Every finding on record at Aaron Manor Nursing & Rehabilitation

Based on observations, interviews, and facility policy, the facility failed to ensure proper hand hygiene was performed during food preparation and service. The findings include: Observation and interview in the kitchen with the Dietary Manager on 6/16/26 at 12:27 PM during food preparation and lunch service identified [NAME] #1 removed her gloves and placed on new gloves 2 times without the benefit of hand hygiene prior to placing on the new gloves. The Dietary Manager indicated that she was aware of the issue and immediately instructed [NAME] #1 to wash her hands. Although the Dietary Manger placed a bottle of hands sanitizer immediately behind [NAME] #1, she was observed a third time failing to wash her hands with glove placement. The Dietary Manager indicated that she was having on-going issues with [NAME] #1's hand hygiene adherence to the facility policy further stating she would be speaking directly to the cook following the observation.The facility's Hand Hygiene policy directs, in part that hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table, which indicates before applying and after removing personal protective equipment, including gloves that either soap and water or alcohol-based hand rub is preferred. The policy further directs that the use of gloves does not replace hand hygiene, and that if the staff's task requires gloves, they must perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observations, review of the clinical record, facility policy and interviews for 3 of 10 sampled residents (Resident #3, Resident #9 and Resident #39) reviewed for dining, the facility failed to provide a dignified dining experience and for 1 of 2 residents (Resident #8) reviewed for an indwelling urinary catheter, the facility failed to provide a privacy cover for the drainage bag. The findings include:1 A. Resident #3's diagnoses included dysphagia (swallowing problems), vascular dementia and hemiplegia (weakness) following a stroke on the left non-dominant side.The annual Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment and required total staff assistance with eating, bed mobility, and transfer.The Resident Care Plan dated 3/28/26 identified a problem with nutritional status, mechanically altered diet, assistance with meals as needed, weight loss, risk for malnutrition, and had oral pharyngeal dysphagia. Interventions included regular diet with puree texture, thin liquid consistency, feed only when alert, required 1:1 feeding, caregivers provide small bites, slow pace, alternate liquids and solids, and check/clear mouth at the end of meal.A physician's order dated 5/24/26 directed regular diet, puree texture, thin liquid consistency, feed only when alert.B. Resident #9's diagnosis included vascular dementia, palliative care, and stroke.The significant change Minimum Data Set assessment dated [DATE] identified Resident #9 had a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment and required total staff assistance with eating, bed mobility, and transfer.The Resident Care Plan dated 4/8/26 identified a significant change for hospice care, and at risk for malnutrition. Interventions included mechanically altered diet, regular puree texture with nectar consistency, and feeding assistance.A physician's order dated 4/27/26 directed a regular diet puree texture, nectar thick consistency liquids, and feeding assistance every shift.C. Resident #39's diagnosis included dementia, feeding difficulties, and seizures.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #39 had short term and long-term memory problems indicating severe cognitive impairment and required total staff assistance with eating, bed mobility, and transfer.The Resident Care Plan dated 6/4/26 identified a nutritional status problem related to hyperlipidemia and was at risk for malnutrition. Interventions included diet and fluids as ordered, elevating head of bed to 35-40 degrees.A physician's order in effect as of 6/22/26 directed to provide a regular diet, regular texture, thin liquid consistency, and cut meats.Observations on 6/18/26 at 8:20 AM identified the food truck was delivered to the Dining Room at 8:05 AM. At 8:33 AM 1 Nurse Aid (NA) began serving the 7 residents at 6 separate table in the dining room. The Administrator entered at 8:33 AM and assisted passing trays. All independent residents at all tables had been delivered their meal trays by 8:33 AM. At 8:43 AM Resident #3 and Resident #9 were served and assisted to eat, 10 minutes after the residents at their table had begun eating.Observations on 6/18/26 at 12:16 PM identified the food truck had been delivered to the Dining Room at 12:20 PM. There were 10 residents present in the dining room seated at 6 separate tables. The NA immediately began passing the meal trays to the residents who were independent but required set up assistance to eat. At 12:30 PM, Residents #3, #9, and #39 had not been provided their meal trays and were sitting with other residents who were eating. Resident #3 was looking at the other resident's food and placing the clothing protector in his/her mouth. Resident #39 was assisted at 12:38 PM 8 minutes after the last resident was served. Resident #9 was assisted at 12:40 PM 10 minutes after the last resident was served, while Resident #3 continued to look around at the other residents eating at his/her table. The Director of Nursing arrived at the dining room and asked if Resident #3 had been assisted. The Director of Nursing brought Resident #3's tray to the table and began assisting him/her at 12:45 PM, 15 minutes after the last resident was served and eating.Observation on 6/22/26 at 8:20 AM of breakfast service identified residents that required set up assistance and could then eat independently were served first. The residents who were totally dependent on staff to assist them to eat were served and assisted last. Two NA's and the Administrator were observed passing out tray and completed service at 8:20 AM. At 8:30 AM 1 NA began assisting Resident #3 and a nurse began assisting Resident #9 and Resident #39, 10 minutes following the last tray served. Interview with NA #2 on 6/22/26 at 8:34 AM identified trays were delivered by table to those who could eat by themselves after their meal was set up. Residents who required assistance would wait to receive their meals until assistance was available. Once all the other trays were passed out and those set up residents were eating independently, the NAs went back and served and assisted the residents who were dependent on staff to eat. Interview with RN #5 (Corporate clinical nurse) 6/22/26 at 8:37 AM indicated that the expectation for serving trays in the Dining Room was to serve everyone at the same table at the same time so that everyone ate together. RN #5 was unable to explain why the residents requiring staff assistance to eat were made to sit watching the other residents eat until after every tray was passed out. Further, RN #5 indicated that Resident #3, #9, and #39 could have been seated at one table together while waiting for enough staff to arrive to assist them so they did not have to watch others eat. A review of the Serving a Meal policy dated 10/25/26 directed, in part, to serve one table at a time. Residents who require assistance to eat should be served at the same time with the feeding attendant.2. Resident #8's diagnosis included retention of urine, obstructive and reflux uropathy (backward urine flow into the ureters and kidneys) and benign prostatic hyperplasia with lower urinary tract symptoms.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #8 had a Brief Interview for Mental Status score of 13 indicating no cognitive impairment, required substantial/maximal assistance with personal hygiene, partial moderate assistance with dressing and transfers, and was independent with bed mobility.The Resident Care Plan dated 4/30/26 identified an alteration in urinary elimination due to urinary catheter placement secondary to benign prostate hypertrophy with urinary retention, and obstruction. Interventions included assessing for removal of the catheter, assessing urine output, changing the catheter and catheter bag per the physician's order, and catheter care every shift. Observations on 6/16/26 at 12:26 PM, and on 6/18/26 at 9:42 AM (with urine visualized in the collection bag), and 6/18/26 at 2:25 PM (urine present) identified Resident #8's collection bag visible from the hallway without the benefit of a privacy cover.Interview and observation with the Director of Nursing on 6/18/26 at 2:45 PM identified Resident #8's catheter bag in view from the hallway. The Director of Nursing indicated the facility policy was to provide a privacy cover, this was a misstep, and she would correct this immediately. A review of the Accommodation of Needs policy dated 10/16/25 directed, in part, based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity and well-being to the extent possible.A review of the Resident's [NAME] of Rights directed, in part, the resident has the right to dignity, respect and freedom to be treated with consideration, respect and dignity.A review of the Catheter Irrigation policy dated 10/16/25 directed, in part, privacy bags will be available and catheter drainage bags will be covered at all times while in use, privacy bags will be changed out when soiled, with a catheter change or as needed.

Based on observations, clinical record review, interviews, and policy for the only sampled resident (Resident #29) reviewed for Activities of Daily Living (ADL), the facility failed to provide fingernail care to a dependent resident. The findings include:Resident #29's diagnoses included schizoaffective disorder, bipolar disorder, and depression.The annual Minimum Data Set assessment dated [DATE] identified Resident #29 had a Brief Interview of Mental Status score of 12 indicating moderate cognitive impairment, required partial/moderate assistance for personal hygiene, and was independent for transfers.The Resident Care Plan dated 5/7/26 identified Resident #29 required assistance with personal care related to generalized weakness, inability to ambulate, and imbalance. Interventions included assisting with bathing, dressing, and hygiene as ordered.Review of the Physician Order Summary Report dated 6/22/26 failed to identify a physician order related to ADL assistance levels.Observation and interview with Resident #29 on 6/16/26 at 2:05 PM identified his/her fingernails on both hands were long with a dark, dirt-like substance underneath. Resident #29 indicated that he/she got his/her fingernails trimmed about a month ago and had requested from numerous Nurse Aides (NAs) to get assistance with trimming because he/she liked their nails shorter but had not received assistance with care.Observation and interview with NA #3 on 6/17/26 at 1:04 PM identified that the NA was responsible for cleaning and trimming resident's fingernails. NA #3 indicated that fingernails should be trimmed and cleaned when observed as long and dirty or per the resident request. NA #3 indicated that she had not yet looked at Resident #29's fingernails during her shift. Observation of Resident #29's fingernails identified that they should not be that long and dirty. NA #3 asked if she could clean and trim his/her fingernails and Resident #29 responded please do.Interview with the Director of Nursing (DON) on 6/17/26 at 1:32 PM identified that the NA is responsible for cleaning/trimming resident fingernails on their shower day, but that any clinical staff could assist residents if fingernails were too long and dirty. She indicated that resident refusals would be communicated to the nurse and documented in a note in the resident's electronic health record. The DON indicated that Resident #29 had refused getting his/her nails trimmed in the past but was unable to identify any documentation of refusals that had been made by Resident #29.Review of the ADLs policy dated 10/16/25 directed in part that care and services will be provided for bathing, dressing, and grooming. Refusal of care and treatment by the residents to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment would possibly lead to unavoidable declines in ADLs. Review of the undated Care of Fingernails/Toenails Policy directed, in part, that the purpose of the procedure was to clean the nail bed and keep nails trimmed to prevent infection. Nail care included regular cleaning and trimming and notifying the supervisor if the resident refused care. Additionally, the policy identified the following information should be recorded in the residents medical record: Date and time that nail care was given, name of individual who administered the care, conditions of the residents nails and nail bed, any difficulties in cutting the resident's nails, any problems/complaints made by the resident, if the resident refused the treatment with the reason why and intervention taken, and the signature and title of person recording the data.

