Every finding on record at Alden of Waterford

Based on observation, interview, and record review the facility failed to ensure a resident received restorative walking services. This applies to 1 of 3 (R1) residents reviewed for restorative services in the sample of 3. The findings include: R1's face sheet shows he has diagnoses including COPD, hypertensive heart disease, type 2 diabetes, chronic venous ulcers to bilateral lower extremities, PVD, history of falling, and heart disease. On 1/26/26 at 9:45 AM, R1 was sitting in his wheelchair he said he is going out for an outpatient appointment this morning. A rolling walker was in his room against the wall. At 1:50 PM, R1 was in his wheelchair in the activity room. R1 said his therapy was discontinued due to his insurance coverage. R1 said he has a walker in his room, and he walks sometimes by himself because staff don't offer to walk with him. On 1/26/26 at 10:21 AM, V4 (RN) said R1 is alert and oriented, compliant with care, has a walker, but she has not seen him walk often. V4 said she does not see restorative staff daily and she does not know when or how often they work with residents.On 1/26/26 at 11:40 AM, V5 (Restorative Nurse) said residents are assessed on admission and quarterly for restorative services. When a resident is discharged from therapy, we receive the recommendations and continue the goals into their restorative program. We do not have designated restorative aides, and the unit managers should be assisting with restorative services, and the floor CNAs are usually the ones who will walk with the residents. R1 should be on a walk to dine program. She was not aware of R1 not receiving those services and said there are a lot of refusals documented. Staff should report a pattern of refusals, and she was not aware of R1 refusing this service. On 1/26/26 at 12:36 PM, V3 (Wound Nurse) said R1 is alert and oriented x3, he goes to the dining room for meals, he self-propels himself in his wheelchair. On 1/26/26 at 1:45 PM, V7 (Certified Nursing Assistant-CNA) said he is not sure who does restorative services for residents. The floor CNA's don't do it. R1 does not walk because of his legs. R1's Restorative Nursing assessment dated [DATE] shows R1 is on a restorative walking program. R1 should walk to and from the dining room for meals with rolling walker and wheelchair to follow. R1's Nursing Rehab Walking report dated 1/13/26 to 1/26/26 shows 11 of 14 days he did not receive restorative walking services. R1's care plan shows he requires assistance with ambulation. Intervention includes place in walk to dine program, assist resident with ambulation. The care plan does not include R1 has refusals prior to 1/26/26.The facility's Restorative Nursing Program states, It is the policy of this facility that a resident is given the appropriate treatment and services to maintain or improve his or her abilities.All residents will be assessed on admission, as change of condition warrants and quarterly thereafter for participation in the Restorative Nursing Program. An individualized program will be developed based on the residents needs as appropriate. The programs will be reflected on the interdisciplinary care plan and consistently carried out by staff.

Based on observation, interview, and record review, the facility failed to provide necessary care and treatment for residents with vascular ulcers. This applies to 2 of 3 residents (R1, R2) reviewed for quality of care in the sample of 3. The findings include: 1. On 1/26/26 at 9:48 AM, V3 (Wound Nurse) provided wound care to R2's vascular wound. R2 was lying in his bed with bilateral protective boots in place. R2's right lower extremity did not have a dressing in place, his right leg was discolored, reddened, with two open areas to the lower leg. V3 cleansed the skin with wound cleanser, applied xeroform, gauze wrap and elastic bandage. R3's left lower leg was reddened and discolored, V3 applied the elastic bandage to his left lower leg. On 1/26/26 at 10:00 AM, R2 said his right leg had a dressing on until recently when he had his shower they removed the dressing. R2 said he had his shower yesterday. On 1/26/26 at 10:30 AM, V3 said she did not know R2's dressing was removed. If a dressing, gets removed it should be re-applied. V3 said maybe the staff removed it when he had his shower yesterday. V3 confirmed R2 received his shower yesterday.R2's Wound Physician Progress note dated 1/23/26 shows right calf venous ulcer measuring 1.5 cm (centimeters) x 0.6 cm x 0.1. Granulation and color: 90% red, 10% pink with light serous drainage. The treatment orders include cleanse with normal saline, apply xeroform, 4x4 gauze, absorbent pad and gauze kerlix dressing and secure with elastic bandage. R2's Physician Order Sheets dated January 2026 shows orders including ace wraps to bilateral lower extremities may remove for ADL care, every shift on in the morning and remove at night. 2. On 1/26/26 at 9:45 AM, R1 was sitting in his wheelchair with his feet resting on the ground. R1's bilateral leg dressings were visible at the end of his pant legs. R1 was wearing shoes without shoelaces and moderate edema to his lower legs, ankles and feet. R1 said he was going out to his outpatient appointment for his legs. R1 said he has burning sensations and pain in his lower legs. At 1:50 PM, R1 was in the activity room, he was sitting in his wheelchair wearing shorts. Gauze wraps and elastic bandages were in place to his lower legs with visible swelling to his lower legs.R1 said he removes the shoelaces so his feet can fit in the shoes. R1 said he does not have a chair to recline in to elevate his legs. R1 said when he is in the wheelchair he rests his feet on the bed in the lowest position. R1 said he would like a reclining wheelchair so he can elevate his legs. On 1/26/26 at 10:21 AM, V4 (RN) said R1 is alert and oriented, he has more swelling and pain in his lower legs. We lower his bed to the lowest position and have his legs on the bed for his swelling. On 1/26/26 at 12:01 PM, V3 (Wound Nurse) said R1 has a chronic history of pain and swelling to his lower legs and has multiple co-morbidities that can affect his edema, including CHF, and kidney disease. His legs get better for a while then get worse. He is at his worst. R1's left leg is more swollen with increased discoloration; he scratches sometimes causing lacerations to his legs. We have educated him on lowering his bed to lowest position and place his feet up. On 1/26/26 at 2:03 PM, V2 (DON) said R1 has vascular wound with increased swelling to his legs. We want him to elevate his legs. R1 said it's difficult for him to elevate his leg when he is in bed. When his feet are resting on the bed in the lowest position his legs are still in a dependent position, not elevated. Increased swelling in the legs could cause weeping, blisters and shortness of breath. V2 said R1 does not have interventions in place to elevate his legs. R1's Wound Physician Progress notes dated 1/23/26 shows (R1) complains of pain to both legs, associated with swelling and redness, both feet mid edema and warm. R1's left leg venous ulcer measuring 4 cm x 4 cm x 0.1 cm. Granulation and color: 90% red, peri wound: warm, erythema, light serosanguineous drainage, infection: cellulitis. Right leg venous ulcers measuring 4 cm x 2 cm x 0.1 cm, 100% red, warm, erythema, and light serosanguineous drainage, infection: cellulitis. 2nd right leg venous ulcer measuring 2 cm x 4.8 cm x 0.1 cm, 30 % red, 10% yellow slough, warm, erythema, and light serosanguineous drainage. Plan of care: leg elevation discussed with patient. R1's current care plan shows he has skin ulcerations related to cellulitis of the lower limbs and venous ulcers with interventions including inspect skin daily with cares, monitor wound related to pain, compression therapy, leg elevation, lubricate dry skin and ambulate as tolerated. The facility's Prevention and Treatment of Pressure Injury and other Skin Alterations states, non-pressure skin alterations i.e.: skin tears, diabetic ulcers, surgical wounds, MASD, lesions and rashes will be documented weekly on a skin progress note.develop a plan of care for either actual or potential alteration in skin integrity.implement preventative measures and appropriate treatment modalities for pressure injuries and/or skin alterations through individualized resident care plan.

Based on interview and record review the facility failed to ensure expired medications were not stored in their medication dispensing machine for 1 of 3 residents (R1) reviewed for medications in the sample of seven.The findings include:The Lab Progress Note for R1 dated 12/4/25 at 7:03 PM showed, V4 (R1's daughter) stated she spoke with V3 Nurse Practitioner NP regarding increased temperature 100.2 degrees Fahrenheit at this time. Per V4, V3 will order intravenous IV antibiotic Imipenem. Will endorse to night shift to carry out order and administer.The Physician's Orders for R1 showed Imipenem-Cilastatin Intravenous Solution 500 MG, use 1 dose IV one time daily for febrile illness was ordered on 12/5/25 to start on 12/5/25.R1's Medication Administration Record dated December 2025 showed he had Imipenem-Cilastatin Intravenous Solution 500 MG ordered to be given on 12/5/25 at 6:00 AM and showed a 9 documented at that time which meant to see progress notes.The Progress Notes for R1 showed, 12/5/25 at 7:14 AM - Imipenem-Cilastatin Intravenous IV solution 500 MG, use 1 dose IV one time a day for febrile illness until 12/13/25 - not available.The electronic Medication Administration (eMAR) Order Note dated 12/5/25 at 7:15 AM showed the order for Imipenem-Cilastatin Intravenous IV solution 500 MG, use 1 dose IV one time a day for febrile illness until 12/13/25 - not available.The Progress Note dated 12/5/25 at 8:04 AM showed R1 was sent to the emergency room per V4's request.On 1/11/25 at 1:35 PM, V2 Director of Nursing - DON stated, V2 stated the day that R1 had a temperature of 100.4 degrees V4 (R1's daughter and Nurse Practitioner) wanted him started on antibiotics immediately. V2 stated they usually would assess and monitor a resident, give medication for a fever, and obtain orders for in house treatment. V2 stated an antibiotic is not usually ordered as an initial treatment. V2 stated V4 wanted an antibiotic ordered and spoke to V3. The antibiotic was to be given on 12/5/25 in the morning. V2 stated the dose that they had in the medication dispensing machine was expired so it could not be given right away. The antibiotic would have been given in the afternoon after it was delivered by pharmacy. V2 stated because the facility couldn't give R1 the antibiotic that morning; V4 wanted him sent to the hospital. V2 stated the medication dispensing machine is maintained by pharmacy and pharmacy is supposed to keep track of the expiration of the medications. V2 stated they don't have the ability to check the dates of the medication until the nurse pulls the medication. The medication sent for restock is done automatically by the pharmacy. V2 stated she did not talk to pharmacy as to why the antibiotic in the machine was expired. V2 stated if a medication is ordered and not in stock, the nurse will check the medication dispensing machine. If it is one of the medications in the machine, then it is taken from there and given. If the medication is not in the machine, then it is given after the medication is received from the pharmacies next delivery.The facility's Automated Medication Storage System policy (7/2015) showed, Medication Outdating: 1. The pharmacy will perform an inventory and/or outdating of the medications residing in the automated medication storage system on a monthly basis. 2. The pharmacy will send replacement storage units filled with those medications due to expire at the facility. 3. Soon to be outdated medications will be returned to the pharmacy in a return tote.

