Every finding on record at Amberwoods of Farmington

Based on review of the clinical record, facility documentation, facility policies, and interviews, for 1 of 2 residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident who was non-ambulatory and dependent on staff for care remained free from injury during a transfer.The findings include:Resident #1 had diagnoses that included multiple sclerosis, obsessive-compulsive disorder, personality disorder, anxiety, morbid obesity, edema, chronic kidney disease, low back pain, arthritis, displaced comminuted fracture of the right femur, and fracture of the left femur. The Resident Care Plan (RCP) dated 3/20/2022 identified Resident #1 is to get out daily of bed at 10:45 AM into an electric wheelchair with interventions that directed use of a mechanical lift with the assistance of two staff. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had intact cognition and was dependent on staff for transfers. Review of the facility Reportable Event Form dated 6/20/2022 at 2:20 PM identified during transfer Resident #1 had a fall in his/her room witnessed by NA #1. Resident #1 complained of left arm pain, and transferred to the emergency room for further evaluation. The new intervention implemented for Resident #1 is three staff for transfers. Review of a written statement by NA #3 dated 6/20/2022 at 2:20 PM identified she assisted NA #1 with repositioning Resident #1 in the wheelchair when the mechanical lift tipped. Review of a written statement by NA #1 dated 6/20/2022 at 2:35 PM identified she and NA #3 were transferring Resident #1 from the bed to the wheelchair using a mechanical lift when the lift tipped over, causing Resident #1 to fall to the floor. NA #1 identified as Resident #1 was falling, his/her left arm grazed the wheelchair armrest and wheel. The nurse's note written by RN #1 (supervisor) dated 6/20/2022 at 4:16 PM identified she was called to assess Resident #1. RN #1 identified upon entering the room, she observed Resident #1 lying supine on the floor, with his/her head at the foot of the bed, and his/her feet toward the doorway. RN #1 identified the wheelchair was located next to Resident #1. RN #1 identified Resident #1 complained of left arm pain, appeared to be very anxious, and was short of breath. RN #1 identified Resident #1 remained on the floor until EMS arrived who assisted with lifting Resident #1 off the floor. RN #1 identified Resident #1 was transferred to the hospital. The emergency room Discharge summary dated [DATE] identified Resident #1 had fall from a mechanical lift, the X-rays and scans were negative. Resident #1 has a contusion on the left side of his/her back. The RCP care plan dated 6/20/2022 identified Resident #1 may fall during transfers. Interventions directed to approach the mechanical lift for positioning from the front of the wheelchair (not the side) and use 3 staff for transfers. The nurse's note dated 6/21/2022 at 12:51 AM identified Resident #1 returned from the emergency room at 11:45 PM. The physician's order dated 4/5/2023 directed for transfers provide the assistance of 3 using a mechanical lift with a large green trim sling. Interview with the Director of Nurses (DNS) on 2/13/2026 at 10:38 AM identified she was employed at the facility in June 2022 as the Assistant Director of Nurses not the DNS.The DNS indicated she did not recall Resident #1 falling out of a mechanical lift, but would investigate. A follow-up interview with the DNS on 2/13/26 at 1:30 PM she confirmed an incident occurred on 6/20/22 in which Resident #1's mechanical lift tipped over and a nurse aide lowered Resident #1 to the floor. The DNS stated she could not determine whether the correct sling was used or whether the legs of the lift were opened during the transfer. The DNS identified staff are responsible for ensuring the proper sling size is used, properly positioning the mechanical lift including opening the base of the lift for stability. Interview with the Director of Maintenance on 2/13/26 at 2:45 PM identified he was not working at the facility in June 2022 and has been at the facility for about a year. The Director of Maintenance indicated that he does not have any records from June 2022 regarding any maintenance or repairs that may have been done to the mechanical lifts. Interview, review of facility documentation, and review of the clinical record with Registered Nurse (RN) #1 on 2/17/26 at 4:15 PM identified on 6/20/2022 she was supervisor on duty and did document a progress note regarding Resident #1's fall out of a mechanical lift. RN #1 stated that during transfers, nurse aides (NA) are responsible for selecting the appropriate sling based on the resident's weight and ensuring the legs of the mechanical lift are opened for stability. RN #1 indicated based on her review of the reportable event dated 6/20/2022 she could not determine whether the correct sling was used or whether the lift's legs were opened at the time of the incident. RN #1 indicated that upon entering the room, Resident #1 was already on the floor; however, she could not recall whether the sling remained attached to the lift, and based on the resident's position, she believed NA #1 and NA #1 had moved Resident #1 from over the bed to the area between the two beds but had not reached the wheelchair. RN #1 stated the mechanical lift had tipped before reaching the wheelchair, which was positioned at the foot of the bed. RN #1 indicated Resident #1's head was near the side of the bed and his/her feet toward the doorway. RN #1 further stated staff were moving the lift out from under the bed and turning toward the space between the beds to align with the wheelchair. RN #1 stated the lift should not have tipped and that it could have occurred if staff failed to open the legs of the lift during movement or if the lift malfunctioned. RN #1 identified she could not determine the exact cause of the incident.Interview with RN #1 on 2/17/26 at 6:00 PM identified she located a read and sign off form dated 2/8/22 signed by NA #1 that indicated she read the policy on mechanical lifts.RN #1 identified the handout was left at the nurse's station for staff to independently read and sign. Review of NA #1 employee file identified NA #1 start date was 2/4/2022 and completed general orientation. NA #1 was terminated on 2/10/2023. Although attempted, interviews with the prior DNS, LPN #2, NA #1, and NA #3 were not obtained. Review of the facility Guidelines for Use of Hoyer Lifts education identified always have 2 staff for transfers one to maneuver lift and one to monitor resident, inspect sling prior to use for being torn or holes, make sure when attaching the resident and sling to the lift the same colors are used on both sides for an even lift, once resident is lifted in ling the resident should be in a sitting position, place residents arms inside the sling, move the lift away from the bed and turn the resident so they are facing the staff member operating the lift, once away from bed lower the arm of the mechanical lift so resident is more stable (due to the center of gravity), and ensue the legs of the mechanical lift are open in the widest position when maneuvering the resident to provide a wide base of support to prevent the lift from tipping over. Review of the facility C.N.A. education and competency Policy identified to ensure all certified nursing assistants must meet state and federal requirements for education, competency, and ongoing training. All newly hired nursing assistants must complete orientation that includes safe handling and transfers. Initial employment requirements prior to assignment the facility will verify successful completion of skills competency validation and facility orientation. The nursing assistant will complete required annual in-service education. Competency validation for safe transfer techniques (including mechanical lifts) will be completed annually and re-evaluated with any identified performance concerns. Review of the facility Mechanical lift transfers policy identified was to ensure safe and proper use of the mechanical lifts for resident's transfers. The policy promotes resident safety, dignity, and prevention of staff injury. This policy applies to all licensed staff, certified nurse aides, rehabilitation staff, and any personnel trained and authorized to perform mechanical lift transfers within the facility. Mechanical lifts shall be maintained and inspected regularly to ensure safe operation. Staff training requirements all staff must receive annual validation and education on safe resident handling principles. Training shall include sling selection and inspection, proper positioning, and emergency procedures. Must have a minimum of 2 trained staff members present during all mechanical lift transfers.

Based on clinical record review, facility documentation review, facility policy review, and interviews for 1 of 3 residents (Resident #1) reviewed for accidents, the facility failed to ensure staff were trained in the use of a mechanical lift. The findings include:Resident #1 had diagnoses that included multiple sclerosis, obsessive-compulsive disorder, personality disorder, anxiety, morbid obesity, edema, chronic kidney disease, low back pain, arthritis, displaced comminuted fracture of the right femur, and fracture of the left femur. The Resident Care Plan (RCP) dated 3/20/22 identified Resident #1 was to get out of bed at 10:45 AM daily into an electric wheelchair with interventions that directed use of a mechanical lift with the assistance of two staff.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had intact cognition and was dependent on staff for transfers. Review of the facility Reportable Event Form dated 6/20/22 at 2:20 PM identified during transfer Resident #1 had a fall in his/her room witnessed by NA #1. Resident #1 complained of left arm pain and transferred to the emergency room for further evaluation. The new intervention implemented for Resident #1 is three staff for transfers. Review of a written statement by Nurse Aide (NA) #3 dated 6/20/22 at 2:20 PM identified she assisted NA #1 with repositioning Resident #1 in the wheelchair when the mechanical lift tipped.Review of a written statement by NA #1 dated 6/20/22 at 2:35 PM identified she and NA #3 were transferring Resident #1 from the bed to the wheelchair using a mechanical lift when the lift tipped over, causing Resident #1 to fall to the floor. NA #1 identified as Resident #1 was falling, his/her left arm grazed the wheelchair armrest and wheel.The nurse's note written by RN #1 (supervisor) dated 6/20/22 at 4:16 PM identified she was called to assess Resident #1. RN #1 identified upon entering the room, she observed Resident #1 lying supine on the floor, with his/her head at the foot of the bed, and his/her feet toward the doorway. RN #1 identified the wheelchair was located next to Resident #1. RN #1 identified Resident #1 complained of left arm pain, appeared to be very anxious, and was short of breath. RN #1 identified Resident #1 remained on the floor until EMS arrived who assisted with lifting Resident #1 off the floor. RN #1 identified Resident #1 was transferred to the hospital. The emergency room Discharge summary dated [DATE] identified Resident #1 had fall from a mechanical lift. The X-rays and scans were negative. Resident #1 has a contusion on the left side of his/her back. The RCP care plan dated 6/20/22 identified Resident #1 may fall during transfers. Interventions directed to approach the mechanical lift for positioning from the front of the wheelchair (not the side) and use 3 staff for transfers. The nurse's note dated 6/21/22 at 12:51 AM identified Resident #1 returned from the emergency room at 11:45 PM. The physician's order dated 4/5/23 directed to provide assistance of three with transfers using a mechanical lift with a large green trim sling. Interview with the Director of Nurses (DNS) on 2/13/26 at 10:38 AM identified she was employed at the facility in June 2022 as the Assistant Director of Nurses not the DNS. The DNS indicated she did not recall Resident #1 falling out of a mechanical lift but would investigate.A follow-up interview with the DNS on 2/13/26 at 1:30 PM identified she confirmed an incident occurred on 6/20/22 because the mechanical lift tipped over which resulted in Resident #1 being lowered to the floor. The DNS identified staff are responsible for ensuring the proper sling size is used, properly positioning the mechanical lift including opening the base of the lift for stability. Interview with the DNS on 2/13/26 at 3:00 PM identified she and the Administrator were unable to provide evidence that NA #1 and NA #3 were trained on mechanical lift transfers.Interview, review of facility documentation, and review of the clinical record with Registered Nurse (RN) #1 on 2/17/26 at 4:15 PM identified she was supervisor on duty on 6/20/22. RN #1 indicated she did not recall the exact details of Resident #1's fall on 6/20/22, she confirmed she documented a progress note indicating that a mechanical lift tipped over, causing the resident's fall. RN #1 indicated based on her review of the reportable event dated 6/20/22 the mechanical lift tipped over causing Resident #1's fall. RN #1 indicated she could not determine whether the correct sling was used or if the mechanical lift legs were opened at the time of the incident. RN #1 identified on 6/20/22 when she entered the room Resident #1 was lying on the floor with his/her head near the side of the bed with his/her feet toward the doorway. RN #1 indicated she could not recall whether the sling was still attached to the lift but believed NA #1 and NA #3 had moved Resident #1 from the bed to an area between the two beds and had not yet reached the wheelchair. RN #1 stated Resident #1's wheelchair was positioned at the foot of the bed and the mechanical lift tipped over before reaching it. RN #1 stated that mechanical lifts do not typically tip over unless staff failed to open the legs for stability or if the mechanical lift malfunctioned. RN #1 indicated she could not identify the exact cause of the incident. RN #1 identified that during transfers, nursing assistants must select the appropriate sling based on the resident's weight and must ensure the lift's legs are fully opened. RN #1 identified she is responsible for staff education, training, and competency validation. RN #1 indicated nursing assistants must receive education and demonstrate competency in mechanical lift use upon hire and annually. RN #1 identified agency staff receive only a brief, two-page general orientation that covers mandatory facility education but does not include training or competency validation for mechanical lift use. RN #1 confirmed agency staff do not demonstrate competency with mechanical lifts while working at the facility. RN #1 stated she and the Administrator could not locate documentation of mechanical lift competency for NA #1 at hire or annually and the mandatory general orientation NA #1 completed on 2/4/22 did not include mechanical lift training or competency validation. RN #1 further stated she could not locate the agency general orientation packet for NA #3.Review of NA #1 employee file identified NA #1 start date was 2/4/2022 and she completed general orientation. NA #1 was terminated on 2/10/2023. Although attempted, interviews with the prior DNS, LPN #2, NA #1, and NA #3 were not obtained. Review of the facility C.N.A. Education and Competency Policy identified to ensure all certified nursing assistants must meet state and federal requirements for education, competency, and ongoing training. All newly hired nursing assistants must complete orientation that includes safe handling and transfers. Initial employment requirements prior to assignment the facility will verify successful completion of skills competency validation and facility orientation. The nursing assistant will complete required annual in-service education. Competency validation for safe transfer techniques (including mechanical lifts) will be completed annually and re-evaluated with any identified performance concerns. Review of the facility Contracted Services Policy identified companies who contract with our facility will adhere to all state and federal requirements. Mandatory education the contractor agrees to complete facility orientation to include all mandatory education and annual training as required by facility in accordance with regulations for any providers entering the facility. Contractors will be able to work in the facility once this training is completed and documentation provided to the facility DNS or upload into portal for agency staff. Random audits may be performed for compliance with facility practices, including infection control procedures.Review of the facility Mechanical lift transfers policy identified was to ensure safe and proper use of the mechanical lifts for resident's transfers. The policy promotes resident safety, dignity, and prevention of staff injury. This policy applies to all licensed staff, certified nurse aides, rehabilitation staff, and any personnel trained and authorized to perform mechanical lift transfers within the facility. Mechanical lifts shall be maintained and inspected regularly to ensure safe operation. Staff training requirements all staff must receive annual validation and education on safe resident handling principles. Training shall include sling selection and inspection, proper positioning, and emergency procedures. Must have a minimum of 2 trained staff members present during all mechanical lift transfers. Review of the facility Guidelines for Use of Hoyer Lifts identified always have 2 staff for transfers one to maneuver lift and one to monitor resident, inspect sling prior to use for being torn or holes, make sure when attaching the resident and sling to the lift the same colors are used on both sides for an even lift, once resident is lifted in ling the resident should be in a sitting position, place residents arms inside the sling, move the lift away from the bed and turn the resident so they are facing the staff member operating the lift, once away from bed lower the arm of the mechanical lift so resident is more stable (due to the center of gravity), and ensue the legs of the mechanical lift are open in the widest position when maneuvering the resident to provide a wide base of support to prevent the lift from tipping over.

Based on observation, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure food was labeled appropriately and temperatures completed prior to serving. The findings include:A tour of the kitchen on 7/24/25 at 10:15 AM with the Food Service Director identified a bottle of thousand island dressing that was half filled with a date of 12/31/24 located in the reach in refrigerator. Interview on 7/24/25 at 10:20 AM with the Food Service Director identified opened condiments such as salad dressing should be used within 3 months of opening and then discarded. Observation of the walk-in freezer on 7/24/25 at 10:30 AM identified a frozen apple pie in saran seal with no open date or expiration date. Interview on 7/24/25 at 10:35 Am with the Food Service Director identified she could not locate the open date or expiration date but believed it was from a recent event. Review of the food temperature log on 7/24/25 at 10:40 AM identified no record of food temperature completed on the following days/meals: On 6/1/25, 6/2/25, 6/3/25, 6/4/25, 6/7/25, the dinner meal temperatures were not completed. On 6/24/25(lunch), on 6/28/25(breakfast, lunch and dinner), on 6/29/25, 6/30/25, and 7/3/35, the temperatures were not completed for the breakfast and lunch meals. On 7/4/25, the temperatures were not complete for breakfast lunch or dinner and on 7/15/25 they were not complete for the dinner meal. Interview on 7/31/25 at 11:15 AM with Dietary Aide #1 identified that she always has to remind [NAME] #1 to complete the food temperatures and log the results, and it seems to be missing on the days in which that staff member works. Interview on 7/31/25 at 11:25 AM with the Food Service Director identified that she speaks about the taking and logging of the food temperatures; however, there have not been any recent in-service training on completing this. She does however agree with Dietary Aide #1 that there does seem to be one specific cook who does not log the temperatures however she had not spoken about it yet to the [NAME] as the [NAME] had been out sick during the survey period. The importance of taking the temperature of the food served to the residents would be to ensure that the food is being served at a safe temperature. [NAME] #1 was out sick for the duration of the survey and was not able to be interviewed. The Marking policy directed that food marking systems are in place to reduce foodborne illness. Salad dressing from the date manufactured should be used within 4 months of opening. The Food Temperature for Tray line policy directed all foods placed in tray line for service are safe for resident consumption. All foods should be brought to the appropriate temperature in the cooking vessel before placing them in the steam table no sooner than 30 minutes prior to service and recorded on the Cooks Temp Log.