Based on observations, interviews, clinical record review, facility documentation, and facility policy reviews for 2 of 2 sampled residents (Resident #6 and Resident #17) reviewed for edema, the facility failed to ensure compression stockings were applied per the physician order or that the physician was notified of resident treatment refusal or for the need of a change in treatment. The findings include:1. Resident # 6's diagnoses included chronic bilateral lower leg edema, congestive heart failure (CHF) and type 2 diabetes. A physician's order dated 4/21/26 directed to apply compression stockings in the morning and remove at night. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had a Brief Interview of Mental Status score of 15 indicating intact cognition, required substantial/maximal assistance with upper body dressing and was dependent on staff for lower body dressing. Additionally, the MDS identified Resident #6 did not have any rejections of care. The Resident Care Plan (RCP) dated 4/30/26 identified Resident #6 had left lower extremity edema. Interventions included Ace wraps as ordered, and encouraging the resident to sit in a recliner to elevate his/her bilateral lower extremities as tolerated. The RCP failed to include compression stocking application. Observation on 6/16/26 at 10:48 AM identified Resident #6 sitting in his/her recliner chair, wearing white socks and grey shoes, without the benefit of compression stockings or elevating his/her legs. Observation on 6/17/26 at 11:33 AM identified Resident #6 sitting in his/her recliner chair, wearing black socks and grey shoes, with a bandage on the left lower extremity without the benefit of wearing compression stockings, Ace wraps, or elevating his/her legs. Interview with Licensed Practical Nurse (LPN) #1 on 6/17/26 at 1:01 PM identified it was the facility policy for residents to receive compression stockings per the physician's directive, with nurses responsible to oversee that the Nurse Aid (NA) had applied the compression stockings. Review of Resident #6's physician's orders directed compression stockings to be applied in the morning and removed in the evening, however LPN #1 identified that despite the active order they were not being applied due to the wound on Resident #6's lower left extremity. Interview with the Director of Nurses (DNS) on 6/17/26 at 1:52 PM identified it was the responsibility of the NA and nurses to follow physician orders for compression stocking application and removal. The DNS stated she would have to check on Resident #6 prior to reviewing the clinical record. Interview and clinical record review with NA #2 on 6/17/26 at 2:10 PM identified she was the regularly assigned NA on the unit for Resident #6, and that plan of care instructions were documented on each Resident's Care Card (directs NA care). Review of Resident #6's Resident Care Card directed for staff to apply compression stockings in the morning and remove nightly. NA #2 identified that it was the NA's responsibility to ensure Resident #6's compression stockings were applied however, staff were not applying them and had not been since the resident returned from the hospital (5/19/26), stating that initially his/her legs could not fit into the compression stockings. NA #2 added that despite the Resident Care Card instructions for compression stockings and Resident #6's legs being less swollen, she could not identify why they were not applied. Interview and record review with the DNS on 6/17/26 at 3:03 PM identified that the compression stocking order for Resident #6 was discontinued on 6/17/26 at 2:57 PM subsequent to surveyor inquiry because it could interfere with healing of the resident's left leg wound and the stockings were difficult for staff to apply. She identified Resident #6 had been hospitalized from [DATE] to 19, 2026, and was readmitted with a physician's order to apply compression stockings, adding staff were sometimes unable to apply them. Review of the Treatment Administration Record (TAR) for May and June 2026 indicated that the compression stockings were documented as being applied and removed daily, except for one refusal on 5/20/26 and 2 blank entries on 5/22/26 and 6/8/26. Review of nurse's progress notes from 5/19/26 through 6/17/26 failed to identify any documentation of refusals or inability to apply Resident #6's compression stockings. The DNS was unable to explain why the nursing staff had been documenting that they were signed off as being used or why there was a lack of documentation that staff were unable to or had difficulty applying the compression stockings. She indicated that she had been verbally informed that staff were unable to apply the compression stockings adding she did not discontinue the order sooner because she was unaware there was an active order. Additionally, the DNS identified that because the physician order was active, staff should have been applying the compression stockings on the resident, and if they were unable to do so the provider should have been notified to give the nursing staff a directive for alternate care for Resident #6. 2. Resident #17's diagnoses included heart failure, peripheral venous insufficiency, and chronic respiratory failure with hypercapnia (high levels of carbon dioxide in the bloodstream). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #17 had a Brief Interview for Mental status score of 14 indicating no cognitive impairment and required partial moderate assistance with dressing, bed mobility, and transfers, substantial/maximum assistance with personal hygiene and putting on footwear. The Resident Care Plan dated 5/5/26 identified heart failure, chronic obstructive pulmonary disease, chronic respiratory failure. Interventions included apply compression stockings to bilateral lower extremities, apply in the morning and remove at bedtime, cardiology and pulmonology consults as needed, monitor for edema per physician orders. A physician's order dated 5/12/26 directed Ace wraps to bilateral lower extremities during the day and remove at bedtime as needed for increased bilateral lower extremity edema, apply compression stockings to bilateral lower extremities during the day shift. Apply the compression stockings in the morning and removal at bedtime. A review of Advanced Practice Registered Nurse (APRN) #1's note dated 5/12/26 failed to identify she had been notified Resident #6 refused his/her compression stockings A review of the Treatment Administration Record (TAR) dated 6/1/26 through 6/22/26 identified that Resident #6 had refused his/her compression stockings to the bilateral lower extremities on 6/9/26, 6/14/26 and 6/18/26. A review of the Resident Care Card (Nurse Aid(NA) care directive) in effect on 6/22/26 directed the application of compression stockings to the bilateral lower extremities, apply the stockings in the morning and remove at bedtime, apply Ace wraps as needed. Observation on 6/16/26 at 2:05 PM, identified Resident #17's bilateral legs and feet were swollen, without the physician ordered compression stockings or Ace wraps, and ankle socks were worn. Observation and interview on 6/22/26 at 10:36 AM identified Resident #17 was without the physician ordered compression stockings or Ace wraps and was wearing ankle socks. Resident #17 indicated s/he did not wear compression socks any longer. Interview and record review with APRN #1 on 6/22/26 at 10:45 AM indicated she was never notified that Resident #17 was not wearing compression stockings. Interview and record review with Registered Nurse (RN) #8 on 6/22/26 at 10:45 AM indicated that the Treatment Administration Record identified refusals of compression stockings on 6/9/26, 6/14/26 and 6/18/26. RN #8 further indicated the policy directed that after 3 refusals the physician or APRN would be notified. RN #8 indicated that the RN Supervisor was responsible to make the notification and could not explain why the facility had not followed their policy. Interview, record review and review of the provider communication book with RN #5 (Corporate clinical nurse) on 6/22/26 at 11:00 AM indicated if there was an order to apply compression stockings they should be applied or if there were refusals, the physician/APRN should be notified. Review of the APRN communication book failed to identify an entry notifying the APRN/Physician of compression stocking refusals. RN #5 stated the physician/APRN should have been notified when Resident #6 refused his/her compression stockings. The Congestive Heart Failure Program directed in part the heart failure screening will be initiated with nursing staff in identifying signs and symptoms of CHF which in part include but are not limited to weight gain, cough shortness of breath, lung sounds and edema. Licensed nursing staff will notify the physician regarding any patient condition changes and document findings in the patient's clinical record. The Notification of Changes Policy directed in part that it was facility's policy to promptly inform the resident's physician when there is a change requiring notification. Additionally, circumstances requiring notification included requiring a need to alter treatment that includes new treatment and discontinuation of treatment.

Based on observations, interviews, facility documentation review and facility policy for 2 of 3 sampled residents (Resident #19 and Resident #54) reviewed for positioning, the facility failed to follow the physician orders for pressure ulcer prevention. The findings include: 1. Resident #19 diagnoses included type 2 diabetes, and peripheral venous insufficiency. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 had a Brief Interview of Mental Status of 13 indicating intact cognition and was dependent on staff for dressing, changing positions in bed and transfers. Additionally, the MDS identified Resident #19 did not have any rejections of care and was at risk for developing pressure ulcer injuries. The Braden Scale Risk Assessment for Predicting Pressure Sores dated 4/29/26 at 8:39 PM identified Resident #19 was at risk for skin breakdown. The Resident Care Plan dated 5/5/26, identified Resident #19 was at risk for skin integrity issues due to venous insufficiency. Interventions included repositioning, and treatments as ordered. The Nurse Skin Check assessment dated [DATE] at 3:41 PM identified blanchable redness to the left heel. The Resident Care Plan dated 6/13/26 identified Resident #19 had bilateral heel redness. Interventions included offloading the heels (removing the source of all pressure) while in bed and apply skin prep to his/her bilateral heels. A physician's order dated 6/13/26 directed to offload Resident #19's bilateral heels every shift while in bed. Observation on 6/16/26 at 9:48 AM identified Resident #19 in bed wearing a hospital gown, with a flat sheet draped over his/her body extending to the ankles, exposing his/her bare feet with heels directly resting on the bed, without the benefit of being offloaded, and no offloading equipment was present, Observation on 6/17/26 at 8:38 AM identified Resident #19 in bed wearing a hospital gown, with a flat sheet draped over his/her body to the mid calves, exposing bare feet, and heels were directly resting on the bed, without the benefit of being offloaded. A flattened, pancaked pillow was noted under the resident's calves. Observation and Interview with Licensed Practical Nurse (LPN) #1 on 6/17/26 at 11:03 AM identified it was the facility's policy for nurses and nurse aids to offload all resident's heels when they were in bed. Observation with LPN #1 identified Resident #19 in bed, wearing a hospital gown, with a flat sheet draped over his/her body to over the calf, exposing bare feet, and heels were directly resting on the bed without the benefit of being offloaded. The flat pancaked pillow was under his/her calves. LPN #1 identified Resident #19 should have had his/her heels offloaded which meant heels should not be touching anything but was unable to identify why the resident's heels were not offloaded as directed by the physician. Observation, interview, and facility documentation review with Nurse Aid (NA) #3 on 6/18/26 at 10:01 AM identified plan of care instruction for her was located on the Resident Care Card. Review of Resident #19's Resident Care Card identified that the resident's heels were to be offloaded when in bed. NA #3 identified Resident #19 in bed with a flat sheet draped over his/her body to the ankles, exposing his/her feet, and the heels were resting directly on a pillow, without the benefit of being offloaded. NA #3 identified Resident #19's heels were not offloaded, and that offloading heels meant the heels were floating, (not touching anything) although she could not identify why the heels were not offloaded, she stated they should have been. 2. Resident #54's diagnoses included a right arm fracture, impaired mobility, chronic fatigue, and falls. The admission Minimum Data Set assessment dated [DATE], identified Resident #54 had a Brief Interview for Mental Status score of 15, indicating cognition was intact, was dependent on staff for assistance positioning in bed and transfers, had a stage 2 pressure ulcer, and was at risk for pressure ulcer development. The Resident Care Plan dated 6/8/26 identified Resident #54 required assistance with activities of daily living and was at risk for skin breakdown. Interventions included assistance with transfers, repositioning, and offloading (removal of all pressure) the heels while in bed. A physician's order dated 6/2/26 directed staff to offload Resident #54's heels while in bed. The Nurse Aid (NA) Resident Care Card (directs resident care) dated 6/17/26 failed to indicate Resident #54's heels should have been offloaded, per the physician order, while in bed. Observations on 6/18/26 at 9:23 AM and 6/22/26 at 8:35 AM identified Resident #54's heels were not offloaded per physician order. Interview and review of Resident Care Card with NA #5 on 6/22/26 at 8:30 AM identified he was unable to determine if Resident #54's heels should have been offloaded, because the intervention was not present on the Resident Care Card. Interview with Licensed Practical Nurse (LPN) #3 (assigned to care for Resident #54) on 6/22/26 at 8:35 AM identified Resident #54's heels were not offloaded despite the physician order directing offloading but should have been. Interview with Registered Nurse (RN) #5 (Corporate Clinical Nurse) and RN #8 on 6/22/26 at 9:12 AM identified the facility should have been following the physician orders and the information should have been written on Resident #54's Resident Care Card. Review of the Pressure Injury Prevention Guidelines dated 10/16/25 directed, in part, the facility was to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Repositioning interventions included ensuring that heels are floated (offloaded) off the surface of the bed using pillows or devices that elevate and offload the heel in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Additionally, staff were to implement interventions per the physician order, document and communicate interventions to resident care staff, and float heels on pillow when in bed.

Based on observations, interviews, facility documentation, and policy, the facility failed to ensure that food temperatures were taken and recorded prior to meal service and failed to ensure meals were served at an appetizing temperature. The findings include: Observation and interview with the Dietary Manager on 6/16/26 at 12:34 PM identified the food truck left the kitchen with a surveyor requested test tray. When the last lunch tray was delivered to the last resident on the unit, the test tray was simultaneously given to the surveyor. The temperature of the sweet potato was 137 degrees ( ) Fahrenheit (F), the broccoli temperature was 114 F, the slice of ham was 104 F, and the ambrosia was 56.3 F. The ambrosia was observed sitting on trays, primarily resting in mostly water with a few melted ice cubes. The Dietary Manager indicated that she would expect the temperature of the hot foods (sweet potato, broccoli and ham) to be at least 140 F and the ambrosia should have been served at a temperature of 40 F or less.Observation and interview on 6/16/26 at 2:30 PM with [NAME] #1 and the Dietary Manager of the facility's lunch temperature logs failed to reflect food temperature documentation for lunch service which began at 11:45 AM. The food log entries for lunch service dated 6/16/26 were blank, The Dietary Manager indicated food temperatures are supposed to be recorded at the time the temperature is taken for all meals according to the facility policy. The facility's Logging Food Temperatures policy directs, in part that temperatures will be recorded on temperature monitoring log, and that correct measures should be taken if temperatures do not reach minimum safe temperature levels. According to the facility's Steamtable Temperatures Log (attached to survey) it directs staff that lunch entrees, starches, pureed starches, vegetables, pureed meats/vegetables, and gravy be greater than 145 F, and that the desserts temperatures are below 40 F. It further directs that hot foods must be greater than 145 F and cold foods must be less than 40 F.

