Sierra Winds

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided for two residents (#6) and (#7) to prevent further resident to resident altercations.

Findings include:

Regarding residents #6 and #7:

-Resident #6 was admitted to the facility February 1, 2024 with diagnosis including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, diabetes mellitus due to underlying condition with unspecified complications.

A care plan initiated in April 2023 and revised July 2023 revealed the resident had a focus for communication problems related to dementia and wandering and impaired cognitive function/dementia or impaired thought processes related to short and long-term memory loss and dementia. Interventions included frequent visual checks, when conflict arises, remove residents to a calm safe environment and allow to vent/ share feelings.

The quarterly MDS (minimum data set) assessment dated November 26, 2024 revealed a BIMS (Brief Interview for Mental Status) score of 06, indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood or behaviors.

The progress notes dated December 20, 2024 documented an alert note that revealed CNA reported that resident #6 was sitting in wheelchair at nurses' station. Resident #7 was sitting near her and they were conversing and holding hands. It was reported that as resident #6 wanted to wheel off to use the bathroom when resident #7 would not let go of the wheelchair, staff needed to intervene. No injury or harm noted to resident #6. Provider made aware and message with contact information for this nurse left for resident #6 family.

-Resident #7 was admitted to the facility December 21, 2024 and discharged December 30, 2024 with diagnosis including urinary tract infection, site not specified, altered mental status, unspecified, encephalopathy, unspecified, hallucinations, unspecified, depression, unspecified, unspecified hearing loss, unspecified ear.

The admission care plan initiated in December 2024 revealed the resident had a focus for behavior problems (verbal aggression) related to altered mental status and episodes of hallucinations and wandering/elopement related to cognitive impairment. Interventions included identifying if there is a pattern and purpose of wandering, administer medications as ordered. Monitor/document for side effects and effectiveness, intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed

The admission MDS (minimum data set) assessment dated December 23, 2024 revealed a BIMS (Brief Interview for Mental Status) score of 10 indicating moderate cognitive impairment. Further review of the MDS revealed indicators for behaviors which included verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others and wandering.

The progress notes dated December 30, 2024 revealed two separate incidents for residents #7 and #6. resident #7 was holding resident #6 hand and wheelchair and refused to let go when the resident wanted to move. Staff intervened to free the resident's wheelchair from the resident. The second incident documented resident #7 was holding onto resident #6 wheelchair who was attempting to go to dinner and refused to let go. Staff had to intervene. Resident refused to have first aid treatment for small cut on her finger. Unable to redirect the resident's behavior. Further review of the progress notes for December 30, 2024 revealed resident #7 had increasing delusions and stated she was being held against her will. Resident #7 became very agitated and aggressive, removed dinner plates from the cart and started throwing them across the floor. The progress noted further revealed resident #7 grabbed the dinner cart and started ramming it into anyone and anything in the hallway. Unable to redirect and refused to go to dinner and was still holding onto the cart at 10:41p.m. A call was made to the DON and the provider. Resident #7 was transferred to the hospital for evaluation and treatment.

Review of the facility investigation with discover date of December 30, 2024 included that both resident #6 and #7 were interviewed. Per the documentation, resident #6 and #7 were seated together holding hands when resident #6 left to go the restroom, Resident #7 held onto resident #6 wheelchair sustaining a skin tear. Residents #6 and 7 were immediately separated and assessed. Resident #7 behaviors continued to escalate during the evening. Per doctor's orders resident #7 was sent to the emergency room where she was admitted. Facility followed their policy for resident -resident event,

An interview was conducted on January 14, 2025 at 10:29a.m. with Licensed Practical Nurse (LPN/ Staff #43). Staff #43 stated has worked for the facility for one year and has received abuse training through the facility online portal and it is the staff's responsibility to keep the residents safe and remove form the situation if there is a resident to resident altercation. Staff #43 stated she witnessed to separate incidents on December 30, 2024 involving residents #6 and #7. Staff # 43 stated the first Incident happened at approximately 2:30p.m. Staff #43 was coming down the hall and noticed staff standing around residents #6 and #7. Staff #43 stated she observed resident #7 had hold of resident #6 hand and wheelchair and resident #6 kept saying she needed to go to the bathroom. Resident #7 refused to let her go. Staff intervened and Resident #6 went to the bathroom. The incident happened the long-term care (LTC) unit, resident #7 resides on the skilled unit. Staff #43 stated resident #7 is kept on the LTC unit during the day, due to the number of staff that could have eyes on her due to her behaviors and wandering. Staff #43 stated when the facility has residents with behaviors or wandering concerns., the facility will keep them in a more populated area to keep eyes on them and that it is safer for resident #7.

Staff #43 stated the second incident happened at approximately 4:30p.m. Staff #43 stated resident #7 remained in the same spot on the unit and refused to move and grabbed resident #6 hand again and refused to let her go. She stated resident #7 said she would not let her go. Staff #43 stated she put hand between the two and told resident #7 to let go as resident #6 was trying to back away when resident #7 grabbed resident #6 wheelchair and sustained a skin tear. The residents were kept apart and are on different units. Staff #43 stated resident #7 would not allow her skin tear to be assessed after multiple attempts. Staff #43 stated the skin tear was located on the middle finger on the resident's right hand- 1cm or less with minimal bleeding. Staff #43 stated after dinner resident #6 was taken back to the skilled unit. Staff #43 stated resident #7 Nor started to take the dinner plates off the cart and tossed them down the hallway and refused to let go off the food cart. Staff #43 stated there were no residents in the hallway. Staff #43 stated she was called into another resident room to assist, leaving resident #7 alone on the unit unsupervised. Staff #43 stated as she went to exit the room she found that resident #7 had barricaded the doorway from the hallway with the treatment and linen cart. Staff #43 stated she was sitting outside the room with no one to supervise or monitor because they had to assist another resident. Staff #43 stated she called the doctor and director and informed of resident #7 escalated behavior and received orders for a psych eval. Staff #43 stated the residents behaviors escalat

Based on clinical record review, interviews, review of policies, the facility failed to ensure that one resident (#1) is free from preventable falls.

Findings include:

-Regarding resident #1

Resident #1 was admitted on January 11, 2023 with diagnoses including:
Muscle weakness (generalized), Neuromuscular dysfunction of bladder, unspecified, Nonrheumatic aortic (valve) stenosis, unspecified atrial fibrillation, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, fall, unspecified lack of coordination

A review of the Minimum Data Set (MDS) dated January 11, 2023 revealed a Brief Interview Mental Status (BIMS) score of 13, indicated being cognitively intact. No behaviors were noted and was always continent of bladder and bowel. It was noted that the resident did have a fall prior to entry and since admission. The resident was assessed to be a partial/moderate assistance (meaning helper does less than half the effort. Helper lifts, hold, or supports trunk or limbs, but provides less than half the effort) for toilet transfers (the ability to get on and off a toilet or commode).

A review of the care plan revealed that the resident was a fall risk and had a goal to maintain current level of mobility with no increase in the incidence of falls/injuries. Interventions included to assist the resident to wear non-slick footwear that fits, engage in activities that improve strength, balance and posture, instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails), keep areas free of obstructions to reduce the risk of falls or injury, keep nurse call light within easy reach. Instruct to use call bell or call out for assistance. Keep personal items within easy reach; bed to be in lowest position with wheels locked.

Review of Clinical Notes dated January 16, 2023 0732 a.m. revealed the resident was fond prone, laying on right side between the toilet and shower in the bathroom. The resident's head was resting on their right arm. The resident complained of pain to the right arm, hip and neck. Resident was transferred from the floor to a wheelchair and started to have a seizure and that lasted 2.5 minutes. A second seizure lasted 1 minute. The resident was then transferred from the wheelchair to bed. 911 was called since no previous history of seizures. Resident was alert and oriented times 3 when paramedics were asking questions. Vitals were blood pressure 111/76, pulse 131, temperature 98.3 and oxygen saturation 87%.

Review of Clinical Notes dated January 19, 2023 at 1:09 p.m. revealed that a registered nurse placed a call to the hospital to follow up on resident's diagnosis post fall. The hospital and family member reluctant to release any information regarding her fall other than the resident is in the Intensive Care Unit (ICU).

An interview was conducted on December 11, 2024 at 2:19 p.m. with staff member #3 Certified Nursing Assistant (CNA) who does not remember the incident or resident. Stated that to reduce the risk of falls, do time with them, give them activities. When asked what do you do if a resident refuses interventions in place to prevent falls, staff #3 stated they can refuse and you can not force them, they have the right to refuse, document and let the charge nurse know or see if another coworker will work with them.

An interview was conducted on December 11, 2024 at 2:25 p.m. with Licensed Practical Nurse (LPN) Staff member #8. Staff #8 stated that residents are assessed for fall risk on admission by Physical Therapy and Occupational Therapy (PT and OT) and they evaluate them. Fall risk residents usually require frequent monitoring, having a low bed, and floor mats if a recent fall. Staff #8 was asked how are interventions assessed to be effective and stated to notify management of the fall. Asked staff #8 what could happen with repeated falls and staff #8 stated they could fall and die, have a major injury and lawsuits. Try to keep them safe.

An interview was conducted on December 11, 2024 at 2:33 p.m. with Director of Nursing (DON) staff member #5. Asked what is successful about the facilities fall plan? Staff #5 stated that fall risk assessments are done to identify and develop a care plan, therapy will service transfers and strengthening. If a fall happens, therapy knows, and are updated on morning meeting. The fall will be reviewed and incorporated into their service if appropriate on the Long Term Care. Another fall risk assessment is done, pain assessments, notify the physician, talk with therapists, talk about various interventions, and cognition concerns. 8 falls are currently listed on the facility Matrix, what do you do for repeated falls was asked. Staff #5 stated that they try to look at additional interventions, cognition issues, incorporate the Restorative Nursing Assistant (RNA) program, try to utilize the wheel chair, fluffy recliners. Asked Staff #5 what could happen if residents fall and staff #5 stated fractures, worst case, head injury.