Based on interview and record review, the facility failed to provide showers as scheduled. This applies to 2 of 2 residents (R1 and R3) reviewed for improper nursing in the sample of 5. The findings include: 1.R1's EMR (electronic data sheet) showed that R1 was admitted to facility on April 18, 2024, with multiple diagnoses including chronic diastolic (congestive) heart failure, paraplegia, schizoaffective disorder, depressive type, morbid (severe) obesity due to excess calories, hypertensive heart disease with heart failure.R1's quarterly MDS (minimum data set) dated October 8, 2025, showed that R1 was cognitively intact and was dependent on staff for showers/bathing.On November 14, 2025, at 11:45 AM, R1 was lying in bed in a hospital gown and stated that she needed assistance of one CNA (Certified Nursing Assistant) for bed baths, R1 stated From what I hear from the CNA's that they don't schedule enough staff. I get bed baths. I am supposed to get showers on Wednesdays and Sundays. The CNAs are darling but there is not enough of them.R1's shower intervention task report showed that R1's showers were scheduled on Wednesday and Sunday evenings. The same reports from October 01-November 14, 2025, were reviewed along with additional shower sheets that were provided by the facility. Based on this information, R1 missed showers on the following scheduled shower dates in October and November 2025: October 8 (Wednesday), October 22 (Wednesday), October 26 (Sunday), November 9 (Sunday). This information showed that R1 did not have a shower for 9 days consecutively from October 20-October 28, 2025. 2. R3's EMR showed that he was readmitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, altered mental status.R3's quarterly MDS dated [DATE], showed that R3 was moderately impaired in cognition and was dependent on staff for toileting and shower/bathing. On November 14, 2025, at 12:07AM, R3 was sleeping in his bed and did not respond to queries. R6 (R3's spouse) who shared his room stated that R3 sleeps a lot and may not be alert enough to respond adequately. R6 stated that she is in the room [ROOM NUMBER]/7 with him and knows what care he receives. R6 stated that R3 gets a bed bath and that he should get one weekly at least but it does not happen. R3's shower intervention task report showed that R3's showers were scheduled on Monday (days) and Friday (evenings). The same reports from October 1-November 14, 2025, were reviewed along with additional shower sheets that were provided by the facility. Based on this information, R3 missed showers on the following scheduled shower dates in October and November 2025:October 13, 2025 (Monday), October 20, 2025 (Monday), October 24, 2025 (Friday), October 31(Friday), November 3 (Monday), November 7 (Friday). This information shows that R3 did not receive showers for 9 days consecutively between October 17 to October 26, 2025, and for an additional 9 days consecutively between November 1 to November 9, 2025.On November 14, 2025, at 3:33 PM, V2 (Director of Nursing) stated that the regulation denotes that the residents are required to have showers once a week. V2 stated that the facility offers showers twice a week. V2 added that the facility goal is that if the shower is scheduled, the resident should receive their showers. Facility Policy and Procedure titled Bath, Tub or Shower (09/20) included:Policy:1. To provide cleanliness and comfort to the resident. 2.To assist the resident in bathing. 3. To prevent body odors. To stimulate circulation and provide a mild form of exercise. 5. To observe the resident's skin condition. Procedure: 6. Assist the resident into the tub or shower.7. Encourage the resident to do as much of his/her own care as possible; supervise and assist as necessary.

Based on interview and record review, the facility failed to notify local law enforcement after an allegation of physical abuse. This applies to 1 of 3 residents (R1) reviewed for physical abuse in the sample of 3. The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure, chronic kidney disease, and pulmonary hypertension. R1's MDS (Minimum Data Set) dated June 12, 2025, showed R1 was cognitively intact. The facility's final report dated August 30, 2025, completed by V1 (Administrator) showed, . On August 24, 2025, it was reported to the Administrator by the nurse on duty that [R1] believes she was 'smacked in the face' by her CNA. CNA was suspended pending investigation. Body check was completed with no new findings, no bruising, no swelling, no alterations to her face. Physician notified. [R1] and Daughter were informed of investigation process. The [local police department] responded to the facility on August 27, 2025, and conducted interviews. On September 3, 2025, at 11:33 AM, V1 said R1's allegation was reported to her in the morning of August 24, 2025. V1 said she spoke with R1 and her daughter on August 24, 2025, and V1 told them she would be filing a report with the state agency. V1 said on Wednesday, August 27, 2025, the police arrived at the building because the family called to file a report. V1 said she did not call the police after receiving R1's allegation of physical abuse. V1 said the only time she would call the police for an abuse allegation would be if the resident requested the police to be called. On September 3, 2025, at 2:15 PM, V1 said she should have notified the local police department immediately after she was notified of R1's allegation of physical abuse. The facility's policy titled Abuse Policy dated March 2025, showed Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. The facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: .7. Filing accurate and timely investigative reports. Abuse Prevention Program. 7. Reporting. g. If the events that cause the reasonable suspicion result in serious bodily injury, the report must be made immediately after forming the suspicion (but no later than two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming suspicion. For more information see crime reporting poster at the facility and call local police. On September 3, 2025, at 2:15 PM, V1 presented the facility's crime reporting poster. The poster showed If you have reasonable suspicion that a crime has occurred against a resident or person receiving care at this facility, federal law requires that you report you suspicion directly to both law enforcement and the state survey agency. If you believe the crime involves serious bodily injury including criminal sexual abuse to the resident, you must report it immediately, but no later than two hours after forming the suspicion. Or if the crime does not appear to cause serious bodily injury to the resident you must report it within 24 hours after forming the suspicion.

Based on interview and record review, the facility failed to notify the physician of a change in condition for a resident. This applies to 1 of 1 resident (R1) who was reviewed for a change in condition. Findings include: On 05/28/2025 at 8:35 AM, V10 (R1's family member) stated that on the evening of 05/22/2025, R1 experienced a change in condition and the facility did not notify the physician before a nurse increased oxygen from 2 liters to 4 liters via nasal cannula. On 05/28/2025 at 1:30 PM, V4 LPN (Agency-License Practical Nurse) stated that she worked with R1 for the first time and took the report from the morning nurse. She was not aware that she had not notified the provider. V4 said the staff involved in assessing R1 said being lethargic is R1's baseline. When R1 was excessively sweating and his oxygen saturation was at 89 percent around 9:00 PM, V10 arrived and requested that R1 be transferred to the hospital. V4 said she called 911 and transferred R1 to the hospital. On 05/28/2025 at 6:00 PM, V3 (LPN) said she worked from 7:00 AM to 7:00 PM, and the incident happened during the turnover of shift. V3 said she assessed R1 along with V4, and took vital signs, which were per his baseline, and then endorsed to V4 since her shift had ended. On 05/22/2025 at 3:11 PM, V7 NP (Nurse Practitioner) stated that she was on call for the facility and did not receive any calls regarding R1's change in condition and transfer to the hospital. On 05/22/2025 at 12:09 PM, V2 (Director of Nursing) stated that it's a standard policy guideline to notify physicians of changes in conditions and any new orders. On 05/22/2025 at 5:28 PM, V8 (R1's NP) stated that they did not hear anything about R1's condition and that the facility should have followed the notification protocol, despite R1's vital signs being at baseline, or R1's previous hospital admissions for failing lungs condition and lethargy. R1's EMR (Electronic Medical Records) shows R1 was a [AGE] year-old male admitted to the facility on [DATE], and R1's diagnoses include acute and chronic respiratory failure with low oxygen and high carbon dioxide, chronic obstructive pulmonary diseases, multiple cardiac diseases, stage five chronic kidney/end-stage renal disease, anemia, hemiplegia, and hemiparesis, and dependence on supplement oxygen. R1's Minimum Data Set indicated that R1's cognition was intact. The facility's clinical practice guidelines on Change in Condition, dated September 2020, indicated that the attending physician or physician/Nurse Practitioner on call will be notified of any change in condition. Under the 'Vital Signs section, showed that oxygen saturation below 90 percent should be reported immediately.

