Idaho State Veterans Home - Post Falls

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, it was determined the facility failed to ensure resident was seen by a podiatry as ordered by the physician. This was true for 1 of 1 resident (Resident #1) reviewed for foot care. This deficient practice created the potential for Resident #1 to experience ongoing thickening of his toenails or other complications due to lack of foot care. Findings include:Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including dementia, heart failure and diabetes.A nursing progress notes, dated 7/31/25 documented Resident #2's health care coordinator would be looking for a podiatrist for a referral to be seen for diabetic foot care.A nursing progress note dated 8/15/25 documented Resident needs a referral from his primary care to see the selected podiatrist for nail care. Form waiting for processing and signature.A physician assistant's progress notes, dated 8/22/25 documented the physician assistant agreed for Resident #1 to be seen by a podiatrist.On 11/11/25 at 11:26 AM, the Wound nurse was observed to change the wound dressings on Resident #1's right and left heels. Resident #2's toenails were observed to be thick, yellowish in color, and misshapen or raised from the nailbeds.Resident #2's record documented he was scheduled to be seen by a Podiatry on 11/12/25. That is about 10 weeks from the date the physician assistant agreed for him to be seen by a podiatrist.On 11/11/25 at 9:21 AM, the Wound Nurse stated Resident #1 had dysphoric (thick, oddly shaped or colored yellow or brown) toenails and it was difficult for them to cut his toenails. When asked about Resident #1's podiatry appointment, the Wound Nurse stated she believed the request was for Resident #1 to be seen by a podiatry for his toenails and consultation for a diabetic shoe. The Wound nurse stated she did not know why Resident #2's appointment took so long to be scheduled.On 11/11/25 at 9:45 AM, the HIM stated she believed she was informed of Resident #1 needing a podiatry in September 2025 and asked the Unit Clerk to submit the necessary paper works, but it was rejected by the [name of hospital] because they don't have Resident #1's information. The HIM stated they found out that Resident #1's being a veteran his care was needed to be transferred from his previous care provider to his current care provider for him to be scheduled for his podiatry appointment. The HIM stated Resident #1's representative needs to make this call to initiate the transfer. The HIM stated they were not aware of this procedure. She stated they thought Resident #1 being a veteran could go to any (name of hospital) for his treatment. When Resident #1's representative made the call, HIM stated Resident #1 paperwork was resent about three times and several phone calls were made to follow up his podiatry appointment.When asked if Resident #1 was referred to a private medical provider, since he had another medical insurance. The HIM stated she made phone calls to a podiatry clinic and was told there was a copay to be paid. The HIM stated Resident #1's representative refused to pay the copay. Other clinic would not accept Resident #1's insurance.On 11/11/25 at 10:05 AM, the CEO stated lots of veteran's families would like their family to be seen at a (name of hospital) and they don't want to be seen outside of the VA (Veterans Affairs) system. The CEO stated unfortunately the (name of hospital) was having a staffing crisis and they can only see so many residents in general. We were not aware of the need for the resident's care to be transferred from one (name of hospital) to another (name of hospital). I have been trying to get a podiatry contract for over a year, but no one was accepting it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record reviews, it was determined the facility failed to prevent the worsening of a pressure ulcer. This was true for 1 of 3 residents (Resident #1) reviewed for pressure ulcer. This deficient practice caused harm to Resident #1 when his pressure ulcer to his right heel deteriorated and became infected. Findings include:The State Operations Manual (SOM) Appendix PP stated a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including dementia, heart failure and diabetes and chronic kidney disease.Resident #1's record documented the following:1.Pressure Ulcer to Right Heel:A Weekly Pressure Ulcer Record documented the following:-7/24/25: Unstageable DTI measured 3.7 cm x 5.5 cm, intact, wound bed not visible, area with bruised appearance, Cleanse with wound cleanser and apply skin prep two times a day.-9/23/25: Unstageable DTI measured 5.5 cm x 6.6 cm, slough present, unstable eschar, with moderate amount of light red/pink discharge, redness and maceration noted on the periwound, no odor. Treatment: cleanse with wound cleanser, apply skin prep and cover with foam dressing.-9/30/25: Stage IV measured 6.3 cm x 7.6 cm, worsening condition, 100% unstable yellow slough and black eschar and draining, with cloudy, yellow/tan discharge, rotten smelling odor noted, redness and warmth on the periwound, wound edges was irregular and macerated due to increased drainage related to eschar becoming unstable. Treatment: cleanse the area with wound cleanser, apply silver alginate and cover with foam dressing,10/7/25: Unstageable Pressure Ulcer measured 6.2 cm x 7.0 cm, infection was suspected, decline in wound healing, with copious amount of cloudy yellow/tan drainage, slough, eschar present, increase in foul smelling odor, maceration to edges of the wound. Treatment: cleanse the area with wound cleanser, apply silver alginate and cover with foam dressing, wound culture obtained, pain with wound care-10/14/25: continues to have foul odor, wound culture was positive, and antibiotic was started, pain with wound care. Physician stated, Likely will need debridement.-10/21/25: antibiotic completed, wound improved in appearance.10/28/25: copious amount of drainage and increase in odor noted, antibiotic was restarted.2. Pressure to Left Heel:A Weekly Pressure Ulcer Record documented the following:-7/24/25: Unstageable Suspected Deep Tissue Injury (DTI), 7.0 x 4.5, intact, wound bed not visible, area with bruised appearance. Cleanse with wound cleanser and apply skin prep two times a day and cover with heel protector.-9/23/25: Unstageable with 100% stable black eschar, measured 4.5 x 6.8, Cleanse with wound cleanser, paint with betadine and cover with foam dressing.-9/30/25: Unstageable with 100% thick black eschar remains stable. Wound clinic referral done on 9/25/25 waiting for approval (name of hospital).-10/7/25: Unstageable with 100% thick black eschar remains some lifting at edges, measured 3.2 x 5.5.-10/14/25: Unstageable with 100% thick black eschar, measured 3.2 x 4.1, improvement noted in size of the wound.-10/21/25: Unstageable with 100% thick black eschar, measured 2.0 x 3.9.-10/28/25: Unstageable with 100% eschar but feels soft and drainage was now noted.The Weekly Pressure Ulcer Record was requested from the HIM. There was one Weekly Pressure Ulcer Record in July 2025. Resident #1 did not have a Pressure Ulcer Record for his left and right heel from 8/1/25 to 9/22/25.Progress Notes:-7/10/25 at 10:40 AM, had three deep tissue injury (DTI) to his left hell and left great toe, and to his right heel. An order was received to cleanse the DTI with wound cleanser, apply skin prep and allow to dry.- 7/12/25 at 2:54 PM, had small open area to his left heel with small amount of red and brown blood noted. The area was cleansed, calcium alginate was placed over the open area, covered with non-adhesive heel protector, and wrapped with Kerlix (woven cotton fabric).-9/8/25 at 5:24 PM, had an open area to his right heel. An order was received to cleanse the area with wound cleanser, apply skin prep and cover with adhesive foam dressing every other day and as needed.-9/20/25 at 5:05 PM, odor was noted to be present to his right heel.-9/25/25 Nurse Practitioner's Notes documented concern with non-healing with eschar present requests wound care clinic evaluation for debridement and further recommendations.- 10/12/25 Wound Culture, obtained from Resident #1's right foot documented the presence of Streptococcus agalactiaae (bacteria).-10/14/25: continues to have foul odor, wound culture was positive, and antibiotic was started, pain with wound care. Physician stated, Likely will need debridement.-10/21/25: antibiotic completed, wound improved in appearance.10/28/25: copious amount of drainage and increase in odor noted, antibiotic was restarted.Treatment Administration Record documented the following:-July, August and September 2025: cleanse left and right heel with wound cleanser and apply skin prep, allow to dry cover with foam dressing.-October 2025: Cleanse left heel with betadine place cut to fit silver alginate and secure with foam dressing.Cleanse right heel with wound cleanser, apply cut to fit alginate to entire wound bed, cover with silicone heel foam dressing.3. Pressure ulcer to buttock/sacrum:Progress Notes:- 6/27/25 at 11:33 AM, documented he had two pressure spots on either side of his buttocks which was intact at this time. A request was made to treat the area with lantiseptic (a moisturizer use to treat or prevent dry, rough, scaly itchy skin and minor skin irritations) two times a day as a barrier.-7/24/25, documented he had intact skin to his buttocks area.-8/1/25 documented Resident #1 had two small open (no measurement) areas to his right and left upper buttocks.-9/20/25 at 5:05 PM, documented odor was noted to be present on his bilateral buttocks.-10/1/25 at 3:27 PM, documented a Wound clinic referral was made last week, still awaiting approval???A Weekly Pressure Ulcer Record documented the following:- 7/24/25: skin intact- 9/23/25: unstageable pressure wound, measured 3.6 x 1.8, slough (non-viable tissue in chronic wounds that can delay healing and attract bacteria) present, with moderate amount of light red/pink discharge, redness and maceration were noted on the periwound (tissue surrounding a wound) area.- 9/30/25: unstageable pressure wound, measured 3.4 x 1.8, slough present, with moderate amount of light red/pink discharge, redness present on the periwound area, slight odor present. Continue to wait for wound clinic referrals to be approved.-10/7/25: unstageable pressure wound, measured 3.2 x 1.8, slough present, increase amount of light red/pink discharge, redness on the periwound area, increase in odor noted, infection was suspected. Treatment: apply honey hydrogel to wound bed, place silver alginate and cover with silicone foam dressing, wound culture to be obtained.-10/14/25: Stage IV pressure ulcer, measured 3.1 x 1.5 x 1.8, slough present, moderate amount of light red/pink discharge, odor still noted, redness on the periwound. Treatment: apply honey hydrogel, lightly pack with silver alginate strip to wound and cover with silicone dressing, antibiotic started.-10/21/25: Stage IV pressure ulcer, wound improved in size, no signs and symptoms of infection noted, no odor noted-10/28/25: Stage IV pressure ulcer, increase in drainage and odor noted with completion of antibiotic last week, plan to resume antibiotic until seen by the Wound clinic.4. Left Buttock:A Weekly Pressure Ulcer Record documented the following:-9/23/25: DTI-9/30/25: Unstageable, with 100% yellow adherent slough, moderate amount of discharge, with redness on the periwound.-10/7/25: Stage IV, with 90% yellow/gray adherent slough, light red/pink discharge.-10/14/25: Stage IV, pain with wound care, improved in appearance.-10/28/25: Stage IV, slight odor detected with assessment, antibiotic restarted due to decline in wound status.Treatment Administration Record documented the following:-July 2025: Apply anasept gel to open area, cover with mepilex every three days. Prevalon boots while in bed and alternating air mattress.-August 2025: cleanse bilateral buttocks with wound cleanser, pat dry, apply Triad (zinc oxide based wound dressing) paste to wound bed and cover with large foam dressing until resolved.-September: cleanse bilateral buttocks with medi-honey (antibacterial).- October: cleanse bilateral buttocks with medi-honey (antibacterial). Cefpodoxime 200 mg two times a day for 14 days for wound infection, from 10/14/25 - 10/21/25, and was resume on 10/28/25 until Wound clinic appointment.The Weekly Pressure Ulcer Record was requested from the HIM. There was one Weekly Pressure Ulcer Record in July 2025. Resident #1 did not have a Pressure Ulcer Record for his left and right buttocks from 8/1/25 to 9/22/25.A Wound Clinic Notes dated 11/3/25 documented Resident #1 had pressure ulcer in the following areas:-a. Right Heel: unstageable, measurement: 4.1 cm x 6.1 cm x 0.1 cm, with sero-sanguineous discharge, odor: foul b. Left Heel: Unstageable, measurement: 3.3 cm x 4.0 cm x 0.0 cm, with sero- sanguineous discharge, odor: foul c. Sacrum: State IV, measurement: 5.0 cm x 1.5 cm x 1.6 cm d. Left Ischial (gluteal area) Tuberosity: unstageable, measurement: 2,5 cm x 3.3 cm x 0.1 cm with sero-sanguineous discharge. e. Right Ischial Tuberosity: Stage III, measurement: 2.1 cm x 3.6 cm x 0.3 cm, odor: foul The Wound Clinic Notes documented He [Resident #1] was in considerable pain, and I was unable to remove unstable eschar from his heels today. Resident #1 was ordered to receive the following wound treatments:-Triad to the heel peri wounds only.-Hydroferra blue (wound dressing) to all wounds. For sacral wound - three small patches into the wound. Do not overfill the woundWeekly Skin/Wound assessment dated [DATE] to 9/26/25 did not document Resident #1 refused his wound care/assessment. There was no assessment documented for the month of October 2025.The Weekly Pressure Ulcer Record was requested from the HIM. There was one Weekly Pressure Ulcer Record in July 2025. There was no Pressure Ulcer Record from 10/1/25 to 9/22/25.On 11/11/25 at 8:52 AM, the CNO stated she started at the facility as an MDS nurse in August 2025 and during that time the facility did not have a Wound Nurse, and she was told that it was the Nurse Managers who provided wound treatment to Resident #1. She became the CNO on 10/26/25, when asked how would you know that the nurse manager was doing the appropriate treatment for Resident #1, the CNO stated I will not be able to answer that question because I was not here during that time. On 11/11/25 at 9:01 AM, the Nurse Manager stated she started as a Nurse Manager three weeks ago. The RN Manager stated when the Wound Nurse left the facility. The Nurse Manager stated she did not know when the Wound Nurse left the facility. She stated it was the Nurse Manager (no longer in the facility) took over the care of Resident #1's wounds. When asked if she was familiar with Resident #1's wound treatment, the Nurse Manager stated she was not since it was the Nurse Manager who did his wound treatment. When asked about the wound clinic appointment for Resident #1, the Nurse Manager stated she was working with HIM to have Resident #1 appointment, and it took a while for it to be scheduled. On 11/11/25 at 9:21 AM, the Wound Nurse stated she first provided treatment to Resident #1's wound on 9/23/25. The Wound Nurse stated she recognized Resident #1 needed sharp debridement procedure for his wounds and recommended for Resident #1 to be seen at Wound clinic. When asked if the physician/provider have seen Resident #1's wound prior to 9/23/25, the Wound Nurse stated, I cannot answer that because I was not here. On 11/11/25 at 9:45 AM, the HIM stated she was made aware Resident #1 needed a wound clinic as well as Podiatry appointment in September 2025 and asked the Unit Clerk to submit the necessary paper works, but it was rejected by the [name of hospital] because they don't have Resident #1's information. The HIM stated they found out that Resident #1's being a veteran his care was needed to be transferred from his previous care provider to his current care provider for him to be scheduled for his wound appointment. The HIM stated Resident #1's representative needs to make this call to initiate the transfer and they were not aware of this procedure. She stated they thought Resident #1 being a veteran could go to any (name of hospital) to another (name of hospital) hospital for his treatment. When Resident #1's representative made the call, HIM stated Resident #1 paper works was resent about three times and several phone calls were made to follow up his wound clinic appointment. The HIM stated when Resident #1's paperwork were accepted he was scheduled for 11/3/25. Resident #1 was harmed when he developed infection to his pressure wound to his right heel. He did not have a Pressure Ulcer Record from 8/1/25 to 9/22/25. The August and September 2025 TAR documented to cleanse his right heel with wound cleanser and apply skin prep and allow to dry. There was no documentation of the status of Resident #1's wounds from 8/1/25 to 9/22/25. The Wound Nurse did not know the status of Resident #1's wounds if he needed debridement prior to her first assessment of Resident #1's wounds on 9/23/25. The current DON did not know the condition of Resident #1's wound since she only started working in the facility about three weeks ago. The Weekly Skin/Wound assessment did not document he was refusing the assessment. Referral to the Wound clinic was requested in 9/25/25. Resident #1 was seen at the Wound clinic on 11/3/25. At the Wound clinic the physician was unable to remove the unstable eschar due to Resident #1 being in considerable pain. The HIM stated they were not aware of the procedure Resident #1's care was needed to be transferred from his previous (name of hospital) to the current (name of hospital).

