimes she is incontinent three to four times daily because she has waited 20 - 25 minutes for the staff to respond to assist her to the bathroom. By the time the staff respond, she is already wet. During the night, the staff only toilet her once, at 4:30 a.m. She is often soaked through the pad and her recliner is wet. Nurse Manager (E)/RN "threatened" to take her recliner away, if she doesn't stop wetting in it. She began to cry when she made this statement. After the OHFC investigation began on 01/26/11, Resident #12's care plan was modified, on 01/26/11, to include toileting her every two hours during the night. Resident #6 was admitted to the facility, after falling at home and sustaining a right [MEDICAL CONDITION]. Documentation throughout the progress notes indicated that Resident #6 was alert, oriented, able to use a call light appropriately, and able to make her needs known. Her care plan noted that she needed the assistance of one staff for activities of daily living, including transferring and toileting. Her care plan also noted that she was continent of bladder. Resident #6 was interviewed during the investigation and requested anonymity. She stated she feared her care would further suffer if staff found out that she complained about the quality of her care. She stated that she has had considerable "trouble" getting proper help from the night shift staff. When she needs to use the toilet at night, staff don't respond timely. Sometimes she has waited 30 to 45 minutes to get help to go to the toilet. She has had "embarrassing accidents" on several occasions because she has waited so long. She has reported this to the nurses but nothing seems to change. She had a fall recently because she tried to toilet herself when the staff didn't come to assist her. She continually worries that she will fall, become incontinent, or that the staff won't respond when she needs them. Resident #6's medical record verified that she recently sustained a fall at 1:10 a.m. while trying to go to the bathroom independently. The fall was unwitnessed and the resident reported she struck her head and spine, necessitating evaluation in the emergency department. Observations on 01/26/11 at 2:35 p.m. identified Resident #11 in the process of self-transferring to the toilet. She directed the investigator to approach her from the right side and was loudly yelling, "I need help and I'm tired of waiting for someone to come." The investigator obtained staff assistance for the resident but she was already seated on the toilet by the time staff arrived. She was very angry. She stated she was incontinent of urine from waiting so long. She also stated that it was "par for the course" not to get the necessary assistance from the staff. She has been incontinent on numerous occasions, simply from waiting too long to be assisted. Resident #11's bladder assessment, dated 11/24/10, indicated that she is alert, oriented, and able to communicate without problems. The resident is occasionally incontinent and able to manage changing her own brief. She requires the assistance of one staff for toileting, as she recognizes the urge to void but can't get to the toilet in time, due to slow mobility. Resident #10 was interviewed on 01/26/11 at 1:40 p.m. She stated that she had resided at the facility for approximately one week. She came to the facility for rehabilitation therapies. She is currently weak and needs help with her activities of daily living, including toileting. She reported that her room-mate laid in a wet bed all night, on one occasion since she has resided at the facility. The room-mate cries at night sometimes and has told her that the staff don't always come to assist her. Resident #10 became tearful with her lip quivering as she spoke. She stated she was presently continent and she wanted to remain continent. She is fearful that she will become incontinent, like her room-mate, if the staff don't come to assist her, when she needs help to use the toilet. Resident #10's room mate requested not to be identified. During interviews with Resident #6 and #7 on 01/26/11, both residents reported concerns regarding the behavior of a male night shift employee. Resident #6 stated that a male employee (name unknown) on the night shift does as little as possible to assist her, when she needs help to go to the toilet. He rushes through care and handles her in a rough manner, as if she were "a piece of meat." On one occasion, he pulled a chair out from behind her too soon, when he was assisting her to the toilet, causing her to stumble and lose her balance. She is fearful of this employee. The employee is rude. He never talks to her or acknowledges her requests. When she asks him something, he doesn't answer. He told her once that he does not like her. She has