Every finding on record at Worland Health and Rehabilitation

Based on observation, medical record review, staff and resident representative interview, the facility failed to ensure an assessment was performed for 7 of 9 sample residents (#1,#3, #4, #5, #6, #7, #8) reviewed for change of condition. This failure resulted in actual harm to residents #4 and #8 who experienced a delay in treatment. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included stroke, anemia, hypertension, renal disease, hemiplegia, and seizure disorder. The following concerns were identified:a. Review of a nursing progress note dated 4/30/26 and timed 5:22 PM showed Resident complained of nausea. [S/he] had incontinent dark tarry stool, outside of baseline as [s/he] is usually continent. Neuro exam attempted, very weak grasp in right and left. Resident able to stand and pivot to bed with x1 assist. Resident eyes unable to meet nurses upon command, PERRL intact. VSS around baseline. Resident had breakfast, refused lunch. Review of a progress note dated 4/30/26 and timed 5:49 PM showed the resident was transferred to the hospital. Further review showed no evidence additional assessments were performed prior to transfer.b. Review of the hospital A emergency department physician note dated 4/30/26 showed s/he arrived from the facility at 5:48 PM due to decreased responsiveness/altered mental status and abdominal pain. The physician described the resident as encephalopathic, exhibiting limited participation, intermittently opening eyes, and wincing. Laboratory results showed a white blood cell count of 0.9 with an absolute neutrophil count (ANC) of 210, a lactic acid level of 2.2, and a procalcitonin of 13.08, confirming the resident is clearly septic without a history of chemotherapy or immunosuppressants. A troponin level of 33 which the physician noted was expected due to renal failure. While waiting for further reports, the resident experienced a self-limiting episode of ventricular tachycardia lasting one minute, during which s/he remained alert. The resident also had an episode of black tarry stool, possibly related to a vasovagal response. Consult with the on-call surgeon revealed the CT scan did not indicate a volvulus; however, the surgeon recommended immediate transfer due to the clinical picture of sepsis, gastrointestinal bleeding, pain, and altered mental status. Further review showed transfer diagnoses of sepsis, altered mental state, abdominal pain, prolonged QT interval, and nonsustained ventricular tachycardia.c. Review of the hospital B discharge summary with a discharge date of 5/1/26 showed the resident developed hypotension and tachycardia during transport, although oxygen saturation remained normal on room air. Interventions included Levophed and multiple liters of intravenous fluids. Laboratory results showed a CMP with a creatinine of 2.87, which was near the resident's baseline of 2.8, and normal potassium, liver enzymes, albumin, and total bilirubin. A CBC revealed a hemoglobin of 14, a white blood cell count of 0.7 with an ANC of 70, and an MCV of 102 with normal platelets. There was no evidence of bacteriuria. Further review showed a worsening lactic acid level of 3.7, an increase from the previous 2.2. A CTA of the abdomen and pelvis showed abnormal enhancement of the rectum and sigmoid colon, with possible sigmoid pneumatosis indicative of colonic ischemia. The report specified there were no signs of mesenteric arterial occlusion. Following a discussion between the surgical team and the resident's granddaughter and POA regarding the significant risks and minimal benefits of surgery, the POA declined surgical intervention. Due to the poor prognosis, the granddaughter elected to transition the resident to comfort care. Resident #4 was admitted to the intermediate care unit and began receiving IV opioids for pain management. Efforts were made to stabilize the resident until additional family members could arrive; however, the resident's condition deteriorated rapidly. The resident expired with his/her granddaughter present. The cause of death was listed as cardiac arrest due to severe acidemia due to lactic acidosis due to colonic ischemia (when at least a 75% reduction in intestinal blood flow for more than 12 hours), with contributing factors listed as renal disease, severe neutropenia (defined as an absolute neutrophil count of less than 0.5 x 109/L (<500/ L), is uncommon but can cause morbidity and mortality from infections), and possible drug induced agranulocytosis (a rare, life-threatening blood disorder characterized by a severe lack of neutrophils) from depakote.d. Review of the medical records showed no head-to-toe physical nursing assessments had been completed since 9/25/25 when there had been a prior reported change of condition. Further review showed a full set of vital signs had been completed on 2/21/26 and the next full set of vital signs was at the time of transfer on 4/30/26.e. Interview with CNA #1 on 7/2/26 at 9:23 AM revealed she had worked with the resident the week prior to his/her transfer and on 4/28/26 s/he had complained of a headache, had been crying, would not eat, slept more, and had episodes of staring off in space. She stated she reported it to the nurse but did not document it as she was told she wasn't allowed to anymore by DON #2. There was no evidence of an assessment or vital signs for 4/28/26.f. Interview with resident's representative on 6/30/26 at 10:27 AM revealed the resident had blood in his/her stool for a few months and she did not believe the resident had been assessed and followed for this appropriately. S/he had an episode on 4/30/26 of bloody stool and was sent to the hospital. From there the resident was life-flighted to another hospital. She reported the physician told her [his/her] death was preventable, and she felt the resident had been ignored.g. Interview with the regional nurse manager and DON #1 on 7/1/26 at 4 PM confirmed there had been a lack of assessment and they would have expected an assessment to be done for change of condition, pain, or decreased food intake. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #8 had no BIMS score or staff cognitive assessment, and diagnoses which included severe vascular dementia with agitation, cognitive communication deficit, macular degeneration, peripheral vascular disease, hypertension, and depression. The following concerns were identified:a. Review of a nursing progress note dated 5/11/26 and timed 4:51 AM showed The resident had one episode of emesis during the shift. The emesis contained undigested food. The writer observed the resident coughing frequently during meals and drinking water. Dr.[name] notified. There was no evidence a physical assessment or vital signs were taken.b. Review of a nursing progress note dated 5/12/256 and timed 10:31AM showed resident is lethargic. difficult to awaken.lung sounds diminished. unable to safely swallow. Vitals : 97.3 56 16 90/50 spo2 87% on r/a. There was no evidence of intervention or reassessment. c. Review of a nursing progress note dated 5/13/26 and timed 3:34 PM showed Shallow breathing, nurse alerted & [and] is aware of Change. resident is currently on comfort measure @ [at] this time. d. Review of a nursing progress note dated 5/14/26 and timed 5:29 AM showed Resident continues shallow breathing during the night. 118/59 14 98.0 60 O2 sat 91% room air. No s/sx of pain or discomfort observed. Comfort measures continued, care ongoing. e. Review of a progress note dated 5/20/2026 and timed 2:47 AM showed the resident expired at 2:15 AM.f. Review of the medical record showed an order dated 5/9/23 which indicated the resident had elected a DNR (do not resuscitate) status, but requested hospitalization. Further review showed no evidence the resident had an order for comfort care. Interview with the DON on 7/7/28 at 11:05 AM confirmed a comfort care order was not obtained until 5/18/26.g. Interview with the regional nurse manager and DON #1 on 7/1/26 at 4 PM confirmed the lack of assessments and there was no alert charting for change of condition. Further interview confirmed the resident was documented as being on comfort care prior to an order being received for comfort care, when the resident's advanced directives indicated the resident wanted hospitalization. 3. Review of the quarterly MDS assessment dated [DATE] showed resident #3 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included right sided hemiplegia, hypertension, peripheral vascular disease, respiratory failure with hypoxia, dysphagia, and encephalopathy. The following concerns were identified:a. Review of a progress note dated 5/5/26 and timed 5:45PM showed Resident feeling SOB [shortness of breath]overnight as reported by night team. Vital signs are stable. Resident has cough, general malaise more than baseline, weakness, congestion symptoms. [S/he] requested to go out to hospital. Sent to local hospital. MD, family notified. Further review showed no evidence of an assessment performed by the previous night team.b. Review of a progress note dated 5/5/26 and timed 6:15 PM showed a blood pressure (BP) of 132/78, heart rate (HR) of 98, and oxygen (O2) of 90% on room air, respiratory rate (RR) of 22, and a temperature of 98 degrees fahrenheit (F). Further review showed no evidence of vital signs from the previous shift with the complaint of shortness of breath. In addition, there lacked evidence of vital signs prior to the vitals that were taken at the time of the transfer with the complaint of shortness of breath. c. Review of the emergency department (ED) note dated 5/5/26 showed The patient is an [AGE] year-old [female/male] presenting to the ED with cough for the past 2-3 days. [S/he] reports expectorating sputum approximately once daily and had nausea this morning. [S/he] denies fever or chills, vomiting, diarrhea, and home oxygen use. [S/he] arrived from a nursing home and reports that many residents there have had similar symptoms. [S/he] has not taken antibiotics or other medications for these symptoms but reports taking lots of Tylenol. [S/he] denies abdominal pain but reports abdominal soreness after heaving from coughing; [s/he] reports sore throat this morning that has resolved. [S/he] was transported here by EMS from the nursing home. At the nursing home they noted an Spo2 of about 82%. EMS gave a breathing treatment and applied oxygen. On arrival to the ER [s/he] had quite a bit of coughing and apparently cleared some secretions. [S/he] now has an SPo2 of 92% on just 2L by nasal canula [sic]. Further review showed the admission diagnoses of respiratory syncytial virus (RSV) infection, acute hypoxemic respiratory failure and lactic acidosis.d. Interview with the social services director on 6/30/26 at 5:20 PM revealed the resident had felt sick on 5/5/26 and it was reported to her by CNA #1 that the nurses refused to assess him/her and s/he wanted to go to the hospital. She reported that the DON #2 had forced the resident to put on a mask in her/his own room and told her/him s/he had allergies during an RSV breakout at the facility. She reported she heard the resident coughing and s/he appeared short of breath. When she got to the hallway that the resident was in she could hear them coughing and s/he appeared short of breath when she got to her/his room. She asked the primary nurse to call the ambulance for the resident. When EMS arrived they took the resident's oxygen saturation and they reported it was low. e. Interview with activities staff #1 on 7/2/26 at 8:16 AM revealed she went to the resident's room to invite him/her to an activity, and the resident had been in bed, which was unusual for that resident. The resident reported s/he had been sick. She asked DON #2 if the resident had been tested for RSV, and had been told s/he had been tested. She reported she checked on the resident later and s/he was feeling worse, so she reported it to DON #2 who said she would assess the resident. She stated DON #2 stopped at the nurses station and asked if any residents in the hallway had been sick, and the CNAs reported resident #3 had been sick. She reported DON #2 went to the resident's room and she heard her tell the resident they just had allergies. There was no evidence the resident had been tested for RSV and no evidence of assessment.f. Interview with CNA #1 on 7/2/26 at 9:23 AM revealed resident #3 had stated s/he wasn't feeling well, and asked to go to the hospital and DON #2 told him/her no. She reported DON #2 forced the mask on resident #3, and stated it was not even on properly and very forcefully. Resident #3 then tried to take off the mask but was physically unable to on his/her own. CNA #1 reported that she had told the primary nurse the the resident wasn't feeling well earlier in the day before the incident with DON #2 but did not chart it as DON #2 told her CNAs were writing too much in the charts. She then went to the social worker and told her about what happened and filled out a grievance for resident #3, and asked if she could help get the resident sent to the hospital or at least assessed. g. Interview with CNA #3 on 7/2/26 at 10:11 AM revealed on 5/13/26 resident #3 was sick with vomiting and diarrhea and DON #2 looked the resident over and told her s/he was fine. She was able to get another nurse to go in and assess her/him who was able to send her/him to the hospital. There was no evidence of vital signs at that time.h. Interview with the regional nurse manager and DON #1 on 7/1/26 at 4 PM confirmed there was a lack of assessment with a change of condition. 4. Review of the quarterly MDS assessment dated [DATE] showed resident #5 had a staff cognitive assessment of 3 out of 15, which indicated severe cognitive impairment for daily decision making, and diagnoses which included vascular dementia, hypertension, diabetes, CVA, depression and need for assistance with personal care. The following concerns were identified:a. Review of a nursing progress note dated 4/26/26 and timed 12:33 PM showed CNA reported resident had 1 episode of vomiting after lunch time. The resident was cleaned. The resident shows no s/s of acute distress.VSS. HOB elevated to 30 degrees. On-call MD was present in the facility and made aware. New order for Ondansetron Give 4 mg by mouth every 6 hours as needed for Nausea and vomiting. PRN medication gives as prescribed and tolerated well. There was no evidence vital signs had been documented and no evidence of physical assessment. Further review showed the last full set of vital signs had been documented on 2/21/26.b. Review of a nursing progress note dated 4/26/26 and timed 4:55 PM showed The resident was seen in bed during rounds throughout shift .No s/s of acute distress noted.The resident had diarrhea3x [sic] during shift. The stool was noted to be foul smelling. PRN Imodium given as prescribed and hydration protocols were implemented throughout shift as well as dietary precautions.On call MD made aware.New order received to test resident for c-diff.Safety and comfort measure maintained.Call light and personal items within reach.All cares and routines rendered.Oncoming nurse made aware. There was no evidence vital signs were obtained or an assessment was performed. c. Review of a nursing progress note dated 4/27/26 and timed 5:42 PM showed Resident drank fluids with assistance. Unable to collect any stool. No bowel movement today. There was no evidence vital signs were obtained or an assessment was performed. d. Review of a nursing progress note dated 4/30/26 and timed 12:06 PM showed Resident refused lunch meal. CNA and nurse both attempted to feed resident. Ensure protein shake was offered and refused by resident. Resident comfortable, no pain noted, VSS. Will try to assist with suppertime meal. There was no indication what the vital signs were or evidence an assessment was performed. e. Review of the medical record showed no documentation when the resident left the facility, no reason for transfer, and no condition was provided at time of transfer. Further review showed a progress note dated 5/7/26 and timed 10:02 PM showed SN contacted [facility name] for update in Resident condition. Charge RN reports pt was admitted at this time for hypernatremia and dehydration. Pt receiving IV fluids at this time. SN contacted POA for update. f. Review of the medical record showed no head-to-toe physical nursing assessments since 2/19/25, when the resident had experienced a previous change of condition.g. Review of the emergency department note dated 5/7/26 and timed 5:30 PM showed The patient is a [AGE] year-old [male/female], presenting to the ED with markedly decreased oral intake for 1 week. Per family, the patient's spouse/caregiver (who shared a room with the patient and ensured the patient ate) died unexpectedly last week; since then, the patient has been eating and drinking very little.Family reports increased sleepiness over the past few days, noted to be more than baseline (previously a frequent [NAME]), with the most sleep reported since Monday. The resident was admitted for hypernatremia with a critical high sodium of 156 mmol/L and failure to thrive. The hypernatremia was corrected in 72 hours and the resident was transferred to a swing bed for end of life care on 5/11/26. The resident expired on 5/22/26 with cause of death listed as hypernatremia, intravascular volume depletion, decreased oral intake and advanced dementia.h. Interview with the resident's representative on 6/30/26 at 10:27 AM revealed s/he had both grandparents residing at the facility and noted that resident #4 frequently assisted with the care of resident #5. Following the unexpected death of resident #4, the representative felt that the quality of care for resident #5 declined significantly. On 5/7/26, she was notified that the resident had been hospitalized . She reported that upon her arrival at the facility, the resident appeared to be in poor condition and had a strong, foul odor.i. Interview with the regional nurse manager and DON #1 on 7/1/26 at 4 PM confirmed there had been a lack of assessments and appropriate follow up assessments for change of condition. Further interview confirmed there had been no documentation for assessment of the resident, their reason/condition for transfer, or the date the resident had been transferred to the hospital. 5. Review of the quarterly MDS assessment dated [DATE] showed resident #6 had a BIMS score of 14 out of 15 which indicated the resident was cognitively intact, and had diagnoses which included chronic obstructive pulmonary disorder, anemia, hypertension, acute on chronic respiratory failure with hypoxia, malnutrition, and pulmonary fibrosis. The following concerns were identified:a. Review of the nursing progress note dated 4/19/26 showed Pt c/o SOB. no other symptoms. O2sat 85%. Pt on 02@4lpm [oxygen at 4 liters per minute] via nasal cannula, Resp 20 and labored. B/p 120/44, HR 60. Nurse increased O2 to 6lpm elevated HOB and notified MD. NO response. Nurse continued to monitor pt. @1145 Pt states [s/he] breathing feels more stable. 02 remained 90-93%. Nurse was able to decrease 02 to 4lpm. Pt was able to maintain o2 sats 91-93. 1200 Pt sitting up in bed Resp unlabored. He ate lunch. He is stable at this time. Will continue to monitor and report to oncoming nurse. There was no evidence of repeat vital signs or assessment until 4/30/26.b. Review of a nursing progress note dated 4/30/26 and timed 7:04 AM showed Summoned to room per med tech. Resident 02 at 68%. Resident assessed by nurse. Call placed to Dr. [name] unable to reach by phone. Text message sent to MD. Resident currently at 4L/NC. Resident 02 increased to 6L/NC per orders. Vitals noted at 160/64, 72, 20, 97.4, 66%. Call place to ambulance. Call placed to [family]. At 6:58a.m. Ambulance here at present. Resident now in route to [facility name]. sent to hospital for hypoxia.c. Review of the emergency department (ED) note dated 4/30/26 showed the resident was seen in the ED for increased oxygen needs at 6 liters per minute (LPM) up from 3LPM. S/he was admitted to the hospital for acute on chronic respiratory failure and treatment of hypoxia.d. Review of the readmission note to the nursing facility dated 5/2/26 showed an oxygen saturation of 86% and no evidence of interventions provided for abnormal vital signs or a follow up assessment was completed.e. Review of a nursing progress note dated 5/3/26 and timed 2:21 PM showed Resident readmitted from hosp. yesterday, is on Doxycycline with no adverse reaction noted. T. 98.0, P. 78, R. 18, BP 129/59, 2 sat 78%. 02 is on, nasal can. Sat retaken and remains in upper 70's. There was no evidence of interventions, a lung assessment, or vital signs being retaken until 5/4/26. f. Review of the nursing progress note dated 6/16/26 and timed 11:29 AM showed Resident reports not feeling well. VS 134/60, 74, 22, 97.6, 89%. No evidence of interventions for low oxygen saturation, a physical assessment, or vital signs were obtained. g. Interview with the regional nurse manager and DON #1 on 7/1/26 at 4 PM confirmed there had been a lack of assessment for change of condition and interventions for abnormal vital signs with appropriate follow up. 6. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 9 out of 15, which indicated moderate cognitive impairment, and diagnoses which included obstructive and reflux uropathy, urine retention, and seizure disorder. The following concerns were identified:a. Review of a progress note dated 6/25/26 and timed 5:23 AM showed the resident was given tylenol for abdominal pain. There was no evidence vital signs were obtained or an assessment was performed.b. Review of a progress note dated 6/25/26 and timed 11:53 AM showed resident vomited x1 with no further episodes ,plan of care continues. There was no evidence vital signs were obtained or an assessment was performed.c. Review of a progress note dated 6/27/26 and timed 8:53 AM showed resident ambulating in hall way, no c/o pain or distress noted , v/s are wnl , appetite normal , hydration and call light are within reach , plan of care continues. d. Review of the progress note dated 6/27/26 at 11:04 AM showed changed residents Foley cath at this time , return urine , and some bleeding noted , will monitor for output and heavy bleeding ,plan of care continues. There was no evidence vital signs were obtained until 6/28/26 or an assessment was performed. e. Interview with LPN #1 on 7/1/26 at 11:41 AM revealed that regarding the episode of vomiting on 6/25/26 she did not check any vitals but did palpate his/her abdomen and did not chart it. She stated vital signs should be taken daily. Further interview showed on 6/27/26 the resident had walked down the hall and complained of pain. She reported s/he held his/her abdomen and pointed to her/his catheter. She checked on him/her later and s/he continued to complain of pain and she changed the foley catheter. She remembered she removed approximately 100mls return output that had some blood in it and she had planned to reassess the resident later. f. Review of a nursing progress note dated 6/28/26 and timed 7:15 AM showed The writer was alerted by the aide that the resident was complaining of bladder pain. The writer observed the Foley catheter tubing with no kinks, a small amount of blood, and the catheter bag was empty. The resident's Foley bag was previously emptied with a total of 500cc. The resident's catheter was irrigated with 60 mL of sterile water. There was resistance and the writer allowed the solution to flow out by gravity. Approximately 10 mL of solution flowed out of the catheter. The catheter was removed. The writer inserted a new Foley , no urine observed in tubing. There was resistance when the writer attempted to inflate the balloon. The residents are as follows: BP 116/68, T 97.2, O2 SAT 93%, RR 18, P 88. 4:00 the writer notified the DON. 4:10 the writer contacted the primary care provider. Awaiting a call back. 4:18 PRN Tylenol given for pain. 4:25 call placed to 911.4:45 the resident left the facility.g. Review of the medical record showed the resident had output as follows: on 6/27/26 at 5:50 AM 400 milliliters (mls), at 11:28 AM 750 mls, at 8:36 PM 15 mls; on 6/28/26 at 4:02 AM no output. There was no evidence the decreased urine output was assessed or interventions were implemented.h. Review of the nursing progress note 6/28/26 at 8:48 AM showed Writer received a phone call from ER Provider at [name of facility] at 0830 this morning regarding this resident. She stated that they were able to replace [his/her] foley catheter, however, in the process of evaluation, it was also determined he was experiencing the beginnings of sepsis due to cholecystitis.Provider stated that resident's [family] and HCP knows and has spoken with resident regarding [his/her] wishes, and does not want to pursue surgical intervention. The provider states she understands the risks of not treating and has spoken with the resident who, due to some lifelong mental limitations, sometimes has difficulty communicating; however, sister states [s/he] understands the risks of choosing comfort care measures. The ER Provider let writer know they have contacted [name of facility] who will be evaluating resident at our facility tomorrow. [S/he] will be transported back to our facility shortly with orders for pain medication as needed.i. Interview with the regional nurse manager and DON #1 on 7/1/26 at 4 PM confirmed assessments were not performed as expected for change of condition or decreased urine output. 7. Review of the discharge MDS assessment dated [DATE] showed resident #1 had a BIMS assessment score of 13 out of 15, which indicated the resident was cognitively intact, and diagnoses that included acute on chronic respiratory failure with hypercapnia and hypoxia, congestive heart failure, pneumonia, pulmonary hypertension, pleural effusion, obstructive sleep apnea and urine retention. The following concerns were identified:a. Review of the nursing progress note dated 5/5/26 and timed 7:34 PM showed Resident came to our facility on 5/4/2026 as a new resident. Resident's med orders were put into PCC for pharmacy to process and meds were stuck in queue. Therefore, meds were not process by pharmacy until today. Meanwhile, resident did not receive [her/his] medication last night or this morning. This writer administered medication according to physician's orders. This writer took Meds out of the pixel and administered the meds to the resident. The resident's v/s were taken before meds were given. (B/P 140/70 HR 119 O2 91% Temp 98.0 R 19) Resident was assessed. Md notified Family [name] notified New Orders implemented V/S were taken. There was no evidence of an assessment since the initial assessment and no evidence of additional vital signs until the resident's discharge on [DATE]. b. Interview with social services on 6/30/26 at 5:20 PM revealed that she had been contacted by resident #1's family about not getting his/her medications and no vital signs were taken. c. Interview with the resident's representative on 6/30/26 at 10:03 AM revealed s/he was told the resident arrived at the facility on 5/4/26 at 11:30 AM and the resident had not had medications at that time. The representative revealed she asked staff about getting her/his routine medication and a tylenol for a headache; however, the next day she was told the resident had not received any medications until late evening on 5/5/26. d. Interview with the occupational therapist on 7/1/26 at 2:02 PM revealed she had performed an initial evaluation and bed mobility assessment on the resident and remembered him/her having shortness of breath during the exams.e. Interview with the regional nurse manager and DON #1 on 7/1/26 at 4 PM confirmed the resident had not received medications for 5/4/26 and received some medications on 5/5/26. Further interview confirmed there was no assessment for the elevated heart rate documented on 5/5/26 and no appropriate follow up. 8. Interview with the regional nurse manager on 7/2/26 at 11:50 AM revealed the expectation for alert charting was to do an assessment and vital signs if indicated and report to the next nurse, and a resident should be on alert charting for at least 72 hrs. She reported concerns and changes of condition were supposed to be communicated during verbal reports and written in the charting to reflect the same. Further interview revealed there was no set time for baseline assessments and reassessments for nursing staff, and if new staff or contract staff wanted to know the residents' baseline they could ask other staff or family members. 9. Review of Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. Nursing Fundamentals [Internet]. Eau [NAME] (WI): [NAME] Valley Technical College; 2021. Chapter 4 Nursing Process showed that an admission assessment should include A comprehensive assessment completed when a patient is admitted to a facility that involves assessing a large amount of information using an organized approach. and an ongoing assessment should include a head-toe assessment is to be completed and any changes in patient condition are reported to the healthcare provider. 4.7 implementation of interventions. After the initial plan of care is developed, continual reassessment of the patient is necessary to detect any changes in the patient's condition requiring modification of the plan. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care. At times, patients may experience a change in condition that makes a planned nursing intervention or provider prescription no longer safe to implement. This decision and supporting assessment finding should be documented in the patient's chart and also communicated during the shift handoff report, along with appropriate notification of the provider of the patient's change in condition.