Based on observation, record review, and interview, the facility failed to honor one of one resident's (Resident (R) 43's) right to self-administer medications when clinically appropriate of 20 sample residents. Specifically, the facility did not conduct a comprehensive assessment of R43's ability to safely self-administer medications and failed to include all prescribed medications in the evaluation. When R43 did not take medications immediately upon staff offering, the medications were withheld, rather than allowing R43 to take them independently and without feeling rushed. This failure compromised R43's dignity and right to participate in decisions regarding their care. Findings include:Review of R43's admission Record (Face Sheet) located under the Profile tab in the electronic medical record (EMR) revealed the facility initially admitted R43 on 05/31/24. R43's pertinent diagnoses included depression and intervertebral disc degeneration.Review of R43's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/25 revealed R43 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident did not have any cognitive impairment. During the review period, R43 did not display any physical, verbal, or other behavioral symptoms directed toward others. R43 did not have any functional limitation in range of motion and was independent with eating, dressing their upper and lower body, and required substantial/maximal assistance with personal hygiene. R43's pertinent diagnoses included depression and schizophrenia. R43 did not receive any antidepressant or antipsychotic medication during the review period [per the resident's choice].Review of R43's care plan, last revised on 04/23/25 and located under the Care Plan tab of the EMR, revealed R43 was approved to self-administer specific medications. The interventions directed staff to continue to reassess R43's ability and safety with their approved self-administration medication each quarter and as needed, and to provide R43 with their Zinc cream to self-administer as approved. The care plan did not identify any other medications for self-administration.During an observation on 07/30/25 at 10:46 AM, Registered Nurse (RN) 10 administered medications to R43 as ordered. During the observation, R43 made multiple comments voicing his frustration with staff having to watch him take his medication. R43 stated that some nurses left his medication at the bedside for him to take at his leisure, while others would not. If he did not take the medication on the nurse's schedule, the nurse would take the medication and leave the room.Review of the facility's Investigation into Abuse Allegation, dated 07/01/25, revealed R43 told the Director of Nursing (DON) that on 06/26/25, RN8 came into his room at 12:07 PM with his medications, which he took without difficulty. She set his psyllium fiber on his table. When he was done with his pills, she wanted him to take the psyllium fiber right then. R43 stated, Doesn't she know that you can't take psyllium fiber with your routine medication? Why can't she just put it in the bathroom near the sink, and I will take it later? R43 stated that he has been taking psyllium fiber for well over 30 years, and that he is perfectly capable and responsible to take it at the right time. He stated that RN8 refused to leave the psyllium fiber in his bathroom, grabbed the cup, and started to leave. R43 stated, I feel like she has the power, and she has to have other people come in here with her because I'm just a big bad ogre. Reading from a notebook, a second entry he read was on 06/20/24 at 16:30; this time it was RN8 and Certified Nursing Assistant (CNA) 1, she did the knock and walk and again did not wait and come in my room, stating that he again was on his phone with a friend and when he asked her [RN8] to come back later, she huffed out of my room with the medications. Although the facility did not verify the allegation of abuse, the facility determined that RN8 occasionally administered R43's medications late and in instances in which RN8 falls behind on scheduled medication passes later in the afternoon. To support resident-centered care and honor the resident's rights, staff indicated that they updated R43's care plan to reflect the administration of Torsemide and Gabapentin at 10:30 AM per the residents request and that if he is participating in an outline or activity, he will communicate with the licensed nurse to inform them that they can be dispensed upon his report, updated R43's care plan, and educated staff. Still, the facility did not address the resident's wish to self-administer his psyllium fiber.Review of R43's Self-Administration of Medications Assessment, dated 09/01/24, located under the Assessments tab in the EMR, revealed an incomplete assessment. Staff completed Section AA for nebulizer treatments and answered some questions in Section A, confirming that R43 could hold the nebulizer and notify staff of any issues. However, they left key questions blank, including those related to monitoring needs, comments, and care plan updates. Staff also failed to complete Sections B and C, which address other medications and the final decision regarding self-administration. In subsequent assessments dated 10/21/24, 10/25/24, 11/30/24, 02/27/25, and 06/01/25, staff evaluated R43 for self-administration of medications other than nebulizer treatments. Each time, they documented that R43 could self-administer ointments, creams, and topical sprays, but did not assess or include any other prescribed medications. This omission occurred despite R43 expressing concerns that nurses refused to leave medications at the bedside and removed them when he did not take them immediately.During an interview on 07/18/25 at 4:25 PM, R43 expressed concerns regarding RN4's administration of medications on 03/29/25, noting that the issue had not been reported to facility staff or leadership. R43 stated that RN4 entered his room to administer nighttime medications and a Lidoderm patch. When R43 requested to eat something before taking his medications, RN4 responded dismissively, saying, I have never seen you take anything with your pills, which R43 perceived as accusatory. R43 explained that RN4 typically left his medications without observing him take them, making it unlikely she would be aware of his routine. R43 described difficulty removing his shoe in preparation for the patch application, after which RN4 left to assist another resident, leaving him waiting. R43 ultimately decided to forgo the patch and redressed, which appeared to irritate RN4 upon her return. When R43 attempted to explain his frustration and referenced a similar delay on 03/27/25 involving RN8 not administering a medication needed to prevent incontinence during social outings, RN4 responded by arguing and suggested he was a difficult resident, referencing a prior facility. R43 stated that the interaction lacked empathy and caused him unnecessary stress.During an interview on 07/31/25 at 2:49 PM, RN4 stated that R43 liked his medications at a specific time. She stated that on 03/29/25 at 8:52 PM, she went to R43's room to administer his medications. She stated that she knocked and waited for him to answer. She told him that she had his medications. She stated he asked her to set his medications down on the table so that he could look them over. She stated he took the medications and had a pain patch to apply. She said that he told her that he needed to eat something with his pills. She said, Oh, ok. She stated R43 got up, got cookies, went to sit on the side of the bed, and started to eat the cookies. RN4 stated that I had 29 residents to care for that night. She stated while he was eating his cookie, she told him she would be back to give a pain pill to another resident. She stated so, she left the room to give a pain pill to another resident, and when she came back in the room, he refused the pain patch. She stated that she would not stay in the room and watch him eat the cookies unless he asked her to. RN4 noted that the nurses were not supposed to leave the medications in the resident's room, but R43 was not going to have it any other way. She stated that if they recertified him, he would be able to self-administer his meds.During an interview on 07/31/25 at 3:41 PM, RN2 stated that R43 felt rushed and uncomfortable during medication administration by RN8 on 06/20/24 and 06/26/24, describing her behavior as hovering and impatient. She stated following that incident, she obtained an order for R43 to self-administer psyllium fiber. However, RN2 reviewed the self-administration assessment completed on 06/01/25 and confirmed it only authorized self-administration of creams and ointments. She admitted that she failed to obtain a physician's order for the psyllium fiber. RN2 stated that if R43 wished to fully self-administer his medications, she would need to complete a new assessment, consult with the physician, and update his medication records and care plan. She emphasized that supporting R43's autonomy would be beneficial to his dignity and well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, facility investigation, and policy review, the facility failed to ensure one of four residents (Resident (R) 4) was free from neglect when staff failed to provide timely and competent care in response to complaints of pain and decreased urinary output of 20 sample residents. As a result, R4, who had a neurogenic bladder and an indwelling catheter, experienced severe pain, and improper placement of an indwelling catheter. Findings include:Review of the facility's policy titled, Freedom From Resident Abuse, Neglect, Mistreatment & Exploitation, dated 06/24 documented, Each resident at the [Facility Name], Idaho State Veterans Homes (ISVHs) has the right to be free from verbal, sexual, physical, and mental abuse; neglect; exploitation; mistreatment including injuries of unknown source; misappropriation of resident property; involuntary seclusion, and crime against a resident.NEGLECT means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a [NAME] of failures or may be the result of one or more failures involving a covered individual and a resident(s).Review of R4's significant change in condition Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/15/25, located under the MDS tab in the electronic medical record (EMR), revealed the facility admitted R4 on 05/03/24. R4 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated R4 was moderately cognitively impaired. R4 required total dependence on toileting and personal hygiene and had an indwelling catheter. R4's pertinent diagnosis included neurogenic bladder.Review of R4's care plan, last revised on 04/15/25, located under the Care Plan tab in the EMR, revealed R4 had an indwelling catheter related to a diagnosis of neurogenic bladder. The care plan interventions indicated R4 had a 16 French catheter with a 10-millimeter (ml) [balloon] and directed staff to change and care for the indwelling catheter per the physician's orders. The care plan also directed staff to assess R4 for signs and symptoms of urinary tract infections, such as changes in urine color, consistency, and odor; behavioral changes, altered vital signs, pain/flank pain, burning, chills, and altered mental status.Review of the Medication Administration Audit Report, dated 10/25/24, provided by the facility, revealed the following pertinent orders:-Lidocaine (local anesthetics) external patch 4 %. Apply to [R4's] back topically one time a day for pain and remove per schedule.-Acetaminophen (pain reliever/fever reducer) oral tablet. Give 1000 milligrams (mg) by mouth three times a day for pain.-Buprenorphine HCl (opioid medication) sublingual tablet 2mg. Give one tablet sublingually three times a day for pain every eight hours.-Methocarbamol (muscle relaxant) oral tablet 1000mg. Give 1000 mg by mouth three times a day for muscle spasms for two Days (10/23/24 - 10/24/24).-Methocarbamol (muscle relaxant) oral tablet 750mg. Give 750 mg by mouth three times a day for muscle spasms (start 12/25/24).-Indwelling Foley catheter [size of the catheter and balloon was not noted]. -Monitor catheter anchor point and tubing to ensure no kinking, blockage, or pain at the insertion site.-Indwelling Foley catheter, change every three months on the first of the month, and PRN (as needed) for malfunction.Review of the provider's Skilled Nursing Follow Up Note, dated 10/22/24 at 8:15 AM, located under the Miscellaneous tab in the EMR, revealed R4 seen for routine follow-up on chronic conditions. R4 reports worsening pain to mid/low back, ongoing for the last 1-2 weeks. Pain seems to grab him. No radiculopathy or other pain in the legs today. He is lying down in bed this morning due to the pain. No recent falls or other injury.Exam: Elderly. Well nourished. Lying down in bed. Abdomen: positive bowel sounds. Soft, hernia is noted. Protuberant. GU: catheter in place, straw-colored urine. Assessment and Plan: Chronic pain syndrome, low back pain, peripheral neuropathy. On gabapentin, Robaxin, Buprenorphine, Tylenol, and a lidocaine patch. Son does not want the pt [patient] to take further opioid medications, given prior history. Today, pain seems to stem from low back grabs/muscle spasms. Will increase Robaxin to 1g three times a day for two days, then reduce to 750mg three times a day routine. Also, referring to pain management, will also ask about heat packs by physical therapy. Continue to monitor.Review of R4's Alert Charting Progress Note, dated 10/22/24 at 9:58 PM, located under the Progress Notes tab in the EMR, revealed Licensed Practical Nurse (LPN) 5 noted Methocarbamol l000mg three times a day for two days for back pain. Action taken: Will monitor.Review of R4's Alert Charting Progress Note, dated 10/23/24 at 3:50 PM, located under the Progress Notes tab in the EMR, revealed Registered Nurse (RN) 9 noted an increase in Robaxin (Methocarbamol). Resident complains of severe pain to [his] lower back this morning, requested to get back in bed, did receive new dose of Robaxin, has not alleviated pain as of this time. Action Taken: Continue to monitor.Review of R4's Alert Charting Progress Note dated 10/23/24 at 9:50 PM, located under the Progress Notes tab in the EMR, revealed the resident complained of back pain this shift, administered medications as ordered. Action taken: Will monitor.Review of R4's Alert Note, dated 10/24/24 at 6:15 AM, located under the Progress Notes tab in the EMR, revealed a Certified Nursing Assistant (CNA) alerted RN9 to a change in R4's condition. RN9 found R4 hyperventilating, tachycardic, diaphoretic, short of breath, vomiting, and reporting epigastric and severe lower back pain. R4's HR [heart rate] > [greater than] 130 [beats per minute (BPM)], R [respirations] 50 [breaths per minute (BPM)], O2 [oxygen saturation] 91% [on] 5LPM [liters per minute (LPM)]. R4 noted with blurry vision, able to communicate [his] needs, denied chest pain, denied headache, yelling he needed to pee, has an indwelling catheter in place, tubing was kinked, tubing removed to drain bladder that alleviated the distress. AT 6:45 AM, vomiting had stopped, diaphoresis resolved, and vitals showed improvement (BP [blood pressure]166/93, HR 108, RR [respiratory rate] 34, O2 94%). R3, who has a history of atrial fibrillation (A-fib), was able to take oral Diltiazem ER [calcium channel blocker used to control rapid heartbeats or abnormal heart rhythms] and sublingual Buprenorphine (opioid pain reliever). R4 declined transfer to the hospital for further evaluation. At 7:10 AM, further improvement noted (BP 149/87, HR 107, RR 28, O2 94%). Methocarbamol (muscle relaxant) administered for pain. At 7:20 AM, RN9 updated the on-call provider, who ordered continued monitoring at the facility and PRN [as needed] Metoprolol Tartrate (beta blocker used to treat high blood pressure) 12.5mg (milligrams) for HR >120 bpm. AT 9:25 AM, RN9 noted that R3 was calmer, reported decreased pain, and had a regular breathing pattern. Vitals: BP 134/82, HR 100, RR 28, O2 91% on 5LPM. Continuing to monitor at this time. Review of R4's Alert Charting Progress Note, dated 10/24/24 at 4:05 PM, located under the Progress Notes tab in the EMR, revealed RN9 noted R4 complained of pain at an eight out of 10. RN9 administered a new dose of Robaxin (methocarbamol) with minimal relief. RN9 noted, continue to monitor and give medications per the physician's orders. Action taken: Will monitor.Review of R4's Alert Charting Progress Note, dated 10/24/24 at 9:46 PM, located under the Progress Notes tab in the EMR, revealed R4 complaining of increased back pain; medications administered as ordered. Action taken: Will monitor.Review of the Medication Administration Record (MAR) dated 10/24, located under the Orders tab in the EMR, revealed that on 10/25/24, RN6 administered the following routine medications to R4 at 8:34 AM: Buprenorphine HCl 2 mg sublingual tablet, Acetaminophen 500 mg tablets (two), Xopenex HFA Inhalation Aerosol 45 mcg/act (two puffs), Lidocaine 4% external patch applied topically to the back. At 8:35 AM: Lamictal 75 mg tablet, Metformin HCl 500 mg tablet, Celexa 20 mg tablet, -Diltiazem HCl ER 180 mg tablet, Eliquis 5 mg tablet, Simethicone 80 mg chewable tablet, Tiotropium bromide monohydrate inhalation capsule 18 mcg, Fluticasone-salmeterol inhalation aerosol powder, breath-activated 500-50 mcg/act, Albuterol sulfate nebulization solution (2.5 mg/3 ml) 0.083%, 3 ml, and Methocarbamol 750 mg tablet.Review of R4's Alert Note, dated 10/25/24 at 9:12 AM, located under the Progress Notes tab in the EMR, revealed the Previous Director of Nursing (PDON) documented, Late entry Per CNA alert charting: On about 9 AM on 10/25/24 while giving a brief change resident indicated his right side of his stomach was hurting and that he was feeling severe pressure in his belly. As we were changing him nurse in [sic] shift came in and she assessed him.Review of R4's Alert Note, dated 10/25/24 at 4:06 PM, located under the Progress Notes tab in the EMR, revealed a V.O. (verbal order) from R4's PA (Physician's Assistant) to send the resident to acute care for further workup of abdominal pain, no urine output, and pain in the pelvis. The resident's son called and was notified at approximately 10:06 AM. 91l called at approximately 9:59 AM. The resident left with AMR [American Medical Response] at 10:39 AM.Review of the Bladder Activity Report, dated 10/15/24 through 10/25/24, provided by the facility, revealed the following documented urinary outputs in cubic centimeters (cc)-10/22/24 at 5:59 AM: 1000cc/5:50 PM: Not