reported his behavior several times to the nurse (name unknown) but nothing ever changes. Resident #7 stated that some of the night shift staff make her uncomfortable because they are not friendly and are abrupt in their approach to her. Observations on 01/26/11 at 2:25 p.m. revealed that Resident #15 was sitting in her wheelchair, in the hallway, crying. She had her hand pressed against her forehead, repeatedly crying out "Please help me, will somebody help me?" The investigator observed this resident for five full minutes, during which time six staff were observed to pass by the resident, without any of them addressing her concern. The investigator then approached Nurse (E)/RN, who stated that the resident wanted pain medication and the resident had already been told that she couldn't have any pain medication until 3:00 p.m. None of the staff who passed by this resident offered any type of non-medication intervention, to help alleviate the resident's discomfort or divert her attention. A Concern/Suggestion form, dated 10/31/10, indicated that Resident #13's ice pack leaked onto her bed and she laid in a wet bed for 33 minutes, because no one answered her call light. A Concern/Suggestion form, dated 11/19/10, indicated that Resident #8 waited for an hour for someone to answer her call light and when she questioned the nursing assistant about it, the nursing assistant made a rude comment to her. A Concern/Suggestion form, dated 12/01/10, indicated that Resident #5 reported that her call light remained unanswered for approximately thirty minutes, while she sat on the toilet, sometime between 6:30 and 7:30 p.m. on 12/01/10. The resident reported that she sat on the toilet so long her left leg went numb. A Concern/Suggestion form, dated 12/6/10, indicated that Resident #20 reported that no one answered his call light for "30 minutes or longer." Concern/Suggestion forms, dated 12/24 and 12/25/10 indicated that Resident #19 reported that she had to wait for 45 minutes on 12/24/10 and an hour on 12/25/10 for someone to respond to her call light. The resident reported that when the nursing assistant answered her call light on 12/25/10, after she waited for an hour, the nursing assistant shut it off and didn't address her need.

Based on documentation and and interviews, the facility failed to implement their abuse prohibition policy. Potentially, this failure applies to all facility residents. The facility's abuse prohibition policy, dated 05/10, indicated that the facility supported a "zero tolerance" for resident abuse and neglect. The policy specified that all allegations of resident abuse, neglect, and injuries of unknown origin would be reported internally to the immediate supervisor, who would notify the Director of Nursing and the Administrator. The policy charged the immediate supervisor with the responsibility of securing the resident's safety (for example, by immediately removing a perpetrator from duty). The policy specified that the supervisor and Director of Nursing would conduct an internal investigation of the allegations and determine if the allegation was reportable to the State agency. The policy further specified that the Director of Nursing and/or the Administrator would complete any external reporting requirements, such as to the State agency or local law enforcement. An incident report, dated 01/18/11 at 10:30 a.m., indicated that a bruise of unknown origin was discovered on Resident #2's left arm. The bruise measured 8.0 x 8.0 and was various shades of purple in color. The facility failed to conduct a thorough investigation of the resident's injury and failed to report the unexplained injury to the State agency. A Concern/Suggestion form, dated 11/09/10, indicated that Resident #3's family member reported that staff "treat her rough and that they plop her, when transferring her." The resident indicated that this happened "all the time/every day." The facility failed to thoroughly investigate Resident #3's concern and failed to report Resident #3's allegation of abuse to the State agency. A Concern/Suggestion form, dated 12/07/10, indicated that Resident #9 reported that three women were in his room to do care between midnight and 1:00 a.m. on 12/07/10. The women (names unknown) were "rough" with him and "tossed" him from side to side. The facility failed to thoroughly investigate Resident #9's concern and failed to report the resident's allegation of abuse to the State agency. A Concern/Suggestion form, dated 12/09/10, indicated that Resident #4 reported that staff were rude when they came to assist her with care at 12:05 a.m. on 12/09/10. The resident reported that staff walked into her room and said, "Oh, you!" The staff then came to her bedside and just grabbed her, when turning her from side to side. The