Based on observations, clinical record review, review of facility documentation, review of facility policy/procedures and interviews for 22 residents (Residents #3, #4, #6, #16, #17, #24, #29, #33, #37, #42, #47, #49, #52, #84, #85, #90, #94, #127, #128, #140, #145 and #146) who received podiatric care from one Podiatrist, the facility failed to ensure a contracted Podiatrist maintained standard precautions, and failed to ensure the podiatry medical equipment was cleaned and disinfected after each resident and prior to use on another resident to prevent cross-contamination and spread of infection. The findings include:Observations on 7/24/25 at 11:40 AM identified the Podiatrist exited Resident #146's room, and was wearing latex gloves, he proceeded to push a cart down the corridor. The cart contained a pair of soiled latex gloves, a small pile of unused gloves, a clear plastic container that contained about a fourth of an inch of bluish colored liquid, the container had a paper towel that covered the bottom of the container, and the container held three metal clipping tools. Two of the clipping tools contained white debris and appeared visibly soiled. The heads of the clipping tools rested in the liquid with the handles resting on the side of the container, also located on the cart was a rotary tool (used for removing dead tissue from nails and skin) and a box that had four different heads that appeared white in color and unused. The head of the rotary tool (sanding tip) appeared off white and used. The cart did not contain hand sanitizer. The observation of the plastic container with fluid also identified there were 3 drops of a red substance on the paper towel that the Podiatrist, when asked, denied were blood. The Podiatrist entered Resident #85's room (Resident #85 had a sign on the door that identified that it was an enhanced barrier precaution room, which indicates that gloves and a gown must be worn for resident care) and spoke briefly with the resident then exited the room and proceeded to Resident #94's room. Once in the room the Podiatrist closed the door and the use of the rotary tool the use of the rotary and clipping tools could be heard from the corridor.At 11:50 AM the Podiatrist exited Resident #94's room with gloves on and entered Resident #85's room. The cart now contained two pairs of soiled gloves on the bottom shelf of the cart. He went into Resident #85's room without changing gloves or performing hand hygiene. The same tools were in the clear plastic container with handles resting on the side of the container and the very tip of the tool in the liquid. There were no gloves observed in the garbage can in the bathroom of Resident #94's room.At 12:00 PM the Podiatrist exited Resident #85's room with gloves on, two pair of gloves remained on the bottom of the cart. The Podiatrist had not donned a gown or performed hand hygiene prior to entering or exiting the room. He then proceeded down the corridor toward the nursing station and was using his phone. At 12:08 PM he entered Resident #37's room. The running of the rotary tool and the sound of the clipping tools could be heard from outside of the room. When the podiatrist exited the room, with gloves in place, was on his phone and two pairs of soiled gloves remained on the bottom shelf of the cart he was utilizing.The affected residents are listed below:Resident #3's diagnoses included Type 2 diabetes mellitus with diabetic chronic kidney disease, dementia, and polyneuropathy.Podiatry consult notes dated 7/24/25 identified Resident #3 had five nails on the right foot and thee nails on the left foot that were dystrophic (misshapen, discolored or thickened), long, brittle, discolored, had fungal odor, pain on palpation and subungual (nail bed) debris with treatment rendered as all normal non dystrophic nails were aseptically (in a manner that is free from contamination by harmful microorganism) trimmed and reduced in length, any benign hyperkeratotic (skin thickening) lesions were cut and pared, and onychomycosis (fungal infection) toenails were aseptically and significantly debrided (removal of thickened, brittle or infected material) and reduced in thickness bulk and length using both manual and mechanical means.Resident #4's diagnoses included chronic viral infection, and idiopathic gout. Podiatry consult note dated 7/24/25 identified Resident #4 had thick painful toenails and calluses on the feet and indicated all nails on the right foot and the 1st nail on the left foot were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated 6 onychomycosis toenails were aseptically and significantly reduced and debrided in thickness, bulk and length using both manual and mechanical means.Resident #6's diagnoses included Type 1 diabetes mellitus, and Waldenstrom Macroglobulinemia (cancer of the blood cells).Resident #16's diagnoses included Type II diabetes mellitus with other diabetic kidney complications and diabetic peripheral angiopathy without gangrene and dementia.Podiatry note dated 7/24/25 identified Resident #16 had a 5th toe amputation secondary to bone infection and chronic thick toenails. The note indicated all nails were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and identified 10 onychomycosis toenails were aseptically and significantly debrided and reduced in thickness, bulk and length using both manual and mechanical means.Resident #17's diagnoses included dementia, type 2 diabetes mellitus and peripheral vascular disease.Podiatry treatment note dated 7/24/25 identified Resident #17 had a high risk for infections, amputations and ulcerations due to comorbidities and identified 6 thick toenails. The note indicated 6 toenails were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and identified 4 normal/non dystrophic nails were aseptically trimmed and reduced in length and 6 onychomycosis toenails were aseptically and significantly debrided and reduced in thickness, bulk and length using both manual and mechanical means.Resident #24's diagnoses included dementia, and candidiasis unspecified (fungal infection caused by yeast).Podiatry visit note dated 7/24/25 identified Resident #24 had 10 moderately painful toenails and indicated all toenails were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris with treatment to 10 onychomycosis toenails aseptically and significantly reduced and debrided in thickness, bulk and length using both manual and mechanical means. The note further identified Resident #24 had marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plat but indicated Resident #24 was not a candidate for oral therapy after review of medications and recommended over-the-counter antifungal topicals.Resident #29's diagnoses included immunodeficiency, and idiopathic chronic gout.Podiatry visit note dated 7/24/25 identified Resident #29 had idiopathic peripheral neuropathy and was at a high risk for infections, amputations and ulcerations and indicated the presence of 2 bilateral hallux (big toe) thick toenails and eight elongated toenails in need of debridement. The note further identified bilateral hallux nails were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated 8 normal/non dystrophic nails were aseptically trimmed and reduced in length and 2 bilateral hallux onychomycosis toenails were aseptically and significantly debrided and reduced in thickness, bulk and length using both manual and mechanical means.Resident #33's diagnoses included type 2 diabetes mellitus, and polyneuropathies. Podiatry visit note dated 7/24/25 identified Resident #33 was seen regarding a stage two hemorrhagic blister/decubitus to the posterior left heel and indicated all 10 toenails were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris but indicated the only care provided was assessment of the posterior left heel area with no debridement of the nails.Resident # 37's diagnoses included type 2 diabetes mellitus, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.Podiatry visit note dated 7/24/25 identified Resident #37 had a high risk for infections, amputations and ulcerations and indicated 6 toenails were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris. The note identified treatment to 4 normal/non dystrophic nails aseptically trimmed and reduced in length and 6 onychomycosis toenails were aseptically and significantly debrided and reduced in thickness, bulk and length using both manual and mechanical means.Resident #42's diagnoses included vascular dementia, and chronic kidney failure.Podiatry visit note dated 7/24/25 identified Resident #42 had 6 toenails that were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated treatment rendered on 6 onychomycosis toenails were aseptically and significantly reduced and debrided in thickness, bulk and length using both manual and mechanical means. The note further identified Resident #42 had marked limitation of ambulation, pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate and was not a candidate for oral therapy after review of medications but recommended over the counter antifungal topicals.Resident #47's diagnoses included sepsis unspecified organism, localized edema and encephalopathy.Podiatry visit note dated 7/24/25 identified Resident #47 had 10 moderately aching painful toenails that were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated treatment rendered as 10 onychomycosis toenails were aseptically and significantly reduced and debrided in thickness, bulk and length using both manual and mechanical means. The note further identified Resident #47 had marked limitation of ambulation, pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate and was not a candidate for oral therapy but recommended over the counter antifungal topicals.Resident #49's diagnoses included type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery without angina pectoris, and peripheral vascular disease.Podiatry visit note dated 7/24/25 identified Resident #49 had a high risk for infections, amputations and ulcerations, had 7 thick toenails and 1 right hallux callous and indicated 7 toenails that were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris. The note identified treatment to 3 normal/non dystrophic nails were aseptically trimmed and reduced in length, 1 hallux distal toe benign hyperkeratotic lesions were cut and pared, and 7 onychomycosis toenails were aseptically and significantly debrided and reduced in thickness, bulk and length using both manual and mechanical means.Resident #52's diagnoses included history of methicillin resistant staphylococcus aureus infection (MRSA), localized edema, heart failure and chronic kidney disease.Podiatry visit note dated 7/24/25 identified Resident #52 had a high risk for infections, amputations and ulcerations and indicated bilateral hallux were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris. The note further identified treatment to 8 normal/non dystrophic nails were aseptically trimmed and reduced in length and bilateral hallux onychomycosis toenails were aseptically and significantly debrided and reduced in thickness, bulk and length using both manual and mechanical means.Resident #84's diagnoses included vascular dementia and an immunodeficiency virus infection.Podiatry visit notes dated 7/24/25 identified Resident #84 had 10 moderately aching painful toenails that were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated treatment rendered to 10 onychomycosis toenails were aseptically and significantly reduced and debrided in thickness, bulk and length using both manual and mechanical means. The note further identified Resident #84 had marked limitation of ambulation, pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate and that the resident was not a candidate for oral therapy but recommended over the counter antifungal topicals and use OTC topical antifungal spray in all shoes.Resident #85's diagnoses included vascular dementia, and acute kidney failure.Podiatry visit note dated 7/24/25 identified Resident #85 had 10 moderately aching painful toenails that were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated treatment rendered to 10 onychomycosis toenails were aseptically and significantly reduced and debrided in thickness, bulk and length using both manual and mechanical means. The note further identified Resident #85 had marked limitation of ambulation, pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate and was not a candidate for oral therapy but recommended over the counter antifungal topicals and use of an OTC topical antifungal spray in all shoes.Resident #90's diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side and adult failure to thrive.Podiatry visit note dated 7/24/25 identified Resident #90 had 9 moderately aching painful toenails that were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated treatment rendered to 9 onychomycosis toenails were aseptically and significantly reduced and debrided in thickness, and length using both manual and mechanical means. The note further identified Resident #90 had marked limitation of ambulation, pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate and was not a candidate for oral therapy but recommended over the counter antifungal topicals and use of OTC topical antifungal spray in all shoes.Resident # 94's diagnoses included Alzheimer's disease, immunodeficiency due to conditions classified elsewhere, and acquired absence of left great toe.Podiatry visit note dated 7/24/25 identified Resident #94 was at risk for amputations, infections and ulcerations with 8 thick painful toenails that were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated treatment rendered to 8 onychomycosis toenails were aseptically and significantly debrided and reduced in thickness, bulk and length using both manual and mechanical means.Resident #127's diagnoses included Alzheimer's disease, and difficulty in walking.Podiatry visit note dated 7/24/25 identified Resident #127 had 10 moderately aching painful toenails that were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated treatment rendered to 10 onychomycosis toenails were aseptically and significantly reduced and debrided in thickness, bulk and length using both manual and mechanical means. The note further identified Resident #127 had marked limitation of ambulation, pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate and was not a candidate for oral therapy but recommended over the counter antifungal topicals and OTC topical antifungal spray in all shoes.Resident #128's diagnoses included peripheral vascular disease, and dementia.Podiatry visit note dated 7/24/25 identified Resident #128 had 10 moderately aching painful toenails that were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated treatment rendered to 10 onychomycosis toenails were aseptically and significantly reduced and debrided in thickness, bulk and length using both manual and mechanical means. The note further identified Resident #128 had marked limitation of ambulation, pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate and was not a candidate for oral therapy but recommended over the counter antifungal topicals and OTC topical antifungal spray in all shoes.Resident #140's diagnoses included dementia, type 2 diabetes mellitus and resistance to multiple antibiotics and extended spectrum beta lactamase (ESBL) resistance.Podiatry visit note dated 7/24/25 identified Resident #140 had a high risk for infections, amputations and ulcerations with 9 toenails that were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated treatment rendered to 1 normal/non dystrophic nails were aseptically trimmed and reduced in length and 9 onychomycosis toenails were aseptically and significantly debrided and reduced in thickness, bulk and length using both manual and mechanical means.Resident #145's diagnoses included vascular dementia, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.Podiatry visit note dated 7/24/25 identified Resident #145 was a high risk for amputations, infections and ulcerations and all toenails were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated treatment rendered to 10 onychomycosis toenails were aseptically and significantly debrided and reduced in thickness, bulk and length using both manual and mechanical means.Resident #146's diagnoses included chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity, and pressure induced deep tissue damage of left heel.Podiatry visit dated 7/24/25 identified Resident #146 was a high risk for amputations, infections and ulcerations with 10 thick painful toenails that were dystrophic, long, brittle, discolored, had fungal odor, pain on palpation and subungual debris and indicated treatment rendered to 10 onychomycosis toenails were aseptically and significantly debrided and reduced in thickness, bulk and length using both manual and mechanical means.Interview on 7/24/25 at 12:09 PM with APRN #1 identified that both she and the Podiatrist are contracted staff at the facility and are expected to follow infection prevention guidelines. When asked about the guidelines she was aware of, APRN #1 answered with the question; you mean like changing gloves and hand hygiene in between patients, after which she exited the unit.Interview on 7/24/25 at 12:16 PM with the Podiatrist identified that he is aware that he should be changing gloves between residents but identified that he had not changed his gloves or washed his hands after providing care. He further identified that between non-infectious residents that do not have visible blood or pus, there is no requirement for cleaning nail equipment nor was there any required dwell time for the equipment in a sanitizing solution prior to using the equipment on another resident. Additionally, he identified that the rotary tool used was not changed or cleaned and does not need to be cleaned unless there is visible contamination which only requires that it be wiped with a piece of dry gauze and when an inquiry was made about the possible spread of fungus, the Podiatrist stated all toenails have fungus. He acknowledged that prior to being on the unit where the observations were made, he had already provided care to about 20 residents. Interview on 7/24/25 at 1:00 PM with the Administrator and DNS identified that any contracted staff are required to maintain infection prevention standards while in the facility. The DNS indicated that contract staff have training from the company that hires them and are required to sign an agreement that they will follow infection prevention protocols when they go to facilities. The Administrator identified that the facility has cameras that reset within 24 hours and would check the availability of the footage for viewing.Interview on 7/28/25 at 12:46 PM with APRN #1 identified that she observed the Podiatrist leave one resident room and wheel himself across the hallway while seated on a stool. She noted that she did not know if the Podiatrist had performed hand hygiene and/or changed his gloves prior to entering the room, but noticed he exited a resident with gloves on. APRN #1 identified that after observing the above, she notified the Administrator about the Podiatrist's infection control practices.Interview on 7/29/25 at 10:00 AM with the DNS identified that contract staff sign the contract that the facility has with the contract agency (the Podiatrist office) and they agree to abide by infection prevention protocols. The facility does not provide education or training for the contracted staff. The DNS further indicated she spoke with the podiatry office and reported the incident. Interview on 7/29/25 at 10:31AM with the Chief Executive Officer of the contracted company providing podiatric services to facility residents (Person #5) identified that the expectation of providers who provide care to residents in the nursing home is to follow OSHA (Occupational Safety and Health Administration) and CDC (Centers for Disease Control) guidelines. Person #5 indicated that providers should remove their gloves between residents and perform hand hygiene and don a clean pair of gloves prior to providing care to the next resident. Person #5 identified all Podiatrists have an OSHA certification but that the company does not have any of the Podiatrist's trainings or certifications but offered to send the Podiatrist's resume as proof of experience. In addition, Person #5 identified the company confirms experience and references and check for an active license and proof of malpractice insurance. Person #5 indicated Podiatrists are supplied with a disinfection tray for disinfecting equipment and described a rectangular shaped compartment that has a tray on the inside and indicated the instruments should be fully submerged and the instruments should be rotated between patients. Person #5 identified the company supplies Sani wipes for the rotary tool and as long as there is no pus or blood on the tools they can just be wiped with the Sani wipes and indicated that she was unsure if wiping the head of the rotary tool with dry gauze was an effective cleaning practice.Review of the CDC guidelines for infection prevention for outpatient podiatry settings identified that hand hygiene should be performed before and after removing personal protective equipment (PPE) and that PPE should be removed before exiting the patient environment. Additionally, the guidance indicates that reusable medical devices (cuticle and nail nippers, forceps) should be cleaned and reprocessed prior to use on another patient, visually inspect reusable medical devices for residual soil prior to disinfection or sterilization, use enzymatic cleaner or detergent and discard according to manufacturer instructions and disinfect devices for the appropriate length of time, at the appropriate temperature and appropriately rinsed after high level disinfection (HLD), all as specified by manufacturer instructions.Interview on 7/29/25 at 5:20 PM with the Administrator and the DNS identified that when the concern with the Podiatrist was brought to her attention, she had the Infection Preventionist ask the Podiatrist to leave the facility, and the Administrator contacted the podiatry company. Review of the podiatry summary with the DNS confirmed that the Podiatrist provided podiatric services to twenty-five residents. She further noted that she was unaware that the podiatrist provided care to a resident with a diagnoses of Hepatitis C, and a resident with an active fungal infection who was not a candidate for oral medications. She further noted that the Podiatrist should have worn PPE (gown) when providing care to residents with enhanced barrier precautions in place.Interview on 7/30/25 at 9:32 AM with the Infection Preventionist (LPN#1), and the ADNS identified that general precautions for care and hygiene was that any contact would be to perform hand hygiene and use gloves. LPN #1 indicated that any equipment being used should be cleaned before and after care and that gowns and gloves should be worn with direct contact in the EBP rooms. LPN #1 indicated that when she was notified on 7/24/25 of the concern with the Podiatrist, he had already left the building for the day. The ADNS identified that the residents seen by the Podiatrist were being monitored and that the Podiatrist was not returning to the facility in the future. LPN #1 identified that changing gloves, hand hygiene and cleaning equipment was the standard practice in place to prevent the spread of organisms between residents.The hand hygiene policy identified that hands should be cleansed before and after resident care, after contact with any blood or body fluids and after handling any contaminated items. Additionally, the policy directed use of the alcohol hand sanitizer after contact with intact skin, after removing gloves, before entering and exiting resident rooms.The Infection Prevention Program identified that enhanced barrier precautions (EBP) require the use of gown and gloves for certain residents during specific high-contact resident care activities which include the provision of hygienic care. The policy further noted that resident's on EBP with have signage posted on the door or wall outside of the resident room.Facility policy for diabetic foot care identified the service of a Podiatrist is utilized for diabetic residents who have calluses, thickened toenails or pressure areas.The provider policy for sterilization/high-level disinfection identified a specific disinfectant to be used for the immersion disinfection of reusable instruments. The policy identified for non-soiled instruments, or instruments with no pus or blood, the instruments should be fully submerged in the disinfectant, the instruments should be rotated between patients and that soiled instruments must be removed from rotation.The provider policy for cleaning, disinfection, sterilization and procedure identified that all reusable instruments, equipment and used surfaces will be decontaminated, disinfected or sterilized prior to use on a patient. The policy indicated that all personnel/staff will follow the hand hygiene policy. The policy identified the cleaning of non-critical patient care items, or all non-disposable patient care equipment shall be cleaned the same regardless of the patient's infection status. The policy indicated the exam/treatment rooms of patients with MDROs, the amount of non-disposable equipment taken into the room shall be limited as much as feasible and identified the items will be cleaned and disinfected using a low to intermediate level disinfectant before taking them out of the room.