noted. Note stating, Response Not Required. -10/23/24 at 5:59 AM: 1875cc/5:17 PM: 1200cc (total 3875cc)-10/24/24 at 5:59 AM: 850cc/5:59 PM: Not noted. Note stating Response Not Required. -10/25/24 at 5:55 AM: 3500ccReview of the Emergency Department (ED) Encounter Note, dated 10/25/24 at 12:17 PM, located under the Miscellaneous tab in the EMR, revealed R4 presented to the ER (emergency room) with worsening abdominal pain and distention. He comes from assisted living facility [nursing home] where apparently, they tried to replace his Foley catheter had a lot of difficulty and pain and no urine output. Here we are seeing that the balloon is most likely inflated within the prostate and not the bladder, and this was removed with improvement of symptoms. He has no urinary retention on ultrasound. CT [Computerized Tomography] abdomen pelvis without acute findings other than incidental right lower lobe pneumonia now seen on chest x-ray. He has leukocytosis. He has neurogenic bladder, we placed a coude catheter and his urinalysis is a nitrite positive UTI [urinary tract infection]. The patient would benefit from observation admission for IV [intravenous] antibiotics for UTI and incidental right lower lobe pneumonia.Review of the facility's investigation, dated 10/25/24 through 11/01/24, provided by the facility, revealed that on 10/25/24 at approximately 11:00 AM, the Abuse Response Team received an allegation of neglect by staff. RN3 and LPN4 reported to the [Nursing] Home Administrator that RN6 left a resident (R4) who was unable to void bladder and in pain of 10 out of 10 to go on a 15-minute break. RN3 and LPN4 responded to screams from R4's room to assess the situation. Upon finding him in distress and showing signs of being in pain, they contacted 911.During an interview on 07/30/25 at 4:24 PM, attempts to review the facility's surveillance video from 10/25/25 proved unsuccessful. The Administrator stated that the facility no longer had the surveillance video because their retention policy was for only 30 days. The Administrator stated that the cameras were only in the corridor and on 10/25/24 showed RN6 exited through one door and returned from a smoke break.Review of RN6's handwritten statement, dated 10/25/24 at 11:16 AM, provided by the facility, revealed that RN6 went to assess R4 with complaints of 10 out of 10 pain. Upon assessment, RN6 found that R4's indwelling catheter was not draining. Upon further assessment, RN6 realized he hadn't urinated in more than 24 hours. Foley flushed without effectiveness. The indwelling catheter was completely changed, resulting in no urine output. Pain pill Buprenorphine given sublingually. R6 was still in 10/10 pain. RN6 told CNA12 and CNA14 that she was going to take a 15-minute break while she allowed the pain medication kick in so R6 would vasodilate. Then she could reassess R6's urinary output and proceed with an emergency room trip if applicable.Review of RN6's verbal statement, dated 10/28/24, provided by the facility, revealed that On Monday, October 28, 2024, at approximately 1510 (3:10 PM), [RN6] provided a verbal statement to the primary investigator [SW2] and [RN1], RN Manager, regarding the allegation of neglect. RN6 was asked about the day she provided care for [R4]. RN6 stated she showed up at 0600, attended a mandatory meeting at 0630, and then went to the floor between 0730 and 0800. She stated [CNA12], [CNA13], and [CNA14] came and got her, explaining [R4] was in 10/10 pain. [RN6] immediately went to assess him. Upon evaluation, his stomach was distended, and no urine was found in his catheter bag. RN6 obtained a 10CC [six] catheter, then attempted to flush [R4's] catheter; however, the fluid splashed back on her, and [RN6] stated the flush was unsuccessful. She states a new Cath kit and foley were pulled out to completely change his catheter. [RN6] explained she texted [name of the previous director of nursing's name], DNS [Director of Nursing Services], around 0900 asking if the bladder scanner was broken but never received a response. The catheter was changed using a 10CC [sic] balloon, but [R4] was still in pain with no urine output. [RN6] explains she went to get [RN4's] pain pill, Buprenorphine, checking it out of the narcotics box on the med cart. She got all his other pills at this time, including gabapentin and Tylenol giving him all the medications all at once. [RN6] reiterated multiple times [that] all the CNAs were present for the pain medications being given, specifically being placed under his tongue. She provided education on the importance of relaxing and talked him through breathing exercises. [RN6] explained to [R4] she was going to give him time to allow for the pain medication to work then come back in to reassess. After, she told [CNA12], [CNA14], and [CNA13] she was taking a l5-minute break, then would reassess him for urine output, but to be prepared that if there wasn't any, she would ship him out. [RN6] explained on her way to break, she stopped in because [previous director of nursing's name] hadn't answered her about the bladder scanner. She wanted the information from a scan to give to the EMTs. [previous director of nursing's name] stated that it was broken. [RN6] stated she was asked multiple questions regarding her process and what procedures she had completed to which she answered. Upon returning from break, she put all her stuff down and was told paramedics were on the way and paperwork was all filled out. [RN6] alleges that she then asked [RN3] what happened and if she had a doctor's orders to discharge [R4] to the ER and [RN3] allegedly stated that, I [RN3] don't give a f***. [RN6] then proceeded to explain she is frustrated due to not being asked about what happened prior to going on break. [RN6] explained she has been a nurse for 26 years and that [RN3] and [LPN4] are brand new nurses and do not have the experience.Further review of the nurse's verbal statement, provided by the facility, revealed that staff asked RN6 the following questions: -When you came into clinicals, you indicated you needed a bladder scanner. When told it was broken, you stated [that] you needed to ship R4 to the ER and call 911. Can you tell me when you placed that call? RN6 stated that she didn't place it. She explained she was going to place the call if needed, which would have been determined after coming back from break and reassessing to see if the pain pill worked. She explained LPN4 and RN3 made the call before she had the ability.-You stated there was no urine output for 24 hours. How did you make that determination? RN6 answered the CNAs told me from night shift the night prior. Then CNA12 talked to me about not having any during that specific shift. CNA18 stated that on pass-down from the night shift, CNA13 had worked the day before and gave her that pass-down.-How did you determine the proper placement of the catheter before the balloon was inflated? RN6 answered by stating, There are a couple different ways to do it. If there was urine output, or you can put a stethoscope up [to] his bladder to listen to the whoosh sound, which is what I did. There were 15 CCs [sic] in the normal balloon that was in prior, and when you put in the new balloon, I only put in l0 CCs [sic] due to concerns of his bladder being full already.-What specific time did you give the medication to the resident? RN6 answered by indicating that she gave the medication right before taking the 15-minute break. She stated she was not positive, but her best guess was 9:15 AM. RN6 explained that she pulled it from the med cart and narcotics box, then immediately gave it to the resident. RN6 further explained that she also attempted other techniques, such as a warm blanket and breathing techniques, to calm the resident. She further expressed that CNA12 and CNA14 witnessed her physically put the pain pill in his mouth.Continued review of the facility's investigation, dated 10/25/24 through 11/01/24, provided by the facility, included a statement from the facility's medical director regarding his professional opinion on auscultation of a bladder using a stethoscope to check the placement of the Foley catheter. The medical director stated you would not be able to determine the placement of a Foley catheter using a stethoscope, as was indicated by RN6. The medical director stated that some nurses and providers used a stethoscope to determine the placement of a G-tube, but never for a Foley catheter. During a telephone interview on 07/30/25 at 4:03 PM, RN6 stated that she arrived at work on 10/25/25 at 6:00 AM, attended a mandatory meeting at 6:30 AM, and was running a little behind due to the meeting. RN6 stated at approximately 7:15 AM, staff notified her that R4 was having a lot of pain. RN6 stated that this was her first day back after four consecutive days off. So, she went to look through some of his paperwork. She stated that apparently, R4 had been complaining of abdominal pain and the inability to urinate for a couple of days, and that none of the nurses really did anything about it. She stated that when she went into the resident's room, the resident complained of 10 out of 10 pain, his abdomen was completely distended, and he did not have any urinary output, noting that there was less than 50cc in his catheter drainage bag and that R4 complained of abdominal pain. -RN6 stated that she completed a full assessment on R4 and tried to see what she could do to relive his pain because he had not urinated from what she concluded from the documentation for greater than 24 hours. RN6 stated that she first tried to flush R4's catheter with 100cc of normal saline to see if it was blocked, adding that when you get a UTI, especially one that's been brewing for a while, the urine gets real thick and kind of like snot, it's nasty. She stated that her attempt to flush the catheter was unsuccessful. So, she removed the catheter and replaced it with a new one to see if she could get urine and gave him some pain medication and then went to look for the bladder scanner so that she could report to the EMT how much urine he retained in his bladder and that if the new catheter had not drained or started to drain, she knew that she was going to send him to the hospital. She stated she interrupted the clinical meeting, looking for the bladder scanner, and stopped to go to the bathroom, since she had been in with R4 for over an hour and a half. -RN6 stated that upon returning to the floor, she found two nurses (RN3 and LPN4) present. RN6 stated one of them was on the phone with 911, and they had not been with this resident all morning, unlike her. She stated so, she asked RN3 if she had obtained a doctor's order because she had not called the doctor yet. RN6 stated she was in the process of gathering the last piece of information (i.e., results of the bladder scanner) and then calling the doctor. She stated reportedly, RN3 said, I don't give a F*** and assisted the paramedics and staff get R4 out the door, but RN3 never asked me once what I did previously for the resident. -When asked how she knew that the new indwelling catheter that she inserted was in place prior to inflating the balloon, RN6 stated that she did not inflate the balloon after inserting the catheter [contrary to her verbal statement, dated 10/28/24], which she believed was the source of confusion. She stated her initial attempt to flush the existing catheter with saline was unsuccessful, indicating a blockage. She stated upon placing a new catheter, she assessed the patient's condition through bowel and bladder sounds, noting signs of fluid retention (tympany).RN6 stated without access to a bladder scanner to confirm, she opted to leave the catheter in place, administer pain medication, and create a calming environment to help the patient relax and vasodilate to allow urine to flow naturally.-When asked if she took a break or left the facility after seeking the bladder scanner, RN6 explained that she informed her team she would be gone for 10-15 minutes to locate the scanner, as her earlier text to the Director of Nursing had gone unanswered. She stated during that time, she briefly used the restroom, stepped outside the back door for a few deep breaths, and looked up the Emergency Medical Services (EMS) contact number on her phone, intending to call them instead of 911, which typically required a doctor's order. She emphasized that she did not leave the facility and returned to the floor within 16 minutes. She stated that she was gathering final assessment details to support a medical decision, noting that the patient was later found to have over 3000cc of retained urine [contrary to the ED Encounter Note, dated 10/25/24] and a severe UTI, explaining the intense pain he was experiencing.During an interview on 07/30/25 at 2:12 PM, RN3 stated that RN6 came into the morning meeting (time unknown), telling us that she might be sending R4 out to the hospital because he had not had urine output in the last 24 hours. RN3 stated shortly after that, approximately 10 minutes later, the clinical meeting finished. As she and LPN4 approached the first two nurses' stations, she stated she could hear R4 screaming. She stated that she went to the resident's room, saw another CNA entering R4's room. RN3 stated so, she asked the CNA where R4's nurse was, and the CNA said that she went on break. RN3 stated so, she went to assess R4 and told the CNA to get the vital sign machine and meet her in R4's room. When she went into R4's room and assessed his vital signs, she stated she tried to check the resident's catheter because he had no urine drainage. When she went to palpate the shaft of his penis, RN3 stated he told her to stop because it was too painful. She stated that she asked if she could remove the catheter and put in a new one, and R4 said, No, don't touch me. RN6 then advised R4 that if he did not want her to touch him, she would need to send him to the hospital, and he said OK. -RN3 stated that she completed a full head-to-toe assessment of R4 to see if there was something else that could be causing the pain. She stated upon assessment, the resident had tympany noted in his right upper quadrant. RN3 stated after that, she left the room. She stated she told him that she would be right back, that she was going to call the resident's son and physician. She stated that she informed the resident's son about his change in status. RN3 stated that the resident's son was ok with sending R4 to the hospital if that was what the doctor wanted. RN3 stated that she spoke to the doctor, who was ok with sending R4 to the hospital, and that she called 911. -RN3 stated about that time, RN6 came back from break and asked her what they were doing. She told her that she heard R4 screaming in the hall and that he would not let her do anything with his catheter. She stated that she asked RN6 what she did, and that RN6 stated that she medicated him with his normal pain meds and was waiting for vagal response. RN3 stated that RN6 said that she replaced the catheter because the other one was not draining, and that the one she placed was also not draining. RN6 said that she listened to R4's stomach and heard the same thing RN3 did. She stated she and RN6 went back into R4's room, waiting for Emergency Medical Services (EMS) and the fire department to arrive. RN3 stated RN6 gave report to EMS and the fire department, then RN3 gave her report. She stated RN6 left the room, but she stayed with him because he was still in pain, and she tried to calm him down. RN3 added that she was not sure if she called the doctor first or 911 because R4 was in so much pain. But the doctor and son were both ok with sending him to the hospital.During a telephone interview on 07/30/25 at 3:15 PM, CNA14 stated that on 10/25/24, R4 was in significant pain and RN6 was trying to determine the cause. CNA14 expressed that she had already provided her statement in court and was unsure what more she could add. During the call, the interviewer verbally reviewed CNA14's witness statement, which had been obtained by the facility on 10/28/24, at approximately 2:28 PM. The statement described CNA14 as being present with RN6 and CNA12, attempting to calm R4, who was visibly in pain, screaming, and appearing unable to get comfortable. It also stated that RN6 removed and replaced R4's catheter, but he remained unable to urinate. According to the statement, RN6 suspected the inability to urinate was due to R4 being tense from pain. The statement further noted that RN3 entered the room shortly after and asked CNA14 to take R4's vitals before they sent him to the hospital. During the review, CNA14 interrupted to clarify that RN3 did not enter the room at that time, but approximately 20 minutes later. The remainder of the statement was reviewed, which indicated that CNA14 cared for multiple residents and was in and out of R4's room. However, CNA14 denied being in and out of the room, stating that R4 was sent to the hospital. When asked if she had anything further to add, CNA14 stated that RN6 did everything she should have done to care for the resident. When asked whether RN6 went on break during that time, CNA14 responded that RN6 had gone to look for a bladder scanner but was unsure if she had taken a break. CNA14 also expressed confusion about the origin of the verbal statement.During a telephone interview on 07/30/25 at 3:35 PM, the PDON stated that on 10/25/24, RN6 came into the conference room during the clinical meeting and said that she felt that she needed to send R4 out because he did not have any urine output in the last 24 hours. PDON stated RN6 then asked about the facility's Doppler (bladder scanner), which was broken, and that the facility needed to reorder one, and that it was ok to send R4 out [to the ER]. She stated at that time, the staff asked RN6 if she needed help, and RN6 said, No, I've got this. PDON stated after the meeting, RN3 and LPN4 went to the floor and reported hearing R4 screaming in pain, and they went to check it out. She stated RN6 was nowhere to be found. PDON stated that when RN6 came back to the unit, RN6 said that she was waiting for the pain medication to take effect. She stated later they found out that RN6 inflated the balloon of the catheter in R4's urethra. She stated R4 went out to the hospital and came back the same day. PDON stated both nurses (RN3 and LPN4) felt strongly that RN6 should not have left R4 in that condition. She stated so, they took all necessary steps because we considered her actions to be neglectful. She stated RN6 went to the Administrator's office, provided a statement, and went home pending