Based on resident interview, resident representative interview, staff interview, record review and policy review, the facility failed to properly obtain grievances and maintain evidence demonstrating the appropriate action and issuance of the grievance decision without repercussions for 4 of 4 residents (#1, #2, #3, #17) reviewed for grievances. The findings were:1. Interview with resident #2's representative on 7/2/26 at 8:45 AM revealed that on 5/10/26 she turned in a grievance regarding medications and on 5/12/26 she had turned in a grievance regarding staffing and 2nd request for a care meeting for the resident. She reported she had taken a picture of the grievance policy on the wall and should have had a resolution on the grievances within 5 days. She stated she never got the meeting she requested or a resolution on the medications. She had also reported grievances on a policy stating she couldn't stay with her family and the DON #2 kept quoting it and could not produce it. She reported that the DON #2 was rude after filing grievances. a. Review of a progress note by DON #2 dated 5/13/26 at 5:18 PM showed [resident #2] already knew about the policy from the first day of admission. The Administrator did allow [resident #2's family] to stay over the first two nights to help her with her anxiety of admitting [resident #2] to this facility. This writer and the Administrator both explained to [resident #2's family], we do not get these types of requests. Due to the level of anxiety [resident #2's family] presented @ the time we allowed her to stay with the complete understanding it would only be for these two days! [resident #2's family] stated, I understand this is something you don't allow but I appreciate it, and I understand it's only for these two days. As of May 11th, 2026, [resident #2's family] refuses to follow the policy and is requesting a meeting with the Administrator and this writer. This writer explained that the Administrator is not available this week and that the week of May 18th, 2026, we would be setting up a meeting. On May 12th, 2026, [resident #2's family] saw me a few times in the hallways, never once did she approach me to speak to this writer about a meeting or anything else! As soon as this writer left the facility [resident #2's family] approached the charge nurse on hall 1 and gave her a note directed to this writer, and she stated This is my 2nd request for a mtg w/you & team Again, [resident #2's family] was informed that we would not be meeting until next week when the Administrator is back in the building!b. Review of a progress note dated 5/13/26 and timed 5:20 AM showed [resident #2's family] left a handwritten note with this nurse requesting to see speak with the DON and/or management team. Family member requested this nurse to give the note to the DON, note left under DON's door.c. Interview with the social services director on 6/30/26 at 5:20 PM revealed she had been aware of resident #2's family's request for care plan meetings and had written a grievance for the family at their request. d. Interview with the human resources director on 6/30/26 at 12:12 PM revealed she had conversations with staff over complaints about DON #2 for staff and residents but did not write up any formal complaints. She had been unaware of a protocol for making it an official complaint. She confirmed she witnessed DON #2 speaking harshly to resident #2's family.e. Interview with medication tech #1 on 6/30/26 at 5:45 PM revealed she witnessed DON #2 yelled at resident #2's family in front of residents and other families and at one point another family tried to step in to help resident #2's family from DON #2's behavior. f. Interview with RN #1 on 7/1/26 at 1419 revealed she had witnessed poor behavior from DON #2 towards resident #2 and his/her family. g. Interview with the administrator on 7/2/26 at 12:30 PM revealed that she did not receive either grievance from the resident's family for 5/10/26 or 5/12/26 or from staff. She reported she never received a request for a meeting with the family.2. Review of a grievance form dated 5/5/26 showed resident #17 reported [DON#2] came to the room to check on [his/her] roommate, [resident #3], in a rude demeanor regarding [resident #3] wearing a mask and insisting she wear one without making known who she was. The form was filled out by the activities staff and reviewed by the administrator with the resolution being DON will identify herself to roommate before assessing the roommate.a. Interview with resident #17 on 7/1/26 at 1:15 PM revealed that DON #2 could be rude when talking to residents and nothing ever happened with it.'b. Interview with the activities staff #1 on 7/2/26 at 8:16 AM revealed she had helped resident #17 with the grievance on DON #2. She stated DON #2 told her she was going to handle the grievance, and she responded to her that it was inappropriate for her to be the one to manage the grievance. She then stated she and DON #2 had a meeting with the administrator where she was asked to re-write the grievance with the pertinent information, which she did not want to do. She stated she and the administrator were headed to speak with the resident when the administrator got called away. She continued to the resident's room and where she found the DON #2 in resident #17's face telling the resident she did not say the things she accused her of. She reported the administrator walked into resident #17's room after the interaction had started. She stated the administrator told her she would address DON #2's behavior. She stated she also reported this interaction to the social worker.c. Interview with the social services director on 7/2/26 at 8:42 AM revealed she had written a grievance on resident #17's behalf and resident #3's behalf.There was no evidence of those grievances and they were not provided by the administrator.d. Interview with the administrator on 7/2/26 at 12:30 PM revealed she had only received the first grievance from resident #17 and she stated she did not rewrite grievances. She interviewed resident #17 to figure out what happened and the resident didn't know the name of the employee because she did not introduce herself. She reported she took DON #2 to the resident's room for identification and the resident confirmed it was DON #2 who had spoken to her in a rude manner. She confirmed she did not address the DON's behavior on the grievance form and did not interview any witnesses to the grievance. 3. Interview with the social services director on 6/30/26 at 5:20 PM revealed she had been approached by CNA #1 about about a mask that had been forced on resident #3, and the resident's request that s/he wanted to go to the hospital. She states she asked the resident's nurse to assess her/him, and call an ambulance if the resident wanted to be transferred to the hospital. She reported she filed a grievance for this. a. Interview with CNA #1 on 7/2/26 at 9:23 AM revealed resident #3 had stated s/he wasn't feeling well, and asked to go in the hallway. She reported DON #2 said the resident couldn't leave his/her room, and she heard resident #3 say s/he wanted to leave to go to the hospital and DON #2 told him/her no and yelled, this is your house for the rest of your life so you'll follow our rules. She reported DON #2 argued back and forth with the resident about it being her house and everyone had to listen to her. She reported DON #2 forced the mask on resident #3, and stated it was not even on properly and very forcefully. Resident #3 then tried to take off the mask but was physically unable to on his/her own. CNA #1 reported that she had told the primary nurse the the resident wasn't feeling well earlier in the day before the incident with DON #2 but did not chart it as DON #2 told her CNAs were writing too much in the charts. She then went to the social worker and told her about what happened and filled out a grievance for resident #3, and asked if she could help get the resident sent to the hospital or at least assessed. She reports she had never been asked about the situation by the administrator.b. Interview with the administrator on 7/2/26 at 12:30 PM revealed she had not received a grievance for resident #3 and did not know about the situation.4. Interview with the social services director on 6/30/26 at 5:20 PM revealed she had been contacted by resident #1's family about not getting his/her medications and no vital signs being taken, and she had filled out a grievance. She stated DON #2 had been aware of the grievances. She stated she also contacted the regional manager and was told to tell the family that DON #2 had it handled. She stated she filed a complaint to the corporate CEO and operations.a. Interview with the administrator on 7/2/26 at 12:30 PM revealed she had not received a grievance for resident #1 and denied knowing about the situation.5. Interview with the social services director on 6/30/26 at 5:20 PM revealed she had at least 3 grievances that had gone missing after she gave them to DON #2. Further interview on 7/2/26 confirmed none of the grievances that were provided had been ones she had written for any of the grievances listed above. 6. Interview with CNA #3 on 7/2/26 at 10:11 AM revealed that DON #2 requested all the staff for a [NAME] wow on 3rd hall and she had been standing in the hallway waiting for a resident who was in the bathroom. She stated she told DON #2 that she couldn't leave the resident alone and the DON insisted. The resident's family then found her/him alone in the bathroom and was upset. She reported she filled out a grievance form. This grievance could not be provided by the facility that resembled this situation. 7. Review of a grievance form dated 5/28/26 from the family of residents #18 and #19 showed they complained of unethical behaviors by the facility that included residents had been told not to report things, had been told not to talk to the State, grievances had been changed or missing, and family members had not been told the whole truth about the state of the facility and family's care. The resolution had been listed as verbal education with staff on 5/27/26 and 5/28/26 regarding professionalism, reporting grievances and given the compliance hotline number. 8. Interview with the administrator on 7/2/26 at 12:30 PM revealed she took over the grievances and made sure they were investigated. She stated grievances had been getting lost and she knew they had an issue, and she had started a Plan of Improvement (PIP). The facility acquired a locked box to submit grievances. 9. Review of the facility policy titled Grievance Procedures Policy last updated March 2025 showed .2. The administrator oversees the grievance procedure and coordinates the center system for collecting, tracking and responding to grievances.6. Grievances are resolved immediately, when possible, by the individual receiving the grievance.7. When immediate resolution is not possible, the grievance is routed to the Grievance Official promptly.8. If the grievance involves abuse, neglect, exploitation, or misappropriation of resident property, the administrator is notified immediately, and an investigation begins.9. The Administrator/designee routes the Grievance Form to the appropriate department manager who reviews the grievance, respond within five business days, and returns the Grievance Form to the Administrator. 10. The person with the grievance has the right to a written decision regarding his/her grievance.14. Grievance forms/investigations are maintained for a minimum of 3 years.