Based on review of facility documentation, review of facility policies and procedures and interviews for the facility reviewed for Administration, the facility administration failed to ensure that all contracted staff who provide direct or indirect care to residents met the training requirements or were provided the mandatory training as outlined in the facility assessment and per regulatory requirements prior to, and while providing ongoing services in the facility. The findings included: Review of the facility assessment dated [DATE] identified under the training plan section indicated a training mechanism for mandatory training of new and existing employees, contracted individuals, and volunteers, in all of the following required areas:Effective communicationResident RightsAbuse, Neglect, and Exploitation Quality Assurance and Performance ImprovementInfection ControlCompliance and EthicsNurse aide competencyBehavioral healthNon-pharmacological interventionsDementia CareOn 8/25/25 at 10:10 AM a request was made to the facility for the education and training documentation listed in the facility assessment training plan for contracted staff. Although the facility was able to provide education and training for two contracted agencies that provided nursing and nurse aide staffing, they failed to provide any documentation of education or training for other contracted agencies who provided direct and indirect care to facility residents. Interview on 8/25/2025 10:10 AM with the Administrator and Assistant Director of Nursing (ADNS) identified the facility obtained contractual services for podiatry, ophthalmology, audiology, wound care, psychiatry, nursing services, provider services, Hospice, laboratory, pharmacy and radiology services. The Administrator indicated that contractual agency nurses and nurse aide staff are the only contractual staff who received training, prior and ongoing, as listed in the facility assessment. The trainings are maintained by the contracted staffing agencies for the nurses and NAs. If the required training is not completed, the nurses and nurse aide agency staff are not able to pick up shifts to work at the facility. The Administrator further identified that the contract staff, such as providers, in the building are instructed to follow direction of the facility staff in the event of an emergency. Interview on 8/25/25 at 12:01 PM with the medical director identified he started working at the facility a little over a year ago and was not aware that he or contracted staff had to provide, or should have received education on communication, resident rights, abuse, neglect, and exploitation, QAPI, infection control, behavioral health or compliance and ethics from the facility. The medical director identified that he has to complete ongoing education to renew his licensure and was never asked to provide proof of continued education to the facility. The medical director indicated that he received a general orientation of the building and was introduced to staff.Interview on 8/26/25 at 10:46 AM with the Administrator and the DNS identified that they were part of the governing body along with the owners of the facility and the medical director and were not aware that contracted providers were to receive mandatory education to include communication, resident rights, abuse, neglect, and exploitation, QAPI, infection control, behavioral health or compliance and ethics, by the facility or that the facility should maintain records of education for the contracted providers on the related topics. The DNS and the administrator indicated that those topics were expected of each practitioner to have knowledge and education as the facility only offered specific general orientation to the facility to include touring of the building, where the restrooms were, who was in charge and contact information for supervisors and administration. The administrator indicated that the contractual staff was not listed in the training plan and that no staff at the facility follows up or verifies education and training requirements for the contracted providers with exception of the nursing and nurse aide staffing agencies and volunteers. The administrator identified the facility only tracks credentials of the contracted providers.Interview on 8/26/25 at 11:45 AM with the administrator and the DNS identified they were part of the development and updating the facility assessment annually as part of the governing body. The administrator identified that she reads the assessment over and makes changes as the needs arise. The administrator then reviewed the training plan section in the facility assessment then identifying that the training plan did outline that the facility would provide mandatory education to contracted individuals and indicated the facility administration must have overlooked that. The administrator identified that the facility assessment did not address the length, frequency or mechanism of training for the contracted individuals and volunteers providing direct and indirect services to the facility residents but indicated that the volunteers received orientation and annual education if they were in the facility for that length of time even though it was not mentioned in the facility assessment.The facility assessment dated [DATE] identified under the training plan section that training had a described length, frequency and a training mechanism for mandatory training of new and existing employees, contracted individuals, and volunteers, in all of the following required areas:Effective communicationResident RightsAbuse, Neglect, and ExploitationQuality Assurance and Performance ImprovementInfection ControlCompliance and EthicsNurse aide competency Behavioral healthNon-pharmacological interventionsDementia CareAlthough the required areas listed above outlined length, frequency and training mechanism for new and existing employees, the facility assessment failed to outline the same parameters for contracted individuals and volunteers.

Based on observation, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 1 of 4 sampled residents (Resident #113) reviewed for pressure ulcers, the facility failed to ensure an assessment was completed upon identification of a pressure ulcer. The findings include:Resident #113 was admitted to the facility on [DATE] with diagnoses that included lack of coordination, type 2 diabetes mellitus with chronic kidney disease, and dementia. The care plan dated 7/9/25 identified Resident #113 was at risk for skin breakdown related to anticoagulant use with interventions that included: administer pressure relieving devices as ordered, apply house lotion as needed, apply treatments as ordered, dietary consult as needed, turn and reposition per facility policy, weekly skin checks by licensed nurse.The admission assessment dated [DATE] identified a new skin issue on the buttocks, denuded (the loss of the outermost layer of skin) skin wound measurements not documented. Review of Braden Assessment from 7/9/25 identified a score of 18 indicating a mild risk for skin impairment. Physician's order dated 7/9/25 directed coccyx apply barrier cream twice daily and after incontinent care as needed for redness after incontinent care.The admission MDS assessment dated [DATE] identified Resident #113 was cognitively intact, had no behaviors, required supervision with bed mobility, substantial/maximal assistance with transfers, partial/moderate to substantial assistance with dressing and partial/moderate assistance with personal hygiene. The assessment further identified that the resident utilized a walker and wheelchair for mobility and was at risk for pressure ulcers however had zero pressure ulcers. The assessment further identified the resident utilized a pressure reducing device on chair, and pressure-reducing device on bed.Physician's order dated 7/9/25 directed body audit weekly on shower days every evening shift every Wednesday update MD/APRN if new skin issues noted. Physician's orders dated 7/14/25 directed to cleanse the coccyx wound with warm soapy water, pat dry. Apply house barrier cream every shift and as needed for redness if soiled or saturated for moisture associated skin damage (MASD). Physician's order dated 7/16/25 directed: air mattress check for placement and proper settings every shift between 145-155 for coccyx wound.Physician's order dated 7/16/25 directed: coccyx cleanse with warm soapy water, pat dry. Apply calcium alginate followed by dry clean The nurse's noted dated 7/16/25 at 2:17 PM identified Resident #113 had a skin injury to the coccyx and was seen by the wound nurse, the APRN was notified, and the resident had an air mattress in place and functioning. Review of Pressure Ulcer List provided by the facility identified Resident #113 had a facility acquired Stage 3 pressure ulcer to the buttocks that started on 7/16/25.Review of Wound Physician/Provider notes identified the first assessment of the wound was on 7/22/25 by the Wound MD who staged it at a Stage 3 Coccyx pressure wound measuring 1.1 cm x 0.6cm x 0.2cm. Interview on 7/31/25 at 2:00 PM with Wound nurse/Infection Control LPN#1 identified she was made aware of the pressure wound on 7/16/25 when therapy was with Resident #113 in the bathroom. Therapy called the Wound Nurse to come look at the wound where she identified there was a wound on the Coccyx. No measurements were made at the time of identification due to the fact the resident was soiled; however, she did not return after the resident was cleaned up to make the initial wound measurements. She notified the APRN of the area and received an initial order for the mattress and treatment to be started and put the resident on the to be seen wound MD list for the following week. LPN#1 identified that wounds should be assessed upon identification and that is usually done by the RN/supervisor however when she was made aware she notified the APRN not the supervisor. Once the patient would be seen by the wound MD they would be responsible for the staging of the wound. The air mattress also was not started until the wound started on 7/16/25 due to the fact they don't typically put an air mattress in place for residents unless they are low in their weight or hospice. LPN#1's oversight is by the ADON. Review of skin observation by LPN#2 on 7/16/25 identified Resident #113 refused. Review of twenty-four-hour report for 7/16/25 and 7/17/25 failed to identify an alteration in Resident #113's skin. Interview on 7/31/25 at 2:00 PM with Resident #113 identified she/he has not refused her/his bottom being seen by anyone since she/he been admitted . Interview on 7/31/25 at 2:25 PM with the DON identified an assessment should be completed upon the identification of a new pressure wound or change in skin. Interview on 7/31/25 at 2:35 PM with the ADON identified her job is to co-sign what is done by the wound nurse/infection control LPN# 1 and does rounding sometimes with the wound physician. Once a wound is identified an assessment should be completely immediately and then weekly going forward unless it is being followed by the wound clinic. The wound nurse does the tracking of the wounds in house and her job is to audit what she is doing and sign off on it. She was never requested to assess Resident #113 on 7/16/25 when the pressure area was identified and does not recall when she was initially notified of the area. Interview on 7/31/25 at 2:40 PM with APRN#1 identified she does order treatments when notified of a change in skin and will look at it if she is made aware of it while in the building, otherwise the wound physician is the one who is managing the orders/treatment and sees the wounds. If she does see the wound and was in house when notified she would put an assessment note in the medical record. Observation on 7/31/25 at 3:10 PM identified a healing pressure ulcer on the coccyx dark pink in color covered by a dry dressing with granulation noted. Review of Pressure Ulcers Skin Breakdown policy directed the nursing staff, and practitioner will assess and document an individual's significant risk for developing pressure ulcers and examine skin for evidence of pressure ulcers and other skin conditions. Review of the body audit policy directed any change in skin will be reported to the charge nurse or supervisor. Newly identified areas will be investigated and documented. Documentation will include measurements, and details of the wound and or skin change.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of six sampled residents (Resident #53) reviewed for accidents, the facility failed to supervise a resident who exhibited wandering behaviors and was at risk for elopement. The findings include:Resident # 53's diagnoses included dementia, anxiety, depression, adjustment disorder, restlessness and agitation.The elopement evaluation dated 4/28/25 identified Resident # 53 was at risk for elopement.The care plan dated 5/27/25 identified Resident #53 was at risk for wandering and elopement with interventions that included: clearly identify the resident's room and bathroom, engage the resident in activity, and re-direct when noted self-propelling in the wheelchair outside the unit, supervision with wheelchair mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #53 had moderate cognitive impairment, required supervision with wheelchair mobility and had not displayed wandering behavior within the past seven days. The note written by RN #1 dated 7/26/25 at 9:32 PM identified that she received a call from a visitor who had assisted Resident #53 from outside the front door back inside the facility. RN #1 identified that Resident #53 was sitting calmly in the lobby when she arrived. In addition, RN #1 identified that a wander guard (alarm) was applied to his/her wheelchair, and the resident was placed on visual checks to be conducted every 15 minutes. The revised RCP dated 7/26/25 identified Resident #53 had a wander guard placed on the wheel chair, check function of the wander guard every night, check the placement of the wander guard on the wheel chair every shift, and check resident every 15 minutes.Review of the timeline of Resident #53's elopement on 7/26/25 via recorded camera footage with the DNS on 7/30/25 at 1:45 PM identified the following:At 7:51 PM; Resident #53 was seated in his/her wheelchair in the front lobby and pushed the bar to open the front door, there were no other staff or residents in the lobby at the time. At 7:54 PM; Resident #53 was able to push the first set of doors open (there are two doors to access the lobby from outside and vice versa. At 7:57 PM; Resident #53 was able to exit the second door leading outside. The camera footage showed Resident #53 self-propelling his/her wheelchair toward the right side of the building. At 7:58 PM; Resident #53 was outside of the viewing capacity of the camera.At 8:02 PM; a female visitor was seen walking out of the facility.At 8:04 PM; Resident #53 was brought back to the front lobby by the female visitor. Interview with RN #1 on 7/29/25 at 9:45 AM identified that she received a phone call from a visitor on 7/26/25 and the visitor conveyed Resident #53 was sitting alone in a wheel chair outside near the front door. She also identified that it was between 7:30 PM to 8:00 PM when she received the call. She identified that the front door was already locked because the receptionist leaves at 6:00 pm and locks the front the door. She also identified that visitors and/or residents could go out the front door by pressing the disabled button to open the front door. She identified that Resident #53 was already inside the front lobby when she came down and identified that Resident #53 was calm and cooperative at that time. She identified that Resident #53 was able to self-propel independently while sitting in the wheelchair and only required supervision. She identified that Resident #53 did not have a wanderguard in place at the time and was not sure whether Resident # 53 should have had a wanderguard at that time. She identified that Resident #53 had cognitive impairments and should not be alone outside the facility without staff supervision. Interview with Person #1 on 7/29/25 at 12:10 PM identified he/she received a call from RN #1 on 7/26/25 who conveyed Resident #53 had exited the facility through the front door and was observed sitting alone outside. She identified that Resident #53 had dementia and should be supervised at all times. Interview with the ADNS on 7/30/25 at 11:45 AM identified that all residents are assessed for elopement risk upon admission, re-admission, quarterly, and/or change of condition. When the resident assessment indicates at risk for elopement, a wanderguard is placed on the resident. She identified that Resident #53's elopement risk assessment on 4/28/25 indicated he/she was at risk for elopement. She identified that the delivery door and the front door were both equipped with a wanderguard alarm system and when activated, it will be heard at the first-floor nursing station. She identified that Resident #53 had a history or attempt to leave the facility, and a wanderguard was used with Resident #53. She identified that Resident #53's responsible party had removed the wanderguard from the resident and would like to place the wander guard alarm on the wheel chair. She could not identify why Resident #53 did not have a wanderguard alarm on the wheel chair. Interview with the DNS on 7/30/25 at 1:15 PM identified that all residents who are at risk for elopement will have a wanderguard placed unless a resident resides on the secured dementia unit. She identified that Resident #53 was identified at risk for elopement on 4/28/25 but did not have a wanderguard in place because even though Resident #53 was at risk for elopement, he/she did not have a current episode of elopement or recent attempt to elope from the facility. She identified that the wanderguard was removed by a family member and Resident #53 wandered within the facility and had never verbalized wanting to go home and/or to go out the facility. She identified that Resident # 53 did not have attempt to leave the facility since the wander guard had been removed. She identified that she had received a call from the nursing staff that Resident #53 was noted outside the facility on 7/26/25 and she had reviewed the facility camera and identified that Resident #53 was outside the facility for a total of 7 minutes. She identified that she did not report the elopement to the state agency because she did not consider the incident an elopement. She also identified that she was not sure whether the nursing staff was aware that Resident #53 was sitting alone in the lobby at that time but, she identified in the facility camera that there was no staff in the lobby when Resident #53 exited the facility.The facility Elopement policy identified that all residents will be assessed for elopement risk upon admission, re-admission, quarterly, or upon a significant change in condition and for those who display new behavior or attempts to elope. The elopement at risk assessment identified resident risk factors such as previous attempt at elopement, dementia diagnosis, cognitive impairment, and making repeated statements that infer dissatisfaction with facility placement. Any residents who are at risk for elopement will have an individualized comprehensive care plan developed.