resident told staff, "That hurts." The Concern form noted that the resident cried when she was asked to recall the events of the incident. The facility failed to thoroughly investigate the resident's concern and failed to report Resident #4's allegation of abuse to the State agency. Resident #4's medical record indicated that she had previously complained about rough treatment by staff on 11/07/10, when she was being assisted to use the bedpan. She stated that when staff rolled her onto her back, it "wasn't very gentle," and she heard a "pop/click" in her shoulder. X-rays were negative for fracture or dislocation, but the resident indicated her right shoulder was painful. She rated her pain as a 10, on a scale of 1 - 10. There was no evidence in Resident #4's medical record that she had right shoulder pain, prior to 11/07/10. The medical record did indicate that a bruise of "unknown origin" was discovered on the underside of her right upper arm on on 10/26/10. The bruise was dark purple in color and measured 6.5 x 14 cm. The facility failed to thoroughly investigate Resident #4's concerns about rough treatment by staff on two occasions, 11/07/10 and 10/26/10. The facility failed to report Resident #4's allegation of abuse on 11/07/10 and failed to report the resident's unexplained injury on 10/26/10. A Concern/Suggestion form, dated 12/01/10, indicated that Resident #5 reported that her call light remained unanswered for approximately thirty minutes, while she sat on the toilet, sometime between 6:30 and 7:30 p.m. on 12/01/10. The resident reported that she sat on the toilet so long her left leg went numb. The facility failed to thoroughly investigate the resident's concern and failed to report the resident's allegation of neglect to the State agency. A Concern/Suggestion form, dated 12/17/10 at 4:00 a.m., indicated that Resident #5 reported a concern regarding the behavior of a male night shift employee. The resident reported that when she activated her call light on 12/17/10 at approximately 4:00 a.m., the male employee peered at her from behind the privacy curtain, in a stance with his arms folded. The male employee didn't interact with her or acknowledge her request. The male employee's mannerisms made her "nervous" and left her with "unsettling" feelings, so she reported his behavior to facility staff. The facility failed to thoroughly investigate the resident's concern. Documentation from the identified employee's personnel file indicated that the employee was previously counseled on 04/06/10, in response to a resident complaint of "rough handling during morning care." The facility failed to thoroughly investigate the resident's concern. A Concern/Suggestion form, dated 11/19/10, indicated that Resident #8 reported that she waited over an hour for her call light to be answered on 11/19/10, between 11:15 p.m. and 12:15 a.m. When the nursing assistant finally responded to her call light, she made a comment about waiting so long. The nursing assistant was rude and told her, "Well I am not going to answer your light on my break." The Concern form noted that the call light log was reviewed with the resident and staff, and staff were re-educated. There was no documented evidence regarding which staff were re-educated. There was no plan for any follow-up monitoring of employee performance.

Based on observation, documentation, and interviews, the facility failed to ensure that residents were free from abuse, in 11 of 20 residents reviewed (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, and 12). Findings include: The facility failed to promote and enforce a resident environment that was free from physical, verbal, and emotional abuse of residents. During the course of the investigation, several residents reported concerns to the investigator about ongoing incidents of mistreatment by staff. Between 10/27/10 and 01/25/11, at least seven residents filed internal concerns that staff were "rough" with them during care. Roughness was described by residents as: staff grabbing onto their extremities, often without warning, and re-positioning them or transferring them in a vigorous manner, causing pain and sometimes physical injury (bruises and/or soreness that does not readily subside). During the survey, fingerprint bruises were observed on one resident's arm, which she stated was caused by staff "grabbing" her during care. Numerous residents expressed concerns that staff entered their rooms, did not explain the nature of their presence, and began performing care and manipulating their bodies in a hurried, forceful fashion, sometimes causing discomfort or pain. Several residents filed internal concerns regarding this type of behavior, which remained a theme among residents interviews during the survey. Some residents cried