Review of the Falls and Fall Risk, Managing policy was reviewed. The policy statement reads: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observations, clinical record review, staff interviews and policies and procedures, the facility failed to ensure fall safety measures were in place to prevent a fall with major injury for one resident (#19). The deficient practice could contribute to residents being injured during a fall.

Findings include:

Resident #19 was admitted on February 7,2023 with diagnoses of metabolic encephalopathy, unspecified dementia severe, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.

The MDS (minimum data set) assessment dated September 27, 2023 revealed that the resident was assessed to be a two +person physical assist for bed mobility, transfer and locomotion on the unit. The assessment included a BIMS (brief interview for mental status) score of 10 indicating the resident had moderate cognitive impairment.

A Hospice note dated February 3, 2024 revealed the resident was disoriented, legally blind and incontinent; and that, all pathways in the resident's area were to be cleared and the clutter removed.

The physician progress note date February 4, 2024 revealed that the resident had underlying advanced dementia, was alert and oriented x 1(alert to person only) and was under hospice care. Further, the note included that the resident had a poor overall prognosis and will continue supportive measures.

The clinical record revealed no documentation that the resident was assessed for risk for fall until February 5, 2024; and, there was no evidence of any fall safety measures that were implemented or in place for resident #19.

The fall risk assessment dated February 5, 2024 revealed a fall risk score of 13 indicating the resident was at risk for fall. Per the assessment, the resident was disoriented x 3 at all times, was incontinent, ambulatory and required the use of an assistive device.



The care plan dated February 8, 2024 revealed that the resident was at risk for falls related to dementia/ non -compliance to safety rules. It also included that the resident had the following fall incidents:
-September 21 and October 5, 2023 - fall with no injury;
-October 14, 2023 - fall with eye laceration;
-October 30, 2023 - fall with no injury;
-November 8, 2023 - fall from the wheelchair with no injury;
-November 22, 2023 - was found on the floor in the bedroom with no injury; and,
-February 5, 2024 -fall with injury
Interventions included to cue, reorient and supervise as needed; frequently monitor resident's position as she is impulsive and may get up quickly; keep bed in lowest position; keep the surroundings free of obstructions; and, remind the resident of safety measures, supervise ambulation.

Further review of the care plan revealed the resident position should be monitored frequently as the resident is impulsive and gets up quickly; bed should be in the lowest position and the surroundings should be kept free from obstructions; the resident was to be reminded of safety measures and ambulation should be supervised to prevent falls; and, the resident was on medications that may cause unsteady gait, frequent falls, balance problems and dizziness/vertigo.

The clinical record revealed no documentation of any fall care plan prior to February 2024.

The alert note dated February 9, 2024 included that the resident was s/p (status post) fall with rib fractures.

The restorative nursing screening note dated April 3,2024 included the resident does not walk and walking was not clinically indicated.

An interview was conducted with registered nurse (RN/staff #1) at 3:00 pm on June 21, 2024. She stated that if a resident has frequent falls, interventions were put in place; however, it was difficult with residents that were confused. The RN said that these residents should be checked often and moved to the nurses' station or day room to keep them in the sightline of staff. She also said that fall mats and low beds are often used as interventions for fall; and that, the family may be asked to visit more often to assist with monitoring as well.

An interview with certified nursing assistant (CNA/staff #4) was conducted June 21, 2024 at 3:10 p.m. She stated that the bed should be kept in the lowest position and fall mats should be used. She further stated that the staff should check the resident frequently and/or moved to the day room especially when staff were busy so everyone can assist in keeping an eye on the resident during busy times. The CNA stated that staff were made aware that a resident was a fall risk during daily report.

An interview was conducted with the director of nursing (DON/staff #4) at 3:40 p.m. on June 21, 2024. The DON stated that residents who were deemed as a fall risk were kept at the nurses' station during periods of high anxiety. Regarding resident #19, the DON stated that the resident used her wheelchair to propel herself and then used furniture to support herself to walk and had a family visit almost every day. She also said that the resident confused but had lucid moments; was incontinent and would get urinary tract infections which would add to her confusion. The DON stated that her expectation was that the staff were aware of the fall precautions needed and would be charting on the interventions and frequent checks to ensure the safety of the resident. During the interview, a review of the clinical record was conducted with the DON who stated that interventions and frequent checks completed by staff were not found; and that, there were no documentation of orders regarding fall precautions or interventions found. The DON stated that without documentation there was no way to show that interventions were in place and were being followed. Per the DON (director of nursing) previous care plan records could not be provided as they were in the previous electronic health record system and she no longer had access to them. The electronic health record system was change earlier in 2024.

Review of facility policy titled Fall Risk Assessment (revised 3/2018) revealed that assessment data will be used to identify underlying medical conditions that may increase the risk of injuries from falls. The policy also revealed the attending physician will collaborate and address modifiable fall risk factors and interventions to try to minimize the consequences of risks that are not modifiable.

Review of the policy Managing Falls and Fall Risk (revised 3/2018) revealed that staff will implement a resident centered fall prevention plan to reduce specific risk factors of falls for each resident at risk for falls. If several possible interventions are identified, the staff may prioritize interventions. If underlying causes cannot be identified, staff will try various interventions based on resident assessment. The staff will monitor and document the resident's response to interventions intended to reduce falling. If falls continue, staff will reevaluate the situation and along with the attending physician shall reconsider possible causes. The policy further states that staff will document the basis for conclusions regarding irreversible risk factors that continue to present a risk for falls.

Based on observations, clinical record review, staff interviews and policies and procedures, the facility failed to ensure fall safety measures were in place to prevent a fall with major injury for one resident (#19).

Findings include:

Resident #19 was admitted on February 7,2023 with diagnoses of metabolic encephalopathy, unspecified dementia severe, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.

The MDS (minimum data set) assessment dated September 27, 2023 revealed that the resident was assessed to be a two +person physical assist for bed mobility, transfer and locomotion on the unit. The assessment included a BIMS (brief interview for mental status) score of 10 indicating the resident had moderate cognitive impairment.

A Hospice note dated February 3, 2024 revealed the resident was disoriented, legally blind and incontinent; and that, all pathways in the resident's area were to be cleared and the clutter removed.

The physician progress note date February 4, 2024 revealed that the resident had underlying advanced dementia, was alert and oriented x 1(alert to person only) and was under hospice care. Further, the note included that the resident had a poor overall prognosis and will continue supportive measures.

The clinical record revealed no documentation that the resident was assessed for risk for fall until February 5, 2024; and, there was no evidence of any fall safety measures that were implemented or in place for resident #19.

The fall risk assessment dated February 5, 2024 revealed a fall risk score of 13 indicating the resident was at risk for fall. Per the assessment, the resident was disoriented x 3 at all times, was incontinent, ambulatory and required the use of an assistive device.

On February 5, 2024 an incident note revealed that the resident was found on the floor of her room yelling for help. The resident complained of right rib pain with a reddened area noted. Per the documentation, the resident reported that she was ambulating from her wheelchair, became unsteady resulting in a fall. It also included that notifications to family, hospice and provider were made; and that, a physician order for chest x ray was received from the provider.

An alert note dated February 6, 2024 included that the resident's X-ray were completed and revealed rib fractures.

The care plan dated February 8, 2024 revealed that the resident was at risk for falls related to dementia/ non -compliance to safety rules. It also included that the resident had the following fall incidents:
-September 21 and October 5, 2023 - fall with no injury;
-October 14, 2023 - fall with eye laceration;
-October 30, 2023 - fall with no injury;
-November 8, 2023 - fall from the wheelchair with no injury;
-November 22, 2023 - was found on the floor in the bedroom with no injury; and,
-February 5, 2024 -fall with injury
Interventions included to cue, reorient and supervise as needed; frequently monitor resident's position as she is impulsive and may get up quickly; keep bed in lowest position; keep the surroundings free of obstructions; and, remind the resident of safety measures, supervise ambulation.

Further review of the care plan revealed the resident position should be monitored frequently as the resident is impulsive and gets up quickly; bed should be in the lowest position and the surroundings should be kept free from obstructions; the resident was to be reminded of safety measures and ambulation should be supervised to prevent falls; and, the resident was on medications that may cause unsteady gait, frequent falls, balance problems and dizziness/vertigo.

The clinical record revealed no documentation of any fall care plan prior to February 2024.

The alert note dated February 9, 2024 included that the resident was s/p (status post) fall with rib fractures.

The restorative nursing screening note dated April 3,2024 included the resident does not walk and walking was not clinically indicated.

An interview was conducted with registered nurse (RN/staff #1) at 3:00 pm on June 21, 2024. She stated that if a resident has frequent falls, interventions were put in place; however, it was difficult with residents that were confused. The RN said that these residents should be checked often and moved to the nurses' station or day room to keep them in the sightline of staff. She also said that fall mats and low beds are often used as interventions for fall; and that, the family may be asked to visit more often to assist with monitoring as well.

An interview with certified nursing assistant (CNA/staff #4) was conducted June 21, 2024 at 3:10 p.m. She stated that the bed should be kept in the lowest position and fall mats should be used. She further stated that the staff should check the resident frequently and/or moved to the day room especially when staff were busy so everyone can assist in keeping an eye on the resident during busy times. The CNA stated that staff were made aware that a resident was a fall risk during daily report.

An interview was conducted with the director of nursing (DON/staff #4) at 3:40 p.m. on June 21, 2024. The DON stated that residents who were deemed as a fall risk were kept at the nurses' station during periods of high anxiety. Regarding resident #19, the DON stated that the resident used her wheelchair to propel herself and then used furniture to support herself to walk and had a family visit almost every day. She also said that the resident confused but had lucid moments; was incontinent and would get urinary tract infections which would add to her confusion. The DON stated that her expectation was that the staff were aware of the fall precautions needed and would be charting on the interventions and frequent checks to ensure the safety of the resident. During the interview, a review of the clinical record was conducted with the DON who stated that interventions and frequent checks completed by staff were not found; and that, there were no documentation of orders regarding fall precautions or interventions found. The DON stated that without documentation there was no way to show that interventions were in place and were being followed. Per the DON (director of nursing) previous care plan records could not be provided as they were in the previous electronic health record system and she no longer had access to them. The electronic health record system was change earlier in 2024.