Based on review of the clinical record, facility documentation, facility policy and interviews for one of five sampled residents (Resident #25) reviewed for vaccinations, the facility failed to offer or provide the pneumococcal #20 vaccination. The findings include: Review of the Infection Preventionist's (LPN #1) vaccine line list identified Resident #25 received the pneumococcal #23 on 10/31/20. There were no other noted pneumococcal vaccines listed as administered.A physician's order dated 12/24/24 directed to administer the pneumococcal vaccine. Resident #25's Pneumonia Vaccine Education Documentation Form, indicated the resident elected and agreed to receive the pneumococcal vaccine PVC #20, dated 12/29/24. A physician's order dated 1/21/25, directed to administer the Prevnar #20 intramuscular suspension prefilled syringe 0.5ml, inject 0.5ml intramuscularly as needed for vaccine. Resident #25 was readmitted (original admit date was 12/24/24) to the facility in March of 2025 and had diagnoses that included a history of MRSA (methicillin resistant staphylococcus aureus-multi-drug-resistant bacteria), chronic kidney disease and bipolar disorder. A physician's order dated 3/19/25 directed to administer the pneumococcal vaccine. The quarterly MDS assessment dated [DATE] identified Resident #25 was moderately cognitively impaired, had no behaviors, and indicated the pneumococcal vaccine was offered and declined. The significant change in status MDS assessment dated [DATE], identified Resident #25 was moderately cognitively impaired, had no behaviors and indicated Resident #25's pneumococcal vaccination was up to date.Interview on 7/29/25 at 11:18 AM with the ADNS and IP, indicated the IP was doing catch up had been the IP nurse at the facility for about a year now. The admission consent forms are utilized indefinitely, no additional consents for vaccinations are required. The residents on the short-term units are reviewed for vaccinations first/ASAP, as their stay at the facility is shorter. The facility does not have all the vaccinations in house. They are ordered resident specific. The only two vaccinations kept in house are the Flu and Covid vaccinations during those seasons. According to the ADNS, the consent forms provided upon admission, for vaccinations and care, have to be signed by the resident or resident's designated person. No additional signature was required. All consents should be signed. No care or vaccinations should ever be administered without consent or signatures. Interview on 7/31/25 at 10:39 AM with the ADNS and IP indicated the facility had been using a different electronic medical record system (EMR) last year and the change occurred around February of 2024. The ADNS then proceeded to review the immunization records in the older EMR and was able to provide further information regarding the other selected resident's vaccination statuses. The new search did not find any offering or documentation regarding Resident #25 being offered the pneumococcal #20 or declining it. According to the CDC Pneumococcal Vaccine timing recommendations (prior vaccines-complete pneumococcal vaccine schedules) for adults over [AGE] years of age, Resident #25 was eligible for the #20 pneumococcal vaccination 1 year after receiving the pneumococcal #23.Review of the Vaccine Administration Guidelines policy, directed, that residents are offered the pneumococcal vaccination. The resident or responsible party signs an informed consent, which documents education on the risks/benefits, of the vaccination and the licensed nurse will document education was provided, manufacturer of the vaccine, lot number, lot expiration date and date and site of administration. It also indicated the infection preventionist nurse to maintain a current list of residents who have received the pneumovax.

Based on review of facility documentation, review of facility policies and procedures and interviews for the facility reviewed for training requirements, the facility failed to ensure that an effective training program was developed, implemented, and maintained for all individuals providing services under a contractual arrangements met the multiple training topic requirements prior to, and while providing ongoing services in the facility according to the facility assessment and regulatory guidance. The findings included:On 8/25/25 at 10:10 AM a request was made to the facility for the education/training documentation to include communication training, resident rights training, Abuse, neglect, and exploitation training, QAPI training, Infection control program training, Compliance and ethics training, nurse aide training, and behavioral health training for all individuals providing direct and indirect services under a contractual arrangements to facility residents. The facility was only able to provide education and training documentation for the mentioned topics for two contracted agencies that provided nursing and nurse aide staffing, but failed to provide any documentation of education or training for other contracted agencies who provided direct and indirect care to facility residents. Interview on 8/25/2025 10:10 AM with the Administrator and Assistant Director of Nursing (ADNS) identified the facility obtained contractual services for podiatry, ophthalmology, audiology, wound care, psychiatry, nursing services, provider services, Hospice, laboratory, pharmacy and radiology services. The Administrator indicated that contractual agency nurses and nurse aide staff are the only contractual staff who received training, prior and ongoing, as listed in the facility assessment. The trainings are maintained by the contracted staffing agencies for the nurses and NAs. If the required training is not completed, the nurses and nurse aide agency staff are not able to pick up shifts to work at the facility. The Administrator further identified that the contract staff, such as providers, in the building are instructed to follow direction of the facility staff in the event of an emergency. Interview on 8/25/25 at 12:01 PM with the medical director identified he started working at the facility a little over a year ago and was not aware that he or contracted staff had to provide, or should have received education on communication, resident rights, abuse, neglect, and exploitation, QAPI, infection control, behavioral health or compliance and ethics from the facility. The medical director identified that he has to complete ongoing education to renew his licensure and was never asked to provide proof of continued education to the facility. The medical director indicated that he received a general orientation of the building and was introduced to staff. Interview on 8/25/25 at 2:15 PM with APRN#2 identified she is a contracted provider and had not received any education or training specific to the facility from the facility. APRN#2 indicated she was not directed to provide the facility with any education or training related to behavioral health, abuse, neglect and exploitation, resident rights, infection control, QAPI, emergency procedures and indicated she had long term care experience and had knowledge of these topics.Interview on 8/26/25 at 10:46 AM with the Administrator and the DNS identified they were not aware that contracted providers were to receive mandatory education to include communication, resident rights, abuse, neglect, and exploitation, QAPI, infection control, behavioral health or compliance and ethics, by the facility or that the facility should maintain records of education for the contracted providers on the related topics prior to and while independently providing services in the facility. The DNS and the Administrator indicated that each practitioner was expected to have knowledge of and be educated in those topics as the facility only offered specific general orientation to the facility to include touring of the building, where the restrooms were, who was in charge and contact information for supervisors and administration. The administrator indicated that the contractual staff was not listed in the training plan and that no staff at the facility follows up or verifies education and training requirements for the contracted providers with exception of the nursing and nurse aide staffing agencies and volunteers. The Administrator indicated there was not a facility staff member responsible for providing education to contracted provider staff. The administrator identified the facility only tracks credentials of the contracted providers.Interview on 8/26/25 at 11:45 AM with the administrator and the DNS identified they were part of the development and updating the facility assessment annually as part of the governing body. The administrator identified that she reads the assessment over and makes changes as the needs arise. The administrator then reviewed the training plan section in the facility assessment then identifying that the training plan did outline that the facility would provide mandatory education to contracted individuals and indicated the facility administration must have overlooked that. The facility assessment dated [DATE] identified under the training plan section that training had a described length, frequency and a training mechanism for mandatory training of new and existing employees, contracted individuals, and volunteers, in all of the following required areas:a. Effective communicationb. Resident Rightsc. Abuse, Neglect, and Exploitationd. Quality Assurance and Performance Improvemente. Infection Controlf. Compliance and Ethicsg. Nurse aide competencyh. Behavioral healthi. Non-pharmacological interventionsj. Dementia CareAlthough the required areas listed above outlined length, frequency and training mechanism for new and existing employees, the facility assessment failed to outline the same parameters for contracted individuals and volunteers. In an interview with the Administrator on 8/26/25 at 11:45 AM identified the facility assessment did not address the length, frequency or mechanism of training for the contracted individuals and volunteers providing direct and indirect services to the facility residents but indicated it was a facility practice to provide the volunteers mandatory training education with orientation and annual education if they were in the facility for that length of time even though it was not mentioned in the facility assessment.Facility education policy identified the facility must develop, implement, and maintain an effective training program for all new and existing staff and volunteers. A facility must determine the amount and types of training necessary based on a facility assessment. Education will be provided to all staff and volunteers as required by state regulation for skilled nursing ability and special care dementia unit. Additional or interim education provided as needed based on facility need, customer feedback, QAPI projects, outcome data, observation, surveillance and any deficient practices identified. Additional in services will be provided for any new facility initiatives or quality improvement.

Based on clinical record review and interviews for one of five sampled residents (Resident #6) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to obtain and complete the PASARR level II screen after the resident received a qualifying diagnosis. The findings include: Resident #6's diagnoses included paranoid schizophrenia, bipolar disorder, depression, and obsessive-compulsive disorder. The quarterly MDS assessment dated [DATE] identified Resident #6 had intact cognition and required extensive assistance for bed mobility, transfers, toileting and hygiene. Interview with SW #1 on 7/31/25 at 9:45 AM identified that the social workers are responsible for submitting requests for a Level II PASARR screening when there is a qualifying diagnosis that was not known when the resident was admitted to the facility. She identified that Resident #6 had new diagnoses of paranoid schizophrenia and bipolar disorder on 1/25/22, which would require a PASARR level II screening to be completed. She identified that she was not employed by the facility at the time the new psychiatric diagnoses were made. SW #1 could not identify why there was no PASARR level II screen completed for Resident #6. She further identified that she audited all long-term residents' medical diagnoses to ensure all residents who had qualifying psychiatric diagnoses had an appropriate PASARR level II screening and assessment completed. She further noted that she was in the process of submitting a PASARR level II screening for Resident #6. Although requested, a facility PASARR level II screen policy was not provided.

Based on a review of clinical records, facility documentation and interviews for one (1) of three (3) residents, (Resident #3), reviewed for accidents, the facility failed to properly position the resident in bed during the provision of care resulting in the resident slipping out of bed and sustained bilateral femur fractures. The finding includes: Resident #3's diagnoses included Multiple Sclerosis (MS), morbid obesity, and muscle weakness. The Resident Care Plan (RCP) dated 6/10/24 identified that Resident #3 was at risk for falls with interventions that included a Hoyer lift for transfers. The annual Minimum Data Set assessment dated [DATE] identified Resident #3 was cognitively intact and required extensive assistance for bed mobility and had impaired range of motion on both sides of the upper and lower extremities. A care plan update dated 8/18/24 identified that the resident was to have 4 siderails during positioning. A physician's order dated 8/1/24 directed the resident to have assistance of two (2) staff for all activities of daily living, a Hoyer lift for transfers and quarter side rails (2) for bed mobility. Review of the facility Reportable Event form dated 8/18/24 identified that at 2:15 PM, Resident #3 was observed lying on the floor on his/her back next to his/her bed. The resident was complaining of pain to bilateral (both) lower extremities, right side greater than the left, and bruising was noted to the right lower extremity on physical exam. The report indicated that the incident was witnessed by NA #4 and NA #5, and the resident was transferred to the Emergency Department (ED) for evaluation. Review of the hospital Discharge summary dated [DATE] identified Resident #3's primary discharge diagnosis included fractures of both the right and left femur and underwent surgical repair on 8/19/24 and 8/21/24. Interview with NA #5 on 9/11/24 at 10:54 AM identified that on 8/18/24, she and NA #4 had just finished doing incontinent care and went to place the Hoyer pad under the resident to prepare to get him/her up out of bed. She identified that she was on the resident's left side and went to turn Resident #3 on his/her right side towards NA #4 but had difficulty turning Resident #3 because the resident was dead weight. She identified that Resident #3 then told her to push harder and although the resident was already up against the upper side rail and on the edge of the bed, NA #5 pushed the resident as requested. NA#5 identified that the resident then started to slide out of the right side of the bed, NA#5 ran to the right side of the bed, and they both guided the resident to the floor. NA #4 stayed with the resident, and she ran to get LPN #3 and RN #2 (Nursing Supervisor). Additionally, she indicated that although the resident was too difficult to move with two 2 NA's, she did not request extra help at the time and continued trying to turn the resident. Interview with NA #4 on 9/11/24 at 11:44 AM identified that at around 1:00 PM on 8/18/24 Resident #3 requested incontinent care and to be changed. She indicated that NA #5 and herself performed incontinent care and then turned the resident onto his/her right side to put the Hoyer pad underneath him/her to get the resident out of bed. NA#4 identified that the resident was on his/her right side and up against the upper side rail and on the edge of the bed. She reported that NA #5 was on the resident's left side and turned the resident towards NA #4 who was on the resident's right side. NA #5 stated that she was having a difficult time positioning the resident onto the right side, and Resident #3 directed NA #5 to push him/her harder. When NA#5 pushed the Resident, Resident #3's left leg went over the side of the bed and the resident started to slide off of the bed. NA #5 ran over to the right side of the bed, and they both guided the resident to the floor. LPN #3 and RN #2 were notified and came to the room immediately. NA #4 indicated that when the resident had requested to be pushed harder onto his/her right side, the resident was already up against the right siderail and close to the edge of the right side of the bed. Interview with Licensed Practical Nurse (LPN) #3 on 9/11/24 at 10:16 AM identified that she was notified by a NA (could not recall which NA) on 8/28/24 that they went to turn Resident #3 on his/her side, his/her legs went over the edge of the bed and the resident had slid out of the bed and was on the floor. She indicated she went in Resident #3's room immediately and Resident #3 was lying on their back on the floor. Interview with Registered Nurse (RN) #2 (Nursing Supervisor) on 9/11/24 at 10:24 AM identified that on 8/23/24 NA #5 reported that Resident #3 had slid out of bed. The resident reported that she/he slid off the bed and was yelling that she/he could not breathe, and reported discomfort to the right leg, ankle and foot. RN #2 called the on-call provider who directed to have the resident transferred to the Emergency Department for further evaluation. Interview with the DNS on 9/11/24 at 12:12 PM identified that if the NA's were having difficulty repositioning Resident #3, she would have expected that they requested more help and not continue to turn him/her per the resident request. The DNS stated subsequent to Resident #3's fall, NA #4 was educated on the proper techniques on positioning a resident in bed. The DNS identified that NA #5 was from an agency therefore was unable to provide reeducation. The DNS further identified that the facility does not have a policy for repositioning.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two (2) of three (3) residents, (Resident #1 and Resident #3), reviewed for care planning, the facility failed to ensure Resident Care Conferences in accordance with facility policy. The findings include: 1. Resident #1's diagnoses included down syndrome and personality disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, exhibited behaviors and required maximal assistance with bed mobility and transfers. The Resident Care Plan dated 7/26/24 identified that Resident #1 required assistance with Activities of Daily Living (ADLs) with interventions that included transferring and ambulating with a hand held assist of one and a gait belt, encouraging the resident to do as much for themselves as possible and initiating a therapy consult as needed. Review of the clinical record for Resident #1 failed to identify any documented Resident Care Conferences (RCC) since the resident's admission on [DATE] (approximately 1 year and 1 month). 2. Resident #3's diagnoses included Multiple Sclerosis (MS), personality disorder, anxiety disorder and obsessive-compulsive disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #3 was cognitively intact and required maximal assistance for bed mobility, transfers and toileting hygiene. The Resident Care Plan (RCP) dated 8/23/24 identified that Resident #3 has a behavior management problem with interventions that included providing emotional support regarding any new onset of disruptive behaviors, repetitive behaviors or withdrawal. Review of the clinical record for Resident #3 from 3/1/24 through 9/11/24 failed to identify any documented Resident Care Conferences (RCC) (6 months). Interview and clinical record review with the DNS on 9/11/24 at 1:00 PM identified that although Resident Care Conferences should be conducted on admission and quarterly, she was was unable to provide either paper or electronic documentation that they had been completed for Resident # 1 or Resident #3. Although attempted, neither Social Worker #1 or Social Worker #2 were available for interview. Review of the Care Conference policy dated (undated) directed, in part, that Resident Care Conferences (RCC) are to be held upon admission, quarterly and as needed. The RCC will be held within 3 (three) days after the resident's admission to the facility with the interdisciplinary team and encourage residents, family members and/or legally responsible party's participation as desired. The Social Worker completes an assessment note or assessment documentation concerning the RCC. The note will relay any changes in the resident's condition, care, approaches to providing care, etc. and have individual, measurable goals. Review of the Social Worker job description identified that the Social Worker is responsible for coordinating and participating in regular interdisciplinary team meetings in the review/reassessment of the resident's progress.