as they attempted to articulate the manner in which they were treated by staff. Other residents voiced concerns that staff yelled at them, scolded them, or made sarcastic remarks to them. All of these staff behaviors resulted in an environment of dehumanization. During the survey, residents expressed apprehension to request staff assistance with care, in fear they would be physically injured, shamed, or insulted by staff. Some residents requested anonymity and stated they feared reprisal by staff, for complaining about inadequate or improper care. This issue has remained unresolved since at least 10/27/10, as evidenced by: A Concern/Suggestion form, dated 12/02/10 at 7:00 a.m., indicated that Resident #12 told staff that Nursing Assistant (R)/NA/(R) was abusive to her that morning. The facility suspended NA/(R) and began investigating the matter. The internal investigation noted that Resident #12, a bilateral [MEDICAL CONDITION], was found alone in the bathroom, crying, standing on her stumps. Her prosthetic legs were next to the bed and she had not been assisted to the toilet by staff. Two employees witnessed NA/(R) telling the resident she "stinks so bad she could vomit." The two employees also witnessed NA/(R) telling the resident that her room reeked of urine and she was getting a shower because "you stink." This comment was followed by the nursing assistant waving her hand in front of her face, in a fanning motion. The facility terminated NA/(R)'s employment on 12/03/10, in connection with this matter. The facility's internal investigation also noted that the unit nurse had counseled NA/(R) a few weeks earlier (exact date not documented) for the same abusive behavior with Resident #12. There was no evidence that the facility increased the supervision of NA/(R) or monitored NA/(R)'s performance afterward, prior to the second incident of 12/02/10, noted above. Resident #12's medical record indicated that she is incontinent of bladder daily, but does have some control present. She is able to identify and respond to the need to toilet. Her toileting plan was to have the assistance of one staff for toileting, when she requested to use the toilet, to ensure safety because the resident is also at risk for falls due to her bilateral amputations. Her care plan reflected that she is alert, oriented, and able to make her basic needs known. Resident #12 was interviewed on 01/27/11 at 10:00 a.m. She was alert, oriented, and friendly. She was aware that NA/(R) no longer worked at the facility. She described NA/(R) as "mean" and stated that NA/(R) frequently made disparaging and demeaning remarks about her odors, her incontinence, and the amount of assistance she needs. She began to cry as she talked about her physical limitations and the comments that NA/(R) directed at her. An incident report, dated 01/18/11 at 10:30 a.m., indicated that a bruise of unknown origin was discovered on Resident #2's left arm. The bruise measured 8.0 x 8.0 cm and was various shades of purple in color. The incident report, completed by administrative nurse (C)/RN, noted that the immediate intervention implemented was padding the resident's grab bars. The incident report also noted that the resident told staff that no one hurt her. The facility concluded that "no maltreatment" occurred. Observations on 01/26/11 at 10:30 a.m. revealed that the above bruise had dissipated into the skin and was no longer measurable. The bruise was located on the resident's left inner arm, near the antecubital space, and was yellowish-green in color. Below the bruise on Resident #2's left forearm were three additional bruises, also yellowish-green in color. These bruises were linear and resembled fingerprints. Resident #2 was interviewed on 01/26/11 at 10:30 a.m. She stated that she needs staff assistance with her care, including repositioning in bed. She stated that some staff are rough when performing her care. She pointed to the bruises on her forearm and said that staff grabbed her there, when helping to re-position her. She stated it "hurt" when the staff pulled on her that way. She said she reported that staff were rough when doing care, when a facility nurse (name unknown) asked her about the origin of the bruises. She said she told the facility nurse that a female nursing assistant on the day shift and a male nursing assistant on the night shift are often rough when they help her with care, especially if the care involves repositioning or transferring. Family member (H) was interviewed on 01/27/11 at 3:30 p.m. She visits at the facility at least two to three times a week. She was informed by facility staff that Resident #2's bruises were caused by the grab bar, even though she and the resident told staff that the bruises resulted from staff grabbing the resident. Family