Based on observations, interviews, facility documentation review and facility policy for 3 of 14 sampled residents (Resident #6, Resident #37, and Resident #54) reviewed for Infection Control practices, the facility failed to institute Enhanced Barrier Precautions (EBP), for residents with wounds, and for resident (Resident #54) failed to perform hand hygiene between glove changes with wound care according to infection control practices. The findings include:1. Resident #6's diagnoses included chronic bilateral lower leg edema, congestive heart failure (CHF) and type 2 diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had a Brief Interview of Mental Status of 15 indicating intact cognition, required substantial/maximal assistance with upper body dressing and was dependent on staff for lower body dressing. The Resident Care Plan in effect on 4/23/26 identified Resident #6 had a left lower extremity wound after an incision and drainage procedure in the hospital on 4/21/26. Interventions included treatment as ordered and monitoring the area for infection. Review of the Clinical admission assessment dated [DATE] at 4:43 PM identified Resident #6 had a new wound to the left shin present on readmission from the hospital. Review of the Hospital Summary dated 5/19/26 identified Resident #6 underwent a bedside incision and drainage to the left lower extremity during the hospital admission, the wound was packed, and an antibiotic was started. The physician's order dated 5/27/26 directed to apply Dakins (1/4 strength) external solution to the left lower extremity (open wound) followed by an ABD pad, secured with kerlix and Ace bandage once per day. Interview with Licensed Practical Nurse (LPN) #1 on 6/17/26 at 1:01 PM identified Resident #6 had an open wound on his/her lower left extremity. Review of the Wound Care Specialist progress notes dated 5/20/26 at 7:17 PM, 5/31/26 at 3:38 PM, 6/3/26 at 5:32 PM, 6/10/26 at 3:21 PM, and 6/18/26 at 2:20 PM identified the left anterior lower leg wound as surgical. Observation on 6/16/26 at 10:48 AM and 6/17/26 at 11:33 AM failed to identify EBP signage or a precaution cart outside Resident #6's room. 2. Resident #37's diagnoses included dementia, wedge compression fracture and severe protein calorie malnutrition. The Clinical admission assessment dated [DATE] at 11:24 PM identified Resident #37 had a stage 2 pressure ulcer to the left gluteal fold present on admission from the hospital. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 had a Brief Interview of Mental Status of 6 indicating severe cognitive impairment, required partial/moderate assistance with transfers, changing positions, and dressing. Additionally, the MDS identified Resident #37 was at risk for pressure ulcers and had 1 unhealed stage 2 pressure ulcer upon admission. The Resident Care Plan dated 4/24/26 identified Resident #37 had skin integrity issues. Interventions included repositioning, and treatments as ordered. The physician's order dated 6/12/26 directed to cleanse the right lateral calf (open wound) with normal saline, pat dry, then cover with a foam dressing daily on the day shift. Review of the nurse's note dated 6/17/26 at 6:39 PM identified the right lateral calf was classified as a venous ulcer by the wound doctor. Observation on 6/16/26 at 10:17 AM and 6/17/26 at 11:30 AM failed to identify EBP signage or a precaution cart outside Resident #37's room. 3. Resident #54's diagnoses included spinal stenosis and osteoarthritis. The Clinical admission assessment dated [DATE] at 8:10 PM identified Resident #54 had a stage 1 pressure ulcer to the sacrum present on admission from the hospital. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 had a Brief Interview of Mental Status of 14 indicating intact cognition, was dependent on staff for assistance with toileting, required substantial/maximal assistance with transfers and changing positions, and had bowel and bladder incontinence. Additionally, the MDS identified Resident #37 was at risk for pressure ulcers and had 1 unhealed stage 2 pressure ulcer upon admission. The Resident Care Plan dated 6/16/26 identified Resident #54 had a stage 2 pressure ulcer to the coccyx. Interventions included repositioning, and treatments as ordered. The Resident Care Plan dated 6/8/26 identified Resident #54 had a stage 2 pressure ulcer in the perianal area and bowel and bladder incontinence. Interventions included wound care per protocol and as ordered, incontinence care, and updating the nurse of any areas of skin breakdown. The physician's order in effect from 6/2/26 through 6/16/26 directed to cleanse the coccyx area stage 2 pressure ulcer (partial thickness loss of skin/open sore) with soap and water, pat dry, then apply Thera (skin protectant) every shift. A. Observation on 6/16/26 at 9:58 AM and 6/17/26 at 11:00 AM failed to identify signage or a precaution cart outside Resident #54's room. Review of the facility Enhanced Barrier Precaution (EBP) list on 6/17/26 at 11:15 AM identified 11 residents with a history of a Multi Drug Resistant Organisms (MDRO) or an indwelling medical device, without the benefit of identifying residents with open wounds (who would have required EBP). Interview and facility documentation review with the Infection Preventionist (IP) on 6/17/26 at 1:15 PM identified it was the facility's policy to initiate EBP for residents with a history of a MDRO, and indwelling medical devices such a G-tubes, foleys and IV's, failing to identify precautions would be initiated for residents with wounds. Review of the facility policy for EBP and the wound list with the IP identified Resident #54 had a pressure ulcer and was not on EBP. The IP indicated that facility policy directed he/she should have been. Additionally, the IP identified she was responsible for placing residents on the precautions which included signage and a physician's order; however, she was not aware that per the facility policy, residents with wounds needed to be on EBP and would conduct an audit on all residents in the facility. Interview with the Director of Nurses (DNS) on 6/17/26 at 1:59 PM identified that it was the facility's policy to place anyone with a history of MDRO or medically indwelling medical device on EBP, however she could not identify if a resident with wounds also needed to be placed on EBP. Re-interview and record review with the DNS on 6/17/26 at 3:03 PM identified that per the facility's policy residents with wounds should also be placed on EBP, but she had been unaware of the facility policy. Review of Resident #6's clinical record identified he/she was readmitted from the hospital with a surgical wound on 5/20/26, and at that time should have been placed on EBP but was not, adding the facility needed to do more education. Interview with the Clinical Regional Nurse (RN) #5 on 6/18/26 at 10:04 AM RN identified it was the facility's policy to place residents who had a history of MDRO's, medically indwelling medical devices, or wounds on EBP. RN #5 identified that Resident #6, #37 and #54 should have been placed on EBP due to wounds and subsequently were placed on EBP with education initiated for the nursing staff. Review of the Enhanced Barrier Precautions Policy dated 10/16/25 directed in part to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms. Additionally, initiation of Enhanced Barrier Precautions included an order obtained for EBP for the following; wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed venous stasis ulcers, and chronic venous stasis ulcers) and/or indwelling medical devices and infection or colonization with a CDC targeted MDRO when contact precautions do not otherwise apply. B. Observation of Registered Nurse (RN) #4 and RN #6 providing wound care to Resident #54 on 6/18/26 at 9:23 AM, identified that both staff were wearing required personal protective equipment (gown and gloves) for enhanced barrier precautions. RN #4 provided incontinence care, which included removal of a urine and stool-soiled brief, changed her gloves but failed to perform hand hygiene prior to placing on another pair of clean gloves prior to applying barrier cream to the wound. RN #6 assisted the resident with positioning while RN #4 performed wound care. RN #6 was noted to remove her gloves and place on a clean set of gloves without performing hand hygiene. Interview with RN #4 on 6/15/26 at 9:50 AM identified hand should be performed between glove changes. An interview with RN #6 on 6/18/26 11:00 AM identified hands should be washed between glove changes. Review of the Hand Hygiene policy 10/16/25 directed staff to perform hand hygiene before performing care procedures, after handling contaminated objects, and after removal of gloves.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for abuse, the facility failed to ensure the State Agency was notified timely of an allegation of abuse. The findings include: Resident #2's diagnoses included adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life), anxiety disorder and chronic pain disorder. The Resident Care Plan (RCP) dated 4/23/24 identified that Resident #2 is at risk for constipation due to decreased mobility and pain management with interventions that included to administer scheduled and/or as needed medications for constipation, review medication side effects and discuss concerns or complications with the provider if indicated and provider to evaluate drug regimen if indicated. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required moderate assistance with personal hygiene, transfers and ambulation. Additionally, it identified that the only behavior exhibited was rejection of care. A physician's order dated 6/8/24 and transcribed by RN #2 at 10:02 AM directed to administer Hemorrhoidal Rectal Ointment 0.25-14-74.9 %, insert one application rectally every six (6) hours as needed for hemorrhoidal inflammation. Interview with RN #2 on 3/11/25 at 11:56 AM identified that Resident #2 on 6/8/24 alleged that NA #1 applied hemorrhoidal ointment, and while doing so stuck his finger into the resident's anus. He reported that that he believed that Resident #2 had made several allegations against staff members while residing at the facility, so it was plausible that the allegation was made, and he just couldn't remember. He identified that for all allegations of abuse, he immediately reports the allegations to the Administrator and the DNS and immediately removes the accused staff member from the unit and sends them home. He reported that he would not document anything until he was directed to do so by the Administrator or DNS. Review of nurse's notes dated 6/1/24 through 6/30/24 failed to identify any incidents or allegations regarding Resident #2, or any notes from RN #2 regarding the need for hemorrhoidal ointment. Review of the State Agency Reportable Events website on 3/11/25 failed to identify the allegation of abuse was reported to the State Agency. Interview with Administrator #2 on 3/11/25 at 12:07 PM identified that on 6/8/24 she was made aware that Resident #2 was alleging that a Nurse Aide (NA #1) applied hemorrhoid ointment to the resident and stuck his finger up the resident's anus, reporting that it was an abuse allegation and it should have been reported to the State Agency, but she was unsure if it had been. She identified that she obtained statements and an investigation was initiated, stating that they unsubstantiated the allegation but she could not recall why. Interview with the DNS on 3/11/25 at 2:16 PM identified that she was not employed at the facility at the time of the 6/8/24 abuse allegation regarding Resident #2 but stated that if a resident reported that a staff member put their finger up their anus/rectum, the staff member should have been sent home immediately pending investigation, the allegation should have been reported to the State Agency immediately and an investigation should have been initiated. Additionally, she identified that an investigation on the 6/8/24 allegation of abuse regarding Resident #2 was not located. Although attempted, interviews with NA #1 and RN #4 (previous interim DNS) were not obtained. Review of the Abuse Prevention policy (undated) directed, in part, that the facility will not condone any form of resident abuse or neglect, and all personnel is to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. Abuse is the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting and kicking. Any allegation or incident of abuse will be reported immediately but no later than two (2) hours of the allegation or occurrence to the Department of Public Health (DPH).