Based on the interview and record review, the facility failed to immediately assess a resident after a reported change in condition. This applies to 1 of 5 residents (R1) who was reviewed for quality of care. Findings include: R1's EMR (Electronic Medical Records) shows R1 was a [AGE] year-old male admitted to the facility on [DATE], and R1's diagnoses include acute and chronic respiratory failure with low oxygen and high carbon dioxide, chronic obstructive pulmonary diseases, multiple cardiac diseases, stage five chronic kidney/end-stage renal disease, anemia, hemiplegia, and hemiparesis, and dependence on supplement oxygen. R1's Minimum Data Set indicated that R1's cognition was intact but dependent on staff for activities of daily living. On 05/28/2025 at 10:45 AM, R2 (R1's spouse) said R1 was sick in the evening of Thursday (05/22/2025), and V3 LPN (Licensed Practical Nurse) did not come to check on him when V5 CNA (Certified Nursing Assistant) called her for R1's lethargy and not eating his meals. R2 said she called V10 (R1 and R2's family). On 05/28/2025 at 2:01 PM, V5 (CNA) said on 05/22/2025 around 6:30 PM when she took the meal tray to R1's room, she was not able to wake him up, and she reported to V3 (LPN), V3 and V4 (Agency-LPN) did not assess R1 until around 7:00 PM. On 05/28/2025 at 12:09 PM, V2 (Director of Nursing) stated that on 05/22/2025 around 7:00 PM, V10 (R1's family) called her regarding R1's condition, and V2 advised V3 to check on R1. On 05/28/2025 at 6:00 PM, V3 said she worked from 7:00 AM to 7:00 PM, and the incident happened during the turnover of shift, and she assessed R1 along with V4 around 7:00 PM. On 05/28/2025 at 1:30 PM, V4 confirmed during the turnover of the shift around 7:00 PM on 05/2/2025, V2 called V3 to check on R1 and both went to R1's room to assess. A review of the R1's clinical document revealed that neither change of condition assessment documentation was completed nor was the change of condition assessment form filled out before transferring R1 to the hospital. On 05/22/2025 at 4:00 PM, V2 (Director of Nursing) stated that it's the facility's standard protocol to attend to residents when changes in conditions are reported and complete the change of conditions assessment form.

Based on interview and record review, the facility failed to submit accurate licensed nurses working hours, for the PBJ (Payroll Based Journal) submission for the months of July, August and September 2024. This applies to all 75 residents who reside in the facility, according to form 671 dated March 24, 2025. The findings include: The CASPER (Certification and Survey Provider Enhanced Reporting) for the facility's Quarter 4, 2024, showed for the metrics, no RN hours and Failed to have Licensed Nurse coverage 24 hours /day, infraction dates of every day from July1, 2024 through September 30, 2024. On March 24, 2025, at 3:30 PM, V1 (Administrator) stated the PBJ hours are submitted from the payroll data through the corporate office. V1 acknowledged that the hours for licensed nurse staffing for the facility for Quarter 4 were not accurately reported. V1 provided documentation of email communication between the corporate office, and HFS (Department of Healthcare and Family Services) dated December 23, 2024, identifying the error in PBJ data submission for CNA (Certified Nursing Assistant) hours, in light of the corporations CNA subsidy program. DHS representative responded on January 15, 2025, informing the corporate office that DHS does allow a one time correction submission for PBJ data. There was no reference in the emails to identify the error in the reporting of licensed Nurse hours for Quarter 4. The facility's PBJ Staffing Data Report, CASPER Report 1705D, FY Quarter 2 2024, (July 1-September 30) run on February 13, 2025, showed the facility triggered for No RN Hours, and Failed to have Licensed Nursing Coverage 24 hours /day. The facility policy titled Staffing Data Submission dated January 14, 2024, showed Policy .will electronically submit direct care staffing information .Staffing information will be submitted timely using the CMS Payroll Based Journal .Guidance 1 .will electronically submit the CMS complete and accurate direct care staffing information that includes the following: a. The category of work for each direct care staff includes but not limited to whether the individual is a registered nurse, licensed practical nurse, .or other as specified by CMS.

Based on observation, interview and record review the facility failed to ensure accurate and timely accounting of controlled medications. This applies to 7 of 7 residents (R2, R18, R21, R24, R48, R69 and R234) reviewed for controlled medications in the sample of 18. The findings include: 1. On March 26, 2025 at 11:25 AM, the first floor AB medication cart was observed with V2 (Director of Nursing). The following observations were made of the medication cart's controlled drug compartment: - R69 had a blister pack of Alprazolam 0.5 mg (milligrams) with 47 tablets remaining that were intact and sealed. R69's controlled drug receipt/record/disposition form for the Alprazolam 0.5 mg showed that there should be 48 tablets remaining in the blister pack. R69's medication administration audit report showed that V17 (Licensed Practical Nurse) administered this medication at 9:28 AM on March 26, 2025. - R234 had a blister pack of Modafinil 200 mg with 29 tablets remaining that were intact and sealed. R234's controlled drug receipt/record/disposition form for the Modafinil 200 mg showed that there should be 30 tablets remaining in the blister pack. R234's medication administration audit report showed that V17 administered this medication at 10:37 AM on March 26, 2025. On March 26, 2025 at 11:29 AM, V17 was asked why the actual number of the controlled medications, and the controlled drug receipts does not match. V17 stated that she did not sign out the medication on the controlled drug receipt after taking it out and administering the medications to the residents, because she was busy preparing the medications for other resident who was going out for a medical appointment. V2 who was present during the interview stated the controlled medications should be signed out from the controlled drug receipt after it is pulled out/taken out of the blister pack to ensure proper count. Review of the first floor AB medication cart controlled substance shift count documentation showed that the on duty/in coming Nurse for March 26, 2025 did not sign the form to indicate that she performed the shift count with the off duty/outgoing nurse. On March 26, 2025 at 11:30 AM, V17 stated that she performed the controlled substance shift count with the outgoing nurse prior to the start of her shift but failed to sign the form. V17 added that there were no discrepancies during the controlled substance shift count. V2 who was present during the interview stated that the incoming and outgoing nurses should sign the controlled substance shift count form, after performing the controlled medication count before the start of each shift, to make sure that all the controlled medications are accurate, matching the actual controlled medication at hand and the controlled drug receipt. 2. On March 26, 2025 at 11:55 AM, the second floor CD medication cart was observed with V2. The following observations were made of the medication cart's controlled drug compartment: - R24 had a blister pack of Alprazolam 0.5 mg with 13 tablets remaining that were intact and sealed. R24's controlled drug receipt/record/disposition form for the Alprazolam 0.5 mg showed that there should be 14 tablets remaining in the blister pack. R24's medication administration audit report showed that V18 (Registered Nurse) administered this medication at 12:00 PM on March 26, 2025. - R21 had a blister pack of Morphine Sulfate 30 mg ER (extended release) with 35 tablets remaining that were intact and sealed. R21's controlled drug receipt/record/disposition form for the Morphine Sulfate 30 mg showed that there should be 36 tablets remaining in the blister pack. R21's medication administration audit report showed that V18 administered this medication at 11:07 AM on March 26, 2025. - R18 had a blister pack of Clonazepam 1 mg with 59 tablets remaining that were intact and sealed. R18's controlled drug receipt/record/disposition form for the Clonazepam 1 mg showed that there should be 60 tablets remaining in the blister pack. R18's medication administration audit report showed that V18 (Registered Nurse) administered this medication at 10:27 AM on March 26, 2025. - R48 had a blister pack of Hydrocodone/Apap (acetaminophen)10-325 mg with 28 tablets remaining that were intact and sealed. R48's controlled drug receipt/record/disposition form for the Hydrocodone/Apap 10-325 mg showed that there should be 29 tablets remaining in the blister pack. R48's medication administration audit report showed that V18 administered this medication at 11:23 AM on March 26, 2025. - R2 had a blister pack of Phenobarbital 1 gr (grain) with 50 tablets remaining that were intact and sealed. R2's controlled drug receipt/record/disposition form for the Phenobarbital 1 gr showed that there should be 51 tablets remaining in the blister pack. R2's medication administration audit report showed that V18 administered this medication at 8:45 AM on March 26, 2025. On March 26, 2025 at 12:01 PM, V18 was asked why the actual number of the controlled medications, and the controlled drug receipts does not match. V18 stated that she did not have the opportunity to sign the controlled drug receipt. According to V18 she gave the above mentioned controlled medications during the morning medication pass, except for R24 which she claimed she just gave. V2 who was present during V18's interview stated that the controlled medications should be signed out from the drug receipt immediately after pulling/taking it out from the blister pack to ensure proper accounting of the medication. The facility's policy regarding controlled drug documentation dated June 2022 showed under purpose, To maintain control and prevent loss and/or diversion of controlled substances. The same policy under the procedure showed in-part, 1. c. Proof of-use forms should be used to document each time a dose of the medication is administered.2. Controlled substances must be counted and verified every shift by authorized professionals, usually at shift change. Balances are documented on the Shift Count form and must be signed by both the incoming and outgoing staff. Any discrepancy between the number of controlled drugs on hand and the sheet's balance must be brought to the attention of the Resident Care/Nursing Director (or equivalent) immediately, following the facility's policy.

Based on observation, interview and record review, the facility failed to follow the menu extension sheet to serve portion sizes as shown for pureed and mechanical soft diets to meet the dietary requirements of the meal. This applies to 6 of 6 residents (R3, R27, R33, R59, R69, and R235) reviewed for dining in the sample of 18. The findings include: Facility menu for Spring Summer 2025 for Monday included Country Fried Steak with cream sauce, Mashed Potatoes, [NAME] Beans as the main meal items. The menu extension sheet for March 24, 2024 showed to use #6 scoop for ground country fried steak. The same extension sheet showed to use #6 scoop for pureed country fried steak and #8 scoop for the pureed beans. Facility portion control chart posted at the tray line service area showed that #6=5 1/3 oz/ounce, #8= 4 oz, and #10=3 oz. On March 24, 2024 at 12:00 PM, V6 (Chef) and V7 (Dietary Aide) were plating the food during the lunch meal tray line service on the 1st floor. V6 used a #8 scoop to serve ground country fried steak along with 2 oz gravy to R3, R27, R59, R69 and R235 who were on mechanical soft diets. V6 used a #8 scoop to serve pureed country fried steak and used a #10 scoop to serve pureed green beans to R33 who was on pureed diet. V5 (Dietary Manager) who was present at tray line was notified of the wrong scoop sizes used for the lunch meal. On March 25, 2025 at 12:19 PM, V9 (Dietitian) stated that the dietary staff should use the scoop sizes as shown on the menu spreadsheets to meet the adequate amount of protein, carbohydrates and calories for the planned meal. Facility Diet Type Report printed on March 24, 2025 showed that R3, R27, R59, R69 and R235 were on mechanical soft diets and that R33 was on pureed diet.