an investigation. The PDON stated that when R6 returned, the ER report indicated the catheter was placed incorrectly. The PDON stated there was no reason RN6 should have waited for the pain medication to take effect because she had given him the pain medication an hour prior. When asked if RN6 went on break after leaving the conference room, the PDON stated that a review of the surveillance video showed RN6 left the building for approximately 15 to 20 minutes, but she could not say where she went or when she left the building. During an interview on 07/30/25 at 4:45 PM, the Activity Director (AD) stated that on 10/25/24, RN6 came into the morning stand-up (clinical meeting) to provide an update about R4. The AD stated RN6 stated that she was going to send him out to the ER due to not urinating. The AD stated that it sounded like RN6 wanted to use the bladder scanner as an intervention, but they did not have access to it, or it was broken at the time. She stated so, they wanted to send R4 to the ER. The AD stated that she saw RN6 come back through the double doors across from her office and next to the bistro, but she was not sure what time this was or where she was coming from, stating that she just did not see her walk back toward the floor [where R4 resided]. During a telephone interview on 07/31/25 at 8:16 PM, CNA12 stated that on 10/25/24, she was training CNA14 and working with R4 alongside CNA13. CNA12 stated R4 had pressed his call light due to a bowel movement. CNA12 stated when CNA12 and CNA14 responded, they noticed R4 was scheduled for a shower. CNA12 explained that R4 preferred bed baths due to his pain, which often caused him to scream-a behavior familiar to the CNAs. She stated while assisting R4, CNA12 observed that he was in more pain than usual and asked if he wanted her to stop the bed bath. She stated CNA14 helped R4 with breathing techniques to manage his pain, which had reportedly started the day before. CNA12 stated RN6 entered the room in response to R4's screaming and labored breathing. CNA12 reported R4's condition to RN6, who began assessing him. She stated the night CNA had mentioned R4 was feeling better than the previous day, although he had minimal urinary output overnight. CNA12 stated that RN6 assessed R4's lower right abdominal pain and checked his bowels, stomach, and bladder for signs of urinary retention. CNA12 stated RN6 asked about R4's urine output, and CNA12 reported approximately 200cc, which was lower than usual. She stated R4 mentioned he had experienced pain the day before. She stated RN6 suspected urinary retention and expressed concern about the lack of a working bladder scanner. CNA12 stated RN6 eventually changed R4's catheter, but no urine was obtained. CNA12 noted that R4 was extremely sensitive to touch and screamed during the procedure. She stated RN6 administered a pain pill and asked R4 if it was dissolving, though CNA12 was unsure when RN6 brought the medication into the room. She stated RN6 stated she would speak to management about the bladder scanner. CNA12 recalled speaking with RN6 and CNA14 after leaving R4's room and asking if they had known about R4's ongoing issues. She stated RN6 responded that the previous nurse had not informed her. CNA12 was unsure whether RN6 took a break but remembered RN6 saying she was stepping out to inquire about the bladder scanner. CNA12 stated she later saw RN6 and LPN4 in R4's room again, approximately 10 to 30 minutes after they had left. CNA12 stated she did not know whether RN6 inflated the catheter balloon but assumed she did, as it appeared consistent with standard nursing practice.During a telephone interview on 08/01/25 at 1:39 PM, CNA13 stated R4 had issues with his catheter the day before (10/24/24) and that RN9 flushed his catheter and was able to get urine output. CNA13 stated so, when CNA15 came to work, she told her to keep an eye on R4 because of these issues. The next day, CNA13 stated she asked CNA15 how R4 was doing, and CNA15 said he was not doing well and that he had only had 200cc output that day. CNA13 stated that she asked CNA15 if she told[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure one of one resident reviewed for restraints (Resident (R) 2) was free of restraints of 20 sample residents. The therapy department failed to assess R2's wheelchair with seat belts in accordance with a physician's order, the facility failed to attempt less restrictive measures prior to restraint use, failed to assess and identify the belts as restraints, and failed to implement a plan to release the restraint having the potential for the resident to be at risk for negative outcomes (skin deterioration, discomfort, decreased quality of life etc.).Findings include:Review of the facility's policy titled, Physical Restraint Use/Evaluation, dated 02/25 revealed the purpose was, To ensure this facility utilizes physical restraints only when alternative interventions to protect the resident's safety have been exhausted, or when the resident has been determined to have the presence of a specific medical symptom that requires the use of a restraint to protect the resident's safety . The use of physical restraints will be evaluated on a continual basis . in conjunction with the residents' MDS [Minimum Data Set] schedule. Physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement. physician's order for the restraint. Obtain physician order to include Type of restraint. Reasons for restraint . Times restraint is to be applied/ released. Establish care plan for use of the restraint. Restraint elimination. Each quarter . the RN [Registered Nurse] Manager shall complete the physical Restraint Elimination Assessment and resident will be evaluated by the Physical Restraint /Reduction Review Committee for a physical restraint reduction program implementation.Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility on [DATE]. Diagnoses included history of cerebral infarction (ischemic stroke when blood flow to the brain is disrupted), paraplegia (paralysis of the legs and lower body), dementia, above the knee amputation, and Parkinson's disease. Review of the quarterly MDS with an Assessment Reference Date (ARD) of 06/08/25 in the EMR under the MDS tab revealed R2 was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated R2 was severely cognitively impaired. R2 was impaired in range of motion (ROM) on one side to his lower extremities. R2 was dependent on staff for shower/baths and required substantial assistance with personal hygiene, upper body dressing, toileting hygiene, and lower body dressing. R2 required set up assistance with eating and oral hygiene. R2 had not received physical or occupational therapy and had not been on a restorative nursing program during the assessment period. R2 was not identified as using any restraints. A request for an assessment of R2's wheelchair with the seat belt and chest belt was made on 07/30/25. A Consultation Request, dated 02/26/24, was provided by the facility to the surveyor. The document read, Evaluate for seat belt use in wheelchair to aid in positioning. Under Findings and Recommended Treatment, Physical Therapy Aid (PTA) 1 documented, Referred to VA [Veteran's Administration]. The assessment was not provided.Review of the Order Summary Report current on 07/27/25 and provided by the facility revealed there was a Physician's Order, dated 08/06/24, that read, Okay to wear double seat belt while in wheelchair for safety and chair positioning. The orders did not address when the belt was to be released.Review of the Care Plan, dated 09/30/23 in the EMR under the Care Plan tab, revealed a focus area of, Mobility/Fall Risk: I am at risk for falls. I am paraplegic. I have a left AKA [above the knee amputation] amputation. I am taking high risk medication that may increase my fall risk. Fall History, Weakness, Unsafe Behaviors, Poor Safety Awareness, Impulsive Decision Maker. Balance impaired due to CVA [cerebrovascular accident] and Parkinson's. The goal was for R2 to, have no serious injury related to falls through the next review period. Interventions in pertinent part included, Resident has double seat belts while in wheelchair that I can release on command. Initiated on 07/26/24. The Care Plan did not identify physical restraint use.Observations revealed R2 had a seat belt and a chest strap in place when he was up in his wheelchair:-On 07/28/25 at 11:53 AM, R2 was observed with both belts in place sitting in his wheelchair near the nurse's station in front of the large screen TV. He was leaning slightly to the left and the chest belt was tight across his chest.-On 07/28/25 at 2:53 PM, R2 was observed sitting in his wheelchair with the waist and chest belts in place with the chest belt tight across his chest. He was sitting near the nurse's station in front of the large screen TV.-On 07/29/25 at 8:38 AM, R2 was sitting in his wheelchair with the seat belt and chest belt in place in the TV area.-On 07/30/25 at 12:27 PM, R2 was eating lunch in the dining room in his wheelchair with both the seat belt and chest belt in place.-On 07/30/25 at 1:39 PM, R2 was sitting in his wheelchair with the seat belt and chest belt in place in the TV area.During an interview on 07/30/25 at 1:13 PM, Certified Nursing Assistant (CNA) 7 stated the staff had to do more for R2 than previously as he was becoming more dependent. CNA7 stated R2 was capable of removing the seat belt and chest belt independently. CNA7 stated the belts were not released when he was up in the wheelchair; the belts were continuously fastened. CNA7 stated R2 leaned to the left and the belts helped him maintain a more upright posture in the chair. CNA7 stated once R2 got up from bed into the wheelchair after breakfast, he remained in his wheelchair for the day and laid back down before day shift staff left at 6:30 PM. CNA7 stated R2 had used the chair with both belts as long as she had worked with him.On 07/30/25 at 3:09 PM, R2 was sitting in his wheelchair in the TV area with both belts in place. CNA7 asked R2 several times to unfasten the seat belt and chest belt to demonstrate that he was able to do it. R2 was not able to release the belts, verified by CNA7.During an interview on 07/30/25 at 2:05 PM, PTA1 stated he was aware of the belts on R2's wheelchair and the initial chest belt fastened with Velcro and R2 had been unable to remove it, and it was a restraint. PTA1 stated R2 had poor trunk control, and the seat belt kept him from sliding down in the chair. PTA1 stated he could not do the evaluation for the wheelchair that was referred on 02/26/24 because he was a PTA and not a Physical Therapist (PT). PTA1 stated he thought the VA sent out someone to evaluate the wheelchair and they put a different back on it, but he did not have any records. PTA1 stated R2 had used the wheelchair with the belt/s (possibly one belt initially with a second one added later) since coming into the facility.During an interview on 07/30/25 at 2:39 PM, Registered Nurse (RN) 3 stated R2 had been declining slowly over time. RN3 stated R2 could release the seat belt and chest belt, and the facility had not considered the belts functioning as restraints. RN3 stated she had previously worked as the MDS Coordinator and asked R2 to release the belts which he previously was able to do. RN3 stated R2 did not have the core strength to sit upright in the chair without the belts, and he also had spasms causing him to slide down. RN3 verified when R2 was sitting in the wheelchair both belts were fastened and there were no periods of release. RN3 stated the facility had not completed a restraint assessment prior to 07/30/25 (during the survey) although she stated she now realized they should have completed the assessments quarterly. RN3 stated she researched to determine if an assessment of the seat belt ordered on 02/26/24 for the therapy referral was completed. RN3 stated PTA1 sent the referral to the VA and the VA indicated the nursing staff should do the assessment. RN3 stated there was no documented assessment of R2's wheelchair with use of the seat belt and chest belt.During an interview on 08/01/25 at 2:14 PM, RN3 stated she asked R2 to release his seat belt and chest belt on 07/30/25. RN3 stated R2 knew where the buckle was but was not able to release the buckle and therefore, the seat belt and chest belts were restraints.During an interview on 08/01/25 at 1:54 PM, the Director of Nursing (DON) stated she and RN3 asked R2 to release his seat belt and chest belts on 07/30/25 and R2 was not able to release them The DON verified the belts were restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and procedure review, the facility failed to provide assistance with baths and shaving for one of one sample residents (Resident (R) 2) requiring substantial assistance from staff, reviewed for activities of daily living (ADLs) of 20 sample residents. This created the potential for discomfort and/or feeling unkempt. Findings include: Review of the facility's undated procedure titled, Nursing Procedure Manual Bathing Procedure, revealed This facility will provide quality resident grooming and hygiene to include bathing/showering of residents at a minimum of once weekly and/or resident preference . Bathing/showering of a resident will be recorded on the specific resident in POC [Point of Care]. If a resident refuses a bath/shower, then the CNA [Certified Nursing Assistant] will document the ADL's [activities of daily living] bathing task in POC as resident refused. The CNA is responsible for the grooming and hygiene of the resident during the bathing/showering process including shampooing hair, shaving facial hair, etc . Review of the facility's undated guideline titled, Nursing Procedure Manual Resident Care Guidelines, revealed In the event a resident either refuses or resists any of the cares offered, then the aide assigned the resident shall indicate this refusal. The information as to the specific refused or resisted is to be documented in POC in the Behavioral Symptoms 3.0 Resists/Rejects Evaluation of Care.Reapproach the resident after a short time to attempt to provide care. If possible, have another staff attempt to engage the resident in participation. Up to three (3) attempts should be made. The resident's refusal or resistance to care(s) shall be communicated per above and to the licensed nurse assigned the resident at the time of the occurrence. The licensed nurse shall assess situation and determine appropriate course for further interventions. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility on [DATE]. Diagnoses included history of cerebral infarction (ischemic stroke when blood flow to the brain is disrupted), paraplegia (paralysis of the legs and lower body), dementia, above the knee amputation, and Parkinson's disease. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/08/25 in the EMR under the MDS tab revealed R2 had a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated R2 was severely cognitively impaired. R2 was impaired in range of motion (ROM) on one side to his lower extremities. R2 was dependent on staff for shower/baths and required substantial assistance with personal hygiene. Review of R2's Care Plan, dated 09/30/23 in the EMR under the Care Plan tab, identified a focus area of Self-care deficit: I require assistance in order to complete my ADLs . The goal was, I will have a neat, clean, tidy appearance, and be dressed appropriately through review period. Interventions included in pertinent part, Personal hygiene: I need max [maximum] assistance of 1 staff, set up items and allow me to do as much as possible for myself.Shower/bathing: I need maximum assistance of 1 - 2 staff for bathing 1 - 2 X [times] a week and as needed. It is difficult to obtain my cooperation with bathing. Re-approach with different staff member as needed and vary the timing. A request for bath/shower records for R2 was made and the Point of Care Documentation Survey Report for the month of June 2025 was provided by the facility, which revealed R2 received baths/showers on 06/07/25, 06/14/25, 06/17/25, 06/25/25, and on 06/28/25. Review of the CNA POC Documentation Survey Report for the month of July 2025 and provided by the facility, revealed R2 received baths/showers on 07/09/25 (there was a 11day gap from his prior shower), 07/16/25, and on 07/23/25. Review of the CNA POC Response History report for the task of Monitor for refusal of agitation, and/or confusion during cares. Resident may show anxiety in times of confusion through agitation for the month of July 2025 under the POC tab revealed one instance on 07/24/25. Review of the Behavior Progress Notes from 06/01/25 - 08/01/25 in the EMR under the Progress Notes tab, revealed no instances of refusals of baths/showers or shaving. Observations during the survey (on 07/28/25 at 10:54 AM, at 11:53 AM, and at 2:53 PM; on 07/29/25 at 8:38 AM, and at 3:53 PM; on 07/30/25 at 12:27 PM and at 1:39 PM) revealed R2 was observed with long stubble/facial hair 1/4 to 1/2 inch long. During an interview on 07/28/25 at 12:34 PM, Family Member (F) 1 stated R2 should have been shaved twice a week when he was given showers. F1 stated R2's facial hair was long, and he needed to be shaved. F1 stated she had brought in an electric shaver and R2 used to be able to shave but now needed staff assistance. During an interview on 07/30/25 at 1:15 PM, Registered Nurse (RN) 3 stated R2 should have been showered twice a week on Wednesdays and Saturdays. During an interview on 07/30/25 at 1:13 PM, CNA7 stated R2 was dependent on staff to shave him. CNA7 stated R2 should have been shaved on shower days and stated he was given a bath today by CNA6. CNA7 stated R2 occasionally refused shaving. During an interview on 07/30/25 at 3:18 PM, CNA6 was asked about providing a bath/shower to R2 and to report the series of events as he provided care. CNA6 stated he had not showered R2 but had given him a bed bath instead. CNA6 stated that after he had given the bed bath, the nurse wanted to do wound care. CNA6 stated after wound care was completed, he offered to provide additional care such as brushing his teeth and shaving to R2 but R2 declined. CNA6 did not report that he had reapproached R2 or solicited assistance to shave him at a later time. CNA6 acknowledged R2 had long stubble.During an interview on 07/30/25 at 2:39 PM, RN3 stated R2 was dependent on staff for most ADLs. RN3 stated R2 should have been shaved twice weekly on his bath days. RN3 stated if R2 refused, it should be documented by the CNAs in POC. During an interview on 07/31/25 at 11:57 AM, RN3 stated CNA6 did not know about charting R2's refusal to be shaved and had not documented this. RN3 verified R2 had long stubble and had not been shaved. During an interview on 08/01/25 at 2:08 PM, the Director of Nursing (DON) stated she had identified a problem with CNAs not completing ADL care, not attempting to provide care several times if a resident refused, and not documenting appropriately. The DON stated when a resident refused ADL care, the staff should attempt to provide the care a total of three times and should document the refusals in POC. The DON verified the bath/shower records did not show two baths/showers per week were provided to R2 and did not show refusals. The DON stated if ADL care was not documented, it was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a restorative nursing program recommended by physical therapy was implemented for one of two residents (Resident (R) 2) reviewed for range of motion of 20 sample residents. This created the potential that R2 would experience a decline in his abilities to perform activities of daily living (ADLs). Findings include: Review of R2's undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility on [DATE]. Diagnoses included history of cerebral infarction (ischemic stroke when blood flow to the brain is disrupted), paraplegia (paralysis of the legs and lower body), dementia, above the knee amputation, and Parkinson's disease. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/08/25 in the EMR under the MDS tab revealed R2 had a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated R2 was severely cognitively impaired. R2 was impaired in range of motion (ROM) on one side to his lower extremities. R2 was dependent on staff for shower/baths and required substantial assistance with personal hygiene, upper body dressing, toileting hygiene, and lower body dressing. R2 required set up assistance with eating and oral hygiene. R2 had not received physical or occupational therapy and had not been on a restorative nursing program during the assessment period. Review of the PT [Physical Therapy] Evaluation & Plan of Treatment, dated 04/15/25 and provided by the facility, revealed R2 would not be picked up by therapy following readmission from the hospital; however, the plan of treatment indicated R2 was to continue with restorative program. The document read, On evaluation it was found he was at his prior level of function and would not be followed by PT, but a RA [Restorative Aid] program would be generated to prevent physical decline. Review of the Care Plan, dated 04/04/25 in the EMR under the Care Plan tab, revealed a focus area of Self-care deficit: I require assistance in order to complete my ADLs, altered mobility, dementia, paraplegia, pain. The goal was to have a neat, clean, tidy appearance and be dressed appropriately. Interventions documented how much assistance R2 required with specific ADLs. The Care Plan did not include the provision of a restorative nursing program to prevent a physical decline. Observation during the survey revealed R2 was able to slowly feed himself lunch on 07/28/25 at 11:53 AM. R2 was leaning slightly to the left in his wheelchair. R2's food was cut into bite sized pieces. R2 was also observed feeding himself breakfast on 07/29/25 at 8:38 AM using built up silverware. He had eaten less than 25% of pancakes cut into bite sized pieces and sausage links cut into pieces. R2 was not observed to complete any other ADLs during the survey except for eating. During an interview on 07/28/25 at 12:31 PM, Family Member (F) 1 stated R2 was not receiving restorative nursing services. F1 stated R2 was paralyzed from the waist down and she thought he would benefit from a restorative program. F1 stated R2 used to shave himself and now he did not. During an interview on 07/30/25 at 1:13 PM Certified Nursing Assistant (CNA) 7 stated R2 was dependent for most ADLs. She stated the staff combed his hair and shaved him but R2 was still able to feed himself. CNA7 stated R2 could still wheel himself in his wheelchair but no longer got himself coffee. CNA7 stated there were two RAs who implemented restorative programs; the CNAs did not do ROM exercises, etc. with residents. During an interview on 07/30/25 at 1:48 PM, Certified Occupational Therapy Aid (COTA) 1 stated the last time R2 was evaluated for PT or Occupational Therapy (OT) was on 04/15/25 after he returned from the hospital. COTA1 stated R2 was not picked up by either PT or OT at that time as he was at his prior level of functioning. COTA1 stated restorative programs were intended to prevent a resident from experiencing a decline. He stated a therapist would generate a restorative program that would be implemented by nursing. During an interview on 07/30/25 at 2:47 PM, Registered Nurse (RN) 3 stated she oversaw the restorative nursing program and would check to see if R2 was on a restorative program. During a joint interview on 07/30/25 at 3:00 PM, RA1 and RA2 stated R2 was not on a restorative program and had not been on one for over a year. RA1 and RA2 stated the PT or OT developed the restorative programs, the Restorative Nurse put the program into the computer system and told them what the program entailed, and they implemented the restorative programs. During an interview on 07/31/25 at 11:47 AM, RN3 stated Physical Therapy Aid (PTA) 1 (Director of Therapy) had missed the PT referral for R2's restorative program. RN3 stated the program was not implemented because she had not received the referral. RN3 stated the typical process was for her to receive a referral from therapy, she entered it into the computer under the task list for the RAs, then she updated the care plan. RN3 stated she then talked to the RAs about the new program. During an interview on 07/31/25 at 2:39 PM, PTA1 stated he could not find a referral to restorative following the PT referral for restorative on 04/15/25. PTA1 stated he could not find it and stated it had not been done. During an interview on 08/01/25 at 2:21 PM, the Director of Nursing (DON) stated she was not aware of the failure of a restorative referral made for R2 to RN3 the restorative nurse. The DON stated there should be a process for restorative referrals from therapy to nursing and it should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure fall interventions were in place for one out of three residents (Resident (R) 2) reviewed for falls of 20 sample residents. Fall interventions such as mats on the floor, bed alarm, low bed, and a wedge were not consistently in place when R2 was in bed. This created the potential for significant injury from falls.Findings include:Review of the facility's policy titled, Interdisciplinary Team, dated 02/25, revealed the purpose was, To provide a process to assess and review results of findings and investigation of resident and employee incidences; determine appropriate interventions to decrease/eliminate incidence(s). A multi-disciplinary workgroup shall be established. The workgroup shall meet on regularly scheduled intervals to review Incident Report(s). The purpose of the workgroup is to further investigate incidents, as necessary, and to determine further interventions and plans to decrease/eliminate the potential for recurrence.Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility on [DATE]. Diagnoses included history of cerebral infarction (ischemic stroke when blood flow to the brain is disrupted), paraplegia (paralysis of the legs and lower body), dementia, above the knee amputation, and Parkinson's disease.Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/08/25 in the EMR under the MDS tab, revealed R2 had a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated R2 was severely cognitively impaired. R2 was impaired in range of motion (ROM) on one side to his lower extremities. R2 was dependent on staff for shower/baths and required substantial assistance with personal hygiene, upper body dressing, toileting hygiene, and lower body dressing. R2 had not received physical or occupational therapy and had not been on a restorative nursing program during the assessment period. R2 had not experienced any falls since the prior MDS assessment.During an interview on 07/28/25 at 12:26 PM, Family Member (F) 1 stated R2 fell and that R2 had fallen lots recently. F1 stated R2 had fallen out of bed and was found on the floor the previous Wednesday. F1 stated R2 had some injuries such as bruises from the fall and had been transferred to the emergency room for evaluation. F1 stated R2 had an amputated leg and was paralyzed from the waist down. F1 stated all of R2's recent falls had been out of bed, and she thought more needed to be done to keep R2 safe.Review of R2's Care Plan, dated 09/30/23 in the EMR under the Care Plan tab, revealed a focus area of I am at risk for falls. I am paraplegic. I have a left AKA [above the knee] amputation. I am taking high risk medication that may increase my fall risk. Fall History, Weakness, Unsafe Behaviors, Poor Safety Awareness, Impulsive Decision Maker. Balance impaired due to CVA [cerebral vascular disease] and Parkinsons. The goal was, I will have no serious injury related to falls through the next review period. Interventions in place prior to the falls beginning in June 2025 included:-Bed is in a lower position with bilateral floor mats initiated on 04/27/24. -Perimeter mattress overlay initiated on 07/05/24.-Double seat belt in wheelchair initiated on 07/26/24; and-Bed alarm initiated on 09/09/24.Observations revealed R2 had a seat belt and a chest strap in place when he was up in his wheelchair on 07/28/25 at 11:53 AM and 2:53 PM; on 07/29/25 at 8:38 AM; and on 07/30/25 at 12:27 PM and 1:39 PM. On 07/29/25 at 3:35 PM, R2 was lying in the bed in a low position with mats on the floor on both sides of the bed, with a perimeter mattress, two positioning bars in place near the head of the bed, and with pillows between his torso and the grab bars on each side.Review of the facility's incident reports revealed R2 fell three times between 06/23/25 and 07/23/25:1. Review of the Un-witnessed Fall report, dated 06/23/25, provided by the facility revealed R2 experienced an unwitnessed fall at 11:00 AM. R2 was found on the floor mat on the left side of the bed; the bedside table was over his bed. The Certified Nursing Assistant (CNA) had checked on him at 10:45 AM. R2 stated he was reaching for something and fell out of his bed. R2 denied hitting his head. Neuro checks were initiated. The physician and family were notified. Factors contributing to the fall included clutter, poor lighting, confusion, recent illness, weakness, gait imbalance, and impaired memory. Interdisciplinary Team (IDT) follow up included ensuring further training of staff to assure all assistive devices were being used. The report did not indicate whether the bed alarm was sounding and/or what assistive devices were not in place. Lab work was requested to rule out infection on encephalopathy.Review of R2's Care Plan for fall risk, dated 09/30/23 in the EMR under the Care Plan tab, revealed a new intervention was added one day after the fall on 06/23/25. A wedge cushion to the left side of the bed was added to the care plan on 06/24/25. 2. Review of the Un-witnessed Fall report completed by Licensed Practical Nurse (LPN) 3, dated 06/28/24 at 2:15 PM, revealed housekeeping staff (person not identified) called nursing due to R2 being found on the floor lying supine with his head on the bottom metal strut of his food tray. Scant blood was observed from a skin tear to his right ankle. R2's incontinence brief contained a large bowel movement that was across from the resident, close to his dresser. Minor bruising was noted to R2's left hand and arm. When rolled R2's shoulder had redness as well as his left buttock. R2's bed was in a low position. R2 stated he was looking for his radio and thought he heard music and that his radio was under his bed. R2 stated he had a persistent headache from the fall. Injuries included an abrasion to his left scapula, bruise to the back of his left hand, burn to his left elbow, and skin tear to his right inner ankle. Neurochecks were completed. Factors included: a urinary tract infection (UTI), gait imbalance, and impaired memory. IDT follow up revealed a wedge would be added while R2 was in bed and staff would be reminded to check the bed alarm.Review of R2's Care Plan for fall risk, dated 09/30/23 in the EMR under the Care Plan tab, revealed the wedge cushion was added to the care plan on 06/24/25 and should have been in place at the time this fall occurred.During an interview on 07/31/25 at 5:13 PM, LPN3 stated this fall occurred after lunch and he was called to the room by a housekeeper. LPN3 stated R2's fall mat was not in place on the floor next to the bed and R2 was lying on the floor. LPN3 stated the overbed table and floor mat could not be used concurrently as the overbed table was unstable when placed on top of the mat. LPN3 verified the fall mats were to be placed on the floor on both sides of the bed. LPN3 stated R2 had been given milk of magnesia prior to the fall due to not having a bowel movement for a few days. LPN3 stated the wedge cushion was not in place and the bed alarm had not been sounding. LPN3 stated, A lot of times alarms do not work. LPN3 stated if the alarm pad was not placed on the mattress at a 90-degree angle and with the toe and head ends lined up correctly, the alarms did not work. He further stated if the alarm had not been turned on, it also would not work. LPN3 stated he typically noted in the Incident Report what interventions were in place and whether or not they were working.No new interventions were added after this fall.3. Review of the Un-witnessed Fall report completed by Registered Nurse (RN) 4, dated 07/23/25, provided by the facility, revealed R2 was found by CNA5, lying on the floor with his head and torso on the floor and his right leg between the mattress and bed frame. The bed was not in a lowered position and the fall mat was not in place. R2 stated he hit the back of his head and his head and right and left shoulders hurt. R2 stated he was trying to reach something. R2 was assessed. When using the Hoyer to get him up he stated, ow but could not identify the source of the pain. R2 had injuries including abrasion to his right buttock, and face. R2 reported pain at a level seven (out of 10 on a scale of 1 to 10). R2 was transported to the emergency room (ER). redness to the left lower cheekbone. Predisposing factors included furniture, confusion, weakness, and impaired memory. A subsequent statement by the Director of Nursing (DON) was added to the Un-witnessed Fall report on 07/23/25 and revealed the DON went to R2's room to further assess. R2 was lying on the window side of his bed; his head, torso and buttock were on the floor; his leg was between the bed frame and floor. The fall mat was folded at the end of the couch, and his positioning wedge was on the couch. His tray table was still above his bed. R2's door side floor mat was in place; the alarm was not sounding. R2 stated ow when the Hoyer lift was used and again when lying in bed when staff moved his left arm and when staff palpated his scalp. R2 was sent to the ER. Neuro checks were completed. IDT follow up documented CNA5 did not know R2 had safety equipment that should be used. Education was provided.Review of the Emergency Department Provider Note, dated 07/23/25 in the EMR under the Misc [miscellaneous] tab, revealed face on ground but rest of body in bed. Catheter bag started to get bloody after the fall. Small hematoma posterior head and bruising on back . small amount of red urine in the Foley tubing, this is a suprapubic Foley. R2 was sent back to the facility on [DATE]. During an interview on 07/30/25 at 4:44 PM, RN4 stated on 07/23/25 she returned from lunch and was notified by her CNA that R2 was on the floor. RN4 stated R2 had hit his head and was lying with his leg on the bed. RN4 stated R2 reported his back hurt, and he was in pain. RN4 stated the DON came and helped her assess R2 and get him off the floor. RN4 stated R2 was in a bad position when found on the floor and she was worried about a brain bleed, so he was sent to the hospital. RN4 stated the fall mat was not in place on the side of the floor where he landed and the wedge was not in place; the fall alarm was not sounding. During an interview on 08/01/25 at 10:42 AM, CNA5 stated she had been employed by the facility for a year and three months. CNA5 stated she found R2 after the fall on 07/23/25. She stated she walked in to check on R2 and he was lying on the floor on the left side of bed. R2 stated he had reached for something. CNA5 stated R2's leg was on the bed, but his head and torso were on the floor. CNA5 stated the fall mat was not in place because the overbed table was in place and the mat and table could not be utilized at the same time due to the table being unstable on top of the mat. CNA5 stated R2's lunch tray was on the overbed table at the time the fall occurred. CNA5 stated the fall alarm was not sounding, and the wedge was not in place. CNA5 stated a nurse had talked to her after the fall to make sure to check the CNA Kardex and implement interventions per the Kardex. CNA5 stated she had seen the wedge in the room but did not know which side of the bed it was supposed to go. During an interview on 07/30/25 at 1:48 PM, Certified Occupational Therapy Assistant (COTA) 1 reviewed service records for R2 and stated the last time he was evaluated by therapy was on 04/15/25 and at that time he was not picked up by therapy due to his abilities remaining the same.During an interview on 08/01/25 at 1:54 PM, the DON stated the nurses should identify if interventions were in place when R2 experienced his falls and this should be documented on the Un-witnessed Fall reports. The DON stated she had been in her position for a month but had identified the lack of documentation regarding the fall reports being problematic. The DON stated she was not aware of the inability to place the floor mat and have the overbed table in place at the same times as reported by staff to the surveyor. The DON stated she had not identified any patterns regarding the falls such as the care planned interventions not being in place. The DON verified she had witnessed on the 07/23/25 fall that the bed was at regular height, the mat was not on the floor on the left side, the alarm was not sounding, and the wedge was not in place. The DON stated she had discussed with CNA5 putting bedside table on the right side so staff could keep the mat and wedge on the left side/window side.