Review of facility policy titled Fall Risk Assessment (revised 3/2018) revealed that assessment data will be used to identify underlying medical conditions that may increase the risk of injuries from falls. The policy also revealed the attending physician will collaborate and address modifiable fall risk factors and interventions to try to minimize the consequences of risks that are not modifiable.

Review of the policy Managing Falls and Fall Risk (revised 3/2018) revealed that staff will implement a resident centered fall prevention plan to reduce specific risk factors of falls for each resident at risk for falls. If several possible interventions are identified, the staff may prioritize interventions. If underlying causes cannot be identified, staff will try various interventions based on resident assessment. The staff will monitor and document the resident's response to interventions intended to reduce falling. If falls continue, staff will reevaluate the situation and along with the attending physician shall reconsider possible causes. The policy further states that staff will document the basis for conclusions regarding irreversible risk factors that continue to present a risk for falls.

Based on observation, interviews and policy review, the facility failed to ensure that residents medications were administered as ordered by the provider based on standards of practice for three residents (#525, # 575, and #550). The deficient practice could result in residents not receiving prescribed doses of medications.

Findings include:

Regarding Resident # 525
-Resident #525 was initially admitted to the facility on September 17, 2021 and readmitted on December 27, 2021 with diagnoses that included osteoarthritis, hyperlipidemia, chronic pain, and bladder disorder.

Review of the annual Minimum Data Set (MDS) assessment dated October 20, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident is cognitively intact. The MDS also indicated that the resident was negative for psychosis, behavioral symptoms, rejection of care, and wandering during the assessment period.

A care plan initiated on February 12, 2024 and revised on April 2, 2023 indicated that the resident refuses care frequently from staff of a specific race and gender. Interventions included to document each episode of refusal with a progress note, and to educate and remind resident of potential risks associated with refusals of care.

Review of the physician's order summary revealed the following medication and treatment orders:
- 6 oz health shake which was indicated for one time a day
- pain assessment every shift
- observe for following signs/symptoms to include temperature >100.4 and other symptoms every shift
- urinary catheter care every shift
- Acetaminophen 500 mg tablet given 1 tablet orally four times a day related to other chronic pain
- Acetic adic 0.25% irrigation solution, use 60 ml via irrigation one time a day every Monday and Thursday
- Atorvastatin 20 mg tablet, give 1 tablet by mouth at bedtime related to hyperlipidemia
- Eliquis 5 mg tablet, give 1 tablet orally two times a day
- Flecainide acetate 50 mg tablet, give 1 tablet orally two times a day
- Furosemide 40 mg tablet, give 1 tablet orally two times a day
- Hydrochlorothiazide 12.5 mg orally one time a day related to edema
- Oxycodone HCL 5 mg tablet, give 1 tablet orally three times a day related to other chronic pain
- Spironoclactone 25 mg tablet, give 1 tablet by mouth one time a day
- HS (hour of sleep) snack. Provide \'bd sandwich or instant oatmeal cup at bedtime.

Review of the February 2024 Medication Administration Report (MAR) revealed the following:
- Acetaminophen 500 mg tablet given 1 tablet orally four times a day related to other chronic pain, was left blank/undocumented on February 3, 8, 17, 24, 25, and 29 for the 1300 administration. Additionally, it was also left blank/undocumented for the 1930 administration on February 21.
- Acetic adic 0.25% irrigation solution, use 60 ml via irrigation one time a day every Monday and Thursday, was left blank/undocumented for February 8, and 29.
- Atorvastatin 20 mg tablet, give 1 tablet by mouth at bedtime related to hyperlipidemia, was left blank/undocumented for February 21.
- Eliquis 5 mg tablet, give 1 tablet orally two times a day, was left blank/undocumented for the hour of sleep administration on February 21. Additionally, it was also left blank/undocumented for the morning administration on February 29.
- Flecainide acetate 50 mg tablet, give 1 tablet orally two times a day, was left blank/undocumented for the morning administration for February 29. Additionally, it was also left blank/undocumented for the hour of sleep administration on February 21.
- Furosemide 40 mg tablet, give 1 tablet orally two times a day, was left blank/undocumented for the hour of sleep for February 21.
- Oxycodone HCL 5 mg tablet, give 1 tablet orally three times a day related to other chronic pain, for left blank/undocumented for the 1300 administration for February 3, 8, 17, 24, 25, and 29.

However, review of resident # 525's eMAR progress notes corresponding to the blank/undocumented medication dates above did not indicate any documentation regarding refusal or reason for non-administration.

Review of the March 2024 MAR revealed the following:
- Acetaminophen 500 mg tablet given 1 tablet orally four times a day related to other chronic pain, was left blank/undocumented on March 6 through 8 for the 1300 administration. Additionally, it was also left blank/undocumented for March 11 and 13 for the 1300 administration.
- Acetic adic 0.25% irrigation solution, use 60 ml via irrigation one time a day every Monday and Thursday was left blank/undocumented for March 7 and March 11.
- Eliquis 5 mg tablet, given 1 tablet orally two times a day, was left blank/undocumented for the morning administration on March 7 and 8. Additionally, it was also left blank/undocumented for the hour of sleep administration on March 31.
- Flecainide acetate 50 mg tablet, given 1 tablet orally two times a day, was left blank/undocumented for the morning administration on March 8. Additionally, it was also left blank/undocumented for the hour of sleep administration on March 31.
- Furosemide 40 mg tablet, given 1 tablet orally two times a day, was left blank/undocumented for the morning administration on March 6 and 8. Furthermore, it was also left blank/undocumented for the hour of sleep administration on March 31.
- Hydrochlorothiazide 12.5 mg orally one time a day related to edema, was left blank/undocumented on March 11.
- Oxycodone HCL 5 mg tablet, given 1 tablet orally three times a day related to other chronic pain, was left blank/undocumented for the 1300 administration on March 6 through 8, as well as March 11 and March 13.
- Spironoclactone 25 mg tablet, given 1 tablet by mouth one time a day, was left blank/undocumented on March 7-8, and on March 11.

However, review of resident # 525's eMAR progress notes corresponding to the blank/undocumented medication dates above did not indicate any documentation regarding refusal or reason for non-administration.

Review of the March 2024 Treatment Administration Report (TAR) revealed the following:
- 6 oz health shake which was indicated for one time a day, was left blank/undocumented on March 8 and March 11.
- pain assessment every shift was left blank/undocumented during the day shift on March 1, 7, 8, and 21. It was also left blank/undocumented for the evening shift on March 8, 16, 22, 26, and 31. Furthermore, it was left blank/undocumented for the night shift on March 22.
- observe for following signs/symptoms to include temperature >100.4 and other symptoms every shift, was left blank/undocumented during the day shift on March 1, 7, 8, and 21. Additionally, it was also left blank/undocumented during the evening shift on March 8, 16, 22, 26, and 31.
- urinary catheter care every shift, was left blank/undocumented for the day shift on March 1, 7, 8, and 21. It was also left blank/undocumented on March 8, 16, 22, 26, and 31. Furthermore, it was left blank/undocumented on March 22.
- HS (hour of sleep) snack. Provide \'bd sandwich or instant oatmeal cup at bedtime on March 16, 22, 26, and 31.

However, further review of progress notes corresponding to the blank/undocumented medication dates above did not indicate any documentation regarding refusal or reason for non-administration.

Review of the facilities grievance log revealed that the only complaint filed by the resident during the month of the alleged event (March 2024) was with regards to Dietary.

Review of the Resident Council Meeting Minutes for the months of January through March 2024 did not reveal any concerns regarding quality of care, other than a comment about manning shortage.

During an interview with resident #525 conducted on April 9, 2024 at 1:11 p.m., she stated that the issue is that the facility uses registry nursing staff

Based on observation, interviews and policy review, the facility failed to ensure that residents medications were administered as ordered by the provider based on standards of practice for three residents (#525, # 575, and #550).

Findings include:

Regarding Resident # 525
-Resident #525 was initially admitted to the facility on September 17, 2021 and readmitted on December 27, 2021 with diagnoses that included osteoarthritis, hyperlipidemia, chronic pain, and bladder disorder.

Review of the annual Minimum Data Set (MDS) assessment dated October 20, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident is cognitively intact. The MDS also indicated that the resident was negative for psychosis, behavioral symptoms, rejection of care, and wandering during the assessment period.

A care plan initiated on February 12, 2024 and revised on April 2, 2023 indicated that the resident refuses care frequently from staff of a specific race and gender. Interventions included to document each episode of refusal with a progress note, and to educate and remind resident of potential risks associated with refusals of care.

Review of the physician's order summary revealed the following medication and treatment orders:
- 6 oz health shake which was indicated for one time a day
- pain assessment every shift
- observe for following signs/symptoms to include temperature >100.4 and other symptoms every shift
- urinary catheter care every shift
- Acetaminophen 500 mg tablet given 1 tablet orally four times a day related to other chronic pain
- Acetic adic 0.25% irrigation solution, use 60 ml via irrigation one time a day every Monday and Thursday
- Atorvastatin 20 mg tablet, give 1 tablet by mouth at bedtime related to hyperlipidemia
- Eliquis 5 mg tablet, give 1 tablet orally two times a day
- Flecainide acetate 50 mg tablet, give 1 tablet orally two times a day
- Furosemide 40 mg tablet, give 1 tablet orally two times a day
- Hydrochlorothiazide 12.5 mg orally one time a day related to edema
- Oxycodone HCL 5 mg tablet, give 1 tablet orally three times a day related to other chronic pain
- Spironoclactone 25 mg tablet, give 1 tablet by mouth one time a day
- HS (hour of sleep) snack. Provide \'bd sandwich or instant oatmeal cup at bedtime.