Based on staff interview and medical record review, the facility failed to ensure written bed hold and transfer notices were given to 6 of 7 (#2, #3, #4, #5, #6, #7) residents reviewed for transfers. The findings were:1. Review of a quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact, and diagnoses which included stroke, anemia, hypertension, renal disease, hemiplegia, and seizure disorder. The following concerns were identified:a. Review of a transfer note dated 4/30/26 showed the resident had a syncopal episode with black tarry stools and was sent to the emergency department. Further review showed no evidence a bed hold or transfer notice had been provided.2. Review of a quarterly MDS assessment dated [DATE] showed resident #5 had a cognitive assessment of 3 which indicated severe impairment for daily decision making, and diagnoses which included vascular dementia, hypertension, diabetes, cerebral vascular accident, depression and need for assistance with personal care.The following concerns were identified:a. Review of a progress note dated 5/7/26 and timed 10:02 PM showed the nurse had followed up with the hospital to get the resident's status. There was no evidence that the resident had been transferred to the hospital and no documentation of the resident's condition prior to the transfer. Further review showed no evidence a bed hold or transfer notice had been provided.3. Review of a quarterly MDS assessment dated [DATE] showed resident #6 had a BIMS score of 14 out of 15 which indicated the resident was cognitively intact, and had diagnoses which included chronic obstructive pulmonary disorder, anemia, hypertension, acute on chronic respiratory failure with hypoxia, malnutrition, and pulmonary fibrosis. The following concerns were identified:a. Review of a progress note dated 4/30/26 and timed 6:45 AM showed the resident was transferred to the hospital for low oxygen saturation readings. Further review showed the bed hold was incomplete and there was no evidence a transfer notice had been provided.4. Review of a quarterly MDS assessment dated [DATE] showed resident #3 had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact, and diagnoses which included right sided hemiplegia, hypertension, peripheral vascular disease, respiratory failure with hypoxia, dysphagia, and encephalopathy. The following concerns were identified:a. Review of a progress note dated 5/5/26 and timed 5:46 PM showed the resident had been sent to the hospital for shortness of breath. Further review showed no evidence a bed hold or transfer notice had been provided.b. Review of a progress note dated 5/13/26 and timed 10:14 AM showed the resident had been sent to the hospital for vomiting and diarrhea. Further review showed no evidence a bed hold or transfer notice had been provided.5. Review of a quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 9 out of 15 which indicated moderate cognitive impairment, and diagnoses which included obstructive and reflux uropathy, urine retention, and seizure disorder. The following concerns were identified:a. Review of a progress note dated 6/28/26 and timed 7:15 AM showed the resident was sent to the hospital for abdominal pain and foley catheter issues. Further review showed no evidence a bed hold or transfer notice had been provided.6. Review of an admission MDS assessment dated [DATE] showed resident #2 had a BIMS score of 99 which indicated the resident had been unable to complete the assessment, and diagnoses which included stroke, hemiplegia, aphasia, apraxia, atrial fibrillation, and hypertension. The following concerns were identified:a. Review of a progress note dated 5/07/26 at 3:07 PM showed the resident was sent to the hospital for low oxygen saturation readings. Further review showed no evidence a bed hold or transfer notice had been provided.7. Interview with the regional nurse manager and DON #2 on 7/1/26 at 4 PM confirmed no bed holds or transfer notices had been provided to the residents or their representatives.

Based on resident representative interview, staff interview and record review, the facility failed to ensure that residents received necessary respiratory care for 1 of 3 (#1) residents reviewed for respiratory care. The findings were:1. Review of the discharge MDS assessment dated [DATE] showed resident #1 had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact, and diagnoses which included acute on chronic respiratory failure with hypercapnia and hypoxia, congestive heart failure, pneumonia, pulmonary hypertension, pleural effusion and obstructive sleep apnea. The following concerns were identified:a. Review of the admission assessment dated [DATE] and timed 1:02 PM showed the resident arrived on 6 liters per minute (LPM) of oxygen via nasal cannula (NC).b. Review of an order placed on 5/5/26 showed oxygen @ 6 L/Min via nasal cannula. May titrate oxygen flow to maintain oxygen saturation above 90%. every shift related to ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPERCAPNIA (J96.22). There was no evidence of oxygen placement or assessment on 5/4/26 or the morning of 5/5/26.c. Review of an order placed on 5/5/26 showed Bipap at NOC at bedtime. There was no evidence of Bipap placement or assessment on 5/4/26.d. Review of an order placed on 5/6/26 showed Rinse Mask with H2O in the morning Rinse with H20 and air dry. There was no evidence that the task had been completed on 5/5/26.e. Review of the order placed on 5/5/26 showed Does resident become short of breath when laying flat OR avoid laying flat to prevent shortness of breath? Y/N every shift. There was no evidence of assessment on 5/4/26 or morning of 5/5/26.f. Review of a progress note dated 5/5/26 and timed 7:34 PM showed Resident came to our facility on 5/4/2026 as a new resident. Resident's med orders were put into PCC for pharmacy to process and meds were stuck in queue. Therefore, meds were not process by pharmacy until today. Meanwhile, resident did not receive [his/her] medication last night or this morning.g. Interview with the resident's representative on 6/30/26 at 10:03 AM revealed she had been told the resident arrived at the facility around 11:30 AM on 5/4/26. She reported she visited the resident at 4 PM on 5/4/26 and noticed s/he did not have a Bipap available. She had not been told she needed to bring the resident's personal Bipap. She reported she obtained the resident's Bipap and had to move furniture around the room to set the machine up for him/her as they were not able to get any staff to help them. h. Interview with the social services director on 6/30/26 at 5:20 PM revealed that on 5/5/26 in the evening she was contacted by resident #1's family about not getting his/her respiratory orders. She reviewed the resident's chart and did not see any documentation that anything had been done for the resident. She then spoke to DON #2 to get resolution on her/his orders not being started. i. Interview with the regional nurse manager and DON #1 on 7/1/26 at 4 PM confirmed the resident was without respiratory assessment and assistance from the time he arrived at the facility until the evening of 5/5/26 where assistance and assessment was first documented.