member (H) stated that the resident has voiced concern to her several times about being handled roughly by the night shift staff. A Concern/Suggestion form, dated 11/09/10, indicated that Family member (I) reported that staff are "rough" when providing care for Resident #3, and staff "plop her, when transferring her." Staff asked Resident #3 when this happened and the resident stated "all the time/every day." The Concern form, completed by Nurse Manager (D)/RN, noted that staff education was completed and a different transfer sling was tried. Other than the notation on the Concern form that staff education was done, there was no documented evidence regarding which specific staff were re-educated or what the content of the training was. In addition, there was no evidence of any follow-up to indicate that the facility was evaluating staff practice during resident care or that the performance of specific staff was being monitored. A Concern/Suggestion form, dated 12/07/10, indicated that Resident #9 reported that three women were in his room to do care between midnight and 1:00 a.m. on 12/07/10. The women (names unknown) were "rough" with him and "tossed" him from side to side. The concern form noted that Administrative nurse (C)/RN provided education to staff, but there was no documented evidence regarding which staff were re-educated. The concern form noted that Nurse (C) checked back with the resident two days later, on 12/09/10, and the resident had no further complaints or concerns regarding rough care. Although facility documentation reflected that after 12/09/10, Resident #9 had no further problems with rough care by staff, Resident #4 filed a concern on 12/09/10 that staff physically mistreated her during the night of 12/09/10. A Concern/Suggestion form, dated 12/09/10, indicated that Resident #4 reported that staff were rude when they came to assist her with care at 12:05 a.m. on 12/09/10. The resident reported that staff walked into her room and said, "Oh, you!" The staff then came to her bedside and just grabbed her, when turning her from side to side. The resident told staff, "That hurts." The Concern form, completed by Nurse Manager (D)/RN, noted that the resident cried when she was asked to recall the events of the incident. Although the Concern form noted that education was given to the staff, there was no documented evidence regarding which staff were re-educated. The progress notes indicated that Resident #4 had previously complained about rough treatment by staff on 11/07/10, when she was being assisted to use the bedpan. She stated that when staff rolled her onto her back, it "wasn't very gentle," and she heard a "pop/click" in her shoulder. X-rays were negative for fracture or dislocation, but the resident indicated her right shoulder was painful. She rated her pain as a 10, on a scale of 1 - 10. There was no evidence in Resident #4's medical record that she had right shoulder pain, prior to 11/07/10. The medical record did indicate that a bruise of "unknown origin" was discovered on the underside of her right upper arm on on 10/26/10. The bruise was dark purple in color and measured 6.5 x 14 cm. According to Resident #4's medical record, she is alert and oriented. A Concern/Suggestion form, dated 10/27/10, indicated that Resident #11 reported a concern that a nursing assistant who was assigned to her care on 10/24/10 at 6:30 p.m. "yelled at" her and didn't complete her care. Nurse Manager (E)/RN followed-up by speaking to the resident about her concern. There was no evidence, however, that Nurse Manager (E)/RN spoke to the nursing assistant regarding his behavior and/or the resident's perception of his behavior. Nurse Manager (E)/RN determined that the nursing assistant and the resident were both having a bad day. There was no evidence that Nurse Manager (E)/RN subsequently monitored the nursing assistant's performance or interviewed other residents regarding the nursing assistant's care of them. According to Resident #11's medical record, she has a [DIAGNOSES REDACTED]. A Concern/Suggestion form, dated 11/19/10, indicated that Resident #8 reported that she waited over an hour for her call light to be answered on 11/19/10, between 11:15 p.m. and 12:15 a.m. When the nursing assistant finally responded to her call light, she made a comment about waiting so long. The nursing assistant was rude and sarcastically told her, "Well I am not going to answer your light on my break." The Concern form noted that the call light log was reviewed with the resident and staff, and staff were re-educated. There was no documented evidence regarding which staff were re-educated. There was no plan for any follow-up monitoring of employee performance. According to Resident #8's medical record, she is alert, oriented, able