Based on observation, interview and record review, the facility failed to provide pureed consistency mashed potatoes and failed to avoid skin on potatoes for mechanical soft diets. This applies to 4 of 4 residents (R27, R33, R63 and R69) reviewed for mechanically altered diets in the sample of 18. The findings include: 1. Facility menu for Spring Summer 2025 for Monday, March 24, 2024 lunch meal included Country Fried Steak with cream sauce, Mashed Potatoes, [NAME] Beans, Dinner Roll. On March 24, 2024 at 12:04 PM, R33 received a pureed consistency meal of country fried steak, mashed potatoes, green beans and pureed bread. The mashed potatoes appeared granular. When asked how her meal was, R33 stated They are not pureeing the foods as much as they should. R33 stated that most of the items don't feel smooth as it usually does. On taste testing the pureed items, the mashed potatoes had granules that did not soften when manipulated on roof of mouth with the tongue and remained whole and needed to be chewed. This was relayed to V6 (Chef) who was on the tray line, and V6 also taste tested the same and agreed that there are granules in the mashed potatoes. V6 stated that the mashed potatoes are made from a powder and that more water should have been used to get a smooth product and then blended in a mixer. V6 added that V8 (Cook) who was new, prepared the mashed potatoes. Facility policy and procedure titled Puree (dated July, 2023) included as follows: Purpose: The puree diet consists of pureed homogenous, and cohesive foods in pudding-like consistency. Any foods that require bolus formation, controlled manipulation, or mastication are excluded. 2. Facility Spring Summer menus for Tuesday, March 25, 2025 lunch meal included Chicken Vesuvio with gravy, [NAME] Peas and Vesuvio Potato Wedges. On March 25, 2025 starting at 11:53 AM, R27, R63 and R69 who were on mechanical soft diets received Vesuvio potato wedges with skin on it along with the rest of the meal. When V5 (Dietary Manager), who was in the area, was asked if residents on mechanical soft were allowed potatoes with skin, V5 responded that the diet extension for the meal showed that they could have it. Review of the same showed an unsigned extension sheet by Dietitian that mechanical soft diets can have Vesuvio potato wedges. Facility policy and procedure titled Regular Ground/Mechanical Soft (dated July, 2023) included as follows: Purpose: The regular mechanical soft diet is for adults who have difficulty chewing. This diet is similar to the regular diet with some modifications to hard to chew foods Menu Guidelines for bread and starches included: Avoid potato skins On March 25, 2025 at 12:13 PM, V9 (Dietitian) stated that the pureed consistency should be like pudding or mashed potatoes that is smooth without lumps. V9 stated that the mechanical soft diets should not have potato skins. V9 stated that the menu spread sheet was marked in error that the mechanical soft can have Vesuvio Potato Wedges that had potato skin. V9 stated that the Corporate Dietitian plans and signs these menus. V9 reported back at a later time that the Corporate Dietitian only signs the first and last page of the 4 week cycle menus. Facility Diet Type Report printed on March 24, 2025 showed that R27, R63 and R69 were on mechanical soft diets and that R33 was on pureed diet.

Based on observation, interview, and record review, the facility failed to provide privacy during activities of daily living (ADL) care, blood glucose level check, and administration of insulin. In addition, facility also failed to ensure that medical record was protected. This applies to 3 of 18 residents (R48, R50, R60) reviewed for privacy in the sample of 18. The findings include: 1. On March 24, 2025, at 4:28 PM, during unit observation on the 2nd floor C/D hallway, a medication cart was parked in the hallway by the nurses' station, and near the seating area outside the dining room. On top of this medication cart was a computer that was left open with R48's information visible. The cart was unattended and people were passing by the cart. A few minutes later, V19 (Nurse) was seen coming out from one of the residents' bedrooms. 2. On March 24, 2025, at 4:55 PM, R50 was on his wheelchair by the seating area outside the dining room. V19 (Nurse/LPN) walked towards R50 to check his blood sugar level, leaving the medication cart with the computer wide open and with R50's health information or medical record visible to others who could pass by the medication cart. In addition, V19 checked R50's blood sugar with presence of 5 other residents and 2 visitors (family members of other residents) who were in the same area. The procedure was visible to others. At 4:59 PM, R50 remained where he was at, V19 administered insulin medications to R50 which was visible to the same residents and visitors. On March 26, 2025, at 12:23 PM, V1 (Administrator) stated if the staff is not with their cart, they must close or lock the computer screen prior to walking away. Resident information should be kept private. Whether there are people around or none, they should lock the computer screen. When staff nurse is checking blood sugar and administering medication shot such as insulin, they're supposed to do it in the privacy of the resident's room to provide privacy and dignity. 3. R60 had multiple diagnoses including vascular dementia with other behavioral disturbance and need for assistance with personal care, based on the face sheet. R60's quarterly MDS (minimum data set) dated January 9, 2025 showed that the resident was moderately impaired with cognition. The same MDS showed that R60 had functional limitation in range of motion to both sides of his upper and lower extremities and required total assistance from the staff with shower/bathing and lower body dressing, and maximum assistance from the staff with upper body dressing. On March 24, 2025 at 11:45 AM, upon entering the resident room, V12 (Certified Nursing Assistant) was observed putting on a disposable brief and clothing to R60 while the resident was in the shower bed. According to V12, he had just given a shower to R60 and had used the shower bed to transport the resident to the room. While the disposable brief and clothing were being put on R60, the privacy curtain was not drawn, and the resident was visible to R79 (roommate). R60 was alert, with confusion and speaks a foreign language. R79 was alert and oriented to witness the ADL (activities of daily living) care being given to R60. On March 26, 2025 at 9:33 AM, V2 (Director of Nursing) stated that during provision of personal care such as putting on a resident's brief and/or putting on a resident's clothing, privacy should always be afforded because the resident's body is exposed. The curtain should be drawn between the residents to ensure that the resident's rights to privacy during personal care is provided. The facility's policy regarding resident's rights dated November 2017 showed, The facility will respect and uphold resident's rights. The same policy showed in-part under procedure, 1. The resident or their representative will be notified of their rights as a resident living in a long-term care facility upon admission and will be provided a copy of the State issued residents' rights pamphlet indicating such rights. The Residents' Rights for people in long-term care facilities pamphlet given to each resident and/or their respective responsible party showed in-part, You have the right to .Privacy, your medical and personal care are private. 29562

Based on observation, interview, and record review, the facility failed to ensure that indwelling urinary catheter was not touching the floor and was not positioned above resident's bladder. This applies to 2 of 3 residents (R28, R78), reviewed for indwelling urinary catheter in the sample of 18. The findings include: Face sheet shows that R28 is a [AGE] year old who has multiple medical diagnoses including benign prostatic hyperplasia without lower urinary tract symptoms, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, obstructive and reflux uropathy, urinary retention, and malignant neoplasm of prostate. R28 has an indwelling urinary catheter upon observation. On March 25, 2025, at 10 :51 AM, V14 (Certified Nursing Assistant/CNA) and V15 (CNA/first floor unit manager), rendered incontinence care to R28 who had a bowel movement. V14 cleaned R28 from front to back and changed his incontinence brief. As V14 and V15 assisted R28 to turn and reposition during incontinence care, they lifted the urinary catheter bag multiple times above his bladder causing the urine in the catheter tube to flow back towards R28's bladder. R28's active care plan shows R28 requires the use of an indwelling catheter related to diagnosis of neuromuscular dysfunction of bladder due to obstructive and reflux uropathy. The same care plan shows interventions including positioning of collection bag below the level of the bladder. The nurse practitioner (NP) notes dated March 21, 2025, shows R28 was seen by infectious disease NP at the facility's request for acute urinary tract infection (UTI). The lab work was positive for >100,000 colonies of enterococcus species. On March 27, 2025, at 11:35 AM, V2 (Director of Nursing/DON) said that urinary bag should be maintained below the bladder so the urine can drain properly to the bag via gravity and prevent backflow of urine to the bladder which can cause infection. 2. R78 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, retention of urine, chronic kidney disease and history of UTI (urinary tract infection), based on the face sheet. On March 24, 2025 at 11:09 AM, R78 was in bed, with her bed on the lowest position. R78's urinary catheter bag which was inside a privacy bag was not attached/hooked on the bed frame. The privacy bag containing the urinary catheter bag was touching the floor. R78's urinary catheter tubing had dark yellow urine with brown sediments. V10 (Restorative Nurse) was present during this observation. On March 25, 2025 at 9:08 AM, R78 was in bed, alert but confused. R78's urinary catheter was draining slightly dark yellow colored urine with sediments. V2 (Director of Nursing) was in the room during this observation. V2 was informed of the privacy bag containing the urinary catheter bag that was observed touching the floor on March 24, 2025. V2 stated that even though the urinary catheter bag was inside a privacy bag, it should not touch the floor to maintain infection control and prevent UTI. 29562

Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician. There were 29 opportunities with 2 errors, resulting in a 6.9% medication error rate. This applies to 1 of 5 residents (R34) reviewed for medication pass in the sample of 18. The findings include: On March 24, 2025, at 4:49 PM, V19 checked R34's blood sugar level, which showed result of 207 mg/dl. V19 administered medications to R34 including Insulin Novolog (Aspart Kwik Pen) 4 units subcutaneously and a Sucralfate 1 gram tablet orally. At 5:01 PM, V19 stated that R34 is supposed to receive 17 units of Novolog according from the sliding scale order, but she felt uncomfortable to give this dose for fear that R34's blood sugar might bottom out. As a nursing judgement she decided to give 4 units. When surveyor asked V19 if she notified the physician about it, V19 did not say anything. After V19 administered the medications, she confirmed that what she gave to R34 were all the medications scheduled at 5PM. Then V19 went to the computer and signed it all in as given. R34's Medication Administration Record (MAR) dated March 2025, shows an order to inject Insulin Aspart according to the sliding scale which means the R34's blood sugar level and its corresponding dose of insulin. The sliding scale shows that if the blood sugar level is between 201 to 225, R34 should receive 17 units of Novolog. The same MAR shows that R34 has a scheduled Nystatin-Triamcinolone External Ointment to apply to R34's back topically twice a day at 9:00 AM and 5:00 PM. V19 did not administer this Nystatin-Triamcinolone ointment, however, V19 signed it along with the 2 medications (Novolog and Sucralfate) as given. R34's progress notes dated March 24, 2025, at 5:40 PM showed that V19 notified the nurse practitioner (NP) about the partial dose of Novolog that she administered to R34. Facility's Policy and Procedure for Medication Administration dated September 2020 shows: Policy: Medications will be administered in accordance with the established policies and procedures. Procedure: Drugs must be administered in accordance with the written orders of the attending physician.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices regarding hand hygiene and gloving during provisions of incontinence care. Staff also failed to wear a complete PPE (Personal Protective Equipment) in an isolation room while providing physical therapy. This applies to 2 of 18 residents (R28, R134), reviewed for infection control in the sample of 18. The findings include: 1. On March 25, 2025, at 10:51 AM, V14 (CNA) and V15 (CNA/first floor unit manager), rendered incontinence care to R8 who had a bowel movement. V14 cleaned R28 from front to back of the perineum, handled the urinary catheter, assisted R28 to turn and reposition, put on a new incontinence brief, handled soiled items (linen and diaper), straightened residents bed linen, and scoot resident up on his bed, and touched overbed table, while wearing the same soiled gloves. On March 26, 2025, at 3:18 PM, V2 (Director of Nursing/DON) stated that when a staff provides incontinence/peri-care to a resident, the staff must perform hand hygiene prior to gloving. When staff goes from dirty to clean tasks, they should change their gloves and perform hand hygiene. V2 also said that when the staff is done with the tasks and they remove their gloves, they should perform hand hygiene. This process is for infection control and ensuring that they are not spreading infection to others, and they are preventing cross contamination. The facility's hand hygiene policy and procedure dated October 2024 shows: It is the policy of the facility that hand hygiene performed to reduce the potential of spread of pathogens. This same policy has guidelines including performing hand hygiene when caring for a resident, when moving from a soiled body site to a clean body site of the same resident, and after any contact with blood, body fluids, or contaminated surfaces. 2. R134 had multiple diagnoses including displaced fracture of greater trochanter of right femur, based on the face sheet. R134's order summary report showed an active order dated March 19, 2025 for, Isolation: Contact Precautions: C-diff (Clostridium difficile). R134's active care plan showed that the resident is on contact isolation precaution related to C-Diff. The same active care plan showed multiple interventions including, Use principles of infection control and universal/standard precautions. Post appropriate isolation outside of the room for staff and visitors. On March 25, 2025 at 1:10 PM, a contact precaution sign was observed posted on the door frame of R134's door. The contact precaution sign showed that providers and staff must, put on gloves and gown before entering the room. V11 (Physical Therapist) was observed inside R134's room providing physical therapy to the resident. V11 was only wearing gloves and no other PPE (Personal Protective Equipment). V2 (Director of Nursing) who was present during this observation stated that all staff including V11 should follow the posted signage on R134's door to wear gloves and gown before entering the room and while providing therapy to the resident, to prevent potential spread of C-Diff infection. The facility's contact precaution policy dated December 2024 showed, The purpose of contact precautions is to prevent transmission of infections that are spread by direct ([for example] person-to-person) or indirect contact with the resident or environment. The policy showed in-part under the guidelines, 1. Use contact precautions for residents as recommended by CDC's (Centers for Disease Control and Prevention) Guidelines for isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). 2. Certain diseases, not limited to ([for example] C. difficile, .) require contact precautions. The same policy showed in-part under procedure, 2. All individuals entering the resident's room must use PPE appropriately, including gloves and gown. Donning PPE upon room entry and doffing before exiting the resident's room is done to contain pathogens 29562

Based on interview and record review, the facility failed to administer, store, and dispose of narcotics in accordance with facility policy. This resulted in nursing staff using R2's medication (a discharged resident) for R10 an active resident in the facility. This applies to 2 resident's (R2 and R10) reviewed for narcotic administration and disposal in a sample of 10 residents. On 3/18/25 at 11:27 AM, surveyor noted R2's Controlled Drug Receipt/Record/Disposition Form for Hydrocodone/APAP 5-325 mg (milligram) tablets showed 30 tablets were dispensed on 12/13/24. R2 was given 7 of the 30 tablets between the dates of 12/19/25 and 1/19/25. R2's MAR (Medication Administration Record) shows the 7th tablet was administered to R2 on 1/19/25 at 10AM, which matches the Controlled Drug Form. R2's Face sheet shows he was discharged from the facility on 1/20/25. As of R2's discharge on 1/20/25, 23 Hydrocodone/APAP 5-325 mg tablets were remaining. R2's Controlled Drug Receipt/Record/Disposition Form shows V2 (DON/Director of Nursing) and V11 (ADON/Assistant Director of Nursing) only counted 21 tablets to destroy on 2/17/25. There was a 2 tablet Hydrocodone/APAP 5-325 mg discrepancy found. On 3/19/25 at 9:39 AM, V1 (Administrator) said she found R2's 2 missing Hydrocodone/APAP tabs were given to another resident, R10, by V14 (RN) and V15 (RN). R10's MAR shows she was given a Hydrocodone/APAP 5-325 mg tablet on 2/13/25 at 1:30 AM by V15 and another Hydrocodone/APAP 5-325 mg tablet on 2/13/25 at 11:00 AM by V14. R10's Controlled Drug Receipt/Record/Disposition Form shows she was given the last Hydrocodone/APAP 5-325 mg tablet of her supply on 2/12/25 at 4AM and did not receive a new supply from pharmacy until 2/14/25. On 3/19/25 at 12:24 PM, V15 (RN) said she used one of R2's Hydrocodone/APAP 5-325 mg tablets for R10 because R10 was in pain and her prescription was not there. V15 said the Hydrocodone/APAP 5-325 mg tablet could have been taken from the emergency floor stock also known as the cubex, but then V15 would have had to call pharmacy. V15 said she knows she wasn't supposed to take any medications from another resident's supply, but R10 was a handful that night. On 3/19/25 at 11:16 AM, V14 said she took one of R2's Hydrocodone/APAP 5-325 mg tabs and gave it to R10 because R10 was having uncontrolled pain and her previous prescription stock had run out. V14 said V15 told her it was authorized by the previous shift to use R2's leftover Hydrocodone/APAP tabs for R10 until her new supply came in. V14 said she didn't think she could get a Hydrocodone/APAP 5-325 mg tab from the cubex to administer to R10 because the pharmacy didn't have an active script and it usually takes over an hour to get the code from the pharmacy to get access to the cubex. On 3/19/25 at 12:58 PM, V2 (DON) said all staff were educated they are not to share or borrow narcotics between residents. V2 (DON) said V14 (RN) and V15 (RN) should have accessed Third Eye, an after-hours physician service, to obtain an order for a one time dose of Hydrocodone/APAP 5-325 mg tablet. V2 said after obtaining the order, V14 and V15 would then fax the script to the pharmacy to obtain a code for the cubex. V2 said the whole process would maybe take 1 hour to obtain and give R10 the pain pill. V2 said no nurse has the authority to okay sharing narcotics between residents. The facility's policy titled, Controlled Drug Documentation dated 06/2022 states, A. Purpose: To maintain control and prevent loss and/or diversion of controlled substances .C. Procedure: . 2. Controlled substances must be counted and verified every shift by authorized professionals, .Any discrepancy between the number of controlled drugs on hand and the sheet's balance must be brought to the attention of the Resident Care/Nursing Director (or equivalent) immediately . The facility's policy titled, New Medication Orders dated 06/2022 states, A. Policy/Purpose: Medications are ordered, provided by pharmacy, and initiated on a timely basis .C. Procedure: .5. For facilities using eMARs for which pharmacy entered orders automatically transmit through an interface to the facility's electronic system, the nurse will fax a signed hard copy of physician's orders to the pharmacy. The pharmacy will enter orders based on the faxed documentation and orders will be electronically transmitted immediately after pharmacist verification .8. Initiate medication when received from pharmacy. 9. For facilities that maintain a contingency supply of medications on site, the nurse may take items from the convenience Box or Emergency Box as needed and if available. a. If order is STAT, use medication from Convenience Boxes, if possible .