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for abuse, the facility failed to remove the accused staff member immediately once the allegation of abuse was made. The findings include: Resident #2's diagnoses included adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life), anxiety disorder and chronic pain disorder. The Resident Care Plan (RCP) dated 4/23/24 identified that Resident #2 is at risk for constipation due to decreased mobility and pain management. Interventions included administering scheduled and/or as needed medications for constipation, review medication side effects and discuss concerns or complications with the provider if indicated and provider to evaluate drug regimen if indicated. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required moderate assistance with personal hygiene, transfers and ambulation. Additionally, it identified that the only behavior exhibited was rejection of care. A physician's order dated 6/8/24 and transcribed by RN #2 at 10:02 AM directed to administer Hemorrhoidal Rectal Ointment 0.25-14-74.9 %, insert one application rectally every six (6) hours as needed for hemorrhoidal inflammation. Review of nurse's notes dated 6/1/24 through 6/30/24 failed to identify any incidents or allegations regarding Resident #2, or any notes from RN #2 regarding the need for hemorrhoidal ointment. Review of NA#1's time card dated 6/8/24 (day of the allegation) identified that NA#1 punched in for work at 7:03 AM and did not punch out unitl 3:09 PM, completing the 7:00 AM to 3:00 PM shift. Interview with RN #2 on 3/11/25 at 11:56 AM identified that he was unsure if he was notified of an abuse allegation made by Resident #2 on 6/8/24 alleging that NA #1 applied hemorrhoidal ointment to the resident and while doing so stuck his finger into the resident's anus. He identified that for all allegations of abuse, he immediately reports the allegations to the Administrator and the DNS and immediately removes the accused staff member from the unit and sends them home, RN #2 reported that following an allegation of abuse, the accused staff member would be removed from the facility immediately, however he could not recall if he had sent NA #1 home on 6/8/24. Interview with Administrator #2 on 3/11/25 at 12:07 PM identified that on 6/8/24 she was made aware that Resident #2 was alleging that a Nurse Aide (NA #1) applied hemorrhoid ointment to the resident and stuck his finger up the resident's anus, reporting that it was an abuse allegation and the staff member should have been removed immediately, but could not recall if that had happened. Interview with the DNS on 3/11/25 at 2:16 PM identified that she was not employed at the facility at the time of the 6/8/24 abuse allegation regarding Resident #2 but stated that if a resident reported that a staff member put their finger up their anus/rectum, the staff member should have been sent home immediately pending investigation. Although attempted, interviews with NA #1 and RN #4 (previous interim DNS) were not obtained. Review of the Abuse Prevention policy (undated) directed, in part, that the facility will not condone any form of resident abuse or neglect, and all personnel is to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. During abuse investigations, residents will be protected from harm and any employee accused of participating in an alleged abuse will be subjected to suspension during the course of the investigation.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for abuse, the facility failed to have documentation that an investigation was completed for an allegation of abuse. The findings include: Resident #2's diagnoses included adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life), anxiety disorder and chronic pain disorder. The Resident Care Plan (RCP) dated 4/23/24 identified that Resident #2 is at risk for constipation due to decreased mobility and pain management with interventions that included administering scheduled and/or as needed medications for constipation, review medication side effects and discuss concerns or complications with the provider if indicated and provider to evaluate drug regimen if indicated. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required moderate assistance with personal hygiene, transfers and ambulation. Additionally, it identified that the only behavior exhibited was rejection of care. A physician's order dated 6/8/24 and transcribed by RN #2 at 10:02 AM directed to administer Hemorrhoidal Rectal Ointment 0.25-14-74.9 %, insert one application rectally every six (6) hours as needed for hemorrhoidal inflammation. Interview with RN #2 on 3/11/25 at 11:56 AM identified that he was unsure if he was notified of an abuse allegation made by Resident #2 on 6/8/24 alleging that NA #1 applied hemorrhoidal ointment and while doing so stuck his finger into the resident's anus. He reported that he believed that Resident #2 had made several allegations against staff members while residing at the facility, so it was plausible that the allegation was made, and he just couldn't remember. He identified that for all allegations of abuse, he immediately reports the allegations to the Administrator and the DNS and immediately removes the accused staff member from the unit and sends them home. He reported that he would not document anything until he was directed to do so by the Administrator or DNS. Review of nurse's notes dated 6/1/24 through 6/30/24 failed to identify any incidents or allegations regarding Resident #2, or any notes from RN #2 regarding the need for hemorrhoidal ointment. Interview with Administrator #2 on 3/11/25 at 12:07 PM identified that on 6/8/24 she was made aware that Resident #2 was alleging that a Nurse Aide (NA #1) applied hemorrhoid ointment to the resident and stuck his finger up the resident's anus, She identified that she obtained statements and an investigation was initiated, stating that they unsubstantiated the allegation but she could not recall why. Additionally, she identified that the investigation should be available in the facility for review and she was unsure why it could not be located, stating it should have been in either the DNS or Social Worker #1's office. Although attempted, interviews with NA #1 and RN #4 (previous interim DNS) were not obtained. Review of the Abuse Prevention policy (undated) directed, in part, that the facility will not condone any form of resident abuse or neglect, and all personnel is to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. All reports of resident abuse shall be promptly and thoroughly investigated by facility management. The individual conducting the investigation will interview staff members (on all applicable shifts) who have had contact with the resident during the period of the alleged incident, interview other residents to whom the accused employee provides care or services when indicated and review all events leading up to the alleged incident.

Based on observations, clinical record review, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #38) reviewed for falls, the facility failed to ensure the bed was left in a low position following the provision of care and failed to provide the level of assistance according to the plan of care, for a resident who was a high fall risk, which resulted in a fall with a major injury. The findings include: Resident #38 was admitted to the facility in August of 2024 with diagnoses that included history of falling, left hip fracture post hemiarthroplasty (hip replacement surgery), dementia and generalized muscle weakness. The Nursing Admission assessment dated [DATE] identified Resident #38 as verbal, confused, and with severe impairment affecting all areas of judgement. Additionally, the Nursing Admission Assessment identified that Resident #38 was able to move all extremities. The Resident Care Plan (RCP) dated 8/6/24 identified Resident #38 as a fall risk due to impaired mobility post left hip hemiarthroplasty related to a left hip fracture due to a fall and dementia. Interventions included keeping the call bell within reach, ensuring appropriate footwear is worn, providing verbal reminders of individual limitations, encouraging the use of a call bell, physical therapy as ordered, education based on ability to learn, observing for alterations in gait, maintaining a clutter free environment and an assist of 2 staff for bed mobility, transfers and mechanical lift transfers. The fall risk assessment dated [DATE] identified Resident #38 as a high fall risk with a total score of 16 (according to the fall risk assessment tool, a total score of 10 or greater is considered a high risk for potential falls and prevention protocol should be initiated immediately and documented on the care plan). Resident #38's high fall risk predisposing factors included history of falls, altered level of consciousness (always disoriented), predisposing diagnoses, medications, incontinence, being chairbound, having experienced a change in condition in the last 14 days and having had a recent hospitalization in the last 30 days. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #38 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), was dependent on staff for toileting hygiene, bed mobility and transfers and was incontinent of bowel and urine. In addition, the MDS identified Resident #38 sustained a fall and a fracture related to a fall within a month prior to admission to the facility. The Resident Care Card (RCC) dated 10/11/24 identified Resident #38 required an assist of 2 staff for bathing, toileting, incontinent care at bed level, bed mobility and transfers using a mechanical lift. The Reportable Event form dated 10/12/24 at 11:30 AM identified Resident #38 rolled out of bed onto the floor striking his/her head and was found lying on the floor on the right hip. Resident #38 sustained a laceration to his/her head and was transferred to the Emergency Department for evaluation. The Post Fall evaluation by RN #1 dated 10/12/24 at 11:30 AM identified that Resident #38 had a fall risk score of 16 when he/she fell out of bed, sustained a 2.5cm by 2cm by 0.2 cm laceration to his/her head and was incontinent at the time of the fall. Additionally, the Post Fall evaluation identified that Resident #38's bed was at an improper height at the time of the fall and identified that an air mattress was applied on 10/11/24 and was subsequently discontinued post fall incident. Review of the hospital Emergency Department Provider Notes dated 10/12/24 identified that Resident #38 struck the top of his/her head in addition to the right side, right shoulder and right hip when he/she fell . Head, Ears, Eyes, Nose and Throat (HEENT) assessment identified that Resident #38 sustained a 4 cm scalp laceration to the crown (top of head) which was repaired surgically (wound was prepped and draped in sterile fashion, cleaned with povidone -iodine, irrigated with sterile water and pressure wash and repaired with tissue adhesive). In addition, a computed tomography scan (CT scan) identified nondisplaced cervical fractures at C1 and C2. A CT scan of the chest, abdomen and pelvis identified non-displaced fractures of the sacrum at S3 and S4. Resident #38 was placed in an Aspen Collar with cervical precautions. Observation on 11/8/24 at 12:10 PM, identified that Resident #38 shared a room with Resident #209. Resident #38 was observed sitting in a customized wheelchair with an Aspen Collar around his/her neck and a healing wound on top of his/her head. A dresser was located to the right side of Resident #38's bed (if Resident #38 is in bed, right side). Interview with RN #1 on 11/6/24 at 10:18 AM identified that she responded when Resident #209 was yelling for help. RN #1 indicated that when she entered the room, she found Resident #38 lying on the floor on his/her right hip and was bleeding from a laceration to his/her head. RN #1 identified that Resident #38 was non-ambulatory and therefore was not considered a fall risk. RN #1 indicated that even though the call bell was within reach, Resident #38 was not physically or mentally able to use it if he needed help. RN #1 identified that the air mattress placed on 10/11/24 (1 day prior to the fall) was immediately discontinued after the fall because Resident #38 did not have any falls within the facility prior to the placement of the air mattress. RN #1 was unable to provide a specific bed level at the time of the fall but confirmed the bed was not in a low position. Interview with Resident #209 on 10/6/24 at 10:35 AM, who is cognitively intact (BIMS score of 15 according to the quarterly MDS assessment dated [DATE]), indicated that Resident #38 was restless before he fell from his/her bed which was in a high position (approximately 3 feet). Resident #209 identified that he/she was laying in his/her bed watching television and heard a thud, he/she then saw Resident #38 lying on the floor on the right side of Resident #38's bed. Resident #209 identified that Resident #38's bed was so high that he/she could see Resident #38 on the floor on the right side of the bed from underneath the bed. Resident #209 indicated he/she yelled for help and pressed the call bell to alert staff. Resident #209 identified that Resident #38's bed was lowered, and floor mats placed on both sides of the bed after the fall. Interview with NA #1 on 11/6/24 at 12:04 PM identified she was assigned to provide care for Resident #38 on 10/12/24 during the 7 AM to 3 PM shift. NA #1 identified that she was the last person who performed care for Resident #38 at 9:30 AM, 2 hours prior to the fall incident. NA #1 identified that she independently assisted Resident #38 with bathing, dressing and repositioning in bed. NA #1 further identified that she had a difficult time repositioning Resident #38 because he/she was stiff, and she could not turn him/her easily. In addition, NA #1 could not identify at what level she left the bed after providing care. NA #1 indicated that Resident #38 may have attempted to climb out of bed to go to the bathroom since he/she was found to be incontinent of urine and stool when observed on the floor. Interview with Physical Therapist (PT) #1 on 11/7/24 at 1:07 PM identified that Resident #38 received physical therapy services from 8/7/24 to 9/18/24. PT #1 identified that Resident #38 always required a maximum assist of 2 staff during therapy due to the risk of falling. PT #1 indicated that Resident #38's dementia, inability to communicate and little to no command following contributed to a lack of progress towards ambulation. PT #1 further identified that the facility does not evaluate the use of air mattresses from an interdisciplinary approach, but instead, it is the responsibility of the nursing department to evaluate the safety of use, and the risk verses benefit of air mattress use. Interview on 10/7/24 at 10:21 AM with DNS #2 indicated Resident #38 was not a fall risk prior to the fall on 10/12/24 hence no indication for fall risk interventions (e.g. placing floor mats and lowering the bed to a low position). DNS #2 was not aware that Resident #38 was identified as a high fall risk since admission to the facility. DNS #2 indicated that the facility initially identified the cause of the fall incident as the air mattress which was placed on the previous day. DNS #2 further indicated that the air mattress was ruled out as the cause of the fall following the interview with resident #209 who gave a witness statement to the facility that Resident #38 fell out of bed because his/her feet became tangled in bed linens. DNS #2 could not explain why NA #1 performed Resident #38's care independently and left the bed at an inappropriate height after care was provided. The DNS was not able to explain how a resident who was dependent on staff for care was able to roll out of bed and sustain a fall with a head injury and fractures. Interview with NA #1 on 11/8/24 at 2:30 PM indicated that she was not aware that Resident #38 required an assist of 2 for care at bed level and indicated that she did not check the Resident Care Card (RCC) to confirm the level of assistance required before performing care. NA #1 further identified that RCC's are kept in resident rooms, yet did not check the RCC. Review of facility policy, Positioning and Repositioning, identified in part, that, staff should check the care plan, assignment sheet or communication system to determine resident's specific positioning needs including special equipment, resident level of participation and the number of staff required to complete the procedure. It also identified that head of bed should be raised to waist level, prior to providing care and bed lowered into lowest position and side rails placed in the appropriate position as indicated in the resident's plan of care after care provision. Documentation of the position in which the resident was placed should be done. Review of facility policy, Falls: Minimizing Risk of Injury, identified in part, that, residents shall be assessed for risk of falling upon admission, quarterly, annually and after a significant change in condition. Residents who are at risk shall have a care plan that addresses interdisciplinary measures to prevent falls and environmental/equipment recommendations to prevent injuries.