Based on medical record review, and resident representative and staff interview, the facility failed to ensure a pharmaceutical services procedure related to accurate acquiring, receiving, dispensing and administration of medications for 1 of 4 sample residents (#1) reviewed for medication availability. The findings were:1. Review of a discharge MDS assessment dated [DATE] showed resident #1 had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact, and diagnoses which included acute on chronic respiratory failure with hypercapnia and hypoxia, congestive heart failure, pneumonia, pulmonary hypertension, pleural effusion, urine retention and obstructive sleep apnea. Review of the physician orders showed the resident was to receive sildenafil citrate oral tablet 20 mg by mouth three times a day for pulmonary hypertension, tamsulosin HCL oral capsule 0.4 mg by mouth in the morning related to urine retention, apixaban oral tablet 2.5 mg by mouth two times per day for atrial fibrillation, metoprolol tartrate oral table 12.5 mg by mouth two times a day for pulmonary hypertension, and pantoprazole sodium oral tablet delayed release 40 mg by mouth in the morning for gastro-esophageal reflux disease without esophagitis. The following concerns were identified:a. Review of a progress note dated 5/5/26 and timed 7:34 PM showed Resident came to our facility on 5/4/2026 as a new resident. Resident's med orders were put into PCC for pharmacy to process and meds were stuck in queue. Therefore, meds were not processed by the pharmacy until today. Meanwhile, resident did not receive [his/her] medication last night or this morning. This writer administered medication according to physician's orders. This writer took Meds out of the pixel and administered the meds to the resident. The resident's v/s were taken before meds were given. (B/P 140/70HR 119 O2 91% Temp 98.0 R 19) Resident was assessed. Md notified. Family [name] notified. New Orders implemented. V/S were taken.b. Review of the medication administration record (MAR) for May 2026 showed no evidence the resident had been administered the sildenafil evening dose on 5/4/26 or the morning, midday or evening dose on 5/5/26.c. Review of the MAR for May 2026 showed no evidence the resident had been administered the tamsulosin on 5/5/26.d. Review of the MAR for May 2026 showed no evidence the resident had been administered the apixaban evening dose on 5/4/26 or the morning dose on 5/5/26. c. Review of the MAR for May 2026 showed no evidence the resident had been administered the metoprolol evening dose on 5/4/26 or the morning dose on 5/5/26. d. Review of the MAR for May 2026 showed no evidence the resident had been administered the pantoprazole dose on 5/5/26. e. Interview with the resident's representative on 6/30/26 at 10:03 AM revealed she was told by staff that the resident arrived at the facility on 5/4/26 at 11:30 AM and the resident did not receive any medications until late in the evening on 5/5/26. f. Interview with the social services director on 6/30/26 at 5:20 PM confirmed on 5/5/26 she was contacted in the evening by resident #1's family about not getting his/her medication as ordered. She revealed when she reviewed the resident's chart and did not see any documentation that anything had been done for the resident, she notified the DON to get resolution on his/her orders not being started. g. Interview with the regional nurse manager and DON #1 on 7/1/26 at 4 PM confirmed the resident was without medications from the time s/he arrived at the facility on 5/4/26 until the evening of 5/5/26 where s/he received some of his/her medications, and then s/he received the rest of his/her medications on 5/6/26. Further interview revealed they would expect residents to receive all medications available upon arrival to the facility.

Based on resident representative and staff interview, medical record review, and manufacturer's recommendation review, the facility failed to ensure residents were free from significant medication error for 1 of 4 (#1) residents reviewed for medication administration. The findings were:1. Review of a discharge MDS assessment dated [DATE] showed resident #1 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included acute on chronic respiratory failure with hypercapnia and hypoxia, congestive heart failure, pneumonia, pulmonary hypertension, pleural effusion, urine retention, and obstructive sleep apnea. Review of the physician's orders dated 5/5/26 showed the resident was to receive sildenafil citrate oral tablet (sildenafil Citrate) give 20 mg by mouth three times a day related to pulmonary hypertension , tamsulosin HCl oral capsule (tamsulosin HCl) and metoprolol tartrate oral tablet (metoprolol tartrate) give 12.5 mg by mouth two times a day related to pulmonary hypertension. The following concerns were identified:a. Review of a progress note dated 5/5/26 and timed 7:34 PM showed the medications were not put into the system until 5/5/26 and the first administration did not occur until the medications were logged into the system. Further review showed the resident had an elevated pulse of 119 beats per minute and there was no evidence the resident's pulse was reassessed.b. Review of the medication administration record for May 2026 showed no evidence the resident received the sildenafil as ordered on 5/4/26 at 6 PM and on 5/5/26 at 8 AM, 12 PM, or 6 PM. Further review showed no evidence the resident received metoprolol as ordered on 5/4/26 at 6 PM and on 5/5/26 at 8 AM.c. Interview with the social services director on 6/30/26 at 5:20 PM revealed on 5/5/26 she was contacted in the evening by resident #1's family related to the resident not receiving his/her medications as ordered. She revealed she had reviewed the resident's chart and did not see any documentation that anything had been done for the resident and she notified the DON for resolution.d. Interview with the occupational therapist on 7/1/26 at 2:02 PM revealed she had done an initial evaluation and bed mobility assessment on the resident on 5/5/26 and remembered him/her having shortness of breath during the exams.e. Interview with the resident's representative on 6//30/26 at 10:03 AM confirmed she had contacted the facility on 5/5/26 related to the resident's medications. Further she revealed the resident reported having a headache and the representative requested tylenol for the resident.f. Interview with the regional nurse manager and DON #1 on 7/1/26 at 4 PM confirmed the resident was without medications from the time s/he arrived at the facility on 5/4/26 at 11:30 AM until the evening of 5/5/26 where s/he received some of his/her medications, and then s/he received the rest of his/her medications on 5/6/26. Further interview confirmed they would expect residents to receive all medications available upon arrival to the facility.g. Review of the manufacturer's recommendations for metoprolol dated 7/2023 showed . 5.1 Abrupt Cessation of Therapy: Following abrupt cessation of therapy with certain beta-blocking agents, exacerbations of angina pectoris and, in some cases, myocardial infarction have occurred. When discontinuing chronically administered LOPRESSOR, particularly in patients with ischemic heart disease, gradually reduce the dosage over a period of 1 to 2 weeks and monitor the patient.Warn patients not to interrupt therapy without their physician's advice.h. Review of Clinical deterioration after sildenafil cessation in patients with pulmonary hypertension dated 2008 showed .short-term effects of a missed dose could include increased shortness of breath with everyday activity, fatigue or low energy as blood flow resistance in the lungs temporarily rises, dizziness or lightheadedness from reduced exercise tolerance .

Based on observation, medical record, and staff and resident interview, the facility failed to ensure medications were safely stored for 1 of 3 residents (#1) reviewed for medication administration. The census was 64. The findings were: Based on observation, medical record, and staff and resident interview, the facility failed to ensure medications were safely stored for 1 of 3 residents (#1) reviewed for medication administration. The census was 64. The findings were: 1. Review of the medical record showed resident #1 had diagnoses that included chronic kidney disease, hypertension, and atherosclerotic heart disease. The following concerns were identified: a. Observation on 4/30/26 at 12:14 PM showed resident #1 had an unlabeled medication cup that contained 1 unmarked white pill. b. Interview with resident #1 on 4/30/26 at 12:14 PM revealed a traveling nurse gave him/her a sodium chloride salt pill a few months ago. The resident reported s/he had high blood pressure (BP) and noticed the pill was not the sodium bicarbonate that s/he had been prescribed, and stated s/he refused to take the medication. S/he reported the nurse had told him/her it did not make a difference and it did the same thing. Further interview revealed the nurse left the medication after the resident refused to take it. c. Review of the physician orders showed the resident had an order for sodium bicarbonate oral tablet 325 milligram (mg) 2 tablets by mouth twice daily for acute kidney failure. Further review showed the resident did not have an order for sodium chloride.d. Review of the medical record showed no evidence of a self-administration of medication assessment.e. Interview with the DON at 12:35 PM revealed the medication in the resident's possession was an over-the-counter (OTC) medication, and she was unable to verify what the medication was. She stated she did not know when the medication was provided to the resident, and could not verify if the medication had been signed off on the medication administration record (MAR). Further interview confirmed she expected the nurses to watch residents take their medication.d. Interview with the regional clinical nursing director on 4/30/26 at 1:05 PM revealed the facility did not have a policy on medication administration.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure infection control techniques were utilized in 1 of 4 units. The findings were: 1. Observation on 4/30/26 at 6:01 AM showed CNA #1 exited room [ROOM NUMBER] with unbagged, soiled bed linens in her hands. She walked down the hall with the soiled linens and put them in the dirty linen bin. 2. Interview with the DON on 4/30/26 at 10:40 AM confirmed soiled linens should be put in a bag before leaving the room. 3. Review of the facility policy titled Soiled Laundry and Bedding last revised February 2026 showed .3. Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items .

Based on staff and resident representative interview, medical record review, facility investigation review, Office of Healthcare Licensing and Surveys ([NAME]) incident report log review, and policy and procedure review, the facility failed to report an injury of unknown source within 2 hours to the State Agency for 1 of 3 sample residents (#1) reviewed for allegations of abuse. The census was 64. The findings were:1. Review of the 11/30/25 quarterly MDS assessment showed the resident had diagnoses which included non-Alzheimer's dementia, anxiety, and depression. The resident had a BIMS assessment of 0 which indicated severe cognitive impairment. The resident was coded as having no falls since admission/entry or the prior assessment. The following concerns were identified:a. Review of a facility reported incident (FRI) dated 3/4/26 showed an allegation of an injury of unknown source occurred on 3/3/26 at 9:40 PM. The staff was made aware on 3/3/26 at 9:43 PM, and the administrator was made aware on 3/3/26 at 9:43 PM. The initial incident report was sent to [NAME] on 3/4/26 at 9:05 PM. b. Review of a progress note dated 3/3/2026 and timed 9:38 PM showed LPN #1 reported new or worsening edema and a change in skin color or conditions. Further review showed the primary care provider (PCP) responded with the recommendation to send the resident to the emergency room (ER) for an x-ray to rule out fractures. c. Review of a progress note dated 3/3/26 and timed 10 PM showed LPN #1 .spoke with [POA] in regards to patient's right knee. Nurse aide had notified this nurse that patient knee looked different than [his/her] baseline. This nurse evaluated patient right knee. There is mild bruising noted to the knee and it is visibly swollen. The knee appears deformed inward slightly. DON as well as MD immediately upon findings. This nurse explained after speaking with MD and MD requested the patient to be sent to ER to evaluate for fractures. When this was all explained to daughter [name], she stated Well, you guys are just going to have to keep her comfortable until tomorrow or something. Who did I call? No one ever answers the phone anyway. This nurse explained again to patient daughter that [his/her] knee is visibly deformed and patient has some mild pain. POA stated she was come to facility or call to try to figure out what to do.d. Review of a progress note by the DON dated 3/04/2026 and timed 12:06 PM showed Resident noted with increased swelling and pain upon touch. Decreased ROM [range of motion] noted to right lower extremity. Resident is non weight bearing. No obvious open areas noted. V/S are WNL [within normal limits], pulse noted to RLE [right lower extremity]. Provider notified of findings. Order received to send resident to ER for evaluation to rule out fracture or dislocation of right knee. Daughter/POA [name] made aware of findings and gave permission to send to ER accompanied by trusted staff member. EMS [emergency medical services] transported resident to ER. Medication list, Facesheet, SBAR [situation, background, assessment, recommendation], transfer packet, and POLST [portable medical order for life-sustaining treatment] given to EMT [emergency medical technician].e. Interview with the SSD on 4/1/26 at 10:45 AM revealed the DON notified the administrative staff of resident #1's right knee injury at the morning staff meeting on 3/4/26. The SSD reported she accompanied resident #1 and his/her POA to the ER, and informed the facility administration the resident had a right femur fracture. Further interview revealed the Adult Protective Services (APS) caseworker arrived at the facility around 4 PM because she had received a report and told the SSD she had not received a report from the facility. The SSD was instructed to open the report.f. Interview with the resident's representative on 4/1/26 at 12:15 PM revealed the resident received surgery to the fractured femur, entered hospice, and passed away.g. Interview with CNA #1 on 4/1/26 at 12:49 PM revealed the resident had complained of pain for approximately 2 weeks prior to being sent to the ER and she had reported it to the nurses every single day.h. Interview with CNA #2 on 4/1/26 at 1:29 PM revealed for the last 3 weeks the resident was in the facility, his/her right knee had been swollen, had greenish purplish bruising and wasn't normal. She reported she let the nurses know and was told they would give the resident pain medication.i. Interview with CNA #3 on 4/1/26 at 1:50 PM revealed she had worked with the resident in mid-February, and the resident had moaned and groaned and said his/her leg was broken. She reported the resident's pain to the nurse and the resident had been provided with pain medication.j. Interview with CNA #4 on 4/1/26 at 3:07 PM revealed the resident sat at the nurses' station and cried ow, ow on the night of 3/3/26. She transferred the resident with the hoyer lift into bed, and noticed the resident's right leg was larger and almost bent and discolored. She stated she reported it to the nurse .k. Interview with LPN #1 revealed the resident had been yelling out in pain after dinner, which was not unusual, however it had been more than usual that night. She stated the resident reported his/her back was hurting, and she rubbed Biofreeze on the resident's back and gave him/her pain medication. She stated the after the CNA transferred the resident into bed, she asked the nurse what had happened that s/he needed the hoyer lift, and told the nurse how the resident's knee looked. She stated the CNA told her she thought it had been reported, and when she went into the resident's room to look at his/her knee, she knew it was broken because of how it looked. She stated she told the CNA not to do anything else with the resident, she had to report it because it was clearly broken. She stated she called the DON, the resident's representative, and the doctor. She stated the doctor wanted the resident sent to the ER for an x-ray, and when she called the resident's representative, they did not want the resident sent to the ER that late at night, and wanted to wait until the morning. She reported the resident was resting at that time and was not in pain.l. Interview with the NHA on 4/2/26 at 11:45 AM confirmed the SSD had notified the former NHA about resident #1's femur fracture on 3/4/26 at 12:55 PM.2. Review of facility policy titled Abuse Reporting and Response provided by the Regional Director of Clinical Operations on 4/2/26 at 11:50 AM showed .2. Staff reports occurrences of injuries of unknown source immediately to the supervisor and Executive Director.4. The Executive Director or designee reports alleged violations to the state survey agency and other officials in accordance with state law (such as Adult Protective Services and local law enforcement) as follows: a. Immediately but not later than 2 hours - All allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on medical record review, staff interview, and provider interview, the facility failed to ensure a safe and orderly discharge from the facility for 1 of 3 sample residents (#2) reviewed for discharge. The findings were:1. Review of the 3/19/26 admission MDS assessment showed resident #2 was admitted to the facility on [DATE]. Review of the initial care plan showed the resident had diagnoses which included nontraumatic hematoma of soft tissue, congestive heart failure (CHF), urinary tract infection (UTI), and mild cognitive impairment. Review of the medical record showed the resident was discharged from the facility on 3/30/26 at 1:30 PM. The following concerns were identified:a. Review of the Physician Medicare Certification dated 3/19/26 and signed by the physician on 3/24/26 showed the resident required daily care for skilled rehab and skilled nursing, and the physician recommended post-SNF care at an assisted living facility (ALF).b. Review of the care conference minutes dated 3/20/26 showed the resident's proposed/approximate discharge date was in 10 days.c. Review of a progress note by LPN #2 dated 3/30/28 and timed 4:18 PM showed Resident discharge from facility @ 1415. Discharge order received and carried out as directed. Vital signs stable at time if discharge. Resident alert and oriented at baseline. No acute distress observed. Discharge instructions, medications and reviewed with resident and responsible party. Education provided regarding medications, treatment plan. Understanding verbalized. All personal belongings sent with resident. Resident left facility via personal transport in stable condition. Appropriate notification completed and documented in medical records.d. Review of a progress note by the SSD dated 3/30/26 and timed 4:38 PM showed This writer spoke to residents [sic] daughter and son regarding residents discharge. The NP was not comfortable signing [his/her] discharge orders d/t [due to] not being able to evaluate resident prior to discharge. e. Interview with the NP on 4/1/26 at 1:05 PM revealed the resident had been admitted to the facility for rehabilitation due to acute CHF. She stated she had been familiar with the resident, who had a history of severe self-care deficits, and a history of skin breakdown. She reported the physician had just signed the resident's certification the week prior for a 30 day stay, and the resident had been discharged from the facility after only 11 days. She stated there were no discharge orders received from the facility at the physician's office, and the physician had been out of town at the time of the discharge. She reported the physician's office received a phone call on 3/30/26 at 2:30 PM from the facility and the caller requested orders to be sent to the pharmacy, and she refused to sign those orders. She reported discharge orders had been requested on 3/30/26 at 4:15 PM for discharge to the resident's apartment, and for physical therapy (PT) and occupational therapy (OT). Further interview revealed there had been no discharge visit, no follow-up physician visit scheduled, no written order for PT and OT, and the discharge was not considered an against medical advice (AMA) discharge.f. Interview with the SSD on 4/2/26 at 10:15 AM revealed the staff thought they had doctor's orders for the discharge because they had lined everything up and sent it off. Staff did not know the doctor had not been contacted until after the resident left. She reported a nurse called the physician's office after they realized the resident needed a narcotic prescription, and the NP would not sign the order because she did not order the discharge.g. Interview with the NHA on 4/2/26 at 10:45 AM revealed the expectation for the discharge process was to have a discharge order from the provider before discharge.h. Interview with LPN #2 on 4/2/26 at 11:18 AM revealed there had been a discharge meeting on 3/37/26, and she had provided the resident with his/her medications with the exception of the narcotics prior to discharge from the facility on 3/30/26.i. Interview with the regional director of clinical operations on 4/2/26 at 11:48 AM confirmed the resident was discharged without signed discharge orders.

Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure residents received adequate supervision and devices to prevent accidents for 5 of 5 sample residents (#1, #9, #10, #11, #15) reviewed for accident hazards. This failure resulted in actual harm to resident #1 who received burns from hot liquid. The failure resulted in a determination of immediate jeopardy due to a lack of implementation of interventions, including adequate supervision and use of safety equipment. The census was 67. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had a BIMS score of 9, which indicated moderate cognitive impairment, and had diagnoses which included stroke, hemiplegia, and dysphagia. Further review showed the resident required setup or cleanup help with eating. Review of the care plan last revised on 2/22/26 showed interventions which included use of a Kennedy cup (spill-proof cup with a lid) for all hot beverages, which was initiated on 01/19/26, and food and fluid should be served at a temperature that was not scalding, which was initiated on 12/11/24. The following concerns were identified:a. Review of an Event Investigation Final Summary dated 1/19/26 showed resident #1 spilled coffee on him/herself on 1/19/26 at 6:30 AM which caused a burn on right leg and a raised reddened area on him/her left thigh. The resident was identified as being at risk for hot liquid injury related to hemiplegia and hemiparesis which had caused hand contractures on one side. The resident used hard cups with a handle that provided him/her with a better grip. The resident was given a Styrofoam cup with no handles at the time of incident. The facility referred the resident to speech therapy for evaluation to see if s/he required special cups or utensils for drinking.b. Review of the emergency department record dated 1/19/26 and timed 12:30 PM showed . burns to the upper inner thighs. These appear to be second-degree burns and do not involve the genitalia and are not circumferential.c. Observation in the dining room on 2/25/26 at 6:50 AM showed an unidentified visitor gave resident #1 a cup of coffee, in a regular cup with no lid. Continued observation showed CNA #2 refilled resident #1's cup at 7:32 AM. The CNA did not provide a lid for the cup or obtain a new cup with a lid.d. Interview with CNA #1 on 2/25/26 at 10:18 AM revealed on 1/19/26 she had given resident #1 a cup of coffee in a Styrofoam cup with no lid due to the facility using disposable dinnerware because of an influenza outbreak. She revealed she left the room to care for another resident, heard screaming, and immediately returned to resident #1's room where she found the resident with coffee spilled into his/her lap. The CNA placed a towel in the resident's lap and tried to dry up what she could; however, she was unable to assist the resident into bed independently, went to get the RN for assistance, and to assess the resident.e. Interview with RN #1 on 2/24/25 at 5:55 PM revealed on the day of the incident, she responded to CNA #1 reporting resident #1 had spilled their coffee in their lap and the CNA needed assistance with the resident. The RN revealed upon entering the room, she observed the resident had wet pants. The RN revealed after staff removed the resident's pants, s/he had what appeared to be burns to the right thigh and a raised, reddened area on his/her left thigh. RN #1 revealed she cleaned the wounds and applied silver wound gel then notified the DON and administrator of situation, and it was determined the resident should be sent to the emergency department for evaluation and treatment.2. Observation in the dining room on 2/24/26 at 2:10 PM showed resident #11 independently obtained coffee from the coffee carafe, into a cup with no lid. Further observation showed the resident placed the coffee cup on his/her walker seat and ambulated by pushing the walker, which caused the coffee to spill.3. Observation in the dining room on 2/25/26 at 7:30 AM showed resident #9 independently obtained hot water from the coffee machine water spout into an open cup with no lid. Further observation showed the resident walked back to his/her table with the cup in one hand, while pushing his/her walker with the other hand.4. Observation in the dining room on 2/25/26 at 7:31 AM showed CNA #2 obtained a cup of water from the coffee machine water spout and checked the temperature, which was 176.7 degrees Fahrenheit.5. Observation in the dining room on 2/25/26 at 7:40 AM showed resident #10 independently obtained coffee, from the coffee machine, in a cup with no lid. The resident then walked back to a table with the cup in one hand while pushing his/her walker with the other. Further observation showed the resident spilled coffee on him/her and the table when trying to set it down. There was no evidence of injury from spilling on him/herself.6. Observation in the dining room on 2/25/26 at 11:30 AM showed resident #15 independently obtained hot water from the coffee machine water spout into a cup without a lid, and mixed it with a packet of cocoa. The resident ambulated back to his/her seat holding the cocoa in his/her right hand, pushing his/her walker with his/her left hand.7. Observation in the dining room on 2/25/26 at 11:32 AM showed resident #9 independently obtained hot water from the coffee machine water spout and walked back to his/her table. 8. Observation in the dining room on 2/25/26 at 11:40 AM showed CNA #2 obtained a cup of water from the coffee machine water spout and checked the temperature, which was 168.7 degrees Fahrenheit.9. Interview with cook #1 on 2/24/26 at 3:25 PM revealed water from the coffee machine was never to be given to residents.10. Interview with dietary aid #1 on 2/24/26 at 5:05 PM revealed coffee and water temperatures were checked in the kitchen and were never to be served directly from the coffee machine.11. Interview with CNA #2 on 2/25/26 at 10:27 AM revealed residents were allowed to independently obtain beverages but they try to help everyone they can. She revealed there was supposed to be two aides in the dining room for meals a half hour prior to meal times for resident assistance; however, there was usually only one. She revealed she was unaware of any interventions in place to keep residents from filling cups with water from coffee machine and residents did not like waiting for an extended time which resulted in them obtaining items independently. Further interview revealed specialty items, such as cups, plates, and utensils were identified on meal trays; however, beverages were usually provided to residents prior to those coming out.12. On 2/25/26 at 2:59 PM the regional clinical director, interim administrator, and administrator were informed of an immediate jeopardy related to a failure to identify and remove accident/hazard risks to residents.13. The facility submitted a removal plan on 2/25/26 at 4:41PM which included:a. The hot beverage machine being taken out of service on 2/25/26 at 3:30 PM.b. Adaptive equipment audits on all residents on 2/25/26 by 7:00 PM. c. Implementation of access to the hot beverage machine only by dietary staff on 2/25/26 by 3:30 PM.d. Signage posted to ask for assistance with beverages 2/25/26 by 3:50 PMe. Education provided for all staff on hot beverages and all the above interventions 2/25/26 by 7:00 PM.14. The removal plan was accepted on 2/25/26 at 5:13 PM.15. The implementation of the removal plan was verified and immediacy was removed on 2/26/26 at 9:05 AM; however, deficient practice remained at a scope and severity of G.

Based on medical record review, staff interview, review of incident and facility documentation, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 7 sample residents (#2) reviewed for abuse. This failure resulted in actual harm to resident #2. The facility had implemented corrective action prior to the survey and was found to be in substantial compliance as of 9/11/25. The findings were:1. Review of the 11/14/25 quarterly MDS assessment showed resident #2 had severely impaired memory, and had verbal behavioral symptoms directed toward others. Further review showed the resident had a diagnosis of non-Alzheimer's dementia. Review of the 8/8/25 admission MDS assessment showed resident #3 had a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. Further review of the resident's medical record showed diagnoses which included dementia and anxiety. The following concerns were identified: a. Review of the facility incident report dated 9/10/25 showed a CNA heard yelling from the room where resident #2 and resident #3 were roommates. The CNA witnessed resident #3 with a Bible in his/her hand raised toward resident #2. The CNA questioned what was going on, and resident #3 responded well [s/he] was in the way. Both residents stated they were fighting. The CNA separated the residents and witnessed blood and scratches on resident #2's face. The nurse assessed both residents for injuries. Resident #3 did not have any injuries. Resident #2 sustained 2 small abrasions to the left cheek. Resident #3 was assigned a 1:1 staff member. A urinalysis (UA) and an order for Seroquel were ordered for resident #3, and his/her family member decided to take the resident home due to the aggression toward his/her roommate. b. Interview with RN #1 on 2/24/26 at 5:55 PM revealed resident #2 and resident #3 had been roommates, and one of them thought the other one was in his/her way. She reported resident #2 had a red spot on his/her check and she cleaned it and left it open to air.c. Interview with CNA #4 on 2/25/26 at 10:59 AM revealed she had taken resident #2 into his/her room to watch television, and resident #3 was on his/her side of the room looking through his/her personal belongings. She went to the nurses' station, and then heard loud noises coming from the room. When she went to check on the residents, they were next to each other, and resident #2 was holding his/her fist up, and resident #3 was holding up a Bible. She stopped them and noticed resident #2 was bleeding from his/her face. She reported resident #3 had tried to leave the room and resident #2 had been in the way. She separated the residents and took resident #2 to the nurse. d. Interview with the SSD on 2/25/26 at 12:20 PM revealed she got resident #2 a beverage and took him/her to an activity and resident #3 was assigned a 1-to-1 staff for supervision. She discussed the 1-to-1 supervision with resident #3's daughter, who opted to take him/her home that day. Further interview revealed all staff received education and a POC (plan of correction) was initiated that day.2. The facility implemented the following corrective action by 9/11/25: a. Resident #2 was provided immediate assessment by the RN for the abrasion on his/her left cheek, the physician was notified for further assessment, and the SSD provided emotional support. b. The families of both residents were immediately notified by the SSD. c. Resident #3 received 1-to-1 supervision by activities staff and the SSD, and a UA was ordered. d. The SSD and resident #3's daughter discussed an action plan to ensure the safety of all residents going forward. The SSD sent referral paperwork to another facility, and the resident's daughter initiated discharge for the resident on 9/10/25. The resident's UA was positive, and the SSD forwarded the results to the resident's family as the resident had already been discharged . e. The facility reported the incident to the [NAME] and the Ombudsman on 9/10/25. f. The facility initiated the abuse investigation which included resident interviews on 9/10/25. g. The facility determined that residents resided in the community were potentially at risk. The DON, SSD, NHA or designee conducted random resident interviews to identify if other residents had experienced mistreatment of any kind. No other issues or concerns were identified. h. The DON and SSD re-educated all staff on de-escalating residents with dementia. All current staff completed the training. New hires completed training upon orientation. i. Weekly audits were started to review the incident reporting database, the grievance management system, resident and family interviews, and Ombudsman feedback. Audits to be done monthly and then as needed for 3 months, and then as needed. On the spot re-education would occur at the time a staff member was president for an incident. Counseling would be provided as indicated. Any issues identified would be trended and reviewed in the facility QAPI meeting to ensure the plan was implemented, sustained, and evaluated for its effectiveness.3. Review of the facility policy, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation updated March 2025 showed .Each resident has the right to be free from abuse, including verbal, mental, sexual or physical abuse .The Center implements policies and processes so that residents are not subjected to abuse by staff, other residents .