Based on observation, interview, and record review the facility failed to follow a physician's treatment order for a resident (R1) with a stage 3 pressure injury to the sacrum. The facility also failed to inform R1's physician of a newly identified pressure injury wound. This applies to 1 of 4 residents reviewed for pressure injuries. The findings include: R1's EMR (Electronic Medical Record) showed R1 had an unhealed chronic stage 3 pressure injury to his sacrum. R1's Braden Scale assessment dated [DATE] showed R1 was at a High Risk for pressure injuries. R1's care plan dated 12/10/2024 showed R1's wound interventions included Treatment as ordered and Wound care consultation as ordered. On 12/10/2024 at 11 AM, R1 was in bed. R1 said last night he had discomfort in his wound area. R1 said he felt as if something was pinching him. On 12/10/2024 at 10:30 AM, V3 (Wound Care Nurse/WCN) was asked to perform wound care to R1's sacral wound. V6 (Hospice Aide) assisted V3 (WCN) with turning R1 in bed for wound care. R1 had an unsecured ABD pad dressing loosely covering his sacrum and buttocks. V3 removed the ABD dressing, and there was a dry 4x4 gauze dressing covering the sacral wound bed. The gauze dressing was adherent to the wound bed and stained with dry serosanguinous drainage, V3 had to moisten the gauze with normal saline to remove the dressing. The peri-wound area was red and irritated, and R1's right buttock had a partially open maroon blister that was bleeding. V3 said it appeared like a popped blood blister. V3 said it was a new DTI (deep tissue injury) pressure wound that measured 4 x 1.5 x 0.5 cm (centimeters). V3 proceeded to clean both wounds and then applied Nystatin (antifungal) cream directly on the sacral wound bed then covered it with a Calcium Alginate dressing. V3 then covered both wounds with an adherent boarded foam dressing. On 12/10/2024 at 1:30 PM, V3 (WCN) said she changed R1's daily sacral wound dressings. V3 said R1's wound was chronic, and would close and reopen. V3 said she had noticed R1's wound bleeding at times and was unsure of the cause. V3 said she does not follow R1's ordered treatment because she feels that the ABD dressing would provide more cushion versus the ordered foam dressing. V3 also said she did not follow the treatment order for the foam dressing because she felt it would not stay on properly. V3 continued to say that she had notified V12 (Wound Physician) of R1's new right buttock wound in the morning and entered a wound care order in R1's EMR. On 12/10/2024 at 3 PM, V12 (Wound Physician) said he had been treating R1's sacral wound for a long time. V12 said the wound would heal and then reopen. V12 said R1 was at high risk for skin breakdown because of his complex medical conditions and poor oral intake. V12 said that based on R1's medical conditions and end-life care his wounds were determined to be unavoidable. However, he still expected to be notified of any skin alterations immediately to ensure proper wound care would be initiated. V12 confirmed that V3 had not notified him of R1's new right buttock wound once it was identified in the morning. V12 continued to say that he expected his wound care orders to be followed as prescribed. V12 said an ABD dressing was not the same as a foam dressing because a foam dressing provided better protection for R1's wound. V12 also said R1's dressings had to be properly secured to ensure proper covering of the open wound bed to prevent possible complications. R1's WASA Form dated 12/10/2024 (completed during the survey) showed R1 had a new DTI pressure wound to his right buttock. The form said the wound measured 4 x 1.5 x 0 cm with bloody exudate drainage. The form said Noted with Skin Injury to Right buttocks. 25% of the area is open, 75% skin is intact but is dark red/purple. R1's Order Summary Report showed an active treatment order for R1's sacral wound initiated on 11/1/2024 for Maxorb II 4 x 4 Apply to sacral topically every day shift for Skin Condition Clean area with NS, apply calcium ag, cover with dressing, apply mycolog in periwound area. The order did not include V12's order for a foam cover dressing. R1's Order Summary Report also showed another treatment order for his right buttock initiated on 12/10/2024 for Maxorb II Ag 4 x 4.75 Apply to Right buttock topically every day shift for Skin Condition CLEANSE AREA W/NS, APPLY MAXORB, AND COVER WITH FOAM DRESSING. R1's Wound Physician Consultation report dated 12/11/2024 showed R1's sacral wound measured 5.5 x 2.8 x 0.2 cm with moderate serosanguinous exudate and the peri-wound was denuded. The report also showed a current treatment order initiated on 10/30/2024 to cleanse the wound with normal saline then apply topically a calcium alginate dressing and apply Mycolog to the peri-wound area and cover with a foam dressing daily. The report continued to show R1's new right buttock wound was also assessed. The report said the pressure injury was a stage 3, measuring 3.6 x 2 x 0.2 cm with moderate serosanguinous drainage. The report showed V12's (Wound Physician) treatment order was to cleanse the wound with normal saline then apply a calcium alginate dressing and apply Mycolog to the peri-wound area and cover with a foam dressing daily. The facility's document titled Job Description Titled: Wound Care Coordinator dated 11/2021, said Essential Functions A. Must ensure that all nursing procedures and protocols are followed in accordance with established policies .E. Administer or assist with wound treatments as ordered by the physician. F. Review treatment orders for completeness of information and accuracy of transcription of the physician's order .M. Update the family/responsible party and attending physician for any changes on wound assessments .P. Consult with other nurses, management, and other related health professionals to assist in assessing, planning and delivering and evaluating patient care .

Based on interview and record review the facility failed to ensure staff safely transferred a resident by not using a gait belt for 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's Face Sheet printed on 12/5/24 showed R1 was a [AGE] year-old female that was diagnosed with abnormalities of gait and mobility, muscle weakness, and history of falls. R1's fall Care Plan with an initiated date of 10/18/24 showed R1 was at risk for falls related to generalized weakness, activity intolerance, severe protein-calorie malnutrition, spinal stenosis, history of falls, and needing assistance with activities of daily living. The facility's Incidents report with a date range of 9/5/24- 12/5/24 showed R1 had a fall on 11/3/24, 11/12/24, and 11/17/24. R1's Progress Note dated 11/17/24 showed a Certified Nursing Assistant (CNA) was walking R1 to the bathroom and R1 lost her balance and fell . The CNA attempted to lower R1 to the ground, but a gait belt was not in use. On 12/5/24 at 11:45 AM, V7 (Restorative Nurse) said she was involved with R1's fall on 11/17/24. V7 said V11(CNA) was assisting R1 to the bathroom when R1 fell . V7 said she went to assess R1. V7 said she found R1 on the floor near the foot of R1's bed. V7 said R1 did not have a gait belt on. V7 said staff should have used a gait belt when assisting R1 to walk. V7 added that a gait belt is used to help stabilize a resident when walking and possibly be used to lower a resident to the ground if needed. On 12/5/24 at 12:52 PM, V11 said on 11/17/24 R1's call light was on. V11 said she entered R1's room and found R1 sitting on the side of the bed wanting to go to the bathroom. V11 said she helped R1 to stand. According to V11, R1 was walking to the bathroom when R1's right leg gave out causing R1 to lose her balance and fell to the ground landing on her right side. V11 said she tried to ease R1 to the ground but R1 did not have a gait belt on. V11 said R1 was a resident that required a gait belt. On 12/524 at 10:13 AM, V10 (Therapy Director) said R1 required assistance from staff to walk and staff should have used a gait belt when assisting R1 to walk. A facility assessment dated [DATE] showed R1 required supervision or touch assistance with ambulating. The facility's Gait Belt/Transfer Belt policy dated 9/2020 showed a gait belt will be used with weight bearing residents who require hands on assistance.