Review of the February 2024 Medication Administration Report (MAR) revealed the following:
- Acetaminophen 500 mg tablet given 1 tablet orally four times a day related to other chronic pain, was left blank/undocumented on February 3, 8, 17, 24, 25, and 29 for the 1300 administration. Additionally, it was also left blank/undocumented for the 1930 administration on February 21.
- Acetic adic 0.25% irrigation solution, use 60 ml via irrigation one time a day every Monday and Thursday, was left blank/undocumented for February 8, and 29.
- Atorvastatin 20 mg tablet, give 1 tablet by mouth at bedtime related to hyperlipidemia, was left blank/undocumented for February 21.
- Eliquis 5 mg tablet, give 1 tablet orally two times a day, was left blank/undocumented for the hour of sleep administration on February 21. Additionally, it was also left blank/undocumented for the morning administration on February 29.
- Flecainide acetate 50 mg tablet, give 1 tablet orally two times a day, was left blank/undocumented for the morning administration for February 29. Additionally, it was also left blank/undocumented for the hour of sleep administration on February 21.
- Furosemide 40 mg tablet, give 1 tablet orally two times a day, was left blank/undocumented for the hour of sleep for February 21.
- Oxycodone HCL 5 mg tablet, give 1 tablet orally three times a day related to other chronic pain, for left blank/undocumented for the 1300 administration for February 3, 8, 17, 24, 25, and 29.

However, review of resident # 525's eMAR progress notes corresponding to the blank/undocumented medication dates above did not indicate any documentation regarding refusal or reason for non-administration.

Review of the March 2024 MAR revealed the following:
- Acetaminophen 500 mg tablet given 1 tablet orally four times a day related to other chronic pain, was left blank/undocumented on March 6 through 8 for the 1300 administration. Additionally, it was also left blank/undocumented for March 11 and 13 for the 1300 administration.
- Acetic adic 0.25% irrigation solution, use 60 ml via irrigation one time a day every Monday and Thursday was left blank/undocumented for March 7 and March 11.
- Eliquis 5 mg tablet, given 1 tablet orally two times a day, was left blank/undocumented for the morning administration on March 7 and 8. Additionally, it was also left blank/undocumented for the hour of sleep administration on March 31.
- Flecainide acetate 50 mg tablet, given 1 tablet orally two times a day, was left blank/undocumented for the morning administration on March 8. Additionally, it was also left blank/undocumented for the hour of sleep administration on March 31.
- Furosemide 40 mg tablet, given 1 tablet orally two times a day, was left blank/undocumented for the morning administration on March 6 and 8. Furthermore, it was also left blank/undocumented for the hour of sleep administration on March 31.
- Hydrochlorothiazide 12.5 mg orally one time a day related to edema, was left blank/undocumented on March 11.
- Oxycodone HCL 5 mg tablet, given 1 tablet orally three times a day related to other chronic pain, was left blank/undocumented for the 1300 administration on March 6 through 8, as well as March 11 and March 13.
- Spironoclactone 25 mg tablet, given 1 tablet by mouth one time a day, was left blank/undocumented on March 7-8, and on March 11.

However, review of resident # 525's eMAR progress notes corresponding to the blank/undocumented medication dates above did not indicate any documentation regarding refusal or reason for non-administration.

Review of the March 2024 Treatment Administration Report (TAR) revealed the following:
- 6 oz health shake which was indicated for one time a day, was left blank/undocumented on March 8 and March 11.
- pain assessment every shift was left blank/undocumented during the day shift on March 1, 7, 8, and 21. It was also left blank/undocumented for the evening shift on March 8, 16, 22, 26, and 31. Furthermore, it was left blank/undocumented for the night shift on March 22.
- observe for following signs/symptoms to include temperature >100.4 and other symptoms every shift, was left blank/undocumented during the day shift on March 1, 7, 8, and 21. Additionally, it was also left blank/undocumented during the evening shift on March 8, 16, 22, 26, and 31.
- urinary catheter care every shift, was left blank/undocumented for the day shift on March 1, 7, 8, and 21. It was also left blank/undocumented on March 8, 16, 22, 26, and 31. Furthermore, it was left blank/undocumented on March 22.
- HS (hour of sleep) snack. Provide \'bd sandwich or instant oatmeal cup at bedtime on March 16, 22, 26, and 31.

However, further review of progress notes corresponding to the blank/undocumented medication dates above did not indicate any documentation regarding refusal or reason for non-administration.

Review of the facilities grievance log revealed that the only complaint filed by the resident during the month of the alleged event (March 2024) was with regards to Dietary.

Review of the Resident Council Meeting Minutes for the months of January through March 2024 did not reveal any concerns regarding quality of care, other than a comment about manning shortage.

During an interview with resident #525 conducted on April 9, 2024 at 1:11 p.m., she stated that the issue is that the facility uses registry nursing staff and they are unfamiliar with the residents so unfamiliar with what medications/treatments each r

Based on clinical record review and staff interviews, the facility failed to ensure a written notice of the bed-hold policy and the implications of returning to the facility was provided to one resident (#423).

Findings include:

Resident # 423 was admitted to the facility on December 27, 2023, with diagnoses of aftercare following joint replacement surgery, unilateral primary osteoarthritis left hip, chronic kidney disease, and acute post hemorrhagic anemia.

A social service note dated December 29, 2023 included resident was able to understand and be understood and had a BIMS (brief interview of mental status) score of 15 indicating intact cognition. Per the documentation, the resident planned to discharge back home.

The Minimum Data Set (MDS) assessment on January 3, 2024, revealed a BIMS score of 15 indicating that the resident had intact cognition.

Review of the clinical record revealed no evidence that the resident #423 was provided with a written notice related to facility's bed-hold policy upon or on resident's admission.

A review of progress notes revealed that on January 9, 2024, revealed that the resident had a change of condition, an order was received to send the resident to the ER for evaluation and treatment; and, the DON and family were informed of the change of condition. Per the documentation, the "resident's medication sheets and record of health history were given"; and, the resident was transported to the hospital.

however, the clinical record revealed no evidence that at the time or within 24 hours of transfer on January 9, 2024, resident #423 and/or resident representative were provided with a notice regarding bed-hold policy that includes information explaining the duration of bed-hold.

In an interview with a licensed practical nurse (LPN/staff #16) conducted on January 12, 2024 at 9:45 a.m., the LPN stated that when a resident is transferred/discharged, she puts in a discharge order in the electronic record and this order will show up in the treatment orders.

In an interview with the social services director (SSD/staff #19) conducted on January 12, 2024 at 10:00 a.m., she stated that the registered nurse was responsible for obtaining consent for bed-hold.

In a later interview with the SSD conducted on January 12, 2024 at 10:40 a.m., the SSD stated that the facility does not have a bed-hold policy.

Based on clinical record review and staff interviews, the facility failed to ensure discharge/transfer paperwork was completed for one resident (#423). The deficient practice could result in resident not receiving a safe and effective transition of care.

Findings include:

Resident # 423 was admitted to the facility on December 27, 2023, with diagnoses of aftercare following joint replacement surgery, unilateral primary osteoarthritis left hip, chronic kidney disease, and acute post hemorrhagic anemia.

A social service note dated December 29, 2023 included resident was able to understand and be understood and had a BIMS (brief interview of mental status) score of 15 indicating intact cognition. Per the documentation, the resident planned to discharge back home.

A nursing note dated December 31, 2023 included the resident remained on antibiotic therapy for 38 days for left hip infection.

The Minimum Data Set (MDS) assessment on January 3, 2024, revealed a BIMS score of 15 indicating that the resident had intact cognition.

A review of progress notes revealed that on January 9, 2024, revealed that the resident had a change of condition. Per the documentation, the resident called for help, had a fixed look, and reported that she was unable to move. The note included that the doctor was notified of the condition; an order was given to send the resident to the ER for evaluation and treatment; and, the DON and family were informed of the change of condition. Further, the documentation revealed 911 was called; the "resident's medication sheets and record of health history were given"; and, the resident was transported to the hospital.

Further review of clinical records revealed no evidence of a physician order for transfer/discharge; and, there was no documentation of any discharge/transfer information was completed for resident #423.

In an interview with a licensed practical nurse (LPN/staff #16) conducted on January 12, 2024 at 9:45 a.m., the LPN stated that when a resident is transferred/discharged, she puts in a discharge order in the electronic record and this order will show up in the treatment orders. Regarding resident #423, the LPN stated that she was unable to locate a physician order for transfer for the resident.

An interview with the Director of Nursing (DON) on January 12, 2024, at 10:32 a.m. Regarding resident #423, the DON stated that the staff mentioned receiving the order in the progress note; however, there was no transfer order found in the clinical record for resident #423. The DON stated that it could be "in the mix of it all" and she did not put it in electronically.

Based on clinical record review and staff interviews, the facility failed to ensure a written notice of the bed-hold policy and the implications of returning to the facility was provided to one resident (#423). The deficient practice may result in resident and resident representatives not being aware of the bed hold policy and their right to return to the facility immediately to the first available bed.

Findings include:

Resident # 423 was admitted to the facility on December 27, 2023, with diagnoses of aftercare following joint replacement surgery, unilateral primary osteoarthritis left hip, chronic kidney disease, and acute post hemorrhagic anemia.

A social service note dated December 29, 2023 included resident was able to understand and be understood and had a BIMS (brief interview of mental status) score of 15 indicating intact cognition. Per the documentation, the resident planned to discharge back home.

The Minimum Data Set (MDS) assessment on January 3, 2024, revealed a BIMS score of 15 indicating that the resident had intact cognition.

Review of the clinical record revealed no evidence that the resident #423 was provided with a written notice related to facility's bed-hold policy upon or on resident's admission.

A review of progress notes revealed that on January 9, 2024, revealed that the resident had a change of condition, an order was received to send the resident to the ER for evaluation and treatment; and, the DON and family were informed of the change of condition. Per the documentation, the "resident's medication sheets and record of health history were given"; and, the resident was transported to the hospital.

however, the clinical record revealed no evidence that at the time or within 24 hours of transfer on January 9, 2024, resident #423 and/or resident representative were provided with a notice regarding bed-hold policy that includes information explaining the duration of bed-hold.

In an interview with a licensed practical nurse (LPN/staff #16) conducted on January 12, 2024 at 9:45 a.m., the LPN stated that when a resident is transferred/discharged, she puts in a discharge order in the electronic record and this order will show up in the treatment orders.

In an interview with the social services director (SSD/staff #19) conducted on January 12, 2024 at 10:00 a.m., she stated that the registered nurse was responsible for obtaining consent for bed-hold.