Based on observations, interviews, clinical record review and facility policy, for 1 of 3 residents (Resident #3) reviewed for nutrition, the facility failed to monitor and accurately document fluid intake and bowel movements resulting in a prolonged hospitalization related to a severe fecal impaction and failed to make speech therapy and dietician referrals with a documented weight loss and poor meal intake. The findings include: Resident #3 was admitted to the facility in August of 2022 and had diagnoses that included spinal stenosis, dementia and protein-calorie malnutrition. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 0), dependent for bathing, dressing, and bed mobility and required substantial/maximal assistance for eating. The MDS identified Resident #3 was always incontinent of both bowel and bladder, was at risk for developing pressure injuries and was on a mechanically altered diet. The Resident Care Plan (RCP) dated 7/16/24 identified Resident #3 was at risk for weight loss and dehydration related to poor intake of meals and included interventions to monitor dietary intake and monitor intake and output (I&O). The RCP identified Resident #3 had pain with interventions to include administering Tylenol and Tramadol (opioid). The RCP did not identify Resident #3 as at risk for constipation despite pain regimen and lack of mobility. a. Review of the facility Laboratory Report dated 8/26/24 identified lab values outside of normal ranges to include an elevated blood urea nitrogen (BUN): 51.3 (normal range: 9-23 mg/dL), creatinine: 1.20 (normal range: 0.55-1.02 mg/dL), and sodium: 146 (normal range: 135-145mmol/L). Elevated BUN, creatinine and sodium levels are all indications of impaired kidney function and/or dehydration. An APRN order dated 8/27/24 directs to encourage an extra 240 milliliters (ml) of fluid every shift. Review of the facility Laboratory Report dated 8/29/24 identified lab values outside of normal ranges to include an elevated BUN (46.2), Creatinine (1.16), and Sodium (146). The physician order dated 8/30/24 directs to decrease Lasix (diuretic) to 20mg for 5 days and then to restart Lasix 40mg daily. Review of the facility Laboratory Report dated 9/4/24 identified lab values outside of normal ranges to include an elevated BUN (50.1), Creatinine (1.11), and Sodium (150). A late entry APRN Progress note dated 9/6/24 at 2:52 PM by APRN #1 identified she spoke at length with Person #3 and that Person #3 was very concerned regarding dehydration. The progress note further identified a plan to continue an extra 240 ml of fluids by mouth every shift, to continue Lasix 40 mg daily, to repeat bloodwork (basic metabolic panel (BMP) the next week and included a new order for a low sodium diet. Review of the Facility Order Summary Report dated 9/10/24 identified an order for Senokot-S 8.6-50 mg (2 tablets) to be administered at bedtime with a start date of 8/23/22, Tramadol 25 mg to be administered 2 times a day with a start date of 1/3/24, and Senna 8.6 mg (2 tabs) to be administered in the morning with a start date of 2/5/24. Review of the facility Laboratory Report dated 9/12/24 identified lab values outside of normal ranges to include an elevated BUN (77.3), Creatinine (1.57), and Sodium (156). A late entry APRN Progress note dated 9/12/24 at 4:14 PM identified Resident #3 continued to have abnormal labs, and that Person #3 and the nursing staff reported Resident #3 as having less alertness and agitation at times. The progress note identified a new order for IV fluids (dextrose 5% water to run at 50ml per hour for 500ml), bloodwork the following morning, a urine analysis and a chest X-ray to rule out pneumonia. The progress note identified the plan for the current situation was discussed with Person #3. Review of the Medication Administration Record (MAR) for August and September of 2024 identified Lasix 20 milligrams (mg) was administered daily from 8/31/24 through 9/4/24 and Lasix 40 mg was administered daily from 9/5/24 through 9/13/24. Review of the facility I&O report from 8/31/24 to 9/13/24 identified large volumes of fluid intake documented by NA #8 during the 7 AM to 3 PM shift as follows: 9/2/24: 1400 ml, 9/4/24: 1800 ml, 9/5/24: 1800ml, 9/6/24: 1400 ml, 9/9/24: 1800 ml, 9/10/24: 1800 ml, and 9/11/24: 1800 ml. Review of the facility Bowel Movement (BM) report from 8/31/24 to 9/13/24 identified NA #8 documented the following BM's: 9/4/24: large loose/diarrhea, 9/5/24: Medium loose/diarrhea, 9/6/24: large loose/diarrhea, 9/9/24: medium formed stool, 9/11/24: medium loose stool/diarrhea. Review of the facility SBAR Communication Form document dated 9/13/24 at 3:22 PM by RN #6 identified Resident #3 was found to have an altered mental status, weakness and was transferred to the hospital for further evaluation and treatment. Review of a hospital Discharge Summary document dated 10/4/24 identified Resident #3 was admitted to the hospital on 9/13/24 and was found to have an acute kidney injury with water deficit (kidneys are suddenly damaged primarily from a lack of fluids in the body), bilateral hydronephrosis (urine unable to drain from the kidneys) related to significant stool impaction, stercoral colitis (rare inflammatory form of colitis that occurs when fecal material leads to distension of the colon) and a urinary tract infection. The Discharge Summary identified Resident #3 had a prolonged hospitalization and initially was ordered to have nothing by mouth, received IV fluids (half normal saline at 100 ml per hour), was treated with IV antibiotics for the urinary tract infection, underwent multiple stool disimpactions, required aggressive bowel regimen, enemas and manual disimpaction. During an interview with the Medical Director (MD #2) on 11/7/24 at 9:32 AM, the I&O report and BM report for the dates of 8/31/24 to 9/13/24 were reviewed. MD #2 identified Resident #3's fluid intake obviously wasn't great and the ordered Lasix should have been held due to worsening lab values. MD #2 identified that if Resident #3 was having BM's at all, the BM's were not sufficient and the facility should have identified that and ordered an X-ray. MD #2 identified that if the bowel regimen was last reviewed in February 2024, it should have been reevaluated since then, due to Resident #3's progressive decline, decrease in mobility and active order of Tramadol (opioid drug). MD #2 further identified he was not notified of any change in condition leading up to the 9/13/24 hospitalization . Interview on 11/7/24 at 10:58am with NA #8 identified Resident #3 did not drink the large volumes of fluid she documented from 8/31/24 to 9/13/24. NA #8 stated she just did not take the time to add up the numbers like she should have and she just wasn't thinking. NA #8 further identified Resident #8 had frequent loose stools and that she reported BM's to the nurses but did not report that the stools were loose because she thought loose stools were normal for Resident #3. She further identified that when documenting in the electronic medical record, she thought the number options were for the number of times residents had BM's verses stool consistency (1: formed stool, 2: loose/diarrhea). During an interview on 11/7/24 at 11:15 AM, the I&O report and BM report for the dates of 8/31/24 to 9/13/24 were reviewed with APRN #1. APRN #1 identified she ordered IV fluids the day before Resident #3 was transferred to the hospital because that is when the nursing staff reported Resident #3 was refusing fluids and further identified she would have ordered IV fluids sooner if she knew fluid intake was poor. When the Lasix orders were reviewed, APRN #1 identified there was a resident representative (Person #3) who insisted Resident #3 have Lasix for edema. APRN #1 indicated she did not review the risk verses benefit of continuing the Lasix with Person #3. During an interview on 11/12/24 at 11:47 AM, DNS #2 was informed that NA #8 identified she documented I&O's and BM's incorrectly. DNS #2 identified incorrect documentation could affect an accurate assessment of care needs and that the RN supervisor should have identified the incorrect documentation and reported it to the APRN. DNS #2 identified NA #8 should have reported Resident #3's loose stools so the RN supervisor could have performed an assessment. Subsequent to surveyor inquiry of inaccurate documentation, the facility initiated staff education for accurate documentation of I&O, BM's and the reporting of any issues/concerns to the charge nurse or nursing supervisor. b. Review of the facility Nutrition assessment dated [DATE] identified Resident #3 was readmitted to the facility on [DATE] with a significant weight loss. Goals identified in the Nutrition Assessment included Resident #3 tolerating the current diet without signs or symptoms of aspiration and meal intake of 50% or greater for 2 out of 3 meals per day. Review of the facility Weight Summary identified a weight of 145.2 pounds on 10/8/24 and a weight of 136.9 pounds on 10/31/24, identifying a further 5.7% weight loss. During an observation in the dining room on 11/4/24 at 12:32 PM, LPN #4 was observed assisting Resident #3 with drinking a chocolate supplement. Resident #3 coughed intermittently with sips of the supplement. By 12:46 PM Resident #3 drank 75% of the supplement and LPN #4 presented a spoonful of mashed potatoes which Resident #3 did not respond to and did not open his/her mouth. At 12:58 PM NA #5 assisted Resident #3 with the remainder of the supplement and removed the meal tray. There was only 1 presentation of food to Resident #3's mouth throughout lunch. Interview with NA #5 on 11/4/24 at 12:58 PM identified Resident #3 ate well prior to a recent hospitalization but since readmission to the facility, Resident #3 does not eat much food. NA #5 identified Resident #3 would eat oatmeal during breakfast on some days but otherwise takes in only fluids. During an observation in the dining room on 11/5/24 at 12:47 PM NA #6 was observed presenting a spoonful of lasagna (mechanical soft) to Resident #3 multiple times. Resident #3 did not respond to the presentation of food, and did not open his/her mouth. NA #7 told NA #6 to stop attempting to feed Resident #3 because Resident #3 only takes in fluids. NA #6 assisted Resident #3 with drinking a chocolate supplement. Resident #3 coughed intermittently with sips of the supplement. Interview with NA #6 on 11/5/24 at 12:55 PM identified she had never previously fed Resident #3 because she usually works on a different nursing unit. Interview on 11/5/24 at 12:56 PM with NA #7 indicated Resident #3 had not been eating food for the past 2 to 3 weeks and Resident #3 often coughed while drinking fluids. NA #7 identified Resident #3 received a meal tray despite not eating food because the nursing supervisor (RN #2) stated it is state mandated for residents to receive meal trays even if they do not eat. Review of the Document Survey Report identified Resident #3 ate less than 50% for more than half of the meals served from 11/1/24 to 11/7/24 and of those meals 5 were documented as refusals. Interview on 11/7/24 at 9:32 AM with MD #2 indicated that due to Resident #3's progressive decline and poor meal intake, the diet should be downgraded to identify if Resident #3 better tolerates a different texture. Interview on 11/7/24 at 4:33 PM with Speech and Language Pathologist (SLP) #1 identified Resident #3 last received speech therapy services from 10/4/24 to 10/10/24 with a recommendation for a mechanical soft texture and thin liquids and stated Resident #3 had a delayed response to presentation of food. SLP #1 indicated food consistency effects palatability of food and when the goal is for residents to take in more food, efforts are made to maintain food consistency. The SLP identified she had not received any reports of poor meal intake or further weight loss for Resident #3 and would have expected to receive a referral if there was a change in condition. SLP #1 further identified that if Resident #3 had poor meal intake, safety would be the priority over palatability and Resident #3 should be evaluated for a diet downgrade. Subsequent to surveyor inquiry, SLP #1 downgraded Resident #3's diet on 11/7/24 to a puree texture and nectar thick liquids. Review of the Speech Therapy SLP Evaluation and Plan of Treatment document dated 11/11/24 identified Resident #4 presented with further decline in swallow function, with decreased intake and observed coughing with thin liquids. Interview on 11/12/24 at 11:51 AM with RN #2 identified she was not aware of Resident #3's poor meal intake and if she were aware, she would have referred Resident #3 back to the SLP and the RD for an evaluation. The facility policy titled Intake/Output states, in part, the purpose is to ensure adequate hydration and prevent dehydration to the extent possible based on each residents individualized care needs and choices and that I&O are instituted for a resident with a change in condition which may alter hydration status. The facility policy titled Charting and Documentation states, in part, documentation in the medical record will be complete and accurate. The facility policy titled Notification Change in Condition, Change in Treatment/Services states, in part, that the facility will inform the resident, resident's physician and the resident's family/legal representative when there is a change of condition. The policy states an RN will perform an assessment once a change of condition is identified and the policy provides examples of changes in condition to include diarrhea, vomiting (assess for dehydration and /or constipation) and changes in intake and output (assess for dehydration and/or fecal impaction).