I. Based on interview and record review the facility failed to send a resident to the hospital in a timely manner when they became aware of the resident's critically low potassium level (2.4mmol (millimoles)/L (liter) with a reference range of 3XXX,d+[DATE].1). This failure resulted in R76 going into cardiac arrest, requiring CPR (Cardiopulmonary Resuscitation) and expiring at the hospital on [DATE]. This applies to 1 of 3 residents (R76) reviewed for quality of care in the sample of 18. The Immediate Jeopardy began on [DATE] at 4:49 PM when V10 Registered Nurse (RN) was made aware of R76's critically low potassium level by the laboratory, received orders to send R76 to the emergency room , called the local private ambulance service and became aware of the ,d+[DATE] hour delay in the expected arrival of the local private ambulance service, and then failed to immediately call 911 for EMS (Emergency Medical Services) to transport R76 to the emergency room . V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 3:25 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. R76's EMR (Electronic Medical Record) shows that R76 was last admitted to the facility on [DATE] with diagnoses including Syndrome of Inappropriate Secretion of Antidiuretic Hormone, Arteriosclerotic Heart Disease, Hypothyroidism, Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease and Fractured Left Femur. R76's Lab Results Report dated [DATE] shows that he had a Basic Metabolic Panel drawn at 1:03 PM. The results showed a critically low potassium level of 2.4mmol (millimoles)/L (liter) (Reference Range 3XXX,d+[DATE].1). This result was called to the facility by the lab at 4:49 PM on [DATE]. R76's Progress Notes written by V10 and dated [DATE] at 7:42 PM state, Clinical labs called the facility and spoke with this RN regarding abnormal lab results. This writer paged (R76's Primary Physician's) office and spoke with (V9- Nurse Practitioner). (V9) advised RN to send resident out to the ER (emergency room ). (Local Private Ambulance) was called around 5:15 PM and ambulance stated a pickup time around ,d+[DATE] hours later. Vital signs were taken and vital signs were as followed: BP (blood pressure): ,d+[DATE], HR (heart rate): 100, Respirations: 18, O2 (oxygen): 94% on 4L (liters) O2. Temperature: 98.8 degrees Fahrenheit. Upon arrival of (Local Private) ambulance around 7:13 PM resident observed unresponsive. Compressions were started immediately. This RN called 911 at 7:15 PM. Another RN called (R76's son) at 7:15 PM as well. Paramedics walked into the scene at 7:22 PM. Resident transported to the ER at 7:34 PM. (R76's son) notified of resident's transfer to the ER. (Primary Physician) paged and notified around 7:55 PM. R76's Progress Notes dated [DATE] at 11:06 PM state, Called (Local Hospital) ER at 11:00 PM for an update on resident. ER nurse notified this writer (that) resident expired in ER. On [DATE] at 3:15 PM, V10 (RN) stated, He (R76) was going to be sent out for a critical lab. The Nurse Practitioner (V9) said to send him out. I called (Local Private Ambulance) and they said their ETA (estimated time of arrival) was ,d+[DATE] hours. The call went in before 6:00 PM and (Local Private Ambulance) was here when we noticed (R76) had coded. I last saw him at 6:30 PM- 6:40 PM. So, he (R76) typically would call out for the nurse. He was alert and oriented x ,d+[DATE]. I remember the night nurse came in early like 6:30 PM that day. (Local Private Ambulance) arrived around 7:00 PM. (Local Private Ambulance) found him but I think I initiated CPR. They transported him to the hospital. The lab called me for the potassium (level). It did not seem urgent. His VS (vital signs) were stable. The labs were done early in the day and he was the basically the same all day. He had a poor appetite. There was no active change with him. Even his O2 (oxygen) was okay. (V9) knows the facility and she knows that we use (Local Private Ambulance). She never sounded like we needed to send him out right away. If the potassium was low then it would cause heart issues. I would think there would be a change in his vital signs. There was no change since the AM. I had him all day. On [DATE] at 11:00 AM, V9 (Nurse Practitioner) stated, They were to send him to the ER. They should have called 911. With a potassium that low that would have been urgent. They never called me back to say that it was going to be ,d+[DATE] hours. On [DATE] at 11:45 AM, V2 (Director of Nursing) stated, It is not acceptable to wait ,d+[DATE] hours for the ambulance. They called me and they told me that they were in the process of putting him on the gurney from (Local Private Ambulance) and he coded. I was told the staff started compressions and one of my staff was really upset with (Local Private Ambulance) because they stood back and didn't help. 911 came and took over. They transported him to the hospital. (R76's) potassium was critically low and with that level, I would have called 911. They should have called (V9) back and let her know. On [DATE] at 12:30 PM, V11 (Agency RN) stated, I am part of the rapid response team at my other job so when I was leaving and I heard the code blue I went up to see what was going on. (V10) had started CPR and the EMTs (Emergency Medical Technicians) from (Local Private Ambulance) were digging around and trying to find things in their bag on the floor. I took over CPR because (V10) was getting tired and then the ambulance guy started yelling at me to, Stop CPR, stop CPR! I yelled back, Why?. I don't know why he was telling me to stop but I didn't stop. Then they put in an IV (intravenous) and then 911 showed up. Eventually, an AED (Automated External Defibrillator) was applied but I don't know who did it. The 911 paramedics gave some medications through the IV and then they took over the scene. I think I heard one of them say that they felt a pulse but by that time we had been working on him for almost 20 minutes. They then loaded him on the gurney and transported him to the hospital. R76's POLST Form (Practitioner Order For Life Sustaining Treatment) shows that R76 requested: Selective Treatment: Primary goal is treating medical conditions with limited medical measures. Do not intubate or use invasive mechanical ventilation. May use non-invasive forms of positive airway pressure, including CPAP and BiPAP. May use IV fluids, antibiotics, vasopressors and antiarrhythmics as indicated. Transfer to the hospital if indicated. The (City) Fire Department Patient Care Record dated [DATE] shows that 911 was called at 7:14 PM, arrived at the facility at 7:19 PM, and arrived to (R76) at 7:21 PM. This document states, In summary, (engine #) were dispatched for the pulseless and not breathing person. Upon our arrival the crew found staff and (Local Private Ambulance) ambulance crew working a cardiac arrest patient. CPR, IO (intraosseous), and 2 rounds of epi (epinephrine) were given PTA (prior to arrival). Patient has a DNR (Do not Resuscitate) with selective measures only. Selective measures are not to intubate or advanced airway done. The crew placed the AutoPulse on the pt. (patient) 20 minutes into CPR the pt. had a rhythm change from asystole to PEA (Pulseless Electrical Activity). The crew moved the patient onto the stretcher, fully secured the patient, and then moved the patient into the back of the ambulance. (Local) Hospital was contacted and gave no further orders . The facility policy entitled Change of Condition dated ,d+[DATE] states, The attending physician or physician on call/NP and responsible party will be notified with changes in a resident's condition. 43. Follow suggested guidelines for reporting clinical problems based on the AMDA (American Medical Directors Association) Guidelines. The AMDA Guideline Form entitled Laboratory Tests/ Diagnostic Procedures (taken from the AMDA Clinical Practice Guideline- Acute Changes in Condition in the Long Term Care Setting 2003) states, *Report Immediately Potassium < (less than) 3.0, > (greater than) 6.0 mg/dl (deciliter) The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: On [DATE] the education listed below was started by the Director of Nursing, will all nursing staff that were working and those that were scheduled to work up coming shifts on [DATE]. Education will continue to be conducted prior to the start of the next shift for each nursing staff and on an ongoing basis until all nurses scheduled to work have been education and demonstrate understanding on the education through written quizzes and/or return demonstration of competency. Education will focus on all nursing staff with the potential to be impacted by the non-compliance and not limited to staff involved in the actual incident. - All residents were reviewed for changes in condition who had critical chemistry lab values. No critical chemistry lab values were identified. - All nursing staff were educated by the Director of Nursing, Nurse Consultant, or designee regarding assessing changes in conditions based on critical chemistry lab values and ensuring timely transport to hospital is arranged. - All nursing staff were educated by the Director of Nursing, Nurse Consultant, or designee on the facility's Change in Condition Policy. - All nursing staff were educated by the Director of Nursing, Nurse Consultant, or designee on the facility's Change in Conditions and Signs and Symptoms from AMDA Clinical Practice Guidelines/Interact 4.0 report immediately. On [DATE], the facility DON, Administrator and Nurse Consultant reviewed policies and procedures on Change in Condition and Change in Conditions and Signs and Symptoms from the AMDA Clinical Practice Guidelines/Interact 4.0 report immediately with the medical director. The review included but is not limited to staffing, environment, addressing risk factors. The following policies were reviewed and no changes made. - Changes in Condition - Change in Conditions and Signs and Symptoms from the AMDA Clinical Practice Guidelines/Interact 4.0 Lab Test Chemistry Report Immediately. - The Administrator and DON conducted a review of compliance using Quality Assurance Audit Tool for changes in condition critical chemistry levels. The audit started on [DATE]. The audits will be done three times a week for four weeks, then weekly for four weeks then monthly x 3 months and then randomly by the Administrator, Director of Nursing, Assistant Director of Nursing/designee until goal of compliance is achieved. The results on the QA audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. - The QA meeting is held at least quarterly and as needed. An emergency QA meeting was held on [DATE] by the Administrator with the Interdisciplinary Care Team and Medical Director. The meeting included discussion in changes in condition related to critical chemistry levels. The Medical Director and Interdisciplinary Care Team approved the Removal Plan. This will be monitored by the Administrator, DON and ADON. The facility presented an abatement plan to remove the immediacy on [DATE]. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on [DATE], and the survey team accepted the abatement plan on [DATE]. II. Based on observation, interview, and record review the facility failed to ensure wound treatments were completed as ordered. The facility also failed to ensure daily weights were obtained as ordered by the physician.This applies to 4 of 18 residents (R7, R428, R34 and R24) reviewed for quality of care in the sample of 18. The findings include: 34490 2. R7's Wound Notes dated [DATE] show that she has has non-pressure ulcers on her right heel, right 5th toe-lateral, right great toe-medial and has a contusion on her right foot dorsum. All of the right foot wounds have an order to apply Betadine and a covering. There is no notation to apply Medihoney to any of the right foot wounds. R7's April Treatment Administration Record (TAR) shows orders for: Betadine-apply to right foot bunion area-cleanse with normal saline, apply betadine then cover with ABD (abdominal) pad then wrap with gauze wrap, secure with tape; Betadine-Apply to right heel-cleanse with normal saline, apply Betadine then cover with ABD pad then wrap with gauze wrap, secure with tape; Betadine-Apply to right lateral 5th toe-cleanse with normal saline, apply Betadine then cover with ABD pad then wrap with gauze wrap, secure with tape. On [DATE] at 12:40 PM, V11 RN (Registered Nurse) performed a dressing change to R7's right foot wounds. After cleansing all of the right foot wounds, V11 applied Betadine to all of the wounds. V11 then applied Medihoney gel to all of the wounds. On [DATE] at 9:31 AM, V2 (Director of Nursing) said that physician's have a reason for ordering specific wound treatments for wounds and the staff should be following what the physician orders. The facility's Prevention and Treatment of Pressure Injury and Other Skin Alterations Policy dated [DATE] shows, Implement preventative measures and appropriate treatment modalities for pressure injuries and/or skin alterations through individualized resident care plan. 3. On [DATE] at 11:01 AM, R428 had a dressing on her right foot. There was yellow drainage on the dressing. The dressing was not dated. R428 said that she has not had the dressing changed in a few days. V2 (Director of Nursing) removed the dressing. The dressing had dried yellow/brown drainage present. R428 had a surgical incision below her right great toe. The peri wound was reddened and slightly swollen. R428's Nurse's Notes dated [DATE] at 10:26 AM shows, Surgical site on the left (should be right) big toe noted to look raw, a bit swollen and slightly red. R428's Treatment Administration Record (TAR) shows an order for: Betadine-apply to right foot incision every day shift until healed. R428's March TAR shows that she did not receive a dressing change on [DATE]. On [DATE] at 9:31 AM, V2 (Director of Nursing) said that R428's wound treatments should be done daily as ordered. V2 said that she usually does R428's wound care but she was not at the facility on [DATE]. V2 said that it should have been done by the nurse. The facility's Prevention and Treatment of Pressure Injury and Other Skin Alterations Policy dated [DATE] shows, Implement preventative measures and appropriate treatment modalities for pressure injuries and/or skin alterations through individualized resident care plan. 47552 4. R34's Facesheet shows R34 has a diagnosis of acute systolic (congestive) heart failure. R34's Order Listing Report dated [DATE] shows an active order of daily weights, started on [DATE]. R34's Weights and Vitals Summary report dated [DATE] shows from [DATE] until [DATE], R34 was not weighed on 20 days. Those dates are [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 10:44 AM, V8 CNA (Certified Nursing Assistant) said that R34 was a daily weight. V8 said all CNAs working that floor know which residents require a daily weight when the task in the electronic charting program is lit up pink. The task will no longer be pink when the task is completed. On [DATE] at 9:44 AM, V7 (Registered Dietitian) said daily weights are important for residents with congestive heart failure because it tells the interdisciplinary team whether the resident is retaining or losing fluid. If the resident retains too much fluid, their heart failure can be exacerbated. Facility Weights policy dated ,d+[DATE] states, Residents will be weighed to establish baseline weights and identify trends of weight loss or weight gain. 5. R24's Facesheet shows R24 has a diagnosis of chronic diastolic (congestive) heart failure. R24's Order Summary Report dated [DATE] shows an active order of daily weights, started on [DATE]. R24's Weights and Vitals Summary report dated [DATE] shows from [DATE] until [DATE], R24 was not weighed on 16 days. Those dates are [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 10:44 AM, V8 said that R24 was a daily weight but was currently at the hospital. V8 said all CNAs working that floor know which residents require a daily weight when the task in the electronic charting program is lit up pink. The task will no longer be pink when the task is completed. On [DATE] at 9:44 AM, V7 said daily weights are important for residents with congestive heart failure because it tells the interdisciplinary team whether the resident is retaining or losing fluid. If the resident retains too much fluid, their heart failure can be exacerbated. Facility Weights policy dated ,d+[DATE] states, Residents will be weighed to establish baseline weights and identify trends of weight loss or weight gain.