In a later interview with the SSD conducted on January 12, 2024 at 10:40 a.m., the SSD stated that the facility does not have a bed-hold policy.

Based on clinical record review, staff interviews, and the facility's policies, the facility failed to meet professional standards of quality by failing to ensure that the physician was notified of low blood pressure readings for one resident (#423). The deficient practice could result in accepted standards of quality service or care not provided to the residents.

Findings include:

Resident #423 was admitted on December 27, 2023, with a diagnoses of chronic kidney disease, hypertensive heart disease with heart failure, and acute post hemorrhagic anemia.

The clinical summary for admission date of December 27, 2023 included diagnoses of heart failure, hypertensive heart disease with heart failure and atherosclerotic heart disease of native coronary artery without angina pectoris. Medications included metoprolol (antihypertensive) and losartan (antihypertensive) with orders to hold these medications for systolic blood pressure of

Based on observations, clinical record reviews, resident and staff interviews, facility documentation, policy, and procedures, the facility failed to ensure safety measures were in place to prevent a fall that resulted in a fracture for one resident (#73); and, the facility failed to ensure water temperatures were within the safe water temperature range for resident use. The deficient practices resulted in a fracture for resident #73; and, placed the residents at increased risk for serious injury and harm, such as burns and scalding. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified.

Findings Include:

On January 9, 2024, at 2:30 p.m., the Condition of IJ was identified. The Administrator (staff #271) and the Director of Nursing (DON/staff #62) were informed of the facility's failure to ensure water temperatures were within the safe water temperature range. During the initial screening there were multiple resident rooms in different hallways had hot-water sinks/faucets temperatures exceeding 120 degrees Fahrenheit (F). Water temperature readings were conducted with the Maintenance Director (staff #56) who tested the water temperatures in 17 resident rooms using facility thermometer and stated that the water temperature readings exceeded 120 degrees Fahrenheit.

The Administrator (staff #271) presented a Plan of Correction (POC) on January 9, 2024 at 4:25 p.m. The administrator was informed that the POC was not acceptable and failed to include the following: in-service regarding high water temperature for which staff will be in-serviced, projected completion date for the in-service, define "all staff", and provide a plan for how the facility will train staff who were not on shift or who are on leave.

A revised POC was received on January 9, 2024, at 5:32 p.m. The Administrator (staff #143) was informed that the POC failed to include "Contractors" as a part of the staff that would be educated. At 5:53 p.m., another POC was received and was accepted at 6:30 p.m.

The accepted POC included the following: the mixing valves were adjusted, all water temperatures were retested, water temperature check in all residents' rooms every 4 hours for the next 14 days and then three times per day, water temperature checks once per shift for at least 90 days then daily after that, all employees will be in serviced on reporting abnormal water temperature, employees that were on vacation will be in-serviced on abnormal water temperature upon their return and calling service company to assess water temperature.

Multiple observations were conducted of the facility implementing its POC, which included in-service training, contractors and plumbers present in the facility, and staff measuring water temperatures in rooms.

On January 10, 2024, at 4:10 p.m., the Condition of IJ was abated after the following: the facility provided documentation that more than 50% of their staff were in-serviced, daily water temperatures records revealed water temperature below 120 degrees F.

Review of the water temperature log revealed that water temperatures were checked on January 5, 2024 and the readings ranged from 100 degrees to 101 degrees Fahrenheit. Continued review of the log revealed that there were water temperature checks conducted from January 6 through 8, 2024.

The facility's water temperature log for multiple resident rooms dated January 9, 2024 included water temperature readings ranges from 108.7 degrees to 112.9 degrees Fahrenheit.

Review of the adjustment to boiler temperature log included that boilers #1, #2 and #3 were adjusted from 125 degrees Fahrenheit to 120 degrees Fahrenheit on January 10, 2024 at 10:15 a.m. Further review of the log revealed that on January 10, 2024 at 2:10 p.m., boiler #3 was adjusted from 120 degrees to 100 degrees Fahrenheit.

In an interview with a licensed practical nurse (LPN/staff #58) conducted on January 9, 2024 at 11:26 a.m., the LPM stated that she had been at the facility for 5 years; and that, she thought that safe water temperature is over 120 degrees Fahrenheit. She stated that she just found out that safe water temperature was 100 degrees Fahrenheit. She further stated that residents complained that the water was too cold but did not complain that the water was too hot.

In an interview conducted with the maintenance director (staff #56) on January 09, 2024, at 11:50 a.m., staff #56 stated that the facility has two boilers for each unit, East and West; and that, the facility had increased the internal temperature of the water in the boiler due to cold weather. Staff #56 further stated that the temperatures were high due to this change; and that, they had not had time to level out and find its "Sweet Spot." He further stated that the last time the water temperatures had been checked was on January 5, 2024.

During the interview, water temperature readings were conducted with the Maintenance Director (staff #56) who tested the water temperatures in 17 resident rooms using facility thermometer. The maintenance director stated that the water temperature readings exceeded 120 degrees Fahrenheit for these 17 resident rooms; and, the readings were as follows:
-131.2 degrees Fahrenheit;
-130.2 degrees Fahrenheit;
-130.2 degrees Fahrenheit;
-130.5 degrees Fahrenheit;
-126.5 degrees Fahrenheit;
-126.3 degrees Fahrenheit;
-126.6 degrees Fahrenheit;
-125.7 degrees Fahrenheit;
-125.5 degrees Fahrenheit.
-125.9 degrees Fahrenheit;
-126.5 degrees Fahrenheit;
-127.6 degrees Fahrenheit;
-126.5 degrees Fahrenheit;
-127.4 degrees Fahrenheit;
-126.5 degrees Fahrenheit;
-129.2 degrees Fahrenheit;
-128.5 degrees Fahrenheit.

An interview was conducted on January 9, 2024 at 3:06 p.m. with another LPN (staff #23) who stated that safe water temperature was at 121 degrees Fahrenheit.

During an interview with a registered nurse (RN/staff #259) conducted on January 9, 2024 at 3:14 p.m., she stated that safe water temperature was at 100 degrees Fahrenheit.

An interview with a restorative nursing assistant (RNA/staff #264) was conducted on January 10, 2024 at 8:53 a.m. The RNA stated that maintenance staff check the water temperatures at the facility. He said that before providing showers/baths to a resident, he checks the water by feeling the water with his hands first. He said that if the water is too hot for him them he adjusts the water temperature to make it comfortable for the residents. The RNA further stated that 100 degrees Fahrenheit was safe water temperature.

An interview with a certified nursing assistant (CNA/staff #204) was conducted on January 10, 2024 at 8:40 a.m. The CNA stated that if the water was too hot she would tell the maintenance staff right away and put it in the work book.

An interview was conducted on January 10, 2024 at 8:53 a.m. with another CNA (staff #284) who said that water temperatures were supposed to be 115 degrees Fahrenheit which is safe the for bathing.

In an interview with another RN (staff #86) conducted on January 10, 2024 at 8:55 a.m., the RN stated that she was not sure on what the safe water temperature readings are. She stated that she will contact the maintenance staff if there is a problem with the water temperature.

During an interview with another LPN (staff #16) conducted on January 10, 2024 at 9:13 a.m., the LPN stated that safe water temperature was under 120 degrees Fahrenheit.

In an interview with the administrator (staff #271) conducted on January 10, 2024 at 11:35 a.m., he stated that the safe water temperature was 100 degrees Fahrenheit.

An interview was conducted on January 10, 2024 at 2:37 p.m. with another CNA (staff #267) who stated that the water temperature for bathing and washing hands was 100 degrees Fahrenheit.

In an interview wi

Based on clinical record review and staff interviews, the facility failed to ensure discharge/transfer paperwork was completed for one resident (#423).

Findings include:

Resident # 423 was admitted to the facility on December 27, 2023, with diagnoses of aftercare following joint replacement surgery, unilateral primary osteoarthritis left hip, chronic kidney disease, and acute post hemorrhagic anemia.

A social service note dated December 29, 2023 included resident was able to understand and be understood and had a BIMS (brief interview of mental status) score of 15 indicating intact cognition. Per the documentation, the resident planned to discharge back home.

A nursing note dated December 31, 2023 included the resident remained on antibiotic therapy for 38 days for left hip infection.

The Minimum Data Set (MDS) assessment on January 3, 2024, revealed a BIMS score of 15 indicating that the resident had intact cognition.

A review of progress notes revealed that on January 9, 2024, revealed that the resident had a change of condition. Per the documentation, the resident called for help, had a fixed look, and reported that she was unable to move. The note included that the doctor was notified of the condition; an order was given to send the resident to the ER for evaluation and treatment; and, the DON and family were informed of the change of condition. Further, the documentation revealed 911 was called; the "resident's medication sheets and record of health history were given"; and, the resident was transported to the hospital.

Further review of clinical records revealed no evidence of a physician order for transfer/discharge; and, there was no documentation of any discharge/transfer information was completed for resident #423.

In an interview with a licensed practical nurse (LPN/staff #16) conducted on January 12, 2024 at 9:45 a.m., the LPN stated that when a resident is transferred/discharged, she puts in a discharge order in the electronic record and this order will show up in the treatment orders. Regarding resident #423, the LPN stated that she was unable to locate a physician order for transfer for the resident.

An interview with the Director of Nursing (DON) on January 12, 2024, at 10:32 a.m. Regarding resident #423, the DON stated that the staff mentioned receiving the order in the progress note; however, there was no transfer order found in the clinical record for resident #423. The DON stated that it could be "in the mix of it all" and she did not put it in electronically.

Based on clinical record review, staff interviews, and the facility's policies, the facility failed to maintain highest practicable well-being according to comprehensive assessment by failing to ensure that the physician was notified of low blood pressure readings for one resident (#423).

Findings include:

Resident #423 was admitted on December 27, 2023, with a diagnoses of chronic kidney disease, hypertensive heart disease with heart failure, and acute post hemorrhagic anemia.