Based on clinical record review, facility documentation, interviews, and policy review, for one (1) of three (3) residents reviewed for abuse ( Resident #2), the facility failed to ensure that allegations of neglect and abuse were investigated in accordance with facility policy. The findings included: Resident #2 had diagnoses that included dementia. A quarterly Minimum Data Set assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with activities of daily living, and refused care on a daily basis. A care plan dated 2/28/24 identified that the resident refuses care with interventions that included to notify the family when the resident refuses care. a) Review of a concern/complaint form dated 1/30/24 identified that Resident #2's family member had concerns that on 1/30/24 the resident was found in the same clothes from the day before, pants and the incontinent brief were saturated with urine. The concern form further identified that NA #6 had neglected to care for Resident #2 for three (3) days (1/27, 1/28, and 1/30/24). The investigation on the concern form identified that when a resident refuses care with a NA a nurse will go in and approach, the resident often refuses care and the NA followed appropriate procedure when the resident refused care. The concern form resolution identified that NA#6 will no longer provide care for Resident #2. Interview with the Director of Nurses on 9/10/24 at 2:01 PM identified that she did investigate the allegation of neglect. She further stated that she had interviewed the NA who stated that the resident was provided with care, however, she did not have any written statements or an investigation to provide. b) A concern form dated 8/13/24 from Resident #2's family member identified that h/she had heard NA#7 talking loudly in another residents room, the NA stated that she was sick of this s*it and the only time the resident is quiet is when h/she is sleeping. Interview with the DNS on 9/10/24 identified that she believed that the alleged incident happened in Resident #6's room, she could not interview the resident because h/she was confused and she did not think the resident had a roommate. The DNS stated that she had investigated the allegation because she had asked NA#7 about the allegation and the NA denied it, further she asked the family member if there was anyone else around who could have heard it and the family member said no one else was around to hear it. The DNS identified that although she did do interviews, she did not have any documentation of these interviews. Review of the abuse policy identified that all allegations involving abuse, neglect, and mistreatment will be thoroughly investigated.

Based on clinical record review, facility documentation, interviews, and policy review, for one (1) of three (3) residents reviewed for abuse ( Resident #2), the facility failed to ensure that allegations of neglect and abuse were reported to the state agency in accordance with facility policy. The findings included: Resident #2 had diagnoses that included dementia. A quarterly Minimum Data Set assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with activities of daily living, and refused care on a daily basis. A care plan dated 2/28/24 identified that the resident refuses care with interventions that included to notify the family when the resident refuses care. a) Review of a concern/complaint form dated 1/30/24 identified that Resident #2's family member had concerns that on 1/30/24 the resident was found in the same clothes from the day before, pants and the incontinent brief were saturated with urine. The concern form further identified that NA #6 had neglected to care for Resident #2 for three (3) days (1/27, 1/28, and 1/30/24). The investigation on the concern form identified that when a resident refuses care, a NA will report the refusal to the nurse, and the nurse will go in and re-approach. The resident often refuses care and the NA followed appropriate procedure when the resident refused care. The concern form resolution identified that NA#6 will no longer provide care for Resident #2. Interview with the Director of Nurses on 9/10/24 at 2:01 PM identified that she did not report the allegation of neglect because she had investigated it immediately. She further stated that she had interviewed the NA who stated that the resident was provided with care, however, she did not have any written statements or an investigation to provide. b) A concern form dated 8/13/24 from Resident #2's family member identified that h/she had heard NA#7 talking loudly in another residents room, the NA stated that she was sick of this s*it and the only time the resident is quiet is when h/she is sleeping. Interview with the DNS on 9/10/24 identified that she believed that the alleged incident happened in Resident #6's room, she could not interview the resident because h/she was confused and she did not think the resident had a roommate. The DNS did not report the allegation because she had asked NA#7 about the allegation and the NA denied it, further she asked the family member if there was anyone else around who could have heard it and the family member said no one else was around to hear it. Review of the abuse policy identified that all allegations involving abuse, neglect, and mistreatment will be reported to the state agency.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of two (2) residents (Resident #1) reviewed for mistreatment, the facility failed to ensure the residents were provided social services support timely after an allegation of abuse/neglect. The findings include: 1. Resident #1's diagnoses included down syndrome, type II diabetes mellitus and congestive heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required maximal assistance with bed mobility and transfers. The Resident Care Plan dated 7/26/24 identified that Resident #1 required assistance with Activities of Daily Living (ADLs). Interventions included transferring and ambulating with a handheld assist of one and a gait belt, encouraging the resident to do as much for themselves as possible and initiating a therapy consult as needed. Review of the facility Reportable Event Form dated 8/28/24 identified that Resident #1's family member called the DNS at 3:00 PM that day reporting neglect due to bruising noted on the resident's body. A body audit was conducted, and bruising was observed to Resident #1's right lower abdomen, right buttocks, right posterior (back) thigh and left inner calf. Review of social service notes from 8/28/24 through 8/30/24 failed to identify any documentation on Resident #1. Although attempted, both Social Worker #1 and Social Worker #2 were unavailable for interview. Interview and clinical record review with the DNS on 9/11/24 at 9:59 AM identified that there were no social service notes documented on Resident #1. She indicated that she was unable to locate any paper documentation and identified that Social Worker #1 was currently out on leave and her last day worked was 8/30/24 and Social Worker #2 resigned and her last day in the facility was on 8/30/24. Although she reported that both Social Worker #1 and Social Worker #2 worked on 8/28/24, 8/29/24 and 8/30/24, she was unable to identify if Resident #1 was offered support after the allegation of neglect. She identified that it was her expectation that following an allegation of abuse or neglect that the social worker would meet with the resident and/or resident representative within 24 hours and at least weekly until there are no further concerns to follow-up and offer support and that each encounter should be documented promptly in the clinical record. Review of the Abuse Prevention Program policy (undated) and the Abuse Investigation and Reporting policy (undated) fail to identify the social workers role in supporting the resident after an allegation of abuse/neglect. Review of the Social Worker job description identified that the Social Worker is responsible for identifying the social service needs of the residents upon admission and establishes an appropriate plan of treatment to ensure optimal achievable quality health care. The Social Worker is also responsible for the maintenance of regular progress notes indicating residents' needs, response to treatment and their adjustment to the environment.

Based on clinical record review, facility documentation, interviews, and policy review for one (1) of three (3) residents reviewed for infection control, (Resident #2), the facility failed to ensure isolation precautions were put into place in a timely manner. The findings include: Resident #2 had diagnoses that included dementia. A quarterly Minimum Data Set assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with activities of daily living, and refused care on a daily basis. A care plan dated 9/4/24 identified that the resident was placed on Enhanced Barrier Precautions (EBP) related to a multi-drug resistant organism (MDRO) with interventions that included to follow precautions in accordance with facility policy and to ensure adequate hand washing. Observation of Resident #2's room failed to identify any signage to identify that the resident was on enhanced barrier precautions or any Personal Protective Equipment (PPE) was available. Interview with the Infection Control nurse on 9/11/24 at 12:30 PM identified that the resident had returned from the hospital on 9/4/24 with a diagnosis of Extended Spectrum Beta-Lactamase (ESBL) infection. This infection required enhanced barrier precautions, however, she had not read the discharge summary from the hospital upon the residents return on 9/4/24 so the precautions were not instituted until she read the discharge summary on 9/10/24 (6 days after the resident's return). Review of the enhanced barrier precautions policy identified that signage will be posted on the door outside the resident's room indicating the need for EBP. Carts with appropriate PPE will be placed outside the resident's room.

Based on observations, review of the clinical record, facility policy, and interviews for 1 of 1 sampled resident (Resident #25) reviewed for choices, the facility failed to honor an out of bed time preference to attend scheduled morning recreational activities. The findings include: Resident #25 's diagnoses included multiple sclerosis, obesity, and low back pain. A Resident Care Conference note dated 10/11/23 indicated Resident #25 expressed the desire to be out of bed in time to attend morning activities. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 as cognitively intact and required extensive 2 person assistance with bed mobility and transfers. The Resident Care Plan dated 11/7/23 identified an activities problem. Interventions included informing Resident #25 of available activities, offering assistance with transportation to and from activities, and encouraging the resident to attend therapeutic recreation programs. Observation on 12/11/23 at 10:38 AM identified Resident #25 was in bed. Interview with Resident #25 on 12/11/23 at 2:41 PM indicated that he/she had wanted to go to the morning activities, however, he/she was not assisted out of bed in time to attend either scheduled morning program. Resident #25 reported the same issue occurred on weekends and caused him/her to miss religious services. Review of the posted daily activity schedule for 12/11/23 identified [NAME] Calisthenics had started at 10:30 AM and Don't Say Bingo had started at 11:00 AM. Observation on 12/12/23 at 10:10 AM identified Resident #25 was in bed. Review of the posted daily activity calendar on 12/12/23 at 10:12 AM identified that the facility's first activity Festive Fitness would be starting at 10:30 AM. Interview with NA #3 on 12/12/23 at 10:12 AM indicated she would be going to Resident #25's room at 10:45 AM to assist with his/her care (15 minutes after the morning program was to begin). NA #3 reported staff were not able to get Resident #25 ready or out of bed any sooner due to the amount of assistance the resident required. Observation and interview with Resident #25 on 12/13/23 at 10:49 AM identified Resident #25 was in bed. Resident #25 indicated that he/she would have liked to have attended the 10:30 AM Rosary. Review of the facility daily activities calendar for 12/13/23 identified that Rosary had begun at 10:30 AM. Interview with NA #4 on 12/13/23 at 10:50 AM identified that Resident #25 was usually up and ready for 11:00 AM. Interview with Recreation Assistant #1 on 12/13/23 at 1:10 PM identified that Resident #25 missed the morning activities due to not being ready on time. Recreation Assistant #1 stated that she had encouraged Resident #25 to come to activities whenever he/she was dressed and ready. Recreation Assistant #1 expressed Resident #25 had missed a few morning activities this week. Although the Resident Care Conference note dated 10/11/23 indicated Resident #25 expressed the desire to be out of bed in time to attend morning activities, the facility failed to ensure Resident #25's preference was honored. Review of the facility Activities policy indicated that programs are scheduled to meet the needs of the residents in the facility.

Based on observation, staff interviews, and policy review, the facility failed to ensure kitchen staff wore appropriate hair restraints and performed hand hygiene. The findings include: An initial tour of the facility kitchen on 12/6/23 at 10:45 AM with the Food Services Director. At 11:00 AM identified Cook #1 was standing in front of the stove, stirring a pot. Cook #1 had a hair net over her ponytail, but the top and front of their hair was not covered, exposing her hair. An interview with Cook #1 identified that she had forgotten to pull the hair net further forward to cover the rest of her hair. A review of the facility policy on hair coverings indicated that staff's hair should be covered entirely. Additionally, the facility policy indicated that if one hair covering is not enough to cover all of a staff member's hair, then the staff member can use a second hair covering. A second visit to the kitchen on 12/12/23 at 11:40 AM identified Cook #2 removing a tray of pork slices from the oven and placed the tray on a cart. Cook #2 took the temperature of the food and wiped the kitchen thermometer with a wipe, lifted a garbage lid and threw the wipe into the garbage. After throwing the wipe away and placing the lid back on the garbage, Cook #2 took the food tray from the cart and placed the tray on a heating cart without the benefit of washing his hands. An interview with the Food Service Director on 12/12/23 at 11:44 AM indicated that Cook #2 should have washed his hands after touching the garbage lid and before moving the food tray to the heating cart. An interview with Cook #2 on 12/12/23 at 11:45 AM identified that he had forgotten to wash his hands and was trying to ensure the cart left the kitchen on time.

Based on staff interview, clinical record review and review of the facility policy for 1 of 2 sampled residents (Resident #62) reviewed for an alteration of skin condition, the facility failed to complete Braden scale assessments per policy. The findings include: Resident #62 was admitted to the facility on [DATE] with diagnosis that included pneumonia, heart failure, and cerebral vascular accident. The Resident Care Plan (RCP) dated 3/22/22 identified a problem with increased potential for skin breakdown and injuries related to incontinence. Interventions included providing an air mattress, ointment to testicles with each incontinent change, incontinent change every 2 hours to monitor bleeding until the area resolves. The RCP dated 1/27/23 identified Resident #62 may experience skin breakdown because of decreased mobility, and incontinence of bladder/bowel. Interventions included providing a pressure reduction mattress set at a weight for 250 pounds and a cushion for the chair, extensive assistance with bowel and bladder incontinent care as needed, and to inspect skin during care for signs of breakdown and/or irritation. A physician's progress note dated 5/16/23, 10/3/23, 10/17/23, 10/24/23, 10/31/23, 11/4/23, and 12/5/23 identified moisture associated skin damage (MASD) to the left buttocks. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was cognitively impaired and required maximal assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use. The MDS further identified Resident #62 required being set up only for eating, was incontinent of bowel and bladder and was at risk for skin breakdown. The MDS also identified Resident #62 had a Braden scale assessment performed and lacked the identification of MASD. Interview and clinical record review with the DNS on 12/11/23 at 2:00 PM identified a Braden scale was completed on 1/28/23 which identified a Resident #62 was at risk but failed to identify subsequent Braden Scale assessments had been completed. The DNS indicated Braden Scale assessments should have been completed quarterly and the MDS Coordinator was responsible for performing the Braden Scale assessments. Interview on 12/11/23 at 2:35 PM with the MDS Coordinator identified he was not aware that he was responsible for completing Braden Scale assessments, had never completed a Braden Scale assessment and thought it was the nurse's responsibility. Facility policy regarding Pressure Injury Risk Assessment identified that a Braden scale will be done weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. 49100

Based on review of the clinical record, facility policy, and interviews for 1 of 1 sampled residents (Resident #95) receiving hemolytic (blood) treatments and who was on a fluid restriction, the facility failed to notify the medical provider when the fluid restriction exceeded physician orders. The findings include: Resident #95's diagnoses included end stage renal disease, hemolytic (blood) treatment, and diabetes. The admission Minimum Data Set assessment dated [DATE] identified Resident #95 was cognitively intact and required extensive assistance of 2 staff with bed mobility and transfers, and extensive assistance of 1 staff with eating. The Resident Care Plan dated 9/19/23 identified Resident #95 received hemolytic treatments. Interventions included providing treatment on Tuesdays, Thursdays, and Saturdays. The care plan failed to identify that Resident #95 was on a fluid restriction. A physician's order dated 11/1/23 through 12/13/23 directed to maintain a 1200 milliliter (ml) fluid restriction. Interview, review of the clinical record, and review of facility documented intake and output sheets with the ADNS on 12/13/23 at 10:22 AM identified a current physician order for a 1200 ml fluid restriction. Fluid amounts were noted to be recorded on both the facility handwritten worksheet and electronic health record. The total amounts on both records were different and the ADNS was unable to identify which document correctly represented the daily 24 hour totals. Total fluid intakes on the electronic health record were noted to exceed the fluid restriction of 1200 ml on 11/12/23, 11/13/23, 11/19/23, 11/25/23, 11/29/23, 12/1/23, 12/3/23, 12/4/23, and 12/6/23. Interview, review of the clinical record, and review of facility documented intake and output sheets with the DNS on 12/13/23 at 10:42 AM identified a physician's order directed a 1200 ml fluid restriction. The DNS indicated that she was unsure which record was being used to determine correct 24 hour totals. The DNS indicated that if Resident #95 exceeded his/her fluid restriction, the information was supposed to be written in the APRN book for review, or, on the weekends, the on-call provider was to be notified. Review of the APRN book failed to identify the APRN had been notified of the excess fluid intakes. Interview with APRN #1 on 12/13/23 at 11:05 AM identified that she had not been notified that Resident #95 had exceeded his/her 1200 ml fluid restriction and indicated that if she had been notified, she would have instructed the charge nurse to notify the hemolytic treatment facility and she would have documented an APRN progress note. Additionally, if a weekend provider had been notified via the third eye communication system, a notification note would have been generated in the clinical record. Review of the hemolytic procedure policy failed to address resident fluid restrictions or when the facility should notify the medical provider of excessive fluid intake.