Based on medical record review, resident and staff interview, facility incident investigation review, state survey agency incident database review, and policy review, the facility failed to report allegations of misappropriation of resident property for 1 of 3 sample residents (#59) reviewed for abuse, neglect, and misappropriation. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #59 had a brief interview for mental status score of 14 out of 15 which indicated the resident was cognitively intact. The following concerns were identified: a. Interview with the resident on 3/4/25 at 11:23 AM revealed s/he had $200 which was missing and had told a housekeeper about it. The resident revealed the money went missing about 3 weeks ago and the money had not been found, returned, or replaced. b. Review of the state survey agency incident database review showed no evidence the allegation of missing money was reported. c. Review of an Investigator Interview Form dated 2/10/25 showed the resident told the social services director s/he was missing $200 from a bank envelope that was on his/her bedside table. The resident was unable to say what happened to the money or when it went missing. d. Interview with the social services director on 3/5/25 at 3:29 PM revealed she was aware the resident was missing money and an investigation was completed. Interview with the social services director on 3/5/25 at 4:52 PM confirmed the allegation of missing money and investigation were not reported to the state survey agency. 2. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating last revised September 2024 showed .1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility .3. Immediately is defined as: a. within two hours of an allegation involving abuse or result [sic] in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury .

Based on observation, medical record review, staff interview, facility activities calendar review and policy and procedure review, the facility failed to provide an activities program designed to support residents in their choice of activities for 1 of 2 sample residents (#48) with activity concerns. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #48 had a diagnosis of dementia with behavioral symptoms such as hitting, kicking and wandering. Further review showed it was very important to the resident to do things with groups of people, very important to go outside when the weather was good, and somewhat important to do his/her favorite activities. The resident had a brief interview for mental status score of 5 out of 15, which indicated severe cognitive impairment. Review of the care plan last revised on 2/26/25 showed [the resident is] dependent on staff for meeting emotional, intellectual, physical, spiritual and social needs interventions which included Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. Please invite me to scheduled activities . Engage in simple, structured activities such as small cognitive games. I like to go for walks to get a snack and soda. I like to be helpful and clean around the building when I am able to. I was a janitor for several years, and I enjoy being helpful. In addition, the resident's plan showed I like to be kept busy with activities and exercise. I like to be busy, and I do not like to be cooped up. I will bang on the SCU [secure care unit] doors and try to exit .Resident is an elopement risk [due to history] of exit seeking and wandering. Interventions included Ask resident if [s/he] would help clean up after meals .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, play games, games that challenge [his/her] memory and cognition. Exercise, resident likes to walk. Resident has a history of being a school janitor, [s/he] likes to clean. Allow [him/her] to assist with clearing tables, wiping hand rails. The following concerns were identified: a. Review of the activities calendar for the SCU showed the activities for 3/4/25 were 10 AM puzzles, 11 AM music, 2 PM matching game, and 4 PM Storytime with [staff name]. Further review showed activities planned for 3/5/25 were 10 AM chair exercise, 11 AM funny videos, and 4:30 PM wet Wednesday. b. Observation on 3/4/25 from 9:49 AM to 10:20 AM showed the resident was pacing with his/her walker up and down the hallway and around the dining room. At 10:11 AM, the social services director entered the secure unit and told resident #48 they would be going to play balloon tennis soon. The staff member left the secure unit, and the resident remained in the unit. Further observation showed the resident was not assisted to the activity, and the s/he continued to pace. c. Observation on 3/5/25 from 8:55 AM to 11:20 AM showed the resident was pacing around the dining room. A CNA encouraged him/her to sit down and watch TV, which s/he did. At 8:59 AM, the resident got up and began pacing up and down the hallway. S/he continued pacing up and down the hallway until 9:54 AM when s/he sat down to have a snack. At 10:37 AM, the resident left the unit with an aide for a shower. At 11:20 AM, the resident was again walking up and down the hallway and followed a staff member into another resident's room. S/he remained there while the staff member gave medication to the other resident. The resident was not invited to or engaged in activities during the observation. d. Observation on 3/5/25 from 1:43 PM to 2:55 PM showed the resident was pacing around the dining room and making statements which included I don't trust that one. She's got a lot of people; she has a network of people. Just between me and you. The resident continued to pace until 1:58 PM when s/he sat and made statements which included Somebody's watching though. But I didn't do it, so I don't care. I didn't do it, so I don't have nothing to hide. I get upset when somebody blames me for something. and There's something wrong somewhere. The resident then asked if s/he could use the broom to sweep up. A CNA told him/her that it was already cleaned up. The resident attempted to empty the trash bin in the dining room. The CNA told him/her they would get it later. The resident pulled the trash bin off the medication cart and began to carry it while staff was engaged with other residents. S/he then began using the broom to mop the floor, dipping it into the trash can and scrubbing the floor with circular motions. d. Review of resident's Life Enrichment Quarterly Review dated 12/29/24 showed Resident loves social activities and Resident continues to be actively engaged in the SNF [skilled nursing facility] community. [S/he] is one of our more outgoing residents in spite of being in the SCU. 2. Interview with the social services director on 3/5/25 at 4:50 PM revealed the facility had one activities staff member on medical leave and one on vacation during the week of the survey. She stated, This is a bad week for us with activities. The social services director revealed they had a planned activities calendar for the SCU, but it was flexible based on what was going on with the residents. She revealed some residents, like [resident #48], like to do activities with the rest of the residents [outside of the SCU]. She revealed the expectation was for the CNAs in the unit to perform structured activities. 3. Review of facility policy titled Activity Programs showed .Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident .Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs .

Based on observation, medical record review, and staff and resident interview, the facility failed to ensure resident diet orders were followed for 1 of 3 sample residents (#50) reviewed for food and nutrition. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #50 had a brief interview for mental status score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included diabetes mellitus. Further review showed the resident was coded for a therapeutic diet. Review of the resident's physician orders showed the resident was to receive a controlled carbohydrate diet, had fingerstick blood sugar checks before meals and as needed, and received insulin per a sliding scale based on fingerstick blood sugar levels. The following concerns were identified: a. Observation on 3/4/25 at 8:36 AM showed the resident received a full cinnamon roll with glaze that was visible on top of the roll and on the plate. Review of the diet card provided with the meal showed the resident should have received a half portion of cinnamon roll with no glaze. Interview with the resident at that time revealed the facility did not follow his/her diabetic diet plan. b. Interview with the dietitian on 3/5/25 at 3:48 PM revealed the facility's diabetic diet included smaller portions of carbohydrates and sugar. Further interview revealed diet cards should be followed during meal service, unless a resident requests something different than the diet card. c. Interview with the dietary manager on 3/5/25 at 9:36 AM revealed the diabetic diet portion is a half portion served without a topping. Further interview revealed an aide would usually catch it if a resident was given a regular portion, and they would get approval from the nurse if the resident requested a full portion. d. Interview with the dietary manager on 3/5/25 at 4 PM confirmed the resident's diet card should have been followed and any requests for items different from the diet should be indicated on the card provided with the meal. Further interview confirmed the resident did not request a full cinnamon roll or glaze for the meal. 50485

Based on observation, medical record review, staff interview, professional standard review, and policy review, the facility failed to ensure infection prevention practices were implemented for 1 of 2 sample residents (#2) observed during personal care. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a brief interview for mental status score of 5 out of 15, which indicated severe cognitive impairment, and diagnoses which included cerebrovascular accident and hemiplegia or hemiparesis. Further review showed the resident was frequently incontinent of bowel and bladder and was dependent on staff for toileting hygiene and personal hygiene. The following concerns were identified: a. Observation on 3/5/25 at 2:22 PM showed CNA #1 and OT #1 assisted the resident into bed. The staff members removed the resident's soiled pants and CNA #1 placed the pants on the floor by the bed. The CNA performed incontinence care and, without removing the soiled gloves, the CNA touched the resident's clean brief, clean pants, shirt, left shoe, blanket, television remote, bed remote, call light, and the outside of the wipe container. Prior to leaving the room, the CNA removed the gloves and used hand sanitizing gel. At that time, the CNA obtained the resident's soiled pants from the floor and carried them to the soiled linen room down the hallway, without placing them in a bag. b. Interview with CNA #1 on 3/5/25 at 2:40 PM revealed she knew she was expected to remove her gloves after contamination and prior to touching anything else in the room; however, she was nervous. In addition, she revealed she should have placed dirty linen items in a bag before exiting the resident's room. c. Interview with the infection preventionist on 3/5/25 at 2:46 PM confirmed contaminated gloves should be removed before touching clean items and staff should were expected to bag soiled items prior to removing them from a resident room. 2. Review of the website www.cdc.gov/infection-control/hcp/isolation-precautions/appendix-a-table dated 11/27/23 showed Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination (see Figure). Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens .Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face) . 3. Review of the policy titled Briefs/Underpads dated 2001 showed .12. Perform perineal care [sic] the resident's back side. 13. Remove the underpad from resident by rolling the underpad toward the inside soiled area. Place the underpad in the nearby receptacle/container. 14. Remove gloves, sanitize hands and replace with clean gloves. 15. Place a clean underpad and brief under the resident. 16. Roll the resident on their back. 17. Fasten the brief. 18. Reposition the bed covers. 19. Discard disposable equipment and supplies in designated containers. 20. Remove gloves and perform hand hygiene. 21. Clean the overbed table and return it to its [sic] proper location . 4. Review of the policy titled Laundry and Bedding, Soiled dated 2001 showed .2. Contaminated Laundry is bagged or contained at the point of collection (i.e., location where it was used) .

Based on medical record review, staff interview, review of incident and facility documentation, and policy and procedure review, the facility failed to ensure residents were free from physical abuse by other residents for 1 of 9 sample residents reviewed. This failure resulted in actual harm to resident #1. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 9/27/24. 1. Review of the 10/6/24 admission MDS assessment showed resident #1 (victim) had a BIMS of 3, which indicated severely impaired cognitive skills, and had diagnoses of non-Alzheimer's dementia and pelvic fractures. Further review showed the resident had limited ability to make concrete requests and exhibited verbal behavioral symptoms toward others. 2. Review of the 7/22/24 admission MDS assessment showed resident #2 (perpetrator) had a BIMS score of 4, which indicated severely impaired cognitive skills. Further review of the resident's medical record revealed a diagnosis of unspecified dementia, severe, with other behavioral disturbance. Further review showed the resident exhibited physical behavioral symptoms directed toward others, and rejection of care had occurred 1 to 3 days of the 7-day look-back period. The following concerns were identified related to a resident-to-resident interaction between resident #1 and resident #2: a. Review of an incident report showed on 9/24/24 at 8:35 PM resident #1 and resident #2 had been visiting in the dining room of the memory care unit after dinner with another resident. They were assisted to their rooms by the CNA #2. For an unknown reason, resident #2 later entered resident #1's room and left the room telling staff that s/he had pushed resident #1 down. CNA #1 entered the room and found resident #1 on the floor of his/her room with a laceration to the scalp. Resident #1 was provided first aid by the Nurse #2 and was sent to the emergency room for evaluation. Resident #1 was diagnosed with a probable pelvic fracture. b. Review of the history and physical from the hospital dated 9/25/24 showed resident #1 was admitted to the hospital with a severe pelvic fracture and exacerbation of his/her severe bone on bone degenerative joint disease of the right hip. c. Interview with the DON on 10/24/24 at 11 AM revealed resident #2 had a gradual dose reduction of his/her antipsychotic medication prior to the incident on 9/24/24, and following the incident the resident's medication was increased back to prior dosage. Further, the resident was moved out of the memory care unit, and had 1-to-1 supervision for 3 weeks before placement in a new facility closer to family. d. Interview with CNA #1 on 10/24/24 at 1:21 PM revealed the incident happened out of nowhere. The CNA reported three residents were sitting at a table and talking to each other when she went to assist another resident to get ready for bed. The CNA then heard a door slam and after she walked into the hall she saw resident #2 had walked out of resident #1's room. The CNA went to resident #1's room and found resident #1 on the floor. The CNA revealed resident #1 was shocked and adamant s/he needed to get off the floor. The CNA placed a pillow under the resident's head and saw the blood from resident #1's head hitting the floor. e. Interview with CNA #3 on 10/24/24 at 2:23 PM revealed there were 3 residents sitting at a table in the dining room and they were getting along great. The CNA guided residents #1 and #2 to their rooms to get ready for bed. While he assisted another resident, the CNA heard a high pitched scream, and after going to the hall to see where the scream came from, the CNA saw resident #2 standing outside resident #1's room, and resident #2 stated s/he won't be doing that again. The CNA redirected resident #2 back to his/her room and got Nurse #2 to assess resident #1. 3. The facility implemented the following corrective action by 9/27/24: a. Resident #1 was provided immediate first aid in-house to the laceration on his/her head and was sent to the emergency room for further evaluation and treatment. b. Resident #2 received 1-to-1 monitoring by staff and labs were ordered to rule out any acute issues. c. The facility reported the incident to the State Survey Agency and the Police Department on 9/24/24. d. Care plans were updated for both residents. e. The DON/Designee reviewed the last 30 days of incidents/accidents to determine any pattern or trends. f. The DON/Designee reeducated all staff who work with residents on abuse and behavior management to decrease the risk of aggression towards other residents. g. Weekly audits were started to review incident/accident documentation and ensure re-education with staff members present during incidents was performed. Audits to be done weekly then monthly and discussed in the QAPI meetings. 4. Review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed .Residents have the right to be free from abuse .1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: . b. other residents .