The clinical summary for admission date of December 27, 2023 included diagnoses of heart failure, hypertensive heart disease with heart failure and atherosclerotic heart disease of native coronary artery without angina pectoris. Medications included metoprolol (antihypertensive) and losartan (antihypertensive) with orders to hold these medications for systolic blood pressure of

Regarding fall with injury for Resident #73

-Resident #73 was admitted to the facility on October 26, 2022 with diagnoses of nontraumatic subcortical intracerebral hemorrhage in hemisphere, unspecified hemiplegia affecting right dominant side, generalized muscle weakness, compression of brain, cerebral edema and pain.

The physician admission note dated October 29, 2022 included assessments of nontraumatic basal ganglia bleed with midline shift and seizures.

A nurse practitioner (NP) note dated October 30, 2022 revealed the resident was alert and oriented x 1-2, had right facial droop, right tongue deviation and was aphasic. Per the documentation, the resident required supervision with transfers and ambulation, required minimal assistance with toileting and will benefit from continued therapy for strengthening, endurance, functional transfers and progressive ambulation. Problems included non-traumatic basal ganglia bleed with midline shift and seizures.

Review of the clinical record revealed the resident was using oxygen, was on heparin (anticoagulant) and was on continuous feeding tube.

The undated active care plan included that the resident was a fall risk, had impaired ability to see in adequate light, was occasionally incontinent with bladder, and had self-care deficit on toileting and transfers. Interventions included the following:
-Keep area clutter free and well lighted;
-Keep call light and most frequently used items in a consistent area within easy reach;
-Check and change frequently for safety and toileting needs;
-Bed in lowest position while in bed for safety;
-Fall risk assessment; and,
-Frequent monitoring and observation to determine safety and prevent falls.

Review of the clinical record revealed the resident had a Brief Interview of Mental Status (BIMS) score of 06 indicating resident had severe cognitive impairment.

A social service note dated November 4, 2022 included that the according to the resident's family, impulsiveness is the resident's natural behavior even before the stroke.

A nursing note dated November 11, 2022 included that at approximately 7:30 p.m., the resident had fallen while ambulating by herself to the bathroom. Per the documentation, the resident forgot she was hooked up to the tube feed line and oxygen which got pulled while she was moving forward and she fell. It also included that the resident suffered a 3 mm (millimeter) laceration to the right eyebrow and had a right hip pain. The documentation included that the resident had full ROM (range of motion) with the presence of pain to the right hip; had no deformities, abrasions or bruising of the right hip; and that, the resident was assisted back to bed and the physician was notified. The documentation did not include intervention to address the resident's complaint of right hip pain.

A nursing note dated November 12, 2022 at 10:23 a.m. revealed the resident's POA (power of attorney) reported that the resident was unable to stand and walk as she could on Friday; and, had reported pain her hip and wrist. The documentation also included that the resident had bruising to the right eye where the laceration was present; and that, the provider was notified and agreed to send the resident to the ER (emergency room) for evaluation and treatment of hip pain. The note also included that the provider agreed to a head CT scan due to resident's recent stroke, heparin use and laceration to the right eyebrow. Per the documentation, the nurse called the county ambulance for transfer of resident to the hospital.

However, the clinical record revealed no evidence that the resident was seen or was transferred to the hospital/ER on November 11, 2022. There was also no documentation found in the clinical record of why the resident was not sent to the hospital/ER.

The fall care plan was revised on November 11, 2022 to include that the resident had a fall with injury on November 11, 2022.

The nursing note dated November 12, 2022 at 5:53 p.m., revealed that at approximately 2:13 p.m., the RN (registered nurse) went into the resident's room after an RT (respiratory therapist) suggested that an X-ray of the right hip and right wrist should be taken s/p (status post) fall. The note included that the PT (physical therapist) stated that the resident was still having trouble standing and walking compared to Friday morning of November 11, 2022. Per the documentation, the DON (director of nursing) told the RN that the DON was not aware of the fall that took place on November 11, 2022 at approximately 7:00 p.m. It also included that the resident's emergency contact like for the resident to go to the ER to have a head CT scan due to a change in condition. Further, the documentation included that X-ray orders of the right wrist and right hip were also ordered.

Another nursing note dated November 12, 2022 at 8:58 p.m. revealed that transportation arrived at approximately 7:15 p.m. to transport resident #73 to the hospital for CT scan of the head and X-rays of the right wrist and right hip.

The nursing note dated November 13, 2022 at 12:15 a.m. included that staff received a report from hospital provider that resident #73 had a right hip fracture.

In an interview with a certified nurse assistant (CNA/staff #205) conducted on January 11, 2024 at 10:30 a.m., the CNA stated that when she sees a resident fall or when a resident is found on the floor, she will pull the call light, get the nurse and check the resident's vital signs. The CNA said that the nurse would take over and the resident is treated immediately.

An interview with a licensed practical nurse (LPN/staff #16) was conducted on January 11, 2024 at 11:30 a.m. The LPN stated that when a resident had a fall, she will conduct head to toe assessment, notify the DON, provider and the resident's medical POA. The LPN stated that if the resident had an injury such as skin tear, laceration or abrasion, it will be treated immediately. The LPN also said that if the resident complained of severe pain or has deformity, the LPN will call 911, send the resident out to the ER; and, she will not wait to hear back from the provider as it could be up to an hour or more.

During an interview with the Director of Nursing (DON/staff #62) conducted on January 11, 2024 at 11:45 a.m., the DON stated that she expected that when a resident fall, staff will take the resident's vital signs, assess the resident and notify the resident's POA, provider and DON. Further the DON stated that care for any injury sustained by the resident will be provided.

Review of the facility policy on Managing Fall and Fall Risk revealed that based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy also included that the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of fall for each resident at risk or with history of falls.

The facility's policy on Standards of Care included each resident is free from evident environment hazards, e.g., absence of hazardous equipment, floor surfaces, furniture, etc. The policy also included that whenever possible residents are assisted in or out of bed to enable as much mobility and stimulation as possible, in full accordance with physician's orders.

Based on record review and interview the facility failed to develop Emergency Preparedness policy and procedures based on the community risk assessments prior to developing the facility's emergency plan. Failure to develop Emergency Plans based on community risk assessments may cause harm to the patients and staff during an emergency.

Findings include:

Based on record review and interview on January 16, 2024, revealed the facility failed to provide a community based risk assessment as required by CFR 483.73.

During the exit conference on January 16, 2024, the above finding was again acknowledged by the management team.

Based on record review and interview the facility failed to have documentation in the emergency preparedness communication plan that complies with Federal, State and local laws that included a method for sharing information. Failure to have a means to share private information to assist in patient care could result in miss information being provided to other providers providing care for the facility's patients.

Findings include:

Based on record review and interview on January 16, 2024, of the facility's Emergency Plan did not include policies and procedures, in the communication plan for the following:
1) Sharing information and medical documentation for patients under the facility's care, as
necessary, with other health care providers to maintain the continuity of care.
2) A means, in the event of an evacuation, to release patient information as permitted under 45
CFR 164.510.
3) A means of providing information about the general condition and location of patients under the
facility's care as permitted under 45 CFR 164.510.

During the exit conference on January 16, 2024 the above finding was again acknowledged by the management team.

Based on observation the facility failed to maintain two (2) special locking exit doors located in the facility. Failing to ensure the correct amount of force needed to release of the exit doors could cause harm to patients and/or staff in an emergency

NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

Observations made while on tour on January 16, 2024, revealed the following;

1) the Health Center West Lounge delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 25 lbf for the left door and 23 lbf for the right door.
2) the Health Center East Dining Room delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 40 lbf for the left door and 20 lbf for the right door.

During the exit conference on January 16, 2024, the above findings were again acknowledged by the management team.

Based on observation, the facility failed to ensure that staff did not use daisy chain power strips (power strip plugged into power strip). The use of daisy chained power strips could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area.

Findings include:

Observations made while on tour on January 16, 2024, revealed three (3) power strips plugged into one another (daisy chain) in the Dietary Supervisor's Office.

During the exit conference conducted on January 16, 2024, the above findings were again acknowledged by the management team.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure an allegation of abuse for one resident (#7) was reported immediately to the SA as required.

Findings include:

-Resident #7 was admitted on December 27, 2021 with diagnoses of osteoarthritis and chronic pain.

The care plan dated December 29, 2021 revealed the resident was alert and oriented x4 and was able to make her own decisions in regards to her leisure interests.

The physician progress note dated August 27, 2023 revealed resident #7 was alert and oriented to person, place, and time, and demonstrated normal affect and judgement.

A nursing note dated September 20, 2023 included that the roommate hit the resident's (#7) right leg; and that, resident #7 was monitored by the nurse. Per the documentation, the resident's right leg had no bruises, redness, or problems with movement.

Another nursing note dated September 20, 2023 revealed that the resident's right leg was sore but that the resident was okay; and that, the medical doctor (MD) was notified about the leg.

-Resident #8 was admitted on July 27, 2023 with diagnoses of muscle weakness, weakness, glaucoma, major depressive disorder, and restless leg syndrome. Resident #8 was admitted to the room that was also occupied by resident #7.

A nursing note dated September 20, 2023 revealed that at 12:29 a.m., the nurse heard a yell and was summoned to the room of residents #7 and #8. Per the documentation, the nurse found resident #8 standing over the right side of resident #7's bed, leaning over the bed; and that, resident #8 said to call 911 and to get person named "Richie out of bed with that man." Per the documentation, resident #8 was reoriented and assisted to the living room recliner where she was observed hourly through the night; and that, the director of nursing (DON), the physician, and resident representative were informed of the incident.

Review of an interdisciplinary team (IDT) note dated September 20, 2023 revealed that the local police were called and had investigated the incident between resident #7 and #8; and that, police officer reported that resident #7 had not been assaulted and there was no harm to resident #7.

Despite documentation that resident #8 hit resident #7 on the right leg, there was no evidence found in the clinical record that the allegation of abuse was reported to the SA as required.

A telephone interview was conducted with Certified nursing assistant (CNA/staff #2) on September 27, 2023 at 9:43 a.m. The CNA stated that as he was getting water for resident #7 when he heard yelling and he went directly to the resident's room. The CNA said he found resident #8 standing by resident #7's right leg; and that, resident #7 was holding her leg. The CNA said that resident #8 was upset and yelling "tell her to leave my son alone". He stated that he assisted resident #8 to the living room and let her sleep in the recliner there. Further, the CNA said that he had not seen resident #8 behave like this before.