51183 Based on observations, clinical record review, review of facility policy, interviews for 1 of 3 sampled residents (Resident #206) reviewed for pressure ulcers and observation of 1 of 1 medication rooms for medication storage and labeling, the facility failed to ensure that a resident's medications were stored in a designated secure area per facility policy and failed to discard expired vaccines and insulin vials after the beyond use date. The findings include: 1. Resident #206 was admitted to the facility in October of 2024 with diagnoses that included osteomyelitis of vertebra, sacral and sacrococcygeal region, depression, and generalized muscle weakness. Physician's orders dated 10/21/24 directed to administer Unasyn injection solution reconstituted 1.5(1-0.5) gram (antibiotic) every 6 hours for wound infection, heparin (anticoagulant) flush 5 milliliters (ml) and sodium chloride flush solution 10 ml, intravenously (IV) every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #206 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 14) and required set up assistance for eating. Resident #206 was independent for bed mobility and dependent for transfers. The Resident Care Plan dated 10/28/24 identified Resident #206 was on intravenous antibiotic therapy due to osteomyelitis. Interventions included enhanced barrier precautions as indicated, administration of IV therapy per physician's order, monitoring the infusion rate every hour, maintaining intake and output every shift, and administering medications as ordered. Observation on 11/4/24 at 12:01 PM and 11/5/24 at 11:00 AM, identified heparin flush 5ML syringes in a full 1/2 galloon storage bag and sodium chloride flush solution syringes in full 1/2 galloon storage bag in Resident #206's room on top of the refrigerator. Interview and observation with RN #2 on 11/5/24 at 11:05AM, identified heparin and normal saline flush syringes on top of Resident #206's refrigerator. RN #2 identified that the medications should not have been stored in Resident #206's room but should have been stored in the medication room or in the medication carts. RN #2 could not explain why Resident #206's medications were store in his/her room. Subsequent to the surveyor inquiry, the mentioned bags of heparin and normal saline flush syringes were removed from Resident #206's room and transferred to a secured area (medication room). 2. Observation of the 2nd floor medication storage room on 11/8/24 at 1:30 PM, identified an open box containing 10 remaining influenza A & B tests which expired 5/31/22 stored on the bottom storage shelf. Further identified inside the medication refrgerator, were 2 open multi-dose 10 milliliter (ml) vials of insulin Lispro dated with the dates they were opened. 1 insulin Lispro multi-dose vial was dated 9/10/24 and 1 insulin Lispro multi-dose vial was dated 9/15/24, both were approximately half full. Interview with Registered Nurse (RN) #2 on 11/8/24 at 2:00 PM identified she was unaware that there were expired influenza tests and open multi-dose vials of insulin past the beyond use date, in the medication storage room. RN #2 could not identify why they were there. RN #2 indicated that opened vials of insulin should be dated when opened and then discarded within 30 days. RN #2 indicated expired medications should be placed in a plastic bin, stored inside the medication storage room, for pick up by the pharmacy on Mondays. Review of facility policy, Medication Storage in the Facility, identified in part, that, medications and biologicals should be safely, securely and properly stored following manufacturers recommendations or those of the supplier. The medication supply should only be accessible to licensed nursing personnel, pharmacy personnel or staff members who are lawfully authorized to administer the medications. Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area. Review of the facility policy, Facility-Storage of Medications directed, in part, that outdated medications are immediately removed from inventory and disposed of according to procedures for medication disposal, and when the original seal of a manufacturer's vial is initially broken, the nurse enter the date opened and the new date of expiration. The expiration date of the vial would be 30 days unless the manufacturer recommends another date. (Insulin Lispro manufacturer instructions specify that opened 10 ml multi-dose vials can only be used for 28 days whether refrigerated or stored at room temperature.)

Based on tour of the dietary department, observations, interviews, and facility policy, the facility failed to label open food items, failed to dispose of expired food items, and failed to store the ice machine scoop in a clean and sanitary manner. The findings included: Tour and observation of the kitchen on [DATE] at 9:07 AM with the Dietary Director identified the following: 1. Observation of the bread rack identified an unsealed bag containing 3 pieces of cake with multiple spots of green mold and an expiration date of [DATE] and an unsealed bag containing 9 pieces of corn bread with an expiration date of [DATE]. 2. Observation of the bread rack additionally identified an unsealed bag containing 2 hotdog rolls, an unsealed bag containing 5 hotdog rolls and an unsealed bag containing 3 hamburger rolls. None of the above bags contained an expiration date or an open date. 3. Observation of the ice machine identified the ice machine scoop holder, which was adhered to the wall near the ice machine, had an inner removable tray which the end of the scoop slid into. There was water within the tray, approximately ,d+[DATE]cm deep, which the scoop was in. The ice machine scoop holder and inner tray had scattered areas of white residue. The scoop was 95% covered in white residue. Observation of the Ice Scoop Sanitizing form which was taped to the wall beside the ice machine identified twice daily (at the end of each shift) sections to sign off running the ice machine scoop through the dish machine. Initials were missing for the second wash on [DATE], and initials were present for the wash [DATE] at 6:10 AM. 4. Observation of the nursing unit nourishment room refrigerator identified a box of Danishes with a date of [DATE] written on the box and a half empty container of thickened cranberry cocktail which included a deliverey date of ,d+[DATE] but no open date. During an interview on [DATE] at 9:37 AM the Dietary Director identified that the expired foods should have been thrown away and the open unlabeled bags should have been labeled with an open date by whoever opened them. The Dietary Director further identified the ice machine scoop holder, inner tray and scoop needed to be run through the dishwasher. Interview with the Administrator on [DATE] at 10:17 AM identified the Danishes and thickened cranberry cocktail in the nourishment room refrigerator needed to be thrown away, and threw them in the garbage. The facility policy titled Food states, in part, all food items should be labeled and dated, all items stored in the refrigerator will be covered, labeled with the contents and the date. All potentially hazardous foods must be discarded within 3 calendar days after the date prepared. The facility policy titled Policy for Ice Machines and Ice Storage Containers stated, in part, that all ice machines and ice storage containers will be maintained in a clean and sanitary manner.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #28) reviewed for advanced directives, the facility failed to complete an advance directive form for a resident upon admission. The findings include: Resident #28 was admitted in October of 2024 with diagnoses that included epilepsy, Parkinson's disease, and dysphagia. The admission Minimum Data Set assessment dated [DATE] identified Resident #28 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 14), required supervision or touching assistance with eating, was dependent with upper body dressing and transfers. The Resident Care Plan dated [DATE] identified Resident #28's code status. Interventions included Resident #28 was a full code, wanted cardiopulmonary resuscitation (CPR) and directed to document the code status in the electronic medical record (EMR). A physician's order dated [DATE] directed a code status of a full code, and included yes to CPR, intubation, oxygen, hospitalization , intravenous hydration, intravenous antibiotics, and for tube feeding needs to discuss with the family first. A History and Physical examination admission note by Medical Director (MD) #2 on [DATE] identified that Resident #28 appeared lethargic during the visit but was able to answer questions. The note further identified Resident #28 was a full code. Review of Resident #28's paper chart on [DATE] at 3:11 PM, identified a blank unsigned advance directive form in the chart. Interview with Advanced Practice Registered Nurse (APRN) #1 on [DATE] at 12:10 PM identified that she did not review and sign the advance directives in the chart for new admission residents and re-admission residents. APRN #1 stated that advance directives were signed by MD #2. Interview with MD #2 on [DATE] at 9:18 AM identified that he signed the advance directives form for residents newly admitted and readmitted to the facility. MD #2 further identified that if he had reviewed a new admission chart and didn't see an advance directive form filled out, he would have filled one out with the resident. MD #2 could not identify why the advance directive form in Resident #28's chart was not filled out and stated, at times, he verified information with Resident #28's representative because Resident #28 was intermittently confused. MD #2 identified that he would be in the facility the following day and would review the advance directives and include the form in the clinical record. In an interview and clinical record review with the Registered Nurse Supervisor (RN) #2 on [DATE] at 1:25 PM, the clinical record failed to reflect documentation of a completed advance directive form and identified a blank admission checklist form. RN #2 identified that she was unaware the advance directive form was blank, and that she had not completed the admission for Resident #28. RN #2 identified the process for filling out the advance directives form was for the resident and/or the resident representative to fill out and sign the form, two staff members verify the information and sign the form, and the provider is notified of the advance directives and an order is added into the EMR. RN #2 stated that there is an admission checklist for staff to follow during the admission process and medications are verified by third shift, but there is no formal process for reviewing all of the admission documents. Review of Resident #28's paper chart on [DATE] at 10:07 AM identified subsequent to surveyor inquiry, the advance directives form was filled out, included telephone consent from Resident #28's representative, and 2 staff signatures, all dated [DATE]. Review of the Advance Directives policy directed, in part, that the plan of care for each resident would be consistent with his or her documented treatment preferences and or advance directive and the nurse Supervisor would be required to inform emergency medical personnel of a resident's advance directives regarding treatment options and provide such personnel with a copy of the directive when transfer from the facility via ambulance or other means is made. Review of the Admission policy does not identify a process for the nursing admission paperwork.

Based on review of the clinical record, facility policy and interviews for 2 of 4 residents (Resident #20 and Resident #33) reviewed for care planning, the facility failed to revise the comprehensive Resident Care Plan (RCP) to reflect the current status of a resident's dialysis access and current diagnosis with interventions for a resident with congestive heart failure. The findings include: 1. Resident #20 was admitted in March of 2023 with diagnoses that included diabetes, chronic kidney disease, and hypertension. A history and physical examination note by Medical Doctor (MD) #2 on 9/13/24 identified Resident #20 had a diagnosis of congestive heart failure (CHF), and the treatment plan would continue with Furosemide (medication to help reduce fluid buildup in the body) and monitoring Resident #20 for fluid overload. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13) and required setup or clean-up assistance with eating and was dependent for lower body dressing and chair/bed-to-chair transfers. The MDS assessment did not include congestive heart failure as an active diagnosis. The RCP dated 10/19/24 identified Resident #20 was at risk for dehydration related to chronic kidney disease and use of Furosemide. Interventions included to elevate the extremities if edema was present and to monitor Resident #20's weight as ordered. Further identified was Resident #20 is at risk for cardiac distress related to hypertension, atrial fibrillation and coronary artery disease. Interventions included to monitor for edema and observe for signs and symptoms of cardiac and respiratory distress. The RCP did not include CHF and interventions to monitor for fluid overload (monitor for neck vein distention, monitor for abnormal lung sounds) or the use of furosemide as part of the treatment plan for CHF. Interview and clinical record review of Resident #33's RCP with Registered Nurse (RN) #4 on 11/7/24 at 1:00 PM identified the clinical record failed to reflect CHF and relevant interventions. RN #4 was not aware that MD #2 had included CHF as a diagnosis for Resident #20 in his history and physical note on 9/13/24. RN #4 stated if she had been aware of the diagnosis, she would have included CHF in the RCP. 2. Resident #33 was admitted in November of 2021 with diagnoses that included end stage renal disease with dependence on renal dialysis, dementia, and depression. A Situation, Background, Assessment, and Recommendation (SBAR) note on 5/6/24 at 8:35 PM identified Resident #33 was sent to the hospital emergency room for evaluation related to abnormal vital signs. A nursing note on 5/11/24 at 8:54 PM identified Resident #33 was readmitted to the facility from the hospital following hospitalization for sepsis and the right chest hemodialysis catheter had tested positive for MRSA. It is further identified Resident #33 has a new hemodialysis catheter in the left chest and is on Bactrim double strength (DS) antibiotic. Physician's orders dated 5/11/24 directed to monitor the dressing for the left upper chest venous catheter for hemodialysis and ensure it was clean, dry, and intact every shift and Resident #33 was on contact precautions every shift for a positive MRSA culture of the (removed) right chest hemodialysis catheter tip. A physician's order discontinued on 5/11/24 directed to monitor the bruit and thrill of the left AV fistula (clogged, not in use), not to obtain blood pressures in the left arm, and check dressing to the right upper chest venous catheter to ensure it was clean, dry, and intact every shift. The order had initially been written on 5/23/23. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #33 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12), received hemodialysis, and required setup or clean-up assistance with eating, and partial/moderate assistance with upper body dressing and lying to sitting on the side of the bed. The May 2024 RCP identified Resident #33 was at risk for complications of dialysis. Interventions included to not obtain blood pressures or blood work from the left arm or in the limb nearest the chest of presently used permacath (central venous catheter for dialysis) , report signs and symptoms of bleeding or leaking of the arteriovenous (AV) fistula area (surgically created passageway between an artery and vein used for dialysis), report signs and symptoms of infections of permacath or AV fistula and to monitor bruit (swooshing sound) and thrill (vibration) of the left arm every shift and then document findings (bruit and thrill indicate that the AV fistula is functioning properly). All interventions listed for this RCP focus have an initiation date of 11/2/21 and there are no revisions or new interventions identified since 11/21/21. The RCP failed to document revisions related to Resident #33 being hospitalized [DATE] through 5/11/24 for sepsis related to an infected hemodialysis catheter in the right chest which was removed at the hospital due to a methicillin-resistant Staphylococcus aureus (MRSA) positive culture of the catheter tip; a new permanent tunneled (placed under the skin forming a tunnel that the catheter passes through) dialysis catheter was placed into the left chest at the hospital on 5/10/24; and Resident #33 was readmitted on contact precautions until completion of oral antibiotics for MRSA. The RCP further failed to identify the AV fistula was clogged and had not been in use for approximately 1 year thereby not requiring checking of the bruit and thrill which monitors for patency of the AV fistula. A physician progress note by Medical Doctor (MD) #2 on 5/22/24 at 10:01 PM for date of service 5/17/24 identified Resident #33 was hospitalized from 5/6/24 through 5/11/24 for sepsis secondary to an infected hemodialysis catheter requiring intravenous vancomycin and Zosyn antibiotics, and a positive MRSA culture which resulted in the hemodialysis catheter being removed and replaced with a new catheter and Resident #33 was to finish 14 days of Bactrim DS antibiotics. Interview and clinical record review of Resident #33's RCP with Registered Nurse (RN) #4 on 11/7/24 at 1:00 PM identified the clinical record failed to reflect documentation of revisions related to Resident #33's hospitalization which resulted in removal of the MRSA infected right chest dialysis catheter, and placement of the new tunneled left chest dialysis catheter, and discontinuation of the AV fistula monitoring due to non-use of the catheter. RN #4 stated any nurse can update the RCP but the ultimate responsibility was hers. RN #4 identified the RCP should have been updated relating to the AV fistula, and she had thought the interventions for checking the dressing were still relevant so it wasn't necessary to update those interventions even though the catheter had been replaced. Review of the Comprehensive Person-Centered Care Plans policy directed, in part, assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change, and the Interdisciplinary Team must review and update the care plan when a resident has been readmitted to the facility from a hospital stay.