Based on observation, interview and record review the facility failed to ensure residents requiring extensive assist were toileted in a timely manner and assisted with eating. This applies to 2 of 18 residents (R377 & R3) reviewed for activities of daily living (ADL's) in the sample of 18. The findings include: 1. R377's face sheet shows her diagnoses to include: Alzheimer's disease. On April 2, 2024 at 9:34 AM, V6 Physical Therapy brought R377 back to her room and told staff that R377 needed to be changed. R377 had a strong urine odor. On April 2, 2024 at 10:21 AM, V3 Certified Nursing Assistant (CNA) changed R377's adult diaper. R377 had urinated through her adult diaper to her pants. The bed and chair (where she sat) was wet. V3 CNA clarified that R377 had wet through her adult diaper. R377's adult diaper was heavily soiled with a strong dark yellow urine. On April 1, 2024 at 10:01 AM, R46 (R377's room mate) stated, she gets upset because she feels like the staff does not help R377. She stated, R377 has dementia and always wets through her pants because she doesn't know to go to the bathroom and the staff doesn't help her. On April 2, 2024 at 9:34 AM, R46 stated, no one has helped R377 that morning to the bathroom. She (R377) needs to be changed. I get very angry, they just let her go. R46's Minimum Data Set, dated dated dated [DATE] shows, she is cognitively intact. R377's bladder task list shows she was changed on April 2, 2024 at 5:36 AM (5 hours earlier). R377's care plan date initiated March 30, 2024 shows, Focus: Bladder support is required secondary to bladder incontinence. Interventions/Tasks: Provide assistance with toileting. 2. On April 1, 2024 at 12:20 PM, R3 was eating lunch in bed. He was leaning to the right, eating with his fingers. There was no one helping him eat. On April 2, 2024 at 9:01 AM, R3 was lying in bed. His breakfast tray was in front of him. There was no one helping him eat. At 12:07 PM, R3 was lying in bed eating lunch. He was eating with his hands. No one was helping him eat. On April 2, 2024 at 12:20 PM, V5 CNA stated, she does not help R3 with eating. She sets him up and lets him eat on his own. R3's care plan date initiated June 19, 2016 shows, Focus: R3 has an ADL self care performance deficit r/t (related to) intellectual disabilities, HTN (hypertension), epilepsy, depressive d/o (disorder), anxiety d/o, hx (history) of humerus fracture (arm). Decrease motivation, refusal to complete ADL's care. Requires assistance with meals . Requires extensive to total dependence from staff to complete ADL's secondary to intellectual impairment. Interventions/Tasks: Offer needed assist and encourage mealtimes . R3's care plan date initiated October 1, 2022 shows, R3 is involved in a restorative eating program secondary to requiring assistance to eat meals. R3 will feed self with assistance. Staff to assist with meat setup and proper upright sitting position Interventions/Task: Provide assist needed for mealtime. Provide assist to resident to scoop food onto spoon with each bite of food. R3's nursing rehab: eating/swallowing task shows, A nursing rehab: Eating: R3 will feed self with assistance. Staff to assist with meal setup and proper upright sitting position .

Based on observation, interview and record review facility failed to provide a safe transfer according to the residents plan of care. This failure resulted in a fall incident that caused two right lower extremity fractures, development of right foot drop and heel cord contractures and have also resulted in long term decline in physical functioning. This failure applies 1 of 8 residents (R12), reviewed for falls in a sample of 15. R12 was admitted to facility 6/10/12 for therapy services after having a right hip surgery. R12 is also diagnosed with [REDACTED]. R12's 6/17/12 Minimum Data Set Assessment (MDS), documents rarely in pain, decreased range of motion (ROM), to one lower extremity, requires extensive assistance with transfers, ambulation, hygiene, toileting and dressing, not steady standing without physical assistance and continent of bladder. This MDS also documents fully intact cognitive status on the BIMS ( Brief Interview for Mental Status), scoring 15 out of 15. R12 was hospitalized after admission due to right hip surgical infection and was readmitted to facility 7/08/12. R12's 7/08/12 hospital discharge summary includes; admitting [DIAGNOSES REDACTED]. On 7/08/12 R12 was observed to have some quadriceps weakness distally. The discharge activity section documents "can be weight bearing as tolerated on right lower extremity assuming her quad function returns." R12's 7/12/12 Physical therapy (PT), plan includes; unable to ambulate at this time, transfer with knee immobilizer and 2 person assist. R12's 7/16 - 7/23/12 PT note includes; "Must wear knee Immobilizer." R12's 8/20 - 8/27/12 PT notes include; Poor standing balance and pain with activity. R12's 7/25/12 physician order [REDACTED]. R12's 8/30/12 fall incident report includes; On 8/30/12 at 2PM in the shower room, R12's right knee buckled while standing on a scale. R12 was being weighted by E5 (certified nurse aide), without a right knee immobilizer in place and R12 told E5 that her right knee was not locking in place, prior to falling. R12 immediately complained of severe right knee pain, sent to the hospital and diagnosed with [REDACTED]. R12's incident report included Z2 (physiatrist / medical director), spoken to about this fall incident and Z2 indicated the lack of immobilizer use does cause harm and can put R12 at a risk for falls. E5's personal file includes an 8/31/12 written counseling for failure to follow transfer precautions as listed in the plan of care when weighing a resident (R12). E5 wrote a response on the counseling form, to include ; E5 was unaware of the splint and did not see it. During 5/09/13 9AM interview, R12 stated she will never forget the 8/30/12 fall incident and how painful it was. R12 said a "little nurse aide was trying to get me on the scale, without using a gait belt, she could not hold me up and dropped me." R12 also said "I told her (E5), my knee had to lock before I could stand and it hadn't." I was so scared and in so much pain. I broke two bones in my knee from that fall. I also developed foot drop in my right foot since the fall from bedrest and the long casts I had to have. It has taken a long time to heal and I would have been out of here a long time ago if it hadn't been for that fall." R12 also said that E5 was fired by facility related to her dropping her on 8/30/12. E5's personal file included an "Employee Separation Report" dated 10/11/12 includes last date worked was 9/08/12. The reason documented for E5 being terminated, was E5 did not work when scheduled and did not respond to facility phone calls. During 5/09/13 3:15PM interview, E9 (therapy manager), said prior to R12's 8/30/12 fall, R12 was assessed to have 3 out of 5 (fair strength in right knee and ankle) and no right heel cord contractures or foot drop. On 7/08/12 readmission, R12's right knee was a 0 / 5 (no strength), so we obtained an order from the doctor for a right knee immobilizer. R12 was to use the right knee immobilizer whenever out of bed. E9 said that R12's right ankle was always tight but she did not have right foot / ankle contractures or foot drop prior to the 8/30/12 fall incident, which she now has. On 5/09/13 at 9AM, R12 observed in bed, alert and oriented to time, place and person. R12 was in good spirits and said that she frequently has a lot of pain in her right knee and foot / ankle. R12's right foot was observed to be in constant extension and with presence of foot drop. R12's care plan on 8/30/12 did not include use of right knee immobilizer, as ordered or two assist as noted by PT. R12's care plan did include use of a gait belt during transfers and assistance as needed.