During an interview with resident #7 conducted on September 27, 2023 at 10:45 a.m., resident #7 stated that she felt that resident #8 did not mean to hurt her; and that, resident #8 was frightened. Resident #7 said that she suffered no injury; and, staff came in and took resident #8 to another room.

In an interview conducted with resident #8 on September 27, 2023 at 10:50 a.m., resident #8 denied anything had happened to her over the past week; and stated that she was okay and safe.

An interview was conducted with the DON (staff #4) on September 27, 2023 at 11:00 a.m. The DON stated that she was the person who had called the police when she learned of the incident between resident #7 and #8 in the morning of September 20, 2023. She stated that the local police officer came out and interviewed resident #7 and the local police officer felt that it was not abuse; and that, resident #8 was hallucinating. Further, the DON stated that she did not report the incident to the SA (State Agency) because she was directed by the administrator to not report the incident because there was no abuse and resident #7 did not want it reported.

During an interview with the administrator (staff #35) conducted on September 27, 2023 at 11:45 a.m., the administrator stated she did not report the incident because resident #8 was in a "dreamlike" state, was very confused and was asking her roommate to get out of bed. The administrator also said that the local police had investigated and concluded that the allegation of abuse was unfounded. The administrator said that the behavior of resident #8 was not willful and that the resident was in a "dream-state". Further, the administrator said that she had not seen resident #8 in such a state before; and that, resident #8 would have no roommates in the future.

The facility policy on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, it revealed that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

Based on clinical record review, resident and staff interviews, the facility failed to ensure 1 of 5 sampled residents (#7) were free from abuse of another. The deficient practice could result in physical and/or emotional harm to the resident.

Findings include:

-Resident #7 was admitted on December 27, 2021 with diagnoses of osteoarthritis and chronic pain.

The care plan dated December 29, 2021 revealed the resident was alert and oriented x4 and was able to make her own decisions in regards to her leisure interests.

The physician progress note dated August 27, 2023 revealed resident #7 was alert and oriented to person, place, and time, and demonstrated normal affect and judgement.

A nursing note dated September 20, 2023 included that the roommate hit the resident's (#7) right leg; and that, resident #7 was monitored by the nurse. Per the documentation, the resident's right leg had no bruises, redness, or problems with movement.

Another nursing note dated September 20, 2023 revealed that the resident's right leg was sore but that the resident was okay; and that, the medical doctor (MD) was notified about the leg.

-Resident #8 was admitted on July 27, 2023 with diagnoses of muscle weakness, weakness, glaucoma, major depressive disorder, and restless leg syndrome. Resident #8 was admitted to the room that was also occupied by resident #7.

The physician admission notes, history and physical dated July 31, 2023 revealed the resident presented with normal affect, normal affect, normal judgement, no anxiety or depression.

The admission minimum data set (MDS) assessment dated August 3, 2023 revealed a brief interview for mental status (BIMS) score of 11 indicating the resident had moderate cognitive impairment. The assessment also included the resident had no behaviors, hallucinations, or delusions.

The care plan dated August 3, 2023 included the resident was at risk for altered cognition. The goal was that the resident will be safe and have needs met. Interventions included repeat instructions as necessary, keep environmental stimuli to a minimum and to maintain consistent routine as possible.

The resident summary note dated September 14, 2023 included the resident was alert, forgetful, and oriented to person and place.

A nursing note dated September 20, 2023 revealed that at 12:29 a.m., the nurse heard a yell and was summoned to the room of residents #7 and #8. Per the documentation, the nurse found resident #8 standing over the right side of resident #7's bed, leaning over the bed; and that, resident #8 said to call 911 and to get person named "Richie out of bed with that man." Per the documentation, resident #8 was reoriented and assisted to the living room recliner where she was observed hourly through the night; and that, the director of nursing (DON), the physician, and resident representative were informed of the incident.

Another nursing note dated September 20, 2023 included that the family and medical power of attorney (MPOA) were notified of room change for resident #8.

Review of an interdisciplinary team (IDT) note dated September 20, 2023 revealed that the local police were called and had investigated the incident between resident #7 and #8; and that, police officer reported that resident #7 had not been assaulted and there was no harm to resident #7.

A telephone interview was conducted with Certified nursing assistant (CNA/staff #2) on September 27, 2023 at 9:43 a.m. The CNA stated that as he was getting water for resident #7 when he heard yelling and he went directly to the resident's room. The CNA said he found resident #8 standing by resident #7's right leg; and that, resident #7 was holding her leg. The CNA said that resident #8 was upset and yelling "tell her to leave my son alone". He stated that he assisted resident #8 to the living room and let her sleep in the recliner there. Further, the CNA said that he had not seen resident #8 behave like this before.

Attempts were made to conduct a phone interview with the CNA (staff #21) and the licensed practical nurse (LPN/staff #91) who were on shift at the time of the incident. However, the attempts were unsuccessful as both staff did not answer the call nor did they return the call.

During an interview with resident #7 conducted on September 27, 2023 at 10:45 a.m., resident #7 stated that she felt that resident #8 did not mean to hurt her; and that, resident #8 was frightened. Resident #7 said that she suffered no injury; and, staff came in and took resident #8 to another room.

In an interview conducted with resident #8 on September 27, 2023 at 10:50 a.m., resident #8 denied anything had happened to her over the past week; and stated that she was okay and safe.

An interview was conducted with the DON (staff #4) on September 27, 2023 at 11:00 a.m. The DON stated that she was the person who had called the police when she learned of the incident between resident #7 and #8 in the morning of September 20, 2023.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure an allegation of abuse for one resident (#7) was reported immediately to the SA as required. The deficient practice could result in abuse not investigated and resident not protected from further abuse.

Findings include:

-Resident #7 was admitted on December 27, 2021 with diagnoses of osteoarthritis and chronic pain.

The care plan dated December 29, 2021 revealed the resident was alert and oriented x4 and was able to make her own decisions in regards to her leisure interests.

The physician progress note dated August 27, 2023 revealed resident #7 was alert and oriented to person, place, and time, and demonstrated normal affect and judgement.

A nursing note dated September 20, 2023 included that the roommate hit the resident's (#7) right leg; and that, resident #7 was monitored by the nurse. Per the documentation, the resident's right leg had no bruises, redness, or problems with movement.

Another nursing note dated September 20, 2023 revealed that the resident's right leg was sore but that the resident was okay; and that, the medical doctor (MD) was notified about the leg.

-Resident #8 was admitted on July 27, 2023 with diagnoses of muscle weakness, weakness, glaucoma, major depressive disorder, and restless leg syndrome. Resident #8 was admitted to the room that was also occupied by resident #7.

A nursing note dated September 20, 2023 revealed that at 12:29 a.m., the nurse heard a yell and was summoned to the room of residents #7 and #8. Per the documentation, the nurse found resident #8 standing over the right side of resident #7's bed, leaning over the bed; and that, resident #8 said to call 911 and to get person named "Richie out of bed with that man." Per the documentation, resident #8 was reoriented and assisted to the living room recliner where she was observed hourly through the night; and that, the director of nursing (DON), the physician, and resident representative were informed of the incident.

Review of an interdisciplinary team (IDT) note dated September 20, 2023 revealed that the local police were called and had investigated the incident between resident #7 and #8; and that, police officer reported that resident #7 had not been assaulted and there was no harm to resident #7.

Despite documentation that resident #8 hit resident #7 on the right leg, there was no evidence found in the clinical record that the allegation of abuse was reported to the SA as required.

A telephone interview was conducted with Certified nursing assistant (CNA/staff #2) on September 27, 2023 at 9:43 a.m. The CNA stated that as he was getting water for resident #7 when he heard yelling and he went directly to the resident's room. The CNA said he found resident #8 standing by resident #7's right leg; and that, resident #7 was holding her leg. The CNA said that resident #8 was upset and yelling "tell her to leave my son alone". He stated that he assisted resident #8 to the living room and let her sleep in the recliner there. Further, the CNA said that he had not seen resident #8 behave like this before.

During an interview with resident #7 conducted on September 27, 2023 at 10:45 a.m., resident #7 stated that she felt that resident #8 did not mean to hurt her; and that, resident #8 was frightened. Resident #7 said that she suffered no injury; and, staff came in and took resident #8 to another room.

In an interview conducted with resident #8 on September 27, 2023 at 10:50 a.m., resident #8 denied anything had happened to her over the past week; and stated that she was okay and safe.

An interview was conducted with the DON (staff #4) on September 27, 2023 at 11:00 a.m. The DON stated that she was the person who had called the police when she learned of the incident between resident #7 and #8 in the morning of September 20, 2023. She stated that the local police officer came out and interviewed resident #7 and the local police officer felt that it was not abuse; and that, resident #8 was hallucinating. Further, the DON stated that she did not report the incident to the SA (State Agency) because she was directed by the administrator to not report the incident because there was no abuse and resident #7 did not want it reported.

During an interview with the administrator (staff #35) conducted on September 27, 2023 at 11:45 a.m., the administrator stated she did not report the incident because resident #8 was in a "dreamlike" state, was very confused and was asking her roommate to get out of bed. The administrator also said that the local police had investigated and concluded that the allegation of abuse was unfounded. The administrator said that the behavior of resident #8 was not willful and that the resident was in a "dream-state". Further, the administrator said that she had not seen resident #8 in such a state before; and that, resident #8 would have no roommates in the future.

The facility policy on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, it revealed that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

Based on clinical record review, resident and staff interviews, the facility failed to ensure one resident (#7) was not subjected to abuse.

Findings include:

-Resident #7 was admitted on December 27, 2021 with diagnoses of osteoarthritis and chronic pain.

The care plan dated December 29, 2021 revealed the resident was alert and oriented x4 and was able to make her own decisions in regards to her leisure interests.

The physician progress note dated August 27, 2023 revealed resident #7 was alert and oriented to person, place, and time, and demonstrated normal affect and judgement.