Based on observation, interviews, clinical record review, and facility policy for 2 out of 3 residents (Resident #10 and Resident #49) reviewed for activities of daily living (ADL) the facility failed to provide oral hygiene for a resident who had mouth pain and required moderate assistance and failed to provide grooming for a dependent resident.The findings include: 1. Resident #10 was admitted to the facility in January of 2024 with diagnoses to include chronic pain, fibromyalgia, rheumatoid arthritis, depression, and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), required set up or clean up assistance with oral care, partial/moderate assistance for personal hygiene, substantial/maximal assistance for upper body dressing, was dependent for bathing, lower body dressing, toileting, bed mobility and transfers. The MDS further identified Resident #10 had pain almost constantly which made it hard to sleep at night and caused limitations in day-to-day activities. The MDS identified Resident #10 without the presence of behavioral symptoms to include no behaviors of rejection of care. The Resident Care Plan (RCP) dated 7/29/24 identified Resident #10 had chronic pain and received psychotropic medications to include Lorazepam (for anxiety) and escitalopram (for depression). The RCP identified ADL's as a focus area but did not include interventions for oral care and identified impaired dentition related to mouth pain with interventions to include daily mouth care and oral brushing with foam brush in the morning and at bedtime. Review of the Treatment Administration Record for October and November of 2024 identified a provider order directing oral brushing with foam brush in the morning and at bedtime documented as completed every day. Review of a Radiology Results Report dated 10/9/24 identified a right hand X-ray was obtained for pain and discomfort with findings that included modest degenerative changes. The report further identified a left wrist X-ray was obtained for pain and discomfort with findings that included mild degenerative joint disease of the wrist. A provider order dated 10/11/24 (initial start date of 1/17/24) directed Orajel Maximum Strength 4x Toothache and Gum to be applied to an effected area every 6 hours as needed for tooth/gum pain up to 4 times per day. A provider order dated 10/11/24 (initial start date of 1/9/24) directed to request a dentist appointment for recurring left sided mouth/gum/tooth pain. A Consultation Record dated 10/17/24 by MD #3 (dentist) directed assisted oral hygiene is required and recommended extractions of 5 teeth. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 14), required partial/moderate assistance with oral care, was dependent for bathing, dressing, toileting, bed mobility and transfers. The MDS further identified Resident #10 had pain almost constantly which made it hard to sleep at night and caused limitations in day-to-day activities. The MDS identified Resident #10 without the presence of behavioral symptoms to include no behaviors of rejection of care. The Resident Care Card dated 11/4/24 directed daily mouth care and oral brushing with foam brush in the morning and at bedtime. Interview with Resident #10 on 11/4/24 at 11:25 AM identified he/she had pain all over, was sensitive to all forms of touch and subsequently chose to spend most of his/her time in bed. Resident #10 further stated I have a gum infection. My gums hurt so badly and indicated he/she does not tolerate tooth brushing and can only eat soft foods due to pain in the mouth. Resident #10 indicated he/she has dry mouth from his/her medications. Resident #10 was observed to have an Orajel tube cut in half and a medicine cup containing a pink mouthwash on the overbed table. Resident #10 was using a swab to rub the Orajel and mouthwash over his/her gums repeatedly throughout the interview. Observation of Resident #10's mouth on 11/4/24 at 11:25 AM identified swollen and inflamed gums, thick white and yellow residue (plaque/calculus) covering all teeth and thickly accumulated between the teeth. The inside of Resident #10's mouth was dry. Observation on 11/5/24 at 9:31 AM identified an unchanged presentation of Resident #10's gums and teeth. Interview with MD #4 (dentist) on 11/7/24 at 2:09 PM identified Resident #10 had a dry mouth due to prescribed medications, that plaque develops quickly for people who have a dry mouth and using a swab for oral care would not be sufficient. MD #4 identified Resident #10 allowed the dental hygienists to brush and floss his/her teeth when they see him/her for routine visits. MD #4 indicated Resident #10 would benefit from improved oral care and that the facility had room to improve in regards to providing oral care for Resident #10. Interview with the Speech and Language Pathologist (SLP #1) on 11/7/24 at 4:33 PM identified Resident #10 last received speech therapy services in July of 2024 and during that time she assisted Resident #10 with oral care when Resident #10 was receiving speech therapy services. SLP #1 identified she provided Resident #10 with a soft bristle toothbrush and floss picks and Resident #10 was delighted. SLP #1 identified Resident #10 enjoyed receiving attention and enjoyed the attention received while receiving oral care. Interview with NA #9 on 11/12/24 at 11:22 AM identified she sets Resident #10 up to perform oral care but on days Resident #10 complains of pain she just washes him/her up and does not set him/her up for oral care. Interview with NA #10 on 11/12/24 at 11:25 AM identified she is frequently assigned to perform care for Resident #10 and she assisted Resident #10 with oral care at times. NA #10 indicated Resident #10 does not like his/her teeth brushed. She further identified Resident #10 had pain with chewing. Interview with DNS #2 on 11/12/24 12:20 PM identified the facility should be providing oral care assistance to Resident #10 based on the level of assistance identified in the MDS assessment. 2. Resident #49 was admitted to the facility in June of 2023 with diagnosis that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysthymic disorder, and muscle weakness. The Quarterly Minimum Data set assessment dated [DATE] identified Resident #49 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 10), dependent for oral hygiene, toileting, bathing, dressing, bed mobility and transfers. Observation on 11/4/24 at 9:05 AM identified Resident #49 with the presence of scattered chin hair across the entire chin at approximately 0.6cm to 0.8cm long. Observation on 11/5/24 at 10:55 AM identified Resident #49 with the presence of scattered chin hair across the entire chin at approximately 0.6cm to 0.8cm long. Interview with DNS #2 on 11/12/24 at 12:20 PM identified residents who are dependent for grooming should have facial hair shaven unless indicated facial hair is preferred. The facility policy titled Activities of Daily Living (ADLs), Supporting states, in part, residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observations, interviews, clinical record review and facility policy, for 1 of 3 residents (Resident #3) reviewed for pressure injuries, the facility failed to provide positioning based on the plan of care and provider order for a dependent resident with an active pressure injury and a history of pressure injuries. Resident #3 was admitted to the facility in August of 2022 and had diagnoses that included spinal stenosis, dementia and protein-calorie malnutrition. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 0), dependent for bathing, dressing, and bed mobility and required substantial/maximal assistance for eating. The MDS identified Resident #3 was always incontinent of both bowel and bladder, was at risk for developing pressure injuries and was on a mechanically altered diet. The Resident Care Plan (RCP) dated 7/16/24 identified Resident #3 was at risk for weight loss and dehydration related to poor intake of meals and included interventions to monitor dietary intake and monitor intake and output (I&O). The RCP identified ADL ' s as a focus area with interventions to include out of bed to adaptive wheelchair daily per 24 hour positioning plan. The RCP identified Resident #33 was at risk for [NAME] integrity and was readmitted to the facility with a right heel suspected deep tissue injury (DTI) (pressure injury of unknown depth/significance) with interventions to include an air mattress, incontinent care every 2 to 3 hours and to turn and reposition in bed every 2 to 3 hours. The RCP did not include an intervention to offload heels or apply offloading boots despite the existence of a right heel DTI. Review of the Order Summary Report dated 10/4/24 identified a Provider order directing a topical treatment of skin prep to the right heel and offloading the right heel with a pillow when in bed or in the wheelchair. Review of the Resident Care Card (RCC) dated 11/4/24 identified Resident #3 was to be out of bed daily to his/her custom wheelchair according to a 24 hour positioning plan and incontinence care was to be provided every 2 to 3 hours and as needed. Attached to the RCC was Custom Wheelchair 24 Hour Positioning Plan document which identified changes in wheelchair poisoning every 2 hours. Interview with NA #5 on 11/4/24 at 2:17 PM identified Resident #4 had been out of bed and in his/her wheelchair since prior to breakfast at 7:30 AM. NA #5 identified Resident #3 remained in the wheelchair since 7:30 AM and had not been repositioned in the wheelchair throughout the day. NA #5 further identified that Resident #3 is transferred back to bed between 2 PM and 2:30 PM daily for repositioning purposes and to provide incontinence care. NA #5 identified there was no incontinent care provided to Resident #3 while he/she was in the wheelchair throughout the day until he/she was transferred back to bed. After reviewing the Custom Wheelchair 24 Hour Positioning Plan with NA #5, NA #5 further verified that she does not reposition Resident #3 while in the wheelchair or provide incontinence care until after resident #3 is transferred back to bed. Observation on 11/5/24 at 9:16 AM identified Resident #3 sitting in a wheelchair with an offloading boot to the left foot, no offloading boot to the right foot. The right foot was directly on the foot rest. Interview with RN #2 on 11/5/24 at 2:30 PM identified Resident #3 wakes up early and is usually transferred out of bed before breakfast. RN #2 identified Resident #3 is incontinent so should receive incontinence care every 2 hours and should be repositioned in his/her wheelchair according to the 24 Hour Wheelchair Positioning Plan. Observation on 11/7/24 at 9:53 AM identified offloading boots on Resident #3 ' s bed, and feet directly on wheelchair footrests. Further observations at 10:15 AM, 10:36 AM, 10:53 AM, 11:20 AM, and 1:10 PM were unchanged. A Skin Check evaluation dated 11/7/24 at 3:30 PM by RN #5 identified a DTI to the right heel measuring 2 centimeters (cm) by 2.5cm and was noted as improving. Interview with RN #5 (infection control and wound nurse) on 11/12/24 at 12:07 PM identified Resident #3 was readmitted to the facility on [DATE] with a right heel DTI which was not included on the facility wound report for the month of November. RN #5 indicated Resident #3 was not added to the wound report because of an oversight. RN #5 identified Resident #3 ' s right foot should be placed in an offloading boot when he/she is sitting in the wheelchair, is in bed, or anytime he/she does not have offloading support of the heels. RN #5 identified the right heel resting directly on the wheelchair footrest could cause further breakdown of the existing DTI. RN #5 identified she was unaware there was no order or care planned interventions for the offloading boots. RN #5 identified there should be a provider order and care plan to include the offloading boots as an intervention. RN #5 identified Resident #3 should be positioned in his/her wheelchair according to the 24-Hour Wheelchair Positioning Plan. The facility policy titled Positioning and Repositioning states, in part, positioning and repositioning is critical for a resident who is immobile or dependent on staff for positioning and repositioning and further states positioning a resident on an existing pressure ulcer (injury) should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing.