Based on medical record review, resident and staff interview, facility investigation review, and policy and procedure review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 3 sample residents (#65) reviewed for abuse. The facility implemented corrective actions and was determined to be in substantial compliance as of 11/22/23. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #65 had moderate memory impairment and diagnoses which included non-Alzheimer's dementia, depression, and generalized muscle weakness. Further review showed the resident required extensive physical assistance of one person for mobility, transfers, dressing, toileting, and locomotion off the unit. Review of the behavior care plan provided by the DON on 12/20/23 showed Resident was involved in an event with a [male/female] resident where the [male/female] resident began to touch [him/her] inappropriately. Although resident is alert and oriented [s/he] did not stop the contact nor did [s/he] report it to staff. Resident waited for staff to approach [him/her] about the event after [his/her] roommate voiced concerns to staff. Resident did not appear to be upset at the time of the event, but rather became upset after being interviewed by staff. Now resident perseverates on event even though [s/he] continues to seek out [male/female] attention . Further review showed interventions which included .Ensure the resident's physical and emotional needs are met promptly and empathetically to prevent the development of manipulative behaviors as a means of seeking attention or fulfilling unmet needs . The following concerns were identified: a. Review of a progress note dated 11/4/23 at 5:18 PM showed IDT Note: Resident was interviewed about an incident of non-consensual sexual contact that happened to [him/her] on 11/3/23. The incident was reported by [his/her] roommate to staff and to SSD on 11/4/23. Resident was groped by another resident and was very shook up by the incident. SSD notified daughter of the situation and what we were doing to address it. Resident was also made aware of what we were doing to address the situation. b. Review of the SSD attempted interview of the alleged perpetrator on 11/4/23 showed Resident was very lethargic during interview and kept [his/her] eyes shut for majority of it. Resident stated Hell, that's an ugly rumor. Resident would not respond to any further questions. Resident has a BIMS of 0 out of 15 [which indicated severe cognitive impairment]. c. Review of the SSD interview with resident #65 on 11/4/23 showed Last night I was in the hallway in front of my room and [the alleged perpetrator] approached me to talk. [S/he] stuck [his/her] had down my shirt and was groping my [chest area]. [S/He] tried to put [his/her] hands down my pants but couldn't. [S/he] groped my crotch over my pants. I was in shock and didn't know what to do. I told [him/her] it was time to go to bed and [s/he] said aren't you going with me. I told [him/her] no and [s/he] left and I went back in to my room. My roommate saw it happen. d. Review of the SSD interview with the resident's roommate on 11/4/23 showed .resident #65 was in the hallway talking to [alleged perpetrator] in front of our room and I glanced out the door and saw the [alleged perpetrator] groping [his/her] [chest area] and crotch. [S/he] was groping [him/her] over the top of [his/her] clothes and I heard [resident #65] tell [the alleged perpetrator] No I don't want that-get out of here. [The alleged perpetrator] left and resident #65 came back in the room. 2. Interview with resident #65 on 12/20/23 at 8:50 AM confirmed s/he had been touched inappropriately at the facility when another resident stuck his/her hand down resident #65's shirt and pants. The resident revealed s/he was unaware of what was happening initially and reported the incident. The resident revealed nurses responded to the allegation immediately and s/he believed the alleged perpetrator was leaving later in the week. The resident confirmed his/her roommate witnessed the incident. The resident revealed as a result of the incident, s/he received health services visits every Wednesday which s/he felt was beneficial. 3. Interview with the DON and SSD on 12/20/23 at 10:07 AM revealed the alleged perpetrator had a prior incident a couple years ago and s/he has a history of sexual behaviors when s/he had a UTI. They revealed the perpetrator was moved to a different hall, away from resident #65, had been accepted to another facility, and was transferring on 12/21/23. They revealed following the incident, the residents were separated immediately and a staff member was assigned to provide 1 on 1 care to the alleged perpetrator. Additional interventions implemented included counseling for resident #65 initiated on 11/9/23, resident and staff interviews during the investigation, manager education on 11/6/23, and all-staff education on 11/20/23 and 11/22/23. They revealed the facility was performing monitoring of all incidents daily with a weekly review of audits. 4. Review of the facility's investigation report showed the correction date was 11/22/23. The corrective action included 1 on 1 staff care, a room relocation to a different hall, a relocation to a different dining room table, and transfer to another facility for the perpetrator. The corrective action for resident #65 was assessment by a physician, and counseling. Staff were re-educated on abuse, the facility interviewed other residents and staff, and the facility implemented monitoring and auditing weekly. The facility was determined to be in substantial compliance on 11/22/23. 5. Review of the policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program hand delivered on 12/20/23 at 12 PM showed .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse .

Based on medical record review, hospital medical record review, resident representative interview, and staff interview the facility failed to identify and assess for change of condition in accordance with professional standards of practice for 1 of 7 residents (#4) reviewed for possible change of condition assessments. This failure resulted in harm to resident #4, whose signs and symptoms of pneumonia, UTI, heart failure and/or heart attack went unaddressed until family intervention. The findings were: Review of the 12/6/22 admission MDS assessment for resident #4 showed resident had a BIMS score of 14 out of 15, which indicated intact cognitive ability. Further assessment review showed resident had a medically complex condition which included anemia, coronary artery disease, renal failure, diabetes mellitus, non-Alzheimer's dementia, history of myocardial infarction, and unspecified pain. Review of the care plan with a revision date of 12/14/22 showed the resident to have a risk for alteration in cardiovascular status and vital signs related to hypertension, history of MI, and atherosclerotic heart disease. Review of the care plan interventions dated 12/14/22 showed facility staff should monitor and document signs and symptoms of malignant hypertension which included headache, visual problems, confusion, disorientation, lethargy, nausea, vomiting, irritability, seizure activity and difficulty breathing. Further review showed interventions to provide anti-hypertension medications as ordered, and report tachycardia (increased heart rate) and unexplained shortness of breath. The following concerns were identified: 1. Review of the resident's February 2023 MAR showed the resident received the medications losartan potassium 100 mg by mouth one time a day related to essential hypertension and metoprolol succinate extended release 50 mg by mouth one time a day related to essential hypertension. Each of these medications had a start date of 11/30/22. No end date was indicated. 2. Review of the resident's March 2023 MAR showed the medications losartan potassium 100 mg and metoprolol succinate extended release were no longer listed on the MAR and were not administered during the month of March. 3. Review of nursing progress notes for the resident showed the first entry for the month of April 2023 occurred on 4/15/23 at 3:02 AM. The note showed Resident reported increased pain in neck and shoulder, scheduled Tylenol administered with noted improvement. Around midnight resident reported same pain. VS [vital signs] BP 141/80, P [pulse] 90, R [respirations] 20 .PRN [as needed] Ibuprofen administered with noted pain improvement . 4. Review of the progress note dated 4/15/23 at 11:59 AM showed Resident's daughter here and concerned about [resident's] breathing, stating [s/he] may have pneumonia. Upon exam found LCTA [lungs clear to auscultation] X 4 [times 4] . [Resident's name] was exhibiting signs of anxiety and c/o upper neck pain .Tylenol given in AM med dose .After 15 minutes, anxiety ceased and resident was relaxing in lounge chair. Then roommate [name] called daughter and expressed [the resident] need a chest x-ray. Daughter arrived again and resident was transported, by facility van, to hospital for x-ray. Review of the progress note dated 4/15/23 at 7:23 PM showed Nurse report from ER nurse [nurse's name]. Resident has slight pneumonia and UTI. 5. Interview with the resident's daughter on 5/2/23 at 11:40 AM revealed the family did not know the resident was not receiving his/her anti-hypertension medications, but they did note the resident developed new symptoms of mood swings, loss of appetite, fatigue, restlessness and edema. 6. Review of the resident's medical record showed a weight of 154.3 pounds was recorded on 4/3/23, and a weight of 170.2 pounds was recorded on 4/28/23, an increase of 15.9 pounds. 7. Review of the 4/24/23 at 9:29 AM eINTERACT SBAR Summary for Providers showed Situation: The Change of Condition/s reported on this CIC [change in condition] evaluation are/were: Edema (new or worsening), Shortness of breath .Pulse: P 101 . 8. Review of the progress note dated 4/24/23 at 9:48 AM showed Daughter notified nurse this am that herself and siblings had decided that they would like [the resident] seen in the ER [emergency room ] for evaluation of the increased edema, SOB [shortness of breath] and overall decline. I offered to contact clinic if need be to address issue. Family requests that [s/he] be seen in ER at this time. ER contacted and notified of condition change and need for evaluation .Resident transported via facility van . 9. Review of the 4/24/23 at 1:15 PM hospital history and physical showed Patient is a [AGE] year-old nursing home resident with known coronary artery disease (status post stenting), congestive heart failure, stage III chronic kidney disease, and mild dementia .At [his/her] nursing home they have been noticing increasing lower extremity edema and decreasing exercise tolerance including difficulty with transfers. Patient is also having some mild shortness of breath .Patient was seen and evaluated in the emergency department secondary to acute exacerbation of congestive heart failure along with concerningly elevated troponin to 1184 with a proBNP of over 32,000 [laboratory results indicative of heart damage] .[the patient's cardiologist] opined that [s/he] likely has ischemic heart disease causing and aggravated by fluid overload .Assessment/Plan: 1. Acute on chronic congestive heart failure .Patient with acute CHF and NSTEMI [a type of myocardial infarction/heart attack] .2. Acute non-ST segment elevation myocardial infarction .3. Chronic kidney disease . 10. Interview with the DON on 5/4/23 at 2:15 PM revealed the facility failed to identify the resident's anti-hypertension medications had been dropped off of the MAR, and should have recognized the medications were not being administered, stating, If we had recognized that was happening we might have prevented [the resident's] decline. 11. Review of the Centers for Disease Control and Prevention's (CDC) Women and Heart Disease found at https://www.cdc.gov/heartdisease/women.htm and accessed on 5/5/23 showed symptoms of heart disease in women include pain in the neck, jaw, or throat, and When to Call 9-1-1 .In some women, the first signs and symptoms of heart disease can be: Heart attack: Chest pain or discomfort, upper back or neck pain, indigestion, heartburn, nausea or vomiting, extreme fatigue, dizziness, and shortness of breath .Shortness of breath, sudden fatigue, or swelling of the feet, ankles, legs, or abdomen .

Based on observation, staff interview, review of facility policy, and review of the 2017 U.S. Public Health Service food code, the facility failed to ensure sanitary meal service during 1 of 2 meal observations (evening meal on 10/24/22). The facility census was 64. The findings were: 1. Observation on 10/24/22 at 5:32 PM showed dietary aide #1 delivered several trays to residents. During the observation the dietary aide placed plates of food for the residents on the table and assisted with dinner ware. The aide adjusted resident clothing, touching the residents' faces, arms, and hands. After coming in contact with residents' clothing, face, arms, and hands, the dietary aide assisted 2 additional residents with their food by placing her hands on the residents' sandwiches and cutting them in half. No hand hygiene was performed prior to touching the sandwiches. 2. Interview with the infection preventionist on 10/26/22 at 1:57 PM revealed all staff were trained in hand hygiene on an annual basis and there was an active hand hygiene monitoring program in place. Further interview revealed staff were expected to perform hand hygiene between all resident contact and prior to new activities. 3. Review of the facility policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated 2001 showed .All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness . before coming in contact with any food surfaces . 4. According to Food Code 2017, U.S. Public Health Service: 2-301.14 FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLE and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were free from physical abuse for 1 of 8 sample residents (#2). This failure resulted in harm to resident #2, who fell and sustained broken ribs after being hit on the back of the head by another resident. The findings were: Review of the 10/28/19 admission minimum data set (MDS) assessment showed resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The resident had a brief interview for mental status (BIMS) score of 99, indicating the resident was cognitively unable to complete the interview. Interview with CNA #1 on 3/11/20 at 12:58 PM revealed resident #2 liked to get in everybody's business which caused problems with other residents, and the staff tried to keep them separated. Interview with CNA #2 on 3/11/20 at 1:10 PM revealed resident #2 had a couple of residents that (s/he) constantly picked at and was hard to redirect. Interview with RN #1 on 3/11/20 at 1:33 PM revealed resident #6 had a habit of being volatile. Further, RN #1 stated resident #2 upset people with the nagging and bossing. Interview with RN #2 on 3/11/20 at 1:45 PM revealed resident #6 and resident #2 had a love/hate relationship were at one time an item. Further, RN #2 revealed resident #2 became more bossy following the discontinuation of an anti-psychotic medication, and resident #6 did not like to be bossed. Interview with the nursing home administrator on 3/11/20 at 2:11 PM revealed resident #6 did have increased behavioral outbursts, and his/her temper was more easily set off. The administrator stated resident #2 did seek out specific individuals to pick at. The following concerns were identified: 1. Review of the progress note dated 2/23/20 and timed 6:57 AM showed resident #6 hit resident #2 on the back of the head with a closed fist. Resident #2 lost his/her balance and tried to catch him/herself on a chair. The note further showed the resident Must have hit (his/her) right back by lower ribs against armrest of wooden chair. 2. Review of a progress note dated 2/23/20 and timed 10;12 AM showed the resident was sent to the emergency room (ER) via facility van in fair condition. The ER notified the facility the resident was being admitted to the hospital with [REDACTED]. 3. Review of progress notes for resident #6 showed documentation of aggressive behavior on 1/30/20, 2/2/20, 2/9/20, and 2/13/20. a. Review of the care plan titled I get confused due to a [DIAGNOSES REDACTED]. There was no evidence of updates related to identified behaviors. b. Review of the care plan titled the resident has impaired cognitive function related to dementia showed it was initiated on 11/27/18, and last revised on 7/2/19. There was no evidence of updates related to identified behaviors. c. Review of the care plan titled admitted on an antipsychotic medication for behavior management related to my dementia and poor coping mechanisms showed it was initiated 6/24/18 and late revised 7/2/19. There was no evidence of updates related to identified behaviors. 4. Review of progress notes for resident #2 showed documentation of behavior that caused agitation in other residents on 1/23/20, 1/28/20, 2/6/20, 2/7/20, 2/9/20 and 2/11/20. a. Review of the care plan titled The resident has impaired cognitive function/dementia or impaired thought process related to dementia showed it was initiated on 10/29/10. There was no evidence of updates related to identified behaviors. b. Review of the care plan titled I have the potential for alteration in my mood and behavior. At times I exit seek, I tell people that I am only here for a little while and that I need to go home to take care of things. I need the keys to my care so I can leave. Resident becomes upset when she feels like she is not allowed to leave or held prisoner. My court appointed guardian has place me here permanently due to my unsafe behaviors at home showed it was initiated on 11/18/19. There was no evidence of updates related to identified behaviors. 5. Review of the facility policy titled Abuse, Neglect, and Exploitation Prohibition and Prevention Program, approved on 3/21/17 showed .A. Every resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; neglect; exploitation; involuntary seclusion; and any physical or chemical restraint not required to treat the resident's medial symptoms or conditions. B. Each community takes reasonable, appropriate steps to ensure that each resident is free from abuse, neglect, and exploitation by anyone, including (but not limited to) staff, other residents, family members, friends, or other individuals.