A nursing note dated September 20, 2023 included that the roommate hit the resident's (#7) right leg; and that, resident #7 was monitored by the nurse. Per the documentation, the resident's right leg had no bruises, redness, or problems with movement.

Another nursing note dated September 20, 2023 revealed that the resident's right leg was sore but that the resident was okay; and that, the medical doctor (MD) was notified about the leg.

-Resident #8 was admitted on July 27, 2023 with diagnoses of muscle weakness, weakness, glaucoma, major depressive disorder, and restless leg syndrome. Resident #8 was admitted to the room that was also occupied by resident #7.

The physician admission notes, history and physical dated July 31, 2023 revealed the resident presented with normal affect, normal affect, normal judgement, no anxiety or depression.

The admission minimum data set (MDS) assessment dated August 3, 2023 revealed a brief interview for mental status (BIMS) score of 11 indicating the resident had moderate cognitive impairment. The assessment also included the resident had no behaviors, hallucinations, or delusions.

The care plan dated August 3, 2023 included the resident was at risk for altered cognition. The goal was that the resident will be safe and have needs met. Interventions included repeat instructions as necessary, keep environmental stimuli to a minimum and to maintain consistent routine as possible.

The resident summary note dated September 14, 2023 included the resident was alert, forgetful, and oriented to person and place.

A nursing note dated September 20, 2023 revealed that at 12:29 a.m., the nurse heard a yell and was summoned to the room of residents #7 and #8. Per the documentation, the nurse found resident #8 standing over the right side of resident #7's bed, leaning over the bed; and that, resident #8 said to call 911 and to get person named "Richie out of bed with that man." Per the documentation, resident #8 was reoriented and assisted to the living room recliner where she was observed hourly through the night; and that, the director of nursing (DON), the physician, and resident representative were informed of the incident.

Another nursing note dated September 20, 2023 included that the family and medical power of attorney (MPOA) were notified of room change for resident #8.

Review of an interdisciplinary team (IDT) note dated September 20, 2023 revealed that the local police were called and had investigated the incident between resident #7 and #8; and that, police officer reported that resident #7 had not been assaulted and there was no harm to resident #7.

A telephone interview was conducted with Certified nursing assistant (CNA/staff #2) on September 27, 2023 at 9:43 a.m. The CNA stated that as he was getting water for resident #7 when he heard yelling and he went directly to the resident's room. The CNA said he found resident #8 standing by resident #7's right leg; and that, resident #7 was holding her leg. The CNA said that resident #8 was upset and yelling "tell her to leave my son alone". He stated that he assisted resident #8 to the living room and let her sleep in the recliner there. Further, the CNA said that he had not seen resident #8 behave like this before.

Attempts were made to conduct a phone interview with the CNA (staff #21) and the licensed practical nurse (LPN/staff #91) who were on shift at the time of the incident. However, the attempts were unsuccessful as both staff did not answer the call nor did they return the call.

During an interview with resident #7 conducted on September 27, 2023 at 10:45 a.m., resident #7 stated that she felt that resident #8 did not mean to hurt her; and that, resident #8 was frightened. Resident #7 said that she suffered no injury; and, staff came in and took resident #8 to another room.

In an interview conducted with resident #8 on September 27, 2023 at 10:50 a.m., resident #8 denied anything had happened to her over the past week; and stated that she was okay and safe.

An interview was conducted with the DON (staff #4) on September 27, 2023 at 11:00 a.m. The DON stated that she was the person who had called the police when she learned of the incident between resident #7 and #8 in the morning of September 20, 2023.

Based on clinical record review, staff interview, facility policy and procedure, the facility failed to ensure care and services related to pressure ulcers/injuries was provided to 1 of 3 sampled resident (#1). The deficient practice resulted in the worsening of the resident's wound.

Findings include:

Resident #1 was admitted on March 14, 2020 with diagnoses of fracture of the lower end of the right femur and type II diabetes.

The physician H&P (history and physical) note dated March 14, 2020 included the resident was alert and oriented x 3, underwent ORIF (open reduction internal fixation) and intramedullary rod placement and had no skin rash with surgical site clean and dry.

The nursing admission note dated March 14, 2020 included the resident was alert and oriented x 4, was continent, used a urinal and had a dressing to the right upper leg that was clean dry and intact. The documentation also included that there was redness on the resident's groin and that the provider and family were aware.

The Braden scale dated March 14, 2020 had a score of 18 indicating the resident was at risk for developing a pressure ulcer.

The care plan dated March 15, 2020 included the resident had an abrasion to the left heel, 5 cm (centimeters) x 4 cm x 0.1 cm. The goal was that the wounds would heal without complication. Interventions included the use of pressure relieving devices as required and to monitor/document skin for redness, skin tears, swelling or pressure areas and to report signs of skin breakdown.

The nutrition evaluation note dated March 16, 2020 included that the skin was intact.

A dietary note dated March 16, 2020 revealed the hip incision was noted to be healing well with no pressure injuries.

The resident summary note dated March 16, 2020 revealed no mention of any wound.

The care plan dated March 17, 2020 included the resident required assistance with turning and repositioning in bed. The goal was that the resident would be assisted to turn /reposition. Interventions included 1/2 side rails used for bed mobility and positioning and to assist the resident to turn/reposition self while in bed.

The daily skilled charting notes dated March 16 through 20, 2020 revealed no pressure wounds documented.

The admission MDS (Minimum Data Set) assessment dated March 21, 2020 included the resident had a BIMS (Brief Interview for Mental Status) score of 10 indicating the resident had moderately impaired cognition. The assessment also included that the resident was at risk for developing PU/PI (pressure ulcers/pressure injuries) and had no unhealed PU/PI. The CAA (Care Area Assessment) section of the MDS revealed that pressure ulcer was triggered for care planning.

The visual skin evaluation dated March 21, 2020 included the resident had an incision/wound to the right hip with sutures, staples, steri-strips that was healing; and, the general skin appearance was warm and dry.

The resident summary dated March 21, 2020 revealed the resident had no pressure ulcer.

A nursing note dated March 22, 2020 revealed that when changing the resident for bed, a CNA (certified nursing assistant) observed a reddened area to the left heel. Per the documentation, it was an open area that measured 5 cm x 4 cm x 0.1 cm with drainage and the area was reddened. It also included that the provider was notified and the area will continue to be monitored.

A visual skin note dated March 22, 2020 included the general skin condition was not intact and the left heel was reddened with no odor or drainage and measured 5 cm x 4 cm x 0.1 cm.

The Braden scale dated March 22, 2020 included the resident had a score of 18 indicating the resident was at risk for developing PU/PI.

The wound assessment dated March 22, 2020 included that the wound to the posterior foot was facility-acquired and the wound type was trauma. Per the documentation, the wound had a distinct and attached wound edge, had abnormal erythematous tissue, had no exudate, and measured 5 cm x 4 cm x

Based on clinical record review, staff interview, facility policy and procedure, the facility failed to assist in maintaining the highest practicable well-being by failing to ensure care and services related to pressure ulcers/injuries was provided for one resident (#1).

Findings include:

Resident #1 was admitted on March 14, 2020 with diagnoses of fracture of the lower end of the right femur and type II diabetes.

The physician H&P (history and physical) note dated March 14, 2020 included the resident was alert and oriented x 3, underwent ORIF (open reduction internal fixation) and intramedullary rod placement and had no skin rash with surgical site clean and dry.

The nursing admission note dated March 14, 2020 included the resident was alert and oriented x 4, was continent, used a urinal and had a dressing to the right upper leg that was clean dry and intact. The documentation also included that there was redness on the resident's groin and that the provider and family were aware.

The Braden scale dated March 14, 2020 had a score of 18 indicating the resident was at risk for developing a pressure ulcer.

The care plan dated March 15, 2020 included the resident had an abrasion to the left heel, 5 cm (centimeters) x 4 cm x 0.1 cm. The goal was that the wounds would heal without complication. Interventions included the use of pressure relieving devices as required and to monitor/document skin for redness, skin tears, swelling or pressure areas and to report signs of skin breakdown.

The nutrition evaluation note dated March 16, 2020 included that the skin was intact.

A dietary note dated March 16, 2020 revealed the hip incision was noted to be healing well with no pressure injuries.

The resident summary note dated March 16, 2020 revealed no mention of any wound.

The care plan dated March 17, 2020 included the resident required assistance with turning and repositioning in bed. The goal was that the resident would be assisted to turn /reposition. Interventions included 1/2 side rails used for bed mobility and positioning and to assist the resident to turn/reposition self while in bed.

The daily skilled charting notes dated March 16 through 20, 2020 revealed no pressure wounds documented.

The admission MDS (Minimum Data Set) assessment dated March 21, 2020 included the resident had a BIMS (Brief Interview for Mental Status) score of 10 indicating the resident had moderately impaired cognition. The assessment also included that the resident was at risk for developing PU/PI (pressure ulcers/pressure injuries) and had no unhealed PU/PI. The CAA (Care Area Assessment) section of the MDS revealed that pressure ulcer was triggered for care planning.

The visual skin evaluation dated March 21, 2020 included the resident had an incision/wound to the right hip with sutures, staples, steri-strips that was healing; and, the general skin appearance was warm and dry.

The resident summary dated March 21, 2020 revealed the resident had no pressure ulcer.

A nursing note dated March 22, 2020 revealed that when changing the resident for bed, a CNA (certified nursing assistant) observed a reddened area to the left heel. Per the documentation, it was an open area that measured 5 cm x 4 cm x 0.1 cm with drainage and the area was reddened. It also included that the provider was notified and the area will continue to be monitored.

A visual skin note dated March 22, 2020 included the general skin condition was not intact and the left heel was reddened with no odor or drainage and measured 5 cm x 4 cm x 0.1 cm.

The Braden scale dated March 22, 2020 included the resident had a score of 18 indicating the resident was at risk for developing PU/PI.

The wound assessment dated March 22, 2020 included that the wound to the posterior foot was facility-acquired and the wound type was trauma. Per the documentation, the wound had a distinct and attached wound edge, had abnormal erythematous tissue, had no exudate, and measured 5 cm x 4 cm x