Based on record review and interview, the facility failed to designate one or more qualified individuals as Infection Preventionists (IPs) who are responsible for the Infection Prevention and Control Program (IPCP) and who physically work onsite at the facility at least part-time. Failure to designate one or more qualified onsite IPs to oversee the implementation and monitoring of infection prevention practices has the potential to result in the inadequate identification, prevention, and control of infections within the facility, placing all 58 residents at increased risk for the transmission of communicable diseases and healthcare-associated infections.Findings include:Review of the facility's undated [Name of Facility] Employee Listing revealed the facility did not have a designated IP who worked on-site at least part-time.During an interview on 08/01/25 at 9:21 AM, the IP who worked at the facility stated that she worked remotely and assisted the facility with its infection control and prevention program and did not spend any time on-site at the facility. She said that she had been assisting the facility since 04/25. She indicated the facility hired an IP, but they quit a few weeks ago, and that no one in the facility was certified or qualified as an IP.During an interview on 08/01/25 at 1:15 PM, the Administrator stated that Registered Nurse (RN) 7 was the facility's previous IP who started in 08/24; however, she was in the process of completing the training, and that the previous Director of Nursing (PDON) oversaw the IPCP. She indicated that RN7 quit on 07/11/25, that the PDON quit on 05/23/25, and that the facility had been actively recruiting for an IP since 07/11/25. At 1:24 PM, the Administrator provided a copy of the PDON's infection preventionist's training certificate. The Administrator stated that RN7 sent her an email dated 06/26/25 indicating that she had completed the infection prevention modules through the Centers for Disease Control; however, she did not have a copy of RN7's completion certificate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure food temperatures were palatable for two out of 20 sample residents (Resident (R) 9 and R43) reviewed for palatability. This created the potential for meal dissatisfaction, decreased intake, and weight loss.Findings include:Review of the facility's policy titled, Dining/Meal Service, dated 2023, revealed Food will be at the proper temperature. to meet each individual's needs and desires.1. Review of R9's admission Record (Face Sheet) located under the Profile tab in the electronic medical record (EMR) revealed R9 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/25, located under the MDS tab in the EMR, revealed R9 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9 was cognitively intact.During an interview on 07/28/25 at 12:05 PM, R9 stated that the food arrived from the kitchen lukewarm at best, or it was cold. R9 stated he was so tired of it. R9 stated the facility told the residents that they were working on it, but it was not getting any better. R9 reported the staff said that they do not have the right equipment to keep the types of plates they have warm and in the meantime their answer was to get your food reheated. R9 stated if he got the food reheated it could be a long wait to get it and by the time they got it back to him, it was cold again. R9 stated he bought his own microwave so he could reheat his food, but the staff did not allow him to have a microwave in his room.2. Review of R43's admission Record, located under the Profile tab in the EMR, revealed R43 admitted to the facility on [DATE]. Review of the annual MDS with an ARD of 06/03/25, located under the MDS tab in the EMR, revealed R43 had a BIMS score of 15 out of 15 which indicated R43 was cognitively intact. During an interview on 07/28/25 at 4:30 PM, R43 stated that the food arrived cold a lot of the time.3. Review of the Week Three Spring/Summer Menu, provided by the facility, revealed lunch on 07/30/25 consisted of orange chicken, fried rice, stir fry vegetables, a fortune cookie, and ice cream. The alternate was crispy shrimp Caesar salad, garlic bread, fruit, and ice cream.On 07/30/25 at 11:17 AM, food temperatures were taken immediately prior to meal service. The steamtable pans of hot foods had been placed into a hot box (heated compartment to keep food warm); the steamtable was not being used to hold food during meal service. The Food Service Manager (FSM) stated there were not that many residents and it took too much time to set up the steam table. The hot box was initially at a temperature of 173 degrees per external thermometer. The FSM verified serving temperatures for hot foods should be a minimum of 135 degrees Fahrenheit (F). Observation revealed food temperatures prior to meal service were:-Orange chicken 168 degrees F-Shrimp 147 degrees F-Fried rice 168 degrees F-Stir fried vegetables 166 degrees F-Mashed potatoes 165 degrees F-Mechanical chicken 181 degrees [NAME] 07/30/25, residents' meals for the 2100 hall (for approximately 15 residents who ate in their rooms) were dished up and placed into the uninsulated stainless steel food cart. Meal service for the 2100 hall cart began at 11:26 AM and continued to 11:40 AM. The temperature of the hot box had dropped to 166 degrees F per the external thermometer at 11:26 AM. The door had been left open when placing pans into the hot box and during the measurement of food temperatures. The FSM stated he had gotten approval for purchase of induction plates which would ensure food temperatures were hot when residents received their meals; however, they had not been purchased yet. On 07/30/25 at 11:30 AM, the external temperature of the hot box had dropped to 152 degrees; the door had been open and the pans with food were uncovered. The FSM stated he tried to keep the hot box as hot as possible with a goal of around 180 degrees F. The FSM stated he would like residents' hot foods to be between 140 - 145 degrees F when they received their meals and cold food should be 35 degrees F. Foods were dished up from the steam table pans, in the hot box, onto trays for the residents. There was no plate warmer utilized to keep plates hot. There were no insulated bases or lids for keeping the plates hot after meals were dished up. A thin clear plastic lid with a hole in the top of it (the size of a quarter) was placed on top of resident's plates. Residents' trays were placed into an uninsulated stainless-steel cart for transportation to the 2100 hall.On 07/30/25 at 11:40 AM, the cart for the 2100 hall was full and two test trays (main selection and alternate selection) were placed onto the cart after all the residents' meals had been dished up. The cart was wheeled out of the kitchen and taken to the 2100 hall. Observation revealed all residents' meal trays were served on the 2100 hall at 11:50 AM and the test trays were evaluated by the FSM and the surveyor at this time. Temperatures of the main selection (orange chicken, rice, and stir-fried vegetables were:-Orange chicken 112 degrees F. It was lukewarm.-Stir fried rice 113 degrees F. It was lukewarm.Temperature of the alternate selection (shrimp Caesar salad) was:-Shrimp 101 degrees F. It was slightly warm. The FSM verified that these temperatures were not hot enough. In addition, there were two pitchers of lemonade on a cart that were not under any means to keep them cold. The temperature of a glass of lemonade was taken and it was 53 degrees F and was cool but not cold. The FSM stated the lemonade should be colder. During an interview on 07/30/25 at 12:15 PM, the FSM stated the large stainless steel food carts were not insulated and foods did not hold their temperatures once dished up and placed into the carts. The FSM stated he had been working to get approval to upgrade the equipment to ensure residents' foods remained hot. During an interview on 07/31/25 at 4:15 PM, the Registered Dietitian (RD) stated residents' foods should be at least 125 - 130 degrees F when they received their meals. The RD stated the cold foods should not be over 50 degrees F.

Based on observation, interviews, and policy review, the facility failed to ensure expired medications were not available for use in one of one medication room reviewed for medication storage and labeling. Failure to ensure expired medications were not available for use had the potential to result in residents receiving expired medications, which may be ineffective or harmful, leading to adverse drug reactions, diminished therapeutic outcomes, and increased risk of complications or hospitalization.Findings include:Review of the facility's policy titled, Pharmacy Services, last reviewed on 02/25, revealed that the Pharmacist shall be responsible for reviewing all medications in the facility for expiration dates. Removal of discontinued or expired drugs from use as indicated at least every thirty (30) days.Review of the facility's policy titled, Floor Stock Medication, last reviewed on 02/25, revealed certain medications shall be available within the facility for occasional use where the pharmacy source was not immediately available. The Pharmacist will be responsible for the replacement and disposal of expired medications.Observations on 07/29/25 at 8:24 AM in the presence of Registered Nurse (RN) 1 revealed the following expired medications were available for use in the medication storage room:-Six urinary pain relief 95 milligram (mg) tabs that expired on 06/25.-Three fleet laxative enemas that expired on 05/25.-One fleet laxative enema that expired on 02/25.-Three bottles of 3% hydrogen peroxide that expired on 09/24.During an interview on 07/26/25 at 8:30 AM, RN1 acknowledged that the expired medications were available for use. RN1 stated that the pharmacy consultant regularly checked for expired medications and that central supply staff were in the medication room this morning; however, she could not say how often central supply staff checked for expired medications. RN1 stated that expired medications should not be available for use.During an interview on 07/29/25 at 8:55 AM, the Pharmacist acknowledged the expired medications and stated that she manually tracked any medication with a pharmacy label and that central supply staff reviewed all other medications.During an interview on 07/29/25 at 9:01 AM, the Director of Nursing (DON), in the presence of the Administrator, stated that expired medications should not be available for use. She said that she was not sure who was responsible for monitoring the medications and would need to follow up. At 11:15 AM, the DON returned and stated that all nurses were responsible for checking the medication rooms for expired medications.

Based on observation, record review, interview, and policy review, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBPs) for one of four residents (Resident (R) 8) reviewed for Transmission-Based Precautions of 20 sample residents. Failure to follow EBPs increases the potential for cross-contamination and transmission of infections to both staff and residents.Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions last reviewed on 03/24, revealed It is the procedure of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms [MDROs]. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ ventilator tubes) even if the resident is not known to be infected or colonized with an MDRO. ii. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. High-contact resident care activities include a. Dressing; b. Bathing; c. Transferring; d. Providing hygiene; e. Changing linens; f. Changing briefs or assisting with toileting; g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ ventilator tubes; and Wound care: any skin opening requiring a dressing.Findings include:Review of the facility's admission Record (Face Sheet), located under the Profile tab in the electronic medical record (EMR), revealed that the facility initially admitted R8 on 05/08/24. His pertinent diagnoses included urinary retention and benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/25, located under the MDS tab in the EMR, revealed R8 had a Brief Interview for Status (BIMS) score of seven out of 15, which indicated R8 had severe cognitive impairment. R8 required total dependence of staff for activities of daily living and had an indwelling catheter related to a diagnosis of BPH. Further review revealed R8 had a urinary tract infection within the last 30 days from the ARD.Review of R8's care plan, last revised on 02/26/25, located under the Care Plan tab in the EMR, revealed R8 was at risk for infection with multidrug-resistant organisms. R8 was placed on EPB to decrease the risk of active infection due to his indwelling catheter. The care plan directed staff to use gloves and a gown for any high contact care activities, such as, but not limited to, dressing, bathing, transfers, hygiene, linens changes, toileting, device care, wound care, etc.During an observation on 07/29/25 at 12:27 PM Certified Nursing Assistant (CNA) 10 assisted R8 back to their room from the dining room. At which time, CNA10 closed the door to the room. At 12:30 PM, CNA10 exited R8's room carrying a clear plastic garbage bag with a white blanket inside. Upon entering R8's room, observations revealed R8 lying in bed with no shirt on. CNA10 properly secured R8's catheter tubing, and the catheter bag was hanging on the side of the bed, below the level of the bladder, and placed in a privacy bag. Observations revealed no evidence that CNA10 disposed of an isolation gown in R8's room.Observation of R8's room on 07/30/25 at 12:40 PM with CNA10 revealed the resident had personal protective equipment (PPE) located inside the closet located in the bathroom, along with a sign indicating EBP. During an interview on 07/29/25 at 2:55 PM, CNA10 reported that she had worked at the facility as an agency CNA for the past three weeks and had cared for R8 for one week. She explained that R8 required one-person assistance with activities of daily living. She stated that day, she helped R8 return to his room after lunch, assisted him into bed, and covered him with a blanket. She stated she then placed the blanket R8 had used during lunch into a bag and took it to the dirty utility room. CNA10 acknowledged that she did not wear PPE while assisting R8 because she did not perform catheter care or empty his catheter bag.During a follow-up interview on 07/30/25 at 1:33 PM, CNA10 reviewed R8's care plan and she confirmed that staff were required to wear gowns and gloves during all high-contact care, including dressing, transfers, and bathing; essentially any care provided in the resident's room, except when delivering a tray without resident contact. She admitted that she should have worn a gown and gloves while assisting R8 on 07/29/25.During an interview on 08/01/25 at 9:21 AM, the Infection Preventionist (IP) for a sister facility, who was assisting the facility because they did not currently have a qualified IP (cross-referenceF882), stated that for residents on EBP, the facility required staff to don (put on) gloves and a gown when they provide any high contact care. She said that the staff kept PPE supplies in the closet located in the bathrooms of residents on EBPs. She stated that the expectation was for staff to don gloves and a gown when providing any high-contact care and when handling linens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure that two (Residents (R)36 and R39) reviewed for abuse out of 23 sampled residents were free from resident to resident abuse.
Findings include:
1.Review of R39's Profile tab of the EMR revealed he was admitted to the facility on [DATE] with diagnosis that included vascular dementia and cerebrovascular disease.