Based on interviews, clinical record review and facility policy, for 1 of 3 residents (Resident #3) reviewed for a rehospitalization , the facility failed to provide a social services follow up with a resident's representatives regarding support and education for advance care planning and goals of care after a change in condition resulting in a hospitalization . The findings include: Resident #3 was admitted to the facility in August of 2022 and had diagnoses that included spinal stenosis, dementia and protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 0), was dependent for bathing, dressing, and bed mobility and required substantial/maximal assistance for eating. A progress note by MD #2 on 7/10/24 identified Resident #3 as eligible for hospice. The Social Services Quarterly Note by Social Worker (SW) #1 on 7/12/24 at 12:38 PM indicated Resident #3 was alert/confused, had family who remained involved/supportive and visited regularly and stated the SW would remain available to Resident #3 for support as needed. Review of the hospital Discharge Summary dated 10/4/24 identified Resident #3 as eligible for routine hospice if aligned with the family's goals of care and that the family was contemplating a feeding tube versus hospice on the day of discharge from the hospital. The Discharge Summary identified Resident #3 with a new code status of Do Not Resuscitate (DNR) (which was a change from a full code status) after multiple palliative care and advance care planning conversations were held with family members. The Social Services Quarterly Note by SW #1 on 10/16/24 at 2:05 PM indicated Resident #3 was alert/confused, was readmitted (readmitted [DATE]) after a hospitalization , had family who remained involved/supportive and visited regularly, and stated the SW would remain available to Resident #3 for support as needed. Interview on 11/6/24 at 2:05 PM with SW #1 identified she was present for a care conference on 10/16/24. Review of the facility care conference document dated 10/16/24 identified the document was not signed by SW #1. SW #1 then identified she was not present for the 10/16/24 care conference and the last care conference she was present for was in July 2024. SW #1 indicated she joined care conferences annually or as needed for long term care residents. SW #1 identified she did not follow up with Resident #3's representatives regarding goals of care since the 10/4/24 readmission to the facility. SW #1 identified that there were 2 resident representatives who had differing goals of care and difficulty coping. SW #1 identified the last time she discussed goals of care with the resident representatives was during the July care conference, despite a change in condition since then. During an interview with DNS #2 on 11/6/24 at 4:06 PM the palliative care and advance care planning conversations noted throughout the hospital Discharge Summary dated 10/4/24 were reviewed. DNS #2 identified an RN supervisor or SW #1 should have followed up with the resident representatives regarding goals of care since admission back to the facility. Interview on 11/7/24 at 4:05 PM with SW #1 identified she wrote a readmission note on 10/16/24 after going to see Resident #3 but did not follow up with the resident representatives since Resident #3's readmission to the facility, despite Resident #3's severe cognitive impairment. SW #1 identified there are a lot of nursing areas discussed during care conferences and indicated it would have been important for her to be present for the meeting to support the resident representatives in a discussion related to goals of care.

Based on observation, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #209) reviewed for pressure ulcers, the facility failed to follow infection control practices when providing wound care. The findings include: Resident #206 was admitted in October of 2024 with diagnoses that included complete paraplegia, osteomyelitis of the sacral, sacrococcygeal region, pressure ulcer right buttock stage 4, pressure ulcer left buttock stage 3. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #206 was cognitively intact (brief interview for mental status (BIMS) score of 14), required set up assistance for eating, partial moderate to dependent assistance for dressing, was dependent for transfers and toileting, independent for bed mobility and had an indwelling catheter for urinary drainage. The Resident Care Plan dated 10/21/24 identified Resident #206 was at risk for skin integrity and was admitted to the facility with a left buttock stage 3 pressure ulcer and a right buttock stage 4 pressure ulcer which since merged into 1 large wound measuring: 10.5 centimeters (cm) by 5cm by 3cm. Interventions included to follow facility skin care protocol, physical therapy (PT)/Occupational therapy (OT) consultation for positioning, measure and document any areas on admission, preventative measures in place, reposition as it meets the resident needs, dietary consult as needed, report any new areas to physician, nurse, nurse practitioner (APRN), pressure redistribution devices as ordered, treatment as ordered, record any new changes to physician, nurse, and air mattress set at 110 per protocol to offload pressure. A Nurse's Note dated 10/25/24 at 12:57 PM identified in part, a right gluteus stage 4 pressure ulcer with full thickness skin and tissue loss which was present upon admission to the facility and included measurements of 10.5cm by 5cm by 2.5 cm with undermining at 10 o'clock and 3 o'clock. The note identified a wound bed of 70% granulation (healthy tissue), 20% slough (layer of dead tissue) 0% eschar (dry dead tissue) and heavy serosanguinous exudate (clear drainage mixed with blood). A Physician Progress Note dated 10/24/24 at 5:10 PM identified a consultation for evaluation and management of the wound. The note identified this was the first evaluation of the wound which was present on admission to the facility for osteomyelitis (infection in the bone) of the sacral area and had been treated with long term intravenous antibiotics. The note identified wound measurements as follows: coccyx stage 4 pressure ulcer: 6cm by 4cm by 1.5cm with undermining at 3 o 'clock to 10 o 'clock measuring 2cm with a wound base of 75% granulation, 25% slough and a large amount of serosanguineous exudate, left buttock stage 3 pressure ulcer: 3.2cm by 2cm by 0.2cm with 75-99% epithelial tissue and a moderate amount of serosanguinous exudate. Observation of a dressing change performed by LPN #3 on 11/6/24 at 10:30 AM, identified LPN #3 performed hand hygiene prior to donning gloves and removed a dirty dressing to the left buttock wound. She then wet the old stuck dressing with normal saline for removal and cleansed the wound with normal saline. LPN #3 then cleansed the wound bed with Dakin's solution. LPN #3 did not provide a clean field to perform further wound care and application of a new clean dressing. The surveyor intervened prior to LPN # 3 beginning preparation of a clean dressing and reminded LPN #3 to remove dirty gloves, perform hand hygiene and don clean gloves. LPN #3 verbalized understanding, performed hand hygiene and then failed to apply clean gloves. LPN #3 then opened the dressing (xeroform gauze), cut the dressing with scissors and then covered the wound with an adherent dressing, all without the benefit of wearing gloves. Interview with LPN # 3 on 11/6/24 at 11:00 AM identified that she did not know the dressing change policy and identified she should have changed her gloves and performed hand hygiene after removing the dirty dressing and before preparing the clean dressing. LPN #3 further identified she did not clean the scissors she used to cut the clean dressing that she applied directly to the wound bed. LPN #3 identified she should have cleansed the scissors prior to cutting the clean dressing and she should have worn gloves when touching the clean dressing. Review of the wound care policy directed, in part, use a disposable cloth to establish a clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. Put on gloves and remove dressing, pull glove over dressing and discard. Wash and dry your hands thoroughly, put on gloves using a no touch technique, pour liquid solutions directly on gauze sponges on their papers. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over wound. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Dress the wound by picking up the sponge by the paper and apply directly to the area. Be certain all clean items are on the clean field.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to obtain the resident's weight in a safe manner while utilizing the mechanical lift and as a result, the resident fell out of the lift and sustained a head injury. The finding includes: Resident #1's diagnoses included neurocognitive disorder, cerebral infarction (stoke) with residual hemiplegia (paralysis of one side of the body). A Quarterly MDS assessment dated [DATE] identified Resident #1 had severe cognitive impairment and was dependent for transfers. The RCP dated 12/19/2023 identified Resident #1 required assist with transfers. Interventions directed Hoyer lift transfers with two (2) staff. A physician order dated 1/18/24 directed assist of two (2) for Hoyer lift transfers. Review of the facility incident report dated 1/31/2024 at 4 PM identified Resident #1 sustained a fall, hit his/her head during a Hoyer lift transfer and sustained a laceration to the back of the head. Resident #1 was transferred to the hospital for evaluation. A nursing note dated 2/1/2024 identified Resident #1 returned to the facility at 4:00 AM from hospital via stretcher with two (2) staples to the back of head that were intact with no bleeding. Review of facility documentation and interview with NA #1 on 2/22/2024 at 11:09 AM identified Resident #1 required a Hoyer lift for transfers. On 1/31/2024, when NA #1 and NA #2 transferred Resident #1 from the wheelchair to bed and they needed to obtain the resident's weight. NA #1 was guiding Resident #1 as he/she was lifted out of the wheelchair. NA #1 then pushed the wheelchair back and let go of Resident #1 while he/she was suspended over the floor to obtain the weight. NA #1 indicated when she let go of Resident #1 and was looking at the scale, Resident #1 pushed with his/her foot against the front bar (perpendicular to the floor) of the Hoyer lift, and the resident flipped over backwards onto the floor. NA #1 further indicated all resident weights using a Hoyer lift are usually obtained when the resident is suspended above the bed, but she did not think to wait to obtain the weight until Resident #1 was over the bed. Although attempted, an interview with NA #2 was unable to be obtained during the survey. Review of the clinical record and facility documentation during an interview with the Administrator and DNS on 2/22/2024 at 11:55 AM identified the NAs should have obtained the resident weight while Resident #1 was over the bed, not when he/she was in the Hoyer over the floor. Interview with the Administrator identified the facility did not have a Hoyer lift weight policy. The facility Lifting Machine, Using a Mechanical Policy directed in part, while using a mechanical lifting device to gently support the resident as he/she is moved.

Based on review of the clinical record, review of facility documentation, review of facility policy and staff interviews for one of five sampled residents reviewed for accidents (Resident #23) the facility failed to transfer the resident as directed by physician to prevent an accident that resulted in injury. The findings include: 1. Resident # 23's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A quarterly MDS assessment dated [DATE] identified Resident # 23 had mildly impaired cognition and required extensive assistance of two (2) people for transfers. The Resident Care Plan (RCP) revised on 12/13/17 identified Resident # 23 had general weakness and was at risk for falling. Interventions included to provide the assistance of two people using the sit to stand lift for all transfers including toileting. Nurse's note dated 12/16/17 at 12:00 PM identified Resident # 23 fell to the floor while being transferred with the sit to stand lift. Nurse's note further identified that as a result of the fall Resident # 23 sustained swelling of the left knee, was unable to straighten his/her leg, and was transferred to the ED for further evaluation. Nurse's note dated 12/16/17 at 8:43 PM identified Resident # 23 had been admitted to the hospital with [REDACTED]. Hospital discharge summary dated 12/21/17 identified Resident # 23 sustained a fractured femur and fractured fibula as a result of a fall from a lift at the facility. Hospital discharge summary further identified Resident # 23 was admitted to the hospital on [DATE], received a surgical repair of his/her femur on 12/17/17 and was discharged from the hospital back to the facility on [DATE]. Review of RE documentation identified NA # 1 transferred Resident # 23 alone using the sit to stand lift when Resident # 23 slid off the lift and fell to the floor. Interview with NA #1 on 2/28/18 at 11:46 AM identified he/she was caring for Resident # 23 on 12/16/17 when Resident # 23 sustained a fall. NA #1 identified he/she had attempted to transfer Resident #23 alone when Resident #23's feet slipped off the platform of the sit to stand lift and Resident #23 fell to the floor. NA #1 identified that although he/she was aware that Resident # 23 required the assistance of two people for transfers, NA #1 attempted to transfer Resident #23 alone because no other staff was available to assist with the transfer. NA #1 further identified in addition to transferring Resident # 23 alone, he/she had placed a pillow on the platform of the sit to stand lift for Resident #23 to stand on during the transfer. NA #1 identified he/she had placed the pillow on the platform per the request of Resident #23. NA #1 further identified Resident #23 requested the pillow be placed on the platform because his/her feet could not reach the platform. NA #1 further identified he/she had used the pillow on the platform of the sit to stand lift on previous transfers of Resident #23. Interview with RN #1 on 2/28/18 at 12:20 PM identified he/she was the supervisor on duty on 12/16/17 when Resident #23 sustained the fall. RN #1 identified NA #1 reported using a pillow with the sit to stand lift. RN #1 further identified that he/she recalled telling NA #1 that he/she should have asked the nurse and/or a NA for assistance with the transfer and that the transfer of Resident #23 should have been done with the assistance of two people. Review of facility documentation identified NA #1 had been deemed competent in the use of the sit to stand lift on 3/20/17. Further review of facility documentation identified NA #1 had attended the facility's NA competency fair that was held on 6/22/17 which included the use of mechanical lifts. Review of facility policy identified two caregivers must perform the transfer of all mechanical lifts.

Based on review of the clinical record, facility documentation, and interview for one of five sampled residents reviewed for accidents (R#139), the facility failed to ensure the wheelchair leg rest was attached appropriately and/or care plan interventions for leg protectors were in place to prevent an injury. The findings include: Resident #139 [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified moderate cognitive impairment, total dependence for transfer and noted the resident did not ambulate. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Reportable Event dated 4/29/13 at 5:00 PM identified the resident was found slumped down in the wheelchair with the right leg rest out of the locked position. A bleeding laceration was noted on the resident's right calf. The Physician, who was in the building, was notified. The physician progress notes [REDACTED]. The physician's orders [REDACTED]. Interview and review of the clinical record and the Reportable Event on 2/18/13 at 10:15 AM with the DNS identified the leg rest was found unlatched and swinging at the time of the incident. The DNS indicated that due to lower extremity edema the resident had fragile skin. The DNS concluded that the injury occurred when the resident slid from the wheelchair scraping the uncovered right calf on the unlocked right leg rest. The resident was provided with a new wheelchair and the NAs were in serviced on ensuring leg rests are appropriately locked in place.