to make her needs known, and has no problem behaviors. Family member (J) was interviewed on 01/25/11 at 2:15 p.m. She stated that Resident #1 no longer resides in the facility because she was unhappy with the care provided by staff. On several occasions, she advocated for Resident #1 and tried to improve the resident's service by identifying obstacles to care, such as impersonal approaches with Resident #1. For example, staff would often enter Resident #1's room to do care and not explain what they were doing. Staff would come to the bedside and begin manipulating the resident, without saying anything to her. On one occasion, staff twisted Resident #1's arm during care, causing her pain. Afterward, Resident #1 was fearful that she would be physically injured by staff during care. Family member (J) stated she reported these issues to the "head nurse" (name not recalled) but nothing seemed to change. The resident continually asked Family member (J) to take her home. According to Resident #1's medical record, she is alert and oriented, with clear and coherent thought processes. On 01/18/11, Resident #1 was discharged AMA (against medical advice) and went home with family. A Concern/Suggestion form, dated 12/17/10 at 4:00 a.m., indicated that Resident #5 reported a concern regarding the behavior of a male night shift employee. The resident reported that when she activated her call light on 12/17/10 at approximately 4:00 a.m., the male employee peered at her from behind the privacy curtain, in a stance with his arms folded. The male employee didn't interact with her or acknowledge her request. The male employee's mannerisms made her "nervous" and left her with "unsettling" feelings, so she reported his behavior to facility staff. The Concern form, completed by Nurse Manager (D)/RN, indicated that Nurse Manager (D) reported the resident's concern to the night supervisor for follow-up. The night supervisor documented that she spoke to Nursing Assistant (K) about his behavior. There was no evidence that this employee's performance was subsequently monitored or that supervisory staff audited his care of residents. During an interview with Nurse Manager (D)/RN on 01/28/11 at 11:28 a.m., she stated that she did not follow-up with the night supervisor regarding Resident #5's concern. Nursing Assistant (K)'s personnel file reflected that he received a "satisfactory" performance review on 12/29/10. The performance review was signed by Nurse (L)/LPN/Night Supervisor and Administrative nurse (B)/RN. The performance review did indicate that Nursing Assistant (K) did not always respect the rights of residents and that he had received education in the areas of using gentle touch when providing care and explaining all care to the resident prior to providing care. The personnel file also indicated that Nursing Assistant (K) was previously counseled on 04/06/10 regarding "unsatisfactory work," in response to a resident complaint of "rough handling during morning care." There was no evidence of any supervisory follow-up between 04/06/10, when he was counseled, and 12/29/10, when his annual performance evaluation was completed. During the OHFC investigation on 01/26/11, two additional residents reported concerns regarding the behavior of a male night shift employee. Resident #6 stated that a male employee (name unknown) on the night shift does as little as possible to assist her, when she needs help to go to the toilet. He rushes through care and handles her in a rough manner, as if she were "a piece of meat." On one occasion, he pulled a chair out from behind her too soon, when he was assisting her to the toilet, causing her to stumble and lose her balance. She is fearful of this employee. The employee is rude. He never talks to her or acknowledges her requests. When she asks him something, he doesn't answer. He told her once that he does not like her. She has reported his behavior several times to the nurse (name unknown) but nothing ever changes. As a result, Resident #6 has stopped asking the night staff for help. She has also limited the amount of time she spends outside of her room. According to Resident #6's medical record, she is alert, oriented, and able to make her needs known. Resident #7 also stated that some of the night shift staff make her uncomfortable because they are not friendly and are abrupt in their approach to her. Resident #7 is alert and oriented. Nurse Managers (D, E, and F)/RNs were interviewed on 1/28/11 at 11:28 a.m., 10:50 a.m., and 9:50 a.m., respectively. Nurse managers (D, E, and F)/RNs all stated that there were no employees on their respective units (three of four care units where resident mistreatment had been alleged) , whose performance was being monitored, as a result of resident complaints about staff care.