Based on clinical record review, review of facility documentation, review of facility policy and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure care was provided safely to prevent a fall with fracture. The finding included: Resident #1 was admitted to the facility with diagnoses that included spinal stenosis, diabetes mellitus, morbid obesity, and anxiety disorder. An admission MDS dated [DATE] identified Resident #1 had moderate cognitive impairment, required moderate assistance for bed mobility, height was 60 inches (5 feet) and weight was 241 pounds. The Resident Care Plan (RCP) dated 10/9/2023 identified Resident #1 required assistance with ADLs and was a fall risk due to weakness, impaired safety awareness and impaired judgement. Interventions directed to assist as needed with ADLS, encourage the resident to call for help before getting up, assist with activities of daily living as needed, and provide a pressure relieving mattress. A facility incident report dated 10/10/2023 at 10:30 AM identified Resident #1 was alert and oriented, required one (1) staff assist for care, and Resident #1 sustained a fall with a left radius (wrist) fracture. Resident #1 was transferred to the hospital and returned with a splint in place and plan for orthopedic follow up. The RCP dated 10/10/2023 directed use of a wide bed with a positioning bar, two (2) staff for care, and side rails for positioning. The facility summary dated 10/13/2023 identified while a NA was providing care, Resident #1 rolled out of bed and fell on to the floor face down. Resident #1 indicated he/she was lying on his/her right side in bed while the NA was washing the resident's back. Resident #1 indicated he/she was holding fine and at some point during the care felt he/she could not keep the position and let his/her hands off the bed and rolled onto the floor while bracing his/her face with the left hand. The NA indicated Resident #1 did not verbalize that he/she was unable to hold the position. Resident #1 was transferred to the hospital for evaluation, and upon return had new orders for non-weight bearing status of the left upper extremity and an orthopedic appointment on 10/20/2023. Resident #1's plan of care was updated to direct two (2) staff to assist with care. Interview with NA #1 on 11/7/2023 at 11:15 AM identified she provided morning care to Resident #1 on 10/10/2023 at 10:30 AM. It was the first time she had cared for the resident, and she received verbal report that Resident #1 required only one (1) staff for care. NA #1 asked Resident #1 if he/she could turn, and assisted Resident #1 to turn onto his/her right side (away from the NA). There was no side rail on either side of the bed, and Resident #1 held onto the bedframe and mattress with his/her left hand. NA #1 indicated Resident #1 was positioned in the middle of the bed with the upper body positioned more towards the side of the mattress, with shoulders slightly forward. NA #1 identified the bed was flat and the height of the bed was waist high for her (about 3 1/2 feet off the floor). As NA #1 rolled Resident #1's brief under Resident #1's bottom and started to wash the resident's back, Resident #1 started to roll out of the bed and fell face down onto the floor on the opposite side of where NA #1 was standing (NA #1 was unable to prevent the resident from rolling out of the bed). Interview with the DON on 11/7/2023 at 1:00 PM identified Resident #1 was not positioned properly when NA #1 started to provide the care on 10/10/2023, and Resident #1 should not have fallen out of the bed. Resident #1 was positioned on her/his side between the middle of the bed and the right side of the bed and Resident #1 should have been centered in the bed before being turned to the side. The DON indicated because of Resident #1's size it may have been difficult to position the resident with one (1) staff to assist. Resident #1's RCP was updated to direct two (2) staff for care, a wider bed and side rails were added to assist with positioning. Review of facility documentation identified subsequent to the fall, all NAs were educated to always position the resident in the center of the bed when providing care and correct positioning of limbs when positioning a resident in a side lying position. Positioning competency validations were completed for each NA. Audits were completed to validate residents were positioned in the center of the bed positioning for observed residents, and a quality improvement project (QAPI) was initiated to address bed positioning on 10/10/2023, resulting in a finding of past non-compliance. The facility policy ADLs (activities of daily living), directed in part, that appropriate care would be provided for residents who are unable to carry out ADLs in accordance with the plan of care, including appropriate support and assistance with hygiene.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1 and #2) reviewed for abuse, the facility failed to ensure adequate supervision for a resident #1 identified with a history of wandering and intrusive behaviors, to prevent a resident-to-resident altercation that resulted in a resident injury. The findings include: 1. Resident #1's diagnoses included dementia, bipolar disorder, restlessness and agitation and type II diabetes. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severe cognitive impairment and required supervision with locomotion on the unit, in his/her room, with transfers and had physical behaviors symptoms directed toward others such as hitting, public sexual acts, pacing, disrobing, or verbal/vocal symptoms one (1) to three (3) of the prior seven (7) days. The Resident Care Plan (RCP) dated 2/8/2023 identified Resident #1 had impaired cognition and frequently paced and walked into other's rooms. Interventions directed to redirect as needed when Resident #1 tries to enter other rooms and use simple direct communication along with verbal cues and task segmentation. Review of the physician's emergency certificate (PEC) dated 2/14/2023 identified Resident #1 had a history of dementia with behavioral disturbance, bipolar disorder with behaviors of constant pacing in the hallways, entering other resident rooms constantly and has had multiple altercations, and not sleeping at night, lying in his/her roommate's bed, agitated and not re-directable. Resident #1 was placed on one-to-one (1:1) and would be transferred to an acute care hospital. Review of the Geri-Psych Hospital Discharge Summary dated 2/28/2023 identified Resident #1 was alert to self only, wandering was part of Resident #1's dementia process, and Resident #1 was stable for discharge to the skilled nursing facility. Review of the behavior monitoring Treatment Administration Record (TAR) for March 2023 identified Resident #1 displayed wandering, pacing and was resistive to care on 3/4 and 3/5/2023. Interventions included redirection, one-to-one observation, ambulation, return to room, toileting, and encouragement to rest. 2. Resident #2's diagnoses included Alzheimer's disease, chronic kidney disease, dementia with psychotic disturbance, delusional disorders, and impulse disorders. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severe cognitive impairment and was independent with locomotion on the unit, his/her room, and transfers and had physical behaviors symptoms directed toward others such as hitting, public sexual acts, pacing, disrobing, or verbal/vocal symptoms one (1) to three (3) of the prior seven (7) days. The Resident Care Plan (RCP) dated 1/21/2022 identified Resident #2 had impaired social interaction related to impaired cognitive thinking and difficulty expressing feelings related to Alzheimer's disease and mood disorder. Interventions directed to remove from situations that trigger aggressive or inappropriate behaviors. A reportable event form and investigation dated 3/9/2023 identified Resident #1 was involved in a resident-to-resident event which resulted in injury to Resident #2. Resident #1 walked into Resident #2's room and began banging on Resident #2's window per Resident #2. Resident #2 got out of bed to try and make Resident #1 stop the behavior; Resident #1 pushed Resident #2 causing Resident #2 to fall, and Resident #2 sustained a hip fracture as a result of the fall. The investigation further indicated Resident #1 had a history of agitation with increased restless behavior and had recently been readmitted from a Geri-Psych facility by PEC for behaviors. Resident #1 record review identified after the incident, Resident #1 was placed on one-to-one (1:1) monitoring, and was subsequently transferred to the hospital. Further review identified nursing note dated 3/10/2022 at 11:03 PM indicated Resident #1 returned from the hospital at 10:45 PM and was identified not a risk of harm to self or others and was placed on every 15-minute checks upon readmission. Resident #2 record review identified the nurse's note dated 3/9/2023 at 5:29 PM identified the DNS was called by the charge nurse to Resident #2's room at 9:15 AM after a NA heard Resident #2 calling for help. The DNS observed Resident #2 crying and sitting on the floor near a corner below the window with his/her back against the closet and Resident #2 complained of right hip pain. Resident #2 indicated he/she was pushed when he/she tried to stop another resident from banging on his/her window. Assessment identified right leg external rotation, a bruise on the left wrist and a skin tear 5 centimeters (cm) by 3 cm on the right elbow, and Resident #2 was transferred to the hospital for evaluation. Review of the x-ray report for Resident #2, dated 3/9/2023, identified a intertrochanteric (bony protrusion of the hip) fracture involving the right hip with avulsion (pulling or tearing away) of the lesser trochanter (bony projection). Review of Resident #2's hospital discharge summary dated 3/12/2023 identified surgery could provide pain relief and therefore surgical treatment was provided, and Resident #2 was transferred back to the facility. A physician progress note dated 3/14/2023 at 3:17 PM identified Resident #2 had an Open Reduction and Internal Fixation (ORIF) procedure for a right hip fracture. Resident #2 tolerated the procedure well, plan to continue pain control, dressing changes, follow-up with Orthopedics and physical therapy. Resident #2 continues to have intermittent behaviors (delirium expected), presently controlled, and Geri-Psych will follow. Interview with the DNS on 3/29/2023 at 2:15 PM identified the investigation concluded Resident #1 wandered into Resident #2's room and was banging on his/her window. Resident #2 attempted to stop Resident #1, but subsequently Resident #1 pushed Resident #2 causing Resident #2 to fall and sustain a right hip fracture. The DNS indicated Resident #1 was known to wander and pace throughout the units and although had not displayed aggressive behavior toward other residents in the past, Resident #1 had exhibited aggressive behavior towards staff. Interview identified although Resident #1 had numerous care plan interventions for wandering (redirect, offer snacks, take back to his/her room), Resident #1 should not have been in Resident #2's room, and should not have been able to push Resident #2. The facility did not provide a policy regarding monitoring residents, resident supervision, or managing wandering residents.

Based on clinical record review, facility documentation, facility policy review, and interviews, for one (1) of three (3) residents reviewed for hydration, (Resident #1), the facility failed to monitor the consumption of fluids and failed to timely address when fluid intake goals were not met for several days. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had no memory and/or recall ability and required total dependence with activities of daily living (ADL) assistance, including eating and drinking. Review of speech therapy note dated 8/29/22 identified Resident #1 with a mild to moderate oropharyngeal dysphagia characterized by oral guard behavior, reduced bolus formation with puree solids, delayed transit and/or bolus hold with puree solids and thin liquids. Resident #1 was to remain on puree solids and thin liquids with aspiration precautions. The Resident Care Plan (RCP) dated 9/2/22 identified a potential for alternation in nutrition with dementia and [CONDITION(S)] with interventions that directed to monitor and record meal intake and honor food preferences within diet allowances. Admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Bloodwork dated 8/29/22 identified that the Blood Urea Nitrogen (BUN) was 38 milligrams per deciliter (mg/dl) (a normal range from 10-24 mg/dl), the creatinine level was 0.6 mg/dl (normal range 0.7 to 1.5 mg/dl), the sodium level was 144 millimoles per liter (mmol/L) (normal range 133-145 mmol/L) and the White Blood Cell (WBC) count was 6.9 thousand per cubic milliliter (K/ul). Review of a nutritional assessment dated [DATE] identified Resident #1 was receiving a regular pureed diet with thin liquids and consumed 50% of meals. Further review identified estimated fluid needs directed 1350 milliliters (ml) and to encourage fluids. Recommendations included 120 ml house nutritional supplement twice daily. A nurse's note dated 9/4/22 at 2:47 PM identified that Resident #1 was alert, nonverbal, and receiving antibiotics for [CONDITION(S)]. The resident was pocketing food and had poor oral intake. Fluids were encouraged and speech evaluation was requested. Review of speech therapy note dated 9/6/22 identified SLP attempted on several occasions to assess swallowing function. Resident #1 was unable to be aroused with tactical and verbal cues. It was unsafe at that time for oral trials due to resident's level of alertness, nursing was notified. Staff stated that the resident was orally guarded over weekend, and lemon [MEDICATION(S)] swab was attempted with the resident biting off the swab. A nurse's note dated 9/6/22 at 4:26 PM identified that Resident #1 was difficult to rouse from sleep, vital signs were stable, blood sugar 269/188 mg/dl. The resident was able to swallow about 70% crushed morning medications but unable to take afternoon medications. Speech therapy was unable to assess related to lethargy, the APRN was updated, and a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) ordered for 9/7/22. The nurse's note dated 9/7/22 at 2:18 PM identified that Resident #1 had continued with lethargy as the shift progressed. The resident opened h/her eyes but was unable to appropriately respond. The resident consumed approximately 60 ml house supplement then sips for breakfast, no solid oral intake. Resident was pocketing crushed medications then drooling from the mouth. No oral intake for lunch nor medication administration related to continued lethargy, vital signs stable, blood sugar 219/215 mg/dl., the APRN #1 was in, and assessed the resident. A progress note written by APRN #1 dated 9/7/22 at 2:24 PM identified Resident #1 with increased lethargy and ongoing poor oral intake since admission the previous week. Further review identified that APRN #1 called and discussed overall decline and change in mentation with the responsible party. At that time Resident #1's responsible party wanted the resident to remain full code. The APRN #1 was awaiting laboratory results that day and would start intravenous fluids once results were available if indicated. Review of bloodwork dated 9/7/22 identified the following results: The BUN had increased to 81 mg/dl (an increase of 43 mg/dl from bloodwork dated 8/29/22) The Creatinine had increased to 1.1 g/dl (an increase of 0.5mg/dl from bloodwork dated 8/29/22) The Sodium level had increased to 163 mmol/L (an increase of 19 mmol/L from bloodwork dated 8/29/22) The White Blood Cell (WBC) had increased to 18.5 K/ul (an increase of 11.6 K/ul). A nurse's note dated 9/7/22 at 8:12 PM identified that secondary to critical laboratory results, APRN #1 recommended to transfer the resident to the hospital. The responsible party was notified and agreed with transfer, Resident #1 transferred to the hospital at 6:45 PM. Review of Resident #1's fluid intake from 9/1 through 9/6/22 identified the following: 9/1/22 540 ml documented by nursing and 420 ml by Nurse Aides (NA) (total fluids 960 ml) 9/2/22 600 ml documented by nursing and 300 ml by NA (total fluids 900 ml) 9/3/22 720 ml documented by nursing and 360 ml by NA (total fluids 1080 ml) 9/4/22 820 ml documented by nurse and 40 ml by NA (total fluids 860 ml) 9/5/22 1080 ml documented by nurse and 120 ml by NA (total fluids 1200 ml) 9/6/22 270 ml and sips documented by nurse and 160 ml by NA (total fluids 430 ml) The aforementioned fluid intakes were below the estimated fluid needs estimated by the dietician on 9/2/22. Review of Medical Intensive Care Unit (ICU) Admission History and Physical dated 9/7/22 for Resident #1 identified upon arrival to the Emergency Department (ED), Resident #1 was noted to be very lethargic with concern for airway protection and had desaturated to 85% and was subsequently intubated by ED physician. Further review identified the resident was nonverbal at baseline, however, was more lethargic over the past few days with minimal oral intake. Altered mental status was likely multifactorial attributed by [CONDITION(S)] (body's extreme response to an infection), uremia (a condition involving abnormally high levels of waste products in the blood) and [CONDITION(S)] (elevated sodium level). The resident was initially hypotensive, blood pressure improved with one-liter [MEDICATION(S)] Ringer's intravenous fluids. The [CONDITION(S)] was likely secondary to [CONDITION(S)] versus extreme dehydration. The resident had creatinine level of 1.3, baseline was around 0.4. Likely prerenal etiology in setting of severe dehydration, as the resident had significant decreased oral intake over the past week since arriving at Skilled Nursing Facility (SNF) and labs were consistent with dehydration. The resident had sodium level of 163, likely hypovolemic [CONDITION(S)] (water deficit to sodium deficit). Plan to continue with intravenous fluids administration and to monitor sodium closely. Resident was NPO (nothing by mouth) as there was high suspicion for aspiration. Interview and clinical record review with RN #1 on 9/26/22 at 11:15 AM identified Resident #1 was very difficult to feed, staff had to leave the fluids on the table and then go back frequently to give another sip of fluids. It took a long time and a lot of encouragement for the resident to swallow and the resident was not eating or drinking much. RN #1 further identified that nurses were responsible to document fluid intake in e-MAR and NAs were also documenting the resident's fluid intake provided by them in the e-chart but on a different flow sheet. RN #1 identified that she included supplements in the documented fluid intake and sometimes if NAs asked her or had difficulty with the computer system, she included fluid intake provided by NAs in her documentation in e-MAR. RN #1 identified that nursing staff on 3:00 PM to 11:00 PM shift were responsible for adding fluid intake for each resident, but that information was not available for review by other nurses. RN #1 identified that since the computer system was implemented in 2022, she has never reviewed resident's total fluid intake since she did not work on the evening shift. Interview with Dietician #1 on 9/26/22 at 11:35 AM identified she assessed Resident #1 on 9/2/22 and identified estimated fluid needs for the resident. Dietician #1 further identified she was unable to recall if she had been notified that the resident's fluid intake was lower than the estimated fluid needs. Dietician #1 identified if she had been notified, she would reassess the resident for change in condition, monitor the resident very closely and implement new interventions to prevent dehydration. Interview with RN #3 on 9/26/22 at 12:15 PM identified the computer program implemented in 2022 did not reflect the resident's total fluid intake provided by nurses and by NA's. Therefore on 8/10/22 staff in-service was implemented directing 24-hour fluid intake checks. RN #3 identified if resident's fluid intake was less than 1000 ml in 24 hours and/or the resident was not meeting estimated fluid needs for 3 days, the charge nurse was responsible to complete hydration observation and write in the APRN book on the unit that the resident was not drinking enough fluids. RN #3 identified there should have been Intake and Output (I and O) book on each unit with estimated fluid needs and 3:00 PM -11:00 PM shift nurse was responsible to add I and O's including what the nurse gave and what NA gave, and the 11:00PM -7:00 AM shift nurse was responsible to follow up. RN #3 further identified that the directions provided during the in-services were not implemented. Although Resident #1 did not meet the estimated fluid goals, there was no hydration observation completed, no I and O books available on the units and no 24-hour tally of Resident #1's fluid intake during admission to the facility. RN #3 further identified that the facility had a documentation problem with the intake and output. RN #3 identified that her expectations were for the facility to implement checks and balances to ensure that Residents #1 I and O's were monitored and followed per facility policy. Interview, clinical record review, and facility documentation review with DNS on 9/26/22 at 2:15 PM failed to provide documentation that Resident #1's fluid intake was monitored and addressed in a timely manner when the resident's fluid intake from 9/1 through 9/6/22 was less than the estimated fluid needs of 1350 ml as directed by the Dietician. The DNS further identified that the facility will immediately implement 24 Hour Intake and Output Work Sheet and Intake and Output form identifying estimated fluid requirements with 24-hour intake total with the determination if the resident met fluid goals. Interview with RN #4 on 9/26/22 at 4:50 PM identified while working during 3:00 PM - 11:00 PM shift she documented total fluid intake that included fluid provided by the nurse and by NA's during the shift she worked. RN #4 further identified that although she worked 3:00 PM - 11:00 PM shift, she was not aware that she was responsible for adding and documenting total fluid intake for 24 hours for all residents that were on I and O monitoring on the unit. Review of facility I and O Monitoring Policy directed in part; I and O monitoring is a simple procedure that does not require a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with APRN # 1 on 9/26/22 at 4:08 PM identified she had not been made aware when Resident #1 was not meeting the h/her estimated fluid needs. APRN #1 further identified that if she had been made aware, she would have assessed the resident, ordered blood work earlier, and determined a further plan. APRN #1 stated that when she reviewed the bloodwork ordered on 9/7/22, the lab values were critical and indicative of dehydration, so she gave orders to send the resident to the hospital Review of facility Resident Hydration and Prevention of Dehydration Policy directed in part; this facility will strive to provide adequate hydration and to prevent and treat dehydration. The dietician will assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need. Minimum fluid needs will be calculated and documented in initial, annual, and significant change assessment. Nurses will assess for signs and symptoms of dehydration during daily care. Nurse Aides will report intakes of less than 1200 ml/day to nursing staff. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan and the physician will be notified.