Review of R39's quarterly MDS with an assessment reference date (ARD) of 06/12/24 located in the MDS tab of the EMR, revealed a BIMS score of 14 out of 15, indicating intact cognition.
Review of R55's Profile tab of the EMR revealed he was admitted to the facility on [DATE] with a diagnosis that included Alzheimer's, dementia, and delirium. R55 was discharged to the hospital on [DATE] and did not return to the facility.
Review of R55's MDS with an ARD of 04/18/24 and located in the MDS tab of the EMR, revealed a BIMS score of zero out of 15, indicating severely impaired cognition.
Review of the facility investigation summary titled, Investigation into Allegations of Resident Abuse dated 03/08/24 provided by the Administrator, revealed a resident-to-resident allegation of physical abuse was reported on 03/04/24 involving R39 and R55. R39 reported that R55 had entered his room, accused R39 of stealing his truck and caused skin abrasions to his arm.
During an interview on 08/13/24 at 8:44 AM R39 stated he didn't remember much about the incident between him and R55 other than R55 came into his room and tried to bother him. R39 stated that staff took care of everything, and nobody bothered him anymore. R39 stated that he was not hurt.
During an interview on 08/13/24 at 10:00 AM Certified Nursing Assistant (CNA) 4 stated that he went in R39's room on 03/08/24 and R39 was laying on his back and holding R55 away from him, yelling to get R55 off him. CNA4 stated that he immediately calmed R55 down and escorted him out of the room. CNA4 stated the incident was immediately reported to the Administrator. CNA4 stated that R55 was known to wander, however was never aggressive before this incident. CNA4 stated that 15-minute checks were initiated on R55. There were no other incidents of resident to resident altercations from R55 until a month later (04/08/24).
During an interview on 08/16/24 at 2:38 PM the Director of Nursing Services (DNS) confirmed the above incident with R55 and R39. She further stated that they have zero tolerance for abuse and they want all staff to protect the residents.
2. Review of the undated admission Record provided by the facility revealed R36 was admitted to the facility on [DATE] with diagnoses including aphasia (language disorder affecting the ability to communicate) cerebral infarction (stroke) with hemiplegia (paralysis to one side of the body) and hemiparesis (weakness on one side of the body).
Review of the quarterly MDS with an ARD of 06/23/23 in the EMR under the MDS tab showed R36 was moderately impaired in cognition.
Review of the Investigation into Allegation of Resident Abuse initiated on 04/18/24, provided by the facility showed a resident-to-resident incident of abuse occurred on 04/18/24 at approximately 11:30 AM between R55 (aggressor) and R36 (victim). R36 was in the hallway on 04/18/24 when R55 grabbed R36's left arm and pulled it down and would not let go. R36 vocalized pain. The incident was witnessed and was documented as being unprovoked on the part of R36. R55 was redirected to his room to calm down. A police report was filed and R55's family member was notified. R55 was then emergently discharged from the facility to the hospital and did not return. X-rays were taken of R36's arm and were negative for physical injury.
During an interview on 08/12/24 at 2:05 PM, R36 was interviewed by asking yes/no questions to which he responded by shaking his head yes or no. R36 shook his head up and down showing yes as the answer to the question of whether he had negative interactions with other residents.
During a subsequent interview on 08/15/24 at 11:46 AM, R36 shook his head yes when asked if his previous negative resident interaction involved R55 grabbing and pulling his arm on 04/18/24. R36 shook his head yes when asked if it caused pain at the time the incident occurred, however denied any lasting injury by shaking his head no.
During an interview on 08/14/24 at 8:28 AM, CNA7 revealed on 04/18/24 around lunch time she witnessed R55 grab R36's arm in the hallway. R55 was removed from the area and staff called 911 (emergency services).
During an interview on 08/14/24 at 11:19 AM, the DNS stated R55's family had not been forthcoming when she screened R55 for admission to the facility. The DNS stated the family denied any aggression or assaultive behavior then later she found out R55's family had been dealing with it for a couple of years. The DNS stated, He [R55] hurt [R36]. The DNS stated there was only one previous incident of physical aggression by R55 towards another resident (R39) that occurred a month prior.
Review of the facility policy tilted Freedom from Resident Abuse, Neglect, Mistreatment and Exploitation revised 06/2021 revealed, Each resident has a right to be free from verbal, sexual, physical, and mental abuse; neglect; exploitation; mistreatment, including injuries of unknown source, misappropriation of resident property, involuntary seclusion, and crime against a resident. Further, each resident at the [Name of Facility] will be treated with dignity and respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to notify the Ombudsman for one (Resident (R)24) of one resident reviewed for discharge. Specifically, the Ombudsman was never contacted and informed of R24's discharge plan.
Findings include:
Review of the facility's policy titled, Involuntary Transfers and Discharges, dated February 2023, documented no information related to notification of the Ombudsman of a resident's discharge to the Hospital in the policy.
Review of R24's Face Sheet, found in the Electronic Medical Record (EMR), under the Profile tab documented an admission date of 04/04/24, with medical diagnoses that included history of Urinary Tract Infections, Benign Prostatic Hyperplasia (an enlarged prostate gland, which can obstruct the outflow of urine), and Alzheimer's Disease.
Review of R24's quarterly Minimum Data Set (MDS), found in the EMR under the MDS tab, with an assessment reference date (ARD) of 04/04/24, documented R24 had severe cognitive impairment.
Review of R24's Progress Note, found in the EMR under the Progress Note tab, dated 07/03/24, documented R24 was sent to the Emergency Department via ambulance.
Review of all Social Services Notes, found in the EMR under the Miscellaneous tab did not document any information that the Ombudsman was notified of R24's discharge to the hospital on [DATE].
During an interview on 08/15/24 at 11:12 AM, the Social Worker said during her orientation at the facility, the other Social Worker provided her with the facility discharge forms and the facility policy on Transfer/Discharge. She said she was not aware she was to send notification to the Ombudsman when a resident was transferred to the hospital and therefore, did not notify the Ombudsman.
During an interview on 08/15/24 at 9:42 AM, the Administrator said the Social Workers were responsible for notification of the Ombudsman when a resident was transferred to the Hospital. She said there was no notification of R24's discharge to the Ombudsman Office. The Administrator confirmed the current facility policy did not address the need to notify the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, and facility policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) assistance received services for one of three residents (Resident (R)23) reviewed for incontinence care in a total sample of 23 residents. This failure placed residents at risk for diminished self-worth, self-esteem, feelings of embarrassment, and/or medical issues.
Findings include:
Review of the facility's undated policy titled, Resident Care Guidelines documented .Noc Cares: Changing resident clothing as appropriate, washing face and hands if applicable., toileting/peri care as appropriate .
Review of the facility's policy titled, Foley Cather Maintenance, dated 2/2023. documented .
Empty bag into receptacle being careful not to contaminate spigot. Wipe after .
Review of the facility's Investigation into Allegation of Resident Abuse report provided by the facility, dated 07/15/24 revealed the following: On 07/09/24 at approximately 8:00 AM, the Abuse Response Team (ART) was notified that Certified Nursing Assistant (CNA) 2 and CNA3 reported that on 07/09/24 at 6:20 AM, they observed R23 with dried bowel on his hands, cheek, neck, his brief was adhered to his skin by bowel, and they had to carefully remove his brief to not irritate his skin. They reported that CNA4 reported that CNA5 had provided cares to R23 at 5:15 AM.
Review of R23's undated Face Sheet, found in the electronic medical record (EMR) under the Profile tab, documented R23 was admitted to the facility on [DATE] with diagnoses including dementia, kidney disease, neurogenic bladder (a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), and uropathy (blockage in the urinary tract).
Review of R23's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/02/24, found in the EMR under the Assessment tab, documented R23 had moderately impaired cognition, was incontinent of bowel function, had an indwelling catheter, and was dependent on staff for personal care and bowel incontinence.
Review of R23's Care Plan, found in the EMR under the Care Plan tab, dated 07/03/24, documented R23 was incontinent of bowel function. Interventions included toilet upon rising, before or after meals, at bedtime, and on my request; every four hours at night if I am awake, monitor for incontinence of bowels, and use of adult incontinent products (briefs/pull ups).
Review of R23's undated Kardex, provided by the Director of Nurses Services (DNS) stated two staff were to be present when providing cares to R23 on 07/08/24.
Review of ADL documentation, provided by the DNS, dated 7/08/24, revealed R23 received indwelling catheter care and had no bowel movement.
During an interview on 08/15/24 at 1:57 PM, the Director of Nursing Services (DNS) said when one unit was busy, a CNA from another unit would obtain the information from the CNAs on the unit and document the information for them. She said a CNA from another unit documented the information on R23 that night, which documented indwelling catheter care was given and R23 had no bowel movement. The DNS said although the CNAs were to document in real time, she said the information was documented prior to last rounds.
During an interview on 08/12/24 at 12:28 PM, R23 had no recollection of any issues with care received at the facility and had no recall of the incident.
During an interview on 08/13/24 at 6:15 PM, CNA4 said during the night shift, there is one CNA assigned to each unit. He said the CNA on the Caribou unit and Sawtooth units help each other during rounds. CNA4 said at approximately 2:00 AM, during rounds, R23 had no bowel movement. CNA4 said indwelling catheters are emptied during last rounds. CNA4 said during the night shift on 07/08/24 to 07/09/24 he and CNA5 started last rounds at 4:00 AM. He said he and CNA5 were doing rounds together in the resident rooms. He said they completed a check and change on a resident, and after coming out of the room, another resident had his call light on. CNA4 said he answered the call light, could not recall what the resident wanted, and assisted the resident. He said he was not sure how long he was in the resident's room. CNA4 said after coming out of the room, at approximately 5:15 AM, CNA5 said told him that both R23 and the resident in the next room were clean and their catheter bags had been emptied. He said this was at approximately 5:15 AM. He said he gave this information to the two CNAs assigned to the day shift. CNA4 said usually he and the CNA assigned on the other unit completed personal care on residents together. CNA4 said he did not check and provide any care to R23 during last rounds.
During an interview on 08/13/24 at 3:17 PM with CNA2 and on 08/13/24 at 4:00 PM with CNA3, they said R23 was confused, was incontinent of bowel function, and had an indwelling catheter. CNA2 said on 07/09/24, she and CNA3 received report from CNA4 during the shift change hand off at 6:00 AM. CNA4 told them that CNA5 had provided care to R23 at 5:15 AM that included emptying his indwelling catheter bag, perineal care, and a clean brief. CNA2 and CNA3 said at approximately 6:20 AM, they entered R23's room, and he had dried feces on his sweater, legs, peri area, face, back, hair, and bed linens. CNA3 said the stool on R23 had not just occurred and had been on R23 for several hours. R23 also had dried feces on his mouth, chest, stomach, and caked stool on the catheter tubing and around the tubing insertion site at his penis, and his testicles were reddened from sitting in stool. CNA2 said it was difficult to remove the stool because the stool was stuck to his brief and skin. CNA2 said she asked him if anyone had cleaned him, and he did not answer. CNA2 said there was dried stool on the catheter tubing, and around his penis at the catheter insertion site. CNA3 said she was shocked at R23's condition. CNA3 said R23 appeared to have had the stool on him for several hours as all of the stool was dried and caked into his brief and skin. She said she and CNA3 used a lot of peri cleanser and warm water and soap to carefully take the brief off of R23 and provide personal care. CNA2 said R23 occasionally groaned during care, which was not unusual. CNA3 said they had to slowly and carefully remove R23's brief to provide care and gave R23 a complete bed bath that took 45 minutes. CNA2 said R23 had 1000 cubic centimeters (ccs) in his indwelling catheter bag, which she was told had been emptied at 5:15 AM. CNA2 said at the completion of care, at 8:00 AM, she and CNA3 reported the incident to the day nurse and the Nursing Manager.
During an interview on 08/14/24 at 11:09 AM, Registered Nurse (RN) 1 said on 07/09/24, she came in to do the treatment to R23's right groin, which she usually completed after personal care. She said when she went into the room on 07/09/24, CNA2 and CNA3 were in the room providing personal care to R23. RN1 said R24 had a moderate amount of dried feces on his hands, face, and body. She said after the CNAs provided personal care, she completed the treatment to R23's right groin and there was no change in his excoriation. RN1 said she completed a skin assessment on R23 and there were no new skin concerns.
Review of the facility's Investigation into Allegation of Abuse report further revealed the following information regarding the interview with CNA5 on 07/12/24. When CNA5 was asked if she provided care to R23, she said she was assigned to the other unit that night and could not recall that resident. She stated she recalled emptying urinary catheters on R23's unit, which she reported she completed. CNA5 said she and CNA4 completed cares for residents who needed checks and changes in pairs.
The Surveyor was not able to interview CNA5 as the telephone number provided by the facility and the Agency was no longer
CNA5's telephone number.
Further review of the Investigation into Allegation of Resident Abuse report and interview with the DNS on 08/15/24 at 1:57 PM, revealed the Abuse Response Team, which consists of the Administrator, herself, the RN Manager, and Social Workers reviewed R23's clinical record and interviewed the staff, who provided care to R23 during the night shift and day shifts. The DNS said at least two rounds were to be completed during the night shift. The DNS said based on the day shift CNAs observations at 6:20 AM, R23's bowel movement had occurred prior to 5:15 AM, as the stool was dried. The DNS stated the Abuse Response Team validated neglect related to R23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure that one of two residents reviewed for insulin use (Resident (R)16) received nursing care and services to address hypoglycemia (low blood sugar) incidents. Specifically, there were instances in which R16's low blood sugars were either not rechecked or documented, and the Physician was not contacted according to the facility's hypoglycemia protocol. This created the potential for R16 to experience untreated hypoglycemia incidents putting her at risk for negative outcomes such as organ damage, coma, or death.
Findings include:
Review of the facility's policy titled, Hypoglycemia, dated February 2023 and provided by the facility stated hypoglycemia occurred when blood glucose (BG) was at or below 80.
Review of the Hypoglycemia Treatment Reference, dated February 2023 and provided by the facility, directed in the event of a BG less than 70 without symptoms of hypoglycemia, that nursing staff 1. Give 15 grams (gm) of carbohydrate such as four ounces of orange juice, 2. Check BG in 15 minutes 3. Hold diabetic medications, and 4. Notify the Physician. For finger stick blood sugar (FSBS) levels less than 70, nursing staff were directed to document interventions in the nurses' note section of the medical record, and FSBS levels and diabetic medications were to be reviewed with the physician.
Review of the undated admission Record, provided by the facility, revealed R16 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus.
Review of the Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/22/24 located in the Electronic Medical Record (EMR) under the MDS tab revealed R16's cognition was intact. R16 received insulin six out of seven days during the assessment period.
Review of current Physician's Orders, provided by the facility showed that R16 was prescribed Lantus (insulin glargine), inject 26 units subcutaneously (beneath or under the skin) two times a day for diabetes mellitus, hold for blood sugar (BS) of less than 115, initiated on 08/08/24. Prior to 08/08/24, the order was for 28 units of Lantus insulin to be injected twice a day.
Review of the Care Plan, dated 04/13/23 and provided by the facility, showed a problem of disease diagnoses which included diabetes mellitus. The goal in pertinent part was for R16 to have no ill effects from BG levels. Interventions in pertinent part were monitoring BG per physician's orders, following hypoglycemia protocols, and notifying the physician of any hypoglycemia events.