Based on medical record and personnel file review, staff interview, and review of facility documentation, logs and policies, the facility failed to ensure staff provided needed services for 1 of 6 sample residents (#6) who had a fall. Resident #6, who was cognitively impaired, did not receive a thorough assessment following a fall, and was found to have a [MEDICAL CONDITION] three days later. The findings were: 1. Review of nursing notes showed on 11/27/18 it was documented resident #6 was grimacing and having increased behaviors when rolling to the left side. The physician ordered an x-ray, which revealed a left [MEDICAL CONDITION]. Review of the facility's incident log showed on 11/27/18 the resident had left hip pain and an x-ray revealed a left [MEDICAL CONDITION]. The facility initiated an investigation for an injury of unknown origin. The following concerns were identified: a. Review of the facility's investigation report (completed 11/30/18) showed the resident sustained [REDACTED]. A fall occurred on 11/24/18 was believed to be the fall that resulted in the resident's [MEDICAL CONDITION]. b. Review of progress notes from 11/1/18 through 12/5/18 showed no documentation of a fall or a nursing assessment following a fall. c. During an interview on 12/5/18 at 2 PM CNA #1 stated she helped RN #1 get the resident off the floor for both falls. When asked if the nurse assessed the resident after either fall, the CNA stated not really, just asked about pain, the resident spoke in gibberish. d. On 12/5/18 at 2:05 PM CNA #2 stated she was working when the resident fell on Saturday (November 24). She stated the nurse (RN #1) asked the resident if s/he was OK, and then instructed the CNA to get the resident off the floor. She further stated she was unsure if the nurse did anything else for an assessment. e. During an interview on 12/5/18 at 3:06 PM RN #1 stated the resident had two falls in the last couple of weeks. She stated the first one the resident was found on the floor next to the bed, and she didn't consider that a fall. She stated the second fall (November 24) the resident was found on the floor in the hallway near his/her room. She stated she performed a minimal assessment which consisted of I just checked to see if (s/he) was feeling OK. She stated she did not get vital signs or assess neuro signs. She stated after she instructed the CNAs to get the resident up, an alarm sounded that she needed to respond to, and she just forgot about it. She stated she did not report or document either fall. She confirmed the facility had provided her education, prior to these incidents, on what to do following a fall. f. During an interview on 12/5/18 at 2:45 PM the DON stated the facility's investigation revealed RN #1 did not report or document two falls for the resident. She stated there was no evidence of an assessment following the falls. She confirmed the RN was terminated for not reporting and following up on falls and resident change in condition. g. Review of the 10/13/18 significant change MDS assessment showed the resident had a BIMS score of 3 (severely impaired cognition). The resident was interviewed for pain, but was unable to state how often s/he had pain, or how severe the pain was. The resident required extensive assistance for transfers and bed mobility. Review of the activities of daily living tracking (ADL) showed the resident required limited to extensive assistance for transfers and bed mobility 11/15/18 through 11/23/18. From 11/24/18 (day of fall) through 11/27/18 the resident required extensive assistance to total dependence. h. Review of the facility investigation report (dated 11/30/18) showed .The fall (s/he) sustained on 11/24/18 is believed to have been the fall that fractured (resident's name) left hip as (his/her) ADL status and behaviors changed on and after that date. Resident's scheduled opiod [MEDICATION NAME] and recent changes in antipsychotics along with resident's cognitive deficit of Alzheimers disease, and frontal lobe tumor made it difficult to identify (his/her) pain. i. During an interview on 12/5/18 at 2:45 PM the DON stated the resident was tapering off [MEDICATION NAME] so behavior changes happened at the same time as the fall. She stated the resident wasn't interviewable. She stated the resident had a change in transfer status after (MONTH) 24th. She further stated on Monday night (November 26) the resident expressed pain when staff were rolling him/her, so the following day the resident's physician was contacted, and the physician then ordered an x-ray. 2. Review of the personnel file for RN #1 showed the facility had provided education on falls, including quizzes dated 12/18/17 and 10/9/16. 3. Review of the facility's Fall Management and Investigation policy (dated 9/1/18) showed E. Post Fall Procedures. 1. A licensed nurse evaluates the resident immediately. The resident is NOT moved until the evaluation is completed, unless there is an immediate safety concern. The evaluation includes but is not limited to: a. Position of resident b. Bleeding, swelling, bruising, redness of skin c. Pain symptoms (verbal/nonverbal) d. Vital signs e. Neuro signs if head injury present or suspected or if the fall is not witnessed. 11. 72-hour post-fall follow-up licensed notes are documented in the resident's record. 4. Review of the facility's policy Abuse, Neglect, and Exploitation Prohibition and Prevention Program (dated 9/1/18) showed the definition of neglect was the failure of the Community, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be intentional (such as withholding or omitting care) or unintentional (e.g., the caregiver should have known that care was needed, but it was not provided).

Based on medical record review, staff interview, and review of facility documentation, logs and policies, the facility failed to ensure a thorough assessment and follow-up for 2 of 6 sample residents (#2, #6) who had a fall. Resident #6, who was cognitively impaired, did not receive a thorough assessment following a fall, and was found to have a [MEDICAL CONDITION] three days later. In addition, the facility failed to ensure that care following a fall was in accordance with facility policy for 1 of 6 sample residents (#6) who fell . The findings were: 1. Review of nursing notes dated 11/27/18 showed resident #6 was grimacing and having increased behaviors when rolling to the left side. The physician ordered an x-ray, which revealed a left [MEDICAL CONDITION]. Review of the facility's incident log showed on 11/27/18 the resident had left hip pain and an x-ray revealed a left [MEDICAL CONDITION]. The facility initiated an investigation for an injury of unknown origin. The following concerns were identified: a. Review of the facility's investigation report (completed 11/30/18) showed the resident sustained [REDACTED]. A fall that occurred on 11/24/18 was believed to be the fall that resulted in the [MEDICAL CONDITION]. b. Review of progress notes from 11/1/18 through 12/5/18 showed no documentation of a fall or a nursing assessment following a fall. c. During an interview on 12/5/18 at 2 PM CNA #1 stated she helped RN #1 get the resident off the floor for both falls. She stated a lift was not used after either fall to get the resident off the floor. When asked if the nurse assessed the resident after either fall, the CNA stated not really, just asked about pain, the resident spoke in gibberish. d. On 12/5/18 at 2:05 PM CNA #2 stated she was working when the resident fell on Saturday (November 24). She stated the nurse (RN #1) asked the resident if s/he was OK, and then instructed the CNA to get the resident off the floor. She stated a lift was not used to get the resident off the floor. She further stated she was unsure if the nurse did anything else for an assessment. e. During an interview on 12/5/18 at 3:06 PM RN #1 stated the resident had two falls in the last couple of weeks. She stated the first one the resident was found on the floor next to the bed, and she didn't consider that a fall. She stated the second fall (November 24) the resident was found on the floor in the hallway near his/her room. She stated she performed a minimal assessment which consisted of I just checked to see if (s/he) was feeling OK. She stated she did not get vital signs or assess neuro signs. She stated after she instructed the CNAs to get the resident up, an alarm sounded that she needed to respond to, and she just forgot about it. She stated she did not report or document either fall. Furthermore, she stated a lift was not used to get the resident off the floor. f. During an interview on 12/5/18 at 2:45 PM the DON stated the facility's investigation revealed RN #1 did not report or document two falls for the resident. She stated there was no evidence of an assessment following the falls. Additionally she stated staff did not use a lift to get the resident off the floor, which was facility policy. g. Review of the 10/13/18 significant change MDS assessment showed the resident had a BIMS score of 3 (severely impaired cognition). The resident was interviewed for pain, but was unable to state how often s/he had pain, or how severe the pain was. The resident required extensive assistance for transfers and bed mobility. Review of the activities of daily living tracking (ADL) showed the resident required limited to extensive assistance for transfers and bed mobility 11/15/18 through 11/23/18. From 11/24/18 (day of fall) through 11/27/18 the resident required extensive assistance to total dependence. h. Review of the facility investigation report (dated 11/30/18) showed .The fall (s/he) sustained on 11/24/18 is believed to have been the fall that fractured (resident's name) left hip as (his/her) ADL status and behaviors changed on and after that date. Resident's scheduled opiod [MEDICATION NAME] and recent changes in antipsychotics along with resident's cognitive deficit of Alzheimers disease, and frontal lobe tumor made it difficult to identify (his/her) pain. i. During an interview on 12/5/18 at 2:45 PM the DON stated the resident was tapering off [MEDICATION NAME] so behavior changes happened at the same time as the fall. She stated the resident wasn't interviewable. She stated the resident had a change in transfer status after (MONTH) 24th. She further stated on Monday night (November 26) the resident expressed pain when staff were rolling him/her, so the following day the resident's physician was contacted who ordered an x-ray. Review of the facility's Fall Management and Investigation policy (dated 9/1/18) showed E. Post Fall Procedures. 1. A licensed nurse evaluates the resident immediately. The resident is NOT moved until the evaluation is completed, unless there is an immediate safety concern. The evaluation includes but is not limited to: a. Position of resident b. Bleeding, swelling, bruising, redness of skin c. Pain symptoms (verbal/nonverbal) d. Vital signs e. Neuro signs if head injury present or suspected or if the fall is not witnessed. 11. 72-hour post-fall follow-up licensed notes are documented in the resident's record. Review of the facility's Safe Resident Movement Program (dated 9/1/18) revealed C. Transferring residents from the floor. When a resident falls or is found on the floor, applicable Health and Wellness fall management and emergency response policies and procedures are followed, as set forth in the Interdisciplinary Policy and Procedure Manual. If and when it is determined that the resident does not require urgent/emergency medical care and the resident is cleared to be transferred from the floor, a device (a total lift or a CAMEL) is used to the transfer the resident from the floor to the bed or a chair, unless the resident is able to self-transfer without weight-bearing assistance. 2. Review of the 10/20/18 quarterly MDS assessment showed resident #2 had a Brief Interview for Mental Status (BIMS) score of 14 (indicating intact cognition). A nursing note dated 12/2/18 showed the resident told staff s/he fell earlier that day and showed staff a bruise on the left lower arm. The resident didn't remember how or when s/he fell . The nurse documented the resident moved the extremities well, ambulated with a walker, and baseline neuros. The following concerns were identified: a. Further review of progress notes and vital signs documentation showed no evidence neuro signs were assessed. b. During an interview on 12/5/18 at 3:31 PM the DON stated she was unable to find documentation of neuro checks and stated they should have been done because it was an unwitnessed fall. Review of the facility's policy Fall Management and Investigation (dated 9/1/18) showed an assessment should include e. Neuro signs if head injury is present or suspected of if the fall is not witnessed .If a head injury if assessed post-fall, of the fall was un-witnessed, the resident is monitored, including vital signs, pupil reactions, signs of nausea/vomiting: a. Every 15 minutes x 4, then b. Every 2 hours x 3, then c. Every shift x 3. 3. During an interview on 12/5/18 at 2:45 PM the DON stated after the fracture involving resident #6, the facility came up with an action plan which included education of staff and monitoring. She stated approximately 23 of 65 staff had been educated so far, and also stated she had not implemented monitoring yet, since she was still in the process of educating staff.