Based on review of the clinical record, review of facility documentation, review of facility policy, and interview, for 1 of 2 residents (Resident #92), reviewed for abuse, the facility failed to ensure the resident was free from resident to resident abuse. The findings include: Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #92 had short and long term memory problems, moderately impaired cognition, required extensive assistance of 1 staff with bed mobility and 2 staff for transfers, and was totally dependent for eating, toilet use, personal hygiene and bathing. Additionally, Resident #92 was always incontinent of bowel and bladder and had no falls. The care plan dated 1/11/18 included interventions to maintain the resident's comfort and quality of life. Physician's orders dated 3/1/18 directed to utilize an alternating air mattress to bed and offload Resident #92's bilateral heels. Resident #551 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #551 had short and long term memory problems, had moderately impaired decision making ability, ambulated independently, exhibited physical behavioral symptoms toward others, was resistive to care, wandered daily, and was frequently incontinent of bowel and bladder. The care plan dated 12/22/17 identified Resident #551 exhibited socially inappropriate behaviors. Interventions included to intervene and redirect at times of inappropriate behavior, remove from situations that may increase or trigger aggressive or inappropriate behavior, and observe for patterns of pacing. Resident #551 had a psychiatric evaluation dated 3/6/18 that identified the resident had increased agitation for several weeks, had been grabbing staff and not letting go, had been pacing the halls with accelerated pace, and was difficult to redirect. The note identified the pattern of aggression was episodic, frequent and unpredictable. Further, the evaluation identified Resident #551 had the potential for harm to self or others when agitated and pacing. Recommendations included to increase the [MEDICATION NAME] Acid to 625mg twice daily and check a level in 1 week, decrease the [MEDICATION NAME] to 15mg at night, discontinue the prn [MEDICATION NAME], administer [MEDICATION NAME] 25mg every 4 hours prn for 14 days, encourage activities, monitor M/B/S/A and report concerns. The evaluation also identified Resident #551 was not a current potential threat to him/her self or others, and the resident's condition could be managed by the facility. A nurse's note, written by the charge nurse, RN #1, dated 3/9/18 during the 11:00 PM to 7:00 AM shift identified Resident #551 was up in the hallway pacing and was returned to bed, but came back out pacing and running in the hallway. Additionally, Resident #551 was not easily redirected. The note indicated that an as needed medication was administered for agitation at 1:38 AM, a snack was provided, and Resident #551 was returned to bed. Further, the note indicated that at 3:35 AM, RN #1 was called to Resident #551's room, after an incident, and Resident #551 was lying calmly in his/her bed. The reportable event form dated 3/9/18 at 3:45 AM identified Resident #551 was observed squatting over Resident #92's torso squeezing his/her cheeks. The residents were immediately separated and Resident #551 was placed on 1:1 observation until sent to the emergency room for an evaluation. A nurse's note dated 3/9/18 identified at approximately 3:50 AM Resident #551 was found on top of Resident #92 holding his/her face firmly with two forearms. Vital signs were obtained, and Resident # 92 was in no acute distress. Initial assessment identified increased redness to Resident #92's face. Resident #92 was immediately transferred to a different room, and the on call Advanced Practice Registered Nurse (APRN), family, DNS, and police were notified. Physician's order dated 3/9/18 directed to send Resident #92 to the emergency room for an evaluation for possible injuries status [REDACTED]. The interagency referral report dated 3/9/18 identified Resident #92 was physically assaulted by another resident. Evaluate for injuries. Resident #92 returned to the facility the same day at 10:00 AM with no new orders or findings, and given a new room on a different unit. Resident #92's hospital discharge paperwork dated 3/9/18 identified the only sign of trauma which may be new is redness to the left shoulder. A statement by NA #8, undated, identified he/she heard NA #5 scream. NA #8 entered the room and found Resident #551 sitting on Resident #92, straddling him/her, leaning over his/her face with his/her arms on the side of Resident #92's face. Staff lifted Resident #551 off Resident #92. While staff were attempting to walk Resident #551 to his/her bed, Resident #551 lunged at Resident #92 but was redirected. Resident #92 laid in bed with his/her eyes opened with a red face. NA #8 indicated in the statement that earlier, Resident #551 was walking a lot and was resistive when the nurse gave him/her medications. NA #8 identified that Resident #551 had never been aggressive with residents and he/she was surprised by the event. A statement by NA #5, undated, identified he/she had just finished rounds at approximately 3:30 AM and heard a noise in Resident #551's room. NA #5 went in and saw Resident #551 on top of Resident #92, sitting across his/her chest leaning toward the top of bed with forearms against the sides of Resident #92's face. Resident #551 was resistive with both NA #5 and NA #8 but they did get Resident #551 off Resident #92. NA #5 went to get supplies as Resident #551 had urinated on Resident #92's head and torso. Additionally, Resident #92's face was redder than normal. NA #5 identified he/she had never seen Resident #551 try and hurt another resident. Resident #551 had walked out of his/her room naked earlier in the shift and NA #8 put a brief and shorts on and the resident he/she went back to bed. A statement by RN #2 dated 3/9/18 identified after the incident, Resident #92's whole bed was moved to a different unit and the resident was washed up because urine was noted to be covering his/her face and torso. A statement by RN #1 undated, identified that Resident #551 had increased agitation and was pacing quickly. A prn medication was given, and the nurse aides assisted Resident #551 back to bed at approximately 1:30 AM. RN #1 documented he/she was next alerted at 3:45 AM that Resident #551 was choking Resident #92. Resident #92's face had increased redness and his/her bed was moved to another room. Resident #551 was placed on 1:1 observation until EMS arrived. Staff provided care to Resident #92 because there was urine on the resident. Interview with the DNS on 5/16/18 at 1:15 PM identified Resident #551 did not have a history of aggressive/assaultive behavior towards residents. Resident #551 did wander and was restless, but was not aggressive. Additionally, there had been no reported incidents related to resident to resident abuse involving Resident #551 prior to the incident on 3/9/18. Interview with NA #5 on 5/21/18 at 12:41 PM identified on 3/9/18 he/she had been in Resident #551's room to provide care although he/she can't remember exactly what time. Resident #551 had been walking around that night. NA #5 indicated he/she had gone on to provide care to other residents and heard a noise from Resident #551's room. When NA #5 heard the noise, he/she went in the room and saw Resident #551 sitting on Resident #92's chest squeezing his/her face. Review of the facility policy on resident abuse identified physical abuse as hitting, slapping, and pinching, kicking and controlling behavior through corporal punishment. CMS interpretive guidance defines the word willful as the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. However, the facility policy for resident to resident altercations where the aggressor is cognitively impaired, identified he/she must be able to process intent to harm. The facility failed to ensure adequate nursing supervision of Resident #551 on 3/9/18 between 1:05 AM (when Resident #551 was given a prn medication for pacing, running, agitation and was not easily redirected) and 3:45 AM, (2 hours 40 minutes), which resulted in the assault of Resident #92.