During an interview on 08/12/24 at 1:51 PM, R16 stated she was administered insulin daily. R16 stated she had been experiencing low blood sugar incidents and one day her BS, was pretty low. R16 stated she was given orange juice for low BS. R16 stated, I can tell if my blood sugar is low, I do not feel good.
Review of the Medication Administration Record (MAR) for July 2023 and provided by the facility showed a morning BG level of 64 in the morning of 07/04/24. The Lantus insulin dose of 28 units was held per physician's orders.
Review of Nurses' Orders - Administration Notes, dated 07/04/24 at 7:35 AM stated, Lantus Subcutaneous Solution, Inject 28 unit subcutaneously two times a day for DM Hold for BS < 115 . In the morning for diabetes If BG <80 mg/dl refer to the hypoglycemia reference guide . Asymptomatic, breakfast in front of patient with juice and sweetened coffee . There were no additional notes showing R16's BG was rechecked after eating breakfast or contacting the physician. Registered Nurse (RN)6 documented the Administration Notes.
During an interview on 08/14/24 at 1:58 PM, RN6 stated if a resident's BG was low, she rechecked it after providing a snack or juice. RN6 stated she assessed the resident for signs and symptoms of hypoglycemia. RN6 stated she looked at the Physician's Orders for what to do after that. RN 6 stated she typically documented rechecking the BG under Vital Signs. The surveyor and RN 6 reviewed R16's BG in the EMR and there was no additional BG level documented on 07/04/24 in the morning after the BG level of 64 at 7:35 AM under Vital signs or in Nurses' Notes. RN6 stated R16's BG levels could be erratic and her BG was at times low in the morning. RN6 stated there was no documentation of R16's BG being rechecked and she stated she had not contacted the Physician regarding the BG of 64.
Review of R16's MAR for August 2024 and provided by the facility showed a morning BG level of 58 in the morning of 08/04/24. The Lantus insulin dose of 28 units was held per physician's orders
Review of Nurses' Orders - Administration Notes, dated 08/04/24 at 8:40 AM stated, Lantus Subcutaneous Solution, inject 28 unit subcutaneously two times a day for DM, Hold for BS < 115. AM Lantus held secondary to blood sugar of 58, snacks and juice given, recheck blood sugar WNL. There were no additional notes showing the physician was contacted on this date or what Resident 16's BG was when it was rechecked. RN5 documented the Administration Notes.
During an interview on 08/16/24 at 1:42 PM, RN5 stated that she had checked R16's BG on 08/04/24 in the morning and it was low so she held the Lantus and rechecked the BG after R16 had a snack. RN5 and the surveyor reviewed the EMR, including Vital Signs, together and RN5 verified the second BG check was not documented. RN5 stated she was not sure what BG level prompted physician notification but she thought it was 60. The Hypoglycemia policy was reviewed and RN5 stated she had not been aware the threshold for physician notification was a BG of 70. RN5 stated the only symptom R16 exhibited when experiencing low BG was hunger. RN5 stated she had not contacted the physician on 08/04/24 but was educated by the Director of Nursing Services (DNS) that the physician should have been notified.
During an interview on 08/16/24 at 12:26 PM, the DNS stated she came into the facility on Monday (08/5/24) and became aware of R16's BG of 58 on 08/04/24. The DNS stated she put in a secure message on 08/05/24, which went to R16's medical providers and nursing staff that documented R16's low BG of 58 on 08/04/24. The DNS stated the physician subsequently decreased R16's dose of Lantus from 28 units to 26 units twice daily on 08/08/24. The DNS stated she had educated RN5 about contacting the physician when BG levels required it, which was a level below 70.
During an interview on 08/15/24 at 12:05 PM, the RN Manager stated if a resident had a BG below 70, the nurse should give four ounces of orange juice and recheck the BG in ten to 15 minutes. If it was still low, more orange juice should be administered and it should be rechecked in another ten to 15 minutes. The RN Manager stated if it was still low, the nurse should notify the physician. The RN Manager and surveyor reviewed the Hypoglycemia Treatment Reference, dated February 2023 and the RN Manager stated the physician should be notified of a BG less than 70 even if it the resident's BG came back to a normal level after administration of orange juice. The RN Manager stated the nurse should document a second BG check under Vitals in the EMR or it could be put into a progress note. The RN Manager stated the physician contact should be documented in a progress note.
During an interview on 08/16/24 at 12:21 PM, the DNS stated she expected nursing staff to notify the provider if a BG level was below the established parameter of 70, hold the insulin and recheck the BG in 15 minutes. The DNS stated subsequent BG levels should be documented with the actual BG level and it should be done under Vitals or in a Nurse's Note.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The facility's policy and protocols failed to address the duration of antibiotic use and address the prophylactic use of antibiotic medications. One of five residents reviewed for antibiotic medication use (Resident (R)4) failed to be assessed for continued antibiotic medication use by the nursing staff.
Findings include:
Review of the facility's policy titled Antibiotic Stewardship Program, dated February 2023 and provided by the facility stated when a resident was admitted to the facility with an antibiotic medication the Infection Preventionist would be notified. The staff nurse would fill out the Infection Report and Criteria Checklist and put it in the Infection Preventionist Nurse's mailbox. The Infection Preventionist would evaluate the use of the antibiotic using the Infection Report and Criteria Checklist form and would evaluate for adverse reactions. The Infection Preventionist would report the findings during Quality Assurance meeting and Antibiotic Stewardship meetings with the goal of continuous monitoring and reduction of inappropriate antibiotic medication use.
Review of the undated Profile, under the Resident tab of the electronic medical record (EMR) showed R4 was admitted to the facility on [DATE] with diagnoses including a urinary tract infection (UTI).
Review of Physician's Orders, dated 01/04/24 and provided by the facility, showed R4 was admitted with an order for an antibiotic medication, Cephalexin, 250 milligrams (mg) once a day for prophylaxis of recurrent cystitis. There was no end date for the antibiotic medication and R4 continued to take the medication during the survey.
The Infection Report and Criteria Checklist for Re4 was requested; it was not provided.
Review of the undated, 2024 2nd Quarter Summary from QA (Infection Control) from the most recent quarterly Antibiotic Stewardship meeting showed six residents received prophylactic antibiotic medications in April 2024, five residents received prophylactic antibiotic medications in May 2024, and eight residents received prophylactic antibiotic medications in June 2024. No issues were identified under the category of Trending.
Review of the undated Monthly Infection Control tracking provided by the facility showed there were seven residents receiving prophylactic antibiotic medications in July 2024 and seven in August 2024 (out of 54 total residents).
During an interview on 08/15/24 at 2:43 PM, the Director of Nursing Service (DNS) stated she had been acting as the Infection Preventionist (IP) since the previous IP resigned about a month ago. The DNS stated that during the time she had been in charge, she had been out of the facility for three weeks. The DON verified the policy for antibiotic stewardship did not address the duration of antibiotic use as a factor to be evaluated and monitored.
During an interview on 08/16/24 at 12:40 PM, the DNS stated infections were reviewed in daily Quality Assurance (QA) meetings and the facility did tracking and trending to identify patterns. The DNS stated if a resident had a UTI, the facility reviewed the culture and sensitivity report and compared them. The DNS stated the infection control documentation included an overview of infections, maps with location, and summaries per unit with the name of medications prescribed. The DNS stated the type of pathogen had not been tracked by the previous IP; however, this was something she would track to identify trends. The DNS stated there was no Infection Report and Criteria Checklist completed for R4 and verified there was a lack of the IP's evaluation of R4's antibiotic use. The DNS stated the Infection Report and Criteria Checklist corresponded with McGreer's guidance regarding antibiotic use criteria. The DNS stated R4 had been on the prophylactic antibiotic Cephalexin since she was admitted to the facility. The DNS stated two urinalysis labs had been ordered in May 2024 due to R4 having a change in cognition; however, the urinalysis reports in May 2024 did not warrant a follow up Culture and Sensitivity (C & S) report be completed because UTIs were not identified. The DNS stated there were currently seven residents out of a total census of 54 residents that received prophylactic antibiotic medications without stop dates being identified.
During an interview on 08/16/24 at 5:01 PM, the DNS stated she attended the quarterly QAPI and Antibiotic Stewardship meetings, also called the Pharmacy and Therapeutic meeting. The DNS verified the prophylactic antibiotic use of seven to eight residents monthly since June 2024 and showed the surveyor the documentation from the previous two quarters with the monthly prophylactic antibiotic use by resident. The DNS confirmed the resident census from May 2024 through current was about 52 - 54 residents. The DNS stated the facility was within their desired percentage and under their goal for infection rate. The DNS stated the facility did not have any goals or criteria for comparing the rate of prophylactic antibiotic use. The DNS stated she did not view the current prophylactic antibiotic use as problematic and it had not been identified through QAPI or the quarterly Antibiotic Stewardship meetings as a concern.
During an interview regarding the facility's (QAPI) program on 08/16/24 at 3:45 PM, the Administrator stated the prophylactic use of antibiotic medications seemed high and she was planning to discuss the issue with the DNS and the Medical Director.

Based on interview, record review, and policy review, the facility failed to ensure one of three residents (Resident (R)23) reviewed for beneficiary notices out of a total sample of 23 residents received the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage form and/or the Notice of Medicare Non-coverage (NOMNC) form when skilled therapy was being discontinued. R23 had skilled days remaining and planned to remain in the facility. This failure did not allow R23/Representative to decide whether to continue with care that might not be paid for by Medicare and did allow for the option to file an appeal.
Findings include:
Review of the facility's policy titled, Medicare Part A and Part B Notification Process dated 06/17/24 and provided by the facility, stated the NOMNC or SNF/ABN would be delivered to the resident/representative by the Health Information staff at least two days prior to the last covered day. The Health Information staff was responsible for filling out the NOMNC and SNF/ABN forms.
Review of R23's undated admission Record, provided by the facility showed an admission date of 05/25/23 with a primary diagnosis of dementia.
Review of R23's Physician's Orders, dated 30/28/24 and provided by the facility, showed the physician ordered speech therapy, occupational therapy, and physical therapy evaluations and approved plans on this date.
Review of the survey form SNF Beneficiary Notification Review, completed by the facility showed R23 was not issued the NOMNC or SNF/ABN form that advised the cost of skilled services if he desired to continue when Medicare discharged him from skilled services as well as information regarding filing an appeal. The form showed that the start date for Medicare Part A Skilled Services was 03/28/24 and the last covered day was 04/07/24. The form showed R23 was discharged from Medicare Part A Services when benefit days had not been exhausted. The documented rationale for not providing the forms was, .miscommunication/ confusion regarding LCD [last covered day].
During an interview on 08/15/24 at approximately 2:30 PM, the Director of Nursing Services (DNS) stated the facility did not have the SNFABN or the NOMNC forms for R23 corresponding with the discontinuation of therapy on 04/07/24.
During an interview on 08/16/24 at 11:00 AM, the Health Information Specialist stated she received notification, typically from the therapy staff, when residents were being discontinued from Medicare Part A and Part B. The Health Information Specialist stated she prepared the SNF ABN and NOMNC forms and got the pertinent signatures, stating she attempted to give at least a two-day notice prior to the discontinuation of services. The Health Information Specialist stated she had been notified of R23's last covered Medicare day and then was told later the same day that the services for R23 would not end; based on that information, she did not prepare the SNF ABN or NOMNC forms. The Health Information Specialist stated she then learned later that R23's last covered day was on 04/07/24 as originally planned. The Health Information Specialist stated she did not understand at the time that she should have issued the notices even though they would have been late (less than two days prior to discontinuation of services). The Health Information Specialist stated she did not complete either notice (SNF ABN or NOMNC), did not provide the notices notice to R23 or his representative and did not communicate the information verbally to R23 or his Representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to ensure the needs of 1 out of 23 sampled residents (Resident (R)16) were accommodated. R16's call light was not placed within R16's reach. This created the potential for R16's physical, emotional and safety needs to be compromised.
Findings include:
Review of the facility's policy titled, Resident Safety Policy, dated February 2023 and provided by the facility revealed, Call lights should be placed and attached in easy reach of resident at all times .
Review of the undated admission Record provided by the facility revealed R16 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), hemiplegia (paralysis to one side of the body) and hemiparesis (weakness on one side of the body).
Review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/24 in the electronic medical record (EMR) under the MDS tab showed R16's cognition was intact.
Review of the Care Plan, dated 04/03/23 and provided by the facility, showed R16 was at risk for falls due to poor mobility, left sided hemiparesis from a stroke, and dementia. Interventions included:
-Important: Be aware that I am unable to use left arm/leg due to stroke .
-Encourage to utilize my call light to seek staff assist with all transfers and ambulation.
Review of the Facility Reported Incident (FRI) investigation, dated 10/04/23 and provided by the facility, showed Registered Nurse (RN)2 received a text message on 09/27/23 at approximately 11:00 PM from Certified Nursing Assistant (CNA) 10 that CNA10 had forgotten to give R16 her call light back when CNA10 left the facility at the end of her shift. The investigation revealed, RN2 then reported to the resident's room to find the door closed. When she entered, she found R10 maladjusted in the bed at a sideways angle in an attempt to reach her nightstand. R16 made a verbal statement to RN2 she was attempting to reach her call light in her nightstand, but CNA10 had hidden it from her . at 2100 [11:00 PM].
On 08/12/24 at 3:02 PM, the surveyor attempted to interview R16 about the incident that occurred on 09/27/23; however, R16 stated she did not want to talk to the surveyor.
During an interview on 08/13/24 at 3:53 PM, the Administrator and Director of Nursing Services (DNS) stated an investigation had been conducted into the incident in which R16's call light had been placed out of her reach. The Administrator and DNS stated neither of them had been employed by the facility at the time the investigation was conducted (both were hired after the investigation). The Administrator stated the investigation verified that R16's call light had been placed outside of R16's reach by CNA10.
During an interview on 08/14/24 at 12:15 PM, RN2 stated she was the charge nurse on 09/27/23 when the call light incident occurred with R16. RN2 stated CNA10 had worked until around 10:00 PM and at around 10:30 PM, CNA10 had texted her to inform her that R16's call light had been placed in the dresser drawer and was not within R16's reach. RN2 stated she did not see the text message until midnight at which time she immediately went to R16's room. RN2 stated when she arrived R16 was lying in the bed cross ways, shouting Help, help, help. RN2 stated R16 told her CNA10 had hidden her call light. RN2 stated she found the call light in a dresser drawer outside of R16's reach. RN2 stated she called the previous DON and he came to the facility at 2:00 AM to conduct an investigation into the incident. RN2 stated call lights should always be placed within reach of residents.
During an interview on 08/15/24 at 11:06 AM, the Social Worker (SW) stated it was the facility's policy for the call light to always be placed within reach of the resident. The SW stated it was a potential safety issue if the light was not placed within the resident's reach.
During an interview on 08/15/24 at 12:00 PM, the Registered Nurse (RN) Manager stated R16 required staff assistance with activities of daily living (ADLS) such as with repositioning and with transfers. The RN Manager stated R16 required a Hoyer lift (mechanical lift) be used for transferring her.
During an interview on 08/16/24 at 12:19 PM, the DNS stated she had not been employed when the call light incident for R16 occurred. The DNS stated staff should not remove the call light out of a resident's reach due to it being a residents' rights and safety issue.