Based on clinical record review, facility documentation and staff interview for 1 of 3 sampled residents reviewed for behaviors (Resident #1), the facility failed to supervise the resident to ensure sharp objects (knifes) were not available and/or failed to send the resident to the hospital per physician order [REDACTED]. The findings include: Resident # 1's [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] identified the resident as non-English speaking, and the resident needs/wants an interpreter to communicate with a doctor or health care staff, had clear speech, able to make self-understood, and able to understand others. The brief interview for mental status (BIMS) identified the interview should not be completed because the resident is rarely/never understood. Additionally, the MDS identified the resident had no short or long term memory impairment. The Resident Care Plan (RCP) dated 1/12/18 identified potential for difficulty communicating and does not speak or understand English. Interventions included to keep communication simple, use gestures verbal and visual, provide interpreter or family as needed, and use communication board and iPhone application for translation. a. Review of the psychiatric progress notes dated 1/9/18 identified that APRN #1 was asked to see resident after inappropriate behaviors i.e.: laughing while waving knife around, no harm to self or others and was isolated episode. The note identified that Resident #1 spoke a rare non English dialect. APRN #1 identified to continue current medications and monitor mood, behaviors, sleep and appetite and to report concerns. Interview with APRN #1 on 2/28/18 at 1:50PM stated that staff reported to her that the resident was collecting knifes. APRN #1 stated that she felt the resident was frustrated and told him to stop collecting knifes and told staff to monitor behaviors and report any concerns. Interview with LPN # 1 on 2/28/18 at 11:10AM stated that she could not remember exactly when but she witnessed the resident waving a knife around and laughing in a sly way. LPN # 1 stated she reported it to the RN Supervisor and was told to make a note of it in the psychiatric book for them to review when they come in. LPN # 1 stated that it is hard to exactly know what the resident's mood was because of his/her language barrier, but he/she was laughing in a sly like manner. Review of nurse's notes identified the following: b. On 1/13/18 at 11:00PM at the beginning of the shift Resident #1 was noted to be hitting the walls with silverware and increased agitation noted. The nurse removed the silverware and gave the resident a back scratcher. The note identified the family spoke to the resident (in the native language) to tell him not to take the silverware and bang the walls. Additionally, the nurse educated the resident as best as she could secondary to a language barrier. The Supervisor was updated and staff was asked to keep an eye on the resident. Interview and review of the clinical record with the Director of Nursing (DON) on 2/28/18 at 10:00AM failed to identify that a physician or psychiatric services were made aware of the resident's behavior and staff failed to implement a care plan to address the unsafe behaviors of collecting silverware and knives. The DON stated that the physicians should have been notified and a care plan implemented to ensure the resident wasn't getting sharp objects. c. On 1/21/18 at 1:00PM Resident #1 was found with a butter knife in hand, removed it from the resident without problem, and the RN Supervisor was made aware. An addendum note identified the resident was seen attempting to grab other utensils, was redirected, and the RN Supervisor was again made aware. Interview with LPN # 2 on 2/28/18 at 11:55AM identified that the resident was in his/her room holding a butter knife saying it's mine. LPN # 2 stated she removed the knife and a while later she found the resident agitated and grabbing for knifes out of the utensils cart. LPN # 2 stated she tried to find out what the resident was doing but because of the language barrier she was unable. d. On 1/29/18 at 2:00PM Resident #1 was found with 4 knifes on different occasions, the knives were taken away from resident, was redirected and the RN Supervisor was aware. Interview with RN #1 (day Supervisor) on 2/28/18 at 10:35AM identified that she was told from the nurse that the resident had knifes in his/her possession. RN #1 stated she went to the resident and removed the knives. Interview with LPN # 1 on 2/28/18 at 11:10AM identified the resident was wheeling down the hall in his/her wheelchair holding a knife and that the LPN #1 took the knife from the resident and reported it to the RN Supervisor. LPN # 1 further stated that she communicated the issue of knives to the RN supervisors because she felt there was nothing else she could do and that it could be hard to communicate with the resident due to the language barrier and the resident only knew a few words in English. e. Review of the psychiatric progress note dated 1/30/18 identified APRN #1 was asked to see patient regarding anger and agitation over a phone cord. The resident continued to gather knifes and hiding them in the chair. No violence or threats of violence. Hits walls and raises fist with knife. The note identified the resident was not a danger to self or others. The resident's antidepressant medication was increased, an as needed (PRN) medication was added for anxiety, and to continue to monitor mood, behaviors, sleep and appetite. Interview with APRN # 1 on 2/28/18 at 1:50PM stated that she was asked to see Resident #1 regarding agitation and anger and the resident continued to get knifes. APRN #1 identified that she received limited answers from Resident #1 related to the language barrier. APRN # 1 stated she increased his/her medications and asked that staff continue to monitor the resident. f. A nurse's note identified that on 1/31/18 at 2:00PM Resident #1 continued to obtain sharp objects, confiscated and redirected, and RN Supervisor aware. Interview with RN # 1 on 2/28/18 at 10:35AM stated that she again went to see the resident after the LPN reported the resident had knifes and the next day it was discussed in morning report. Interview with the DON on 2/28/18 at 9:30AM stated that she found out about Resident # 1 having knifes around 1/29/18 and had psychiatry see the resident the next day. The DON stated that staff was in-serviced on ensuring silverware was either behind the nurses station or locked in the nourishment room so the resident could not obtain the silverware. The DON stated that they also implemented not passing silverware until staff is present. The DON further stated that she checked that day to ensure all units were doing what was implemented. However, has not checked again since the first day. Review of the RCP in effect at that time with the DON identified although a care plan was implemented on 2/1/18 regarding the resident using push pins to scratch self and hoarding utensils, the care plan failed to identify the resident obtaining and keeping knives, being agitated at times while holding knives and lacked interventions regarding ensuring the resident would not have access to knives. g. A nurses note on 2/3/18 at 2:30PM identified Resident #1 continued to get knives/utensils, redirected each and every time, all objects removed and RN Supervisor aware. Interview with LPN # 2 on 2/28/18 at 11:55AM stated that the resident was found several times that day with knives and that she took them away from the resident. LPN # 2 stated she did not know how the resident obtained the knives, except he/she is very mobile in his/her wheelchair and could have gotten them anywhere. h. A nurse's note on 2/4/18 at 7:30AM identified that the resident was found with 2 or 3 laundry towels wrapped around a knife with the blade sticking out at least 2-3 inches. Resident #1 also wrapped black electrical tape around the towels, and the RN Supervisor was aware. Several attempts to interview the charge nurse and RN supervisor were unsuccessful. i. A nurses note on 2/6/18 at 8:30AM identified an NA reported Resident # 1 entered the room and made a threatening gesture showing a butter knife to cut his/her roommates (Resident #2) neck and drink his/her blood. The residents were separated and assessed and Resident # 1 was brought to the nurse's station and placed on a 1 to 1 supervision. Additionally, the psychiatrist and family were notified. Nurse's notes at 3:30PM identified the resident was transferred down to the first floor, was maintained on 1 to 1 supervision and the psychiatrist came in and evaluated the resident. Facility documentation dated 2/6/18 at 8:30AM identified Resident # 1 threatened Resident # 2 with a butter knife. The documentation identified NA # 1 was feeding Resident # 2 when Resident # 1 came into the room, gestured cutting his/her own throat with a knife, put a cup on the neck where the cut would be and motioned to drink the blood. The residents were separated, Resident # 1 was placed on a 1 to 1, the police were notified and the psychiatrist was called and asked to see the resident. Review of a Psychiatry note dated 2/6/18 at 1:57PM identified that he/she was asked to see the resident on an urgent basis because the resident was seen making the gesture of slitting his/her roommates throat and drinking the blood from a cup. Resident # 1 was seen laughing after making the gesture of slitting his/her roommate's throat with a knife which was very disturbing. The note further identified probable [MEDICAL CONDITION] with behavioral disturbances, resident speaks only a non-English language/dialect so was difficult to interview and assess extent of cognitive deficits. The resident had some mood lability in past few days, had been collecting dinner knives and push pins since the past few weeks but in the past few days has escalated on this behavior. The note identified the resident was found with 8 knives last week and 5 knives this week, hiding them in his/her wheelchair. The note identified the resident did not have a history of violence but had gotten into verbal altercation with others, got agitated and sometimes difficult to redirect. Additionally, the note identified resident made gestures of slitting roommate's throat and drinking his blood. The resident is a danger to self and/or others and needs a higher level of care. PEC (Physician Emergency Certificate) completed. Review of the PEC (Physician Emergency Certificate) dated 2//6/18 identified difficult to assess related to language barrier, found hoarding knives and push pins, and made gestures that he/she wanted to slit roommates throat. Pt is a danger to self and others needs a higher level of care. A physician order [REDACTED].#1 to Hospital #1 via a Physician Emergency Certificate (PEC) and for Resident #1 to have 1 to 1 supervision until the resident left the facility. When Hospital #1 was unable to accept the resident, staff failed to notify the ordering physician that the resident could not be transferred at that time. Interview with RN # 1 on 2/28/18 at 10:35AM stated that she was notified by LPN # 1 regarding making gesture to slit roommates throat. RN # 1 stated she went to see the resident and asked for the knife and that the resident was laughing. RN # 1 stated she searched and assessed the resident and found no other knives. RN # 1 stated that she placed the resident on a 1 to 1 and notified the police and psychiatry. Interview with LPN # 1 on 2/28/18 at 11:10Am stated that NA # 1 came to her and said that Resident # 1 came into the room and gestured that he/she was going to slit Resident #2's throat with a knife and drink his/her blood. LPN # 1 stated she went to the room and checked on Resident # 2 and notified the RN Supervisor. LPN # 1 stated that Resident # 1 remained with her and that she found another knife on the resident and took it away. LPN # 1 stated that the resident was placed on a 1 to 1 at that time. LPN # 1 further stated that the resident was quiet after the incident but could not tell us why he/she did that due to his language barrier. Interview with MD # 1 on 2/28/18 at 12:20PM stated that she received a call after the incident on 2/6/18 to come in and assess the resident. MD # 1 stated when she saw the resident he/she was calm, but difficult to assess due to the residents language barrier. MD # 1 stated that she asked the resident some questions of why he/she was doing this but was unable to get answers. MD # 1 stated that because knives were involved and the resident had history of verbal aggression she completed a PEC to send the resident to the hospital for an evaluation. Interview with NA # 1 on 2/28/18 at 1:00PM stated that she was feeding Resident # 2 when Resident #1 came into the room and wheeled up alongside of her. NA # 1 stated that Resident # 1 was holding a knife and called Resident # 2 by name and gestured that he/she was slitting the residents throat and then placed a pill cup under the area and motioned that he/she was drinking the blood. NA # 1 told Resident # 1 not to do that and Resident # 1 laughed and repeated the same gesture of taking a knife and making the motion of slitting the throat and drinking the blood of the roommate. NA # 1 stated that she went to take the knife from the resident, but Resident #1 grabbed her hand and slid the knife under the cushion of the chair. NA # 1 stated that she called for the nurse and the nurse came and took it away. NA# 1 further stated that she left the room and Resident # 1 followed behind her and tried to take the knife off the medication cart where the nurse left it. Additionally, NA # 1 stated that when the resident was at the nursing station after the incident he/she tried again to reach for knives as they were pulling the utensil cart down the hallway. NA # 1 stated that at that time, the resident reached under chair and pulled out another knife which the RN Supervisor took from the resident. NA # 1 stated that in the past she has seen the resident with push pins and a back scratcher trying to hit others with it and that she has told the resident no and he/she has put it down. j. Review of the nurse's notes dated 2/7/18 at 6:00AM identified that Resident #1 continued on 1 to 1 monitoring, found to be awake on rounds. Review of 24 hour report sheets dated 2/7/18 identified on the 11-7 shift was unable to comply with 1 to 1 after 5/6AM secondary to inadequate staffing. Although a physician order [REDACTED].#1 required 1 to 1 supervision until the resident left the facility, 1 to 1 was not provided for a period of hours due to a lack of staff to perform the 1 to 1 supervision. No other provisions for resident safety were implemented during this time. Review of the clinical record with the DON on 2/28/18 at 9:30AM identified while reviewing who was assigned to do the 1 to 1 with the resident, she discovered the resident was not maintained on 1 to 1 as ordered by the physician. Further review of the clinical record including the care plan with the DON failed to identify that any other interventions were implemented to ensure the resident's safety and supervision when the resident was removed from the 1 to 1 on the 11 to 7 shift. The DON further stated that the 1 to 1 was resumed on the day shift at 7am. Observation on 2/27/18 at 12PM identified 8 residents seated in the dining room awaiting meal service with their silverware placed in front of them and no staff present. Further observation noted staff in the hallway passing beverages, placemats and silverware to the residents in their rooms. The beverage/silverware cart was observed to be parked right outside of Resident # 1's room and Resident # 1 was noted to be sitting in the doorway of his/her room. Additionally, Resident # 1 was observed to wheel out to the steam table where staff were noted trying to communicate what was for lunch and the resident passed by the silverware utility cart. Interview with APRN # 2 on 2/28/18 at 11:56AM stated that she was not made aware the resident was not sent to hospital # 1 until she came in on 2/8/18 to do rounds. APRN # 2 stated that she saw the resident that day (2/8/18) and the resident was currently on a 1 to 1 at all times for violent and aggressive behaviors and was waiting for a bed to open at hospital # 1 for the resident to be evaluated. APRN # 2 stated that had she been made aware there was a delay in transferring the resident to the hospital she would have told staff to maintain the 1 to 1 and if the resident's behaviors escalated to send the resident to the ER. Interview with MD # 1 on 2/20/18 at 12:20PM stated she was not made aware the resident was not sent out after she completed the PEC and physician order [REDACTED]. MD # 1 stated that the resident was to remain on a 1 to 1 until a bed became available and would have made sure the resident did not have access to knives. Sec. 17a-502. (Formerly Sec. 17-183). Commitment under emergency certificate. Examination of patient. Explanation of rights. Hearing. Private hospitals ' notification to commissioner. Immediate discharge of patient. Notification of next of kin. Prohibited commitments to chronic disease hospitals. (a) Any person who a physician concludes has psychiatric disabilities and is dangerous to himself or others or gravely disabled, and is in need of immediate care and treatment in a hospital for psychiatric disabilities, may be confined in such a hospital, either public or private, under an emergency certificate as hereinafter provided for not more than fifteen days without order of any court, unless a written application for commitment of such person has been filed in a probate court prior to the expiration of the fifteen days, in which event such commitment is continued under the emergency certificate for an additional fifteen days or until the completion of probate proceedings, whichever occurs first. In no event shall such person be admitted to or detained at any hospital, either public or private, for more than fifteen days after the execution of the original emergency certificate, on the basis of a new emergency certificate executed at any time during the person ' s confinement pursuant to the original emergency certificate; and in no event shall more than one subsequent emergency certificate be issued within fifteen days of the execution of the original certificate. If at the expiration of the fifteen days a written application for commitment of such person has not been filed, such person shall be discharged from the hospital. At the time of delivery of such person to such hospital, there shall be left, with the person in charge thereof, a certificate, signed by a physician licensed to practice medicine or surgery in Connecticut and dated not more than three days prior to its delivery to the person in charge of the hospital. Such certificate shall state the date of personal examination of the person to be confined, which shall be not more than three days prior to the date of signature of the certificate, shall state the findings of the physician relative to the physical and mental condition of the person and the history of the case, if known, and shall state that it is the opinion of the physician that the person examined has psychiatric disabilities and is dangerous to himself or herself or others or gravely disabled and is in need of immediate care and treatment in a hospital for psychiatric disabilities. Such physician shall state on such certificate the reasons for his or her opinion. (b) Any person admitted and detained under this section shall be examined by a physician specializing in psychiatry not later than forty-eight hours after admission as provided in section 17a-545, except that any person admitted and detained under this section at a chronic disease hospital shall be so examined not later than thirty-six hours after admission. If such physician is of the opinion that the person does not meet the criteria for emergency detention and treatment, such person shall be immediately discharged . The physician shall enter the physician ' s findings in the patient ' s record. (c) Any person admitted and detained under this section shall be promptly informed by the admitting facility that such person has the right to consult an attorney, the right to a hearing under subsection (d) of this section, and that if such a hearing is requested or a probate application is filed, such person has the right to be represented by counsel, and that counsel will be provided at the state ' s expense if the person is unable to pay for such counsel. The reasonable compensation for counsel provided to persons unable to pay shall be established by, and paid from funds appropriated to, the Judicial Department, however, if funds have not been included in the budget of the Judicial Department for such purposes, such compensation shall be established by the Probate Court Administrator and paid from the Probate Court Administration Fund. (d) If any person detained under this section, or his or her representative, requests a hearing, in writing, such hearing shall be held within seventy-two hours of receipt of such request, excluding Saturdays, Sundays and holidays. At such hearing, the person shall have the right to be present, to cross-examine all witnesses testifying, and to be represented by counsel as provided in section 17a-498. The hearing may be requested at any time prior to the initiation of proceedings under section 17a-498. The hearing shall be held by the court of probate having jurisdiction for commitment as provided in section 17a-497, and the hospital shall immediately notify such court of any request for a hearing by a person detained under this section. At the conclusion of the hearing, if the court finds that there is probable cause to conclude that the person is subject to involuntary confinement under this section, considering the condition of the respondent at the time of the admission and at the time of the hearing, and the effects of medication, if any, and the advisability of continued treatment based on testimony from the hospital staff, the court shall order that such person ' s detention continue for the remaining time provided for emergency certificates or until the completion of probate proceedings under section 17a-498. (e) The person in charge of every private hospital for psychiatric disabilities in the state shall, on a quarterly basis, supply the Commissioner of Mental Health and Addiction Services, in writing with statistics that state for the preceding quarter, the number of admissions of type and the number of discharges for that facility. Said commissioner may adopt regulations to carry out the provisions of this subsection. (f) The superintendent or director of any hospital for psychiatric disabilities shall immediately discharge any patient admitted and detained under this section who is later found not to meet the standards for emergency detention and treatment. (g) Any person admitted and detained at any hospital for psychiatric disabilities under this section shall, upon admission to such hospital, furnish the name of his or her next of kin or close friend. The superintendent or director of such hospital shall notify such next of kin or close friend of the admission of such patient and the discharge of such patient, provided such patient consents, in writing, to such notification of his or her discharge. (h) No person, who a physician concludes has active suicidal or homicidal intent, may be admitted to or detained at a chronic disease hospital under an emergency certificate issued pursuant to this section, unless such chronic disease hospital is certified under Medicare as an acute care hospital with an inpatient prospective payment system excluded psychiatric unit.

Based on clinical record review, review of facility documentation and interviews for three of five sampled residents (Resident #4, #10 and #11) who were reviewed for hydration, the facility failed to effectively monitor fluid status. The findings include: 1. Resident #4's [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE] identified that Resident #4 had good skin turgor. The interim admission care plan dated [DATE] directed the documentation of Resident #4's intake. Review of the laboratory blood work dated [DATE] identified a Blood Urea Nitrogen (BUN) of 14 (normal value range ,[DATE] mg/dl) and a Creatinine of 0.8 (normal value range 0.7 -14 mg/dl). A physician's orders [REDACTED]. The nurse's note dated [DATE] identified Resident #4 presented with a temperature of 99.3 degrees and fluids were encouraged with fair results. On [DATE] the resident's intake at dinner was approximately 10%. The laboratory blood work dated [DATE] identified a BUN of 24 with a Creatinine of 1.1. The nutritional assessment dated [DATE] identified that the estimated fluid needs for Resident #4 was 1900 millimeters (ml) per day and the resident averaged 1080 ml in one day. The admission Minimum Data Set assessment dated [DATE] identified that Resident #4 had severe cognitive deficits and was independent with eating after one person assistance with set up. The resident care plan dated [DATE] identified a potential for dehydration related to vomiting. Interventions directed to monitor the intake and output every shift, monitor the frequency of vomiting and document, monitor for signs and symptoms of dehydration, dry mucous membranes, fever, sunken eyes, and poor skin turgor, encourage fluid intake and report blood work as ordered. The nurse's note dated [DATE] identified Resident #4 complained of nausea and diarrhea. The physician's progress note dated [DATE] identified that Resident #4 was seen for twenty-four hours of nausea, vomiting and diarrhea with increased malaise. The plan was to rule out infectious process, will place on clear liquid diet for twenty-four hours, intake and output for seventy-two hours and monitor, and vital signs for seventy-two hours. A physician's orders [REDACTED].#4 a clear liquid diet for twenty-four hours and intake and output monitored for seventy two hours. On [DATE] a physician's orders [REDACTED]. Blood work dated [DATE] identified a BUN of 32 and a Creatinine of 1.1. A physician's orders [REDACTED]. Review of the facility's Intake and output policy identified that it is the facility policy to maintain an accurate record of the resident's Intake and Output whenever a resident is at risk for fluid imbalances. On [DATE] the blood work identified that the BUN was 47 and the Creatinine was 1.5. The Advanced Practice Registered Nurse (APRN) ordered the administration of intravenous fluids at 50 cubic centimeters (cc) per hour for one liter. Review of the resident daily flow sheets from [DATE] through [DATE] failed to reflect that the resident's Intake and Output was monitored as ordered and the nurse's notes dated [DATE] through [DATE] failed to reflect documentation that Resident #4 was assessed for dehydration. The nurse's note dated [DATE] identified the charge nurse was called to the Resident #4's room. Resident #4 had labored breathing and was unresponsive, the blood pressure was ,[DATE] then ,[DATE], the heart rate was 92, respirations were 22, the temperature 97 and oxygen saturation level was 95%. Resident #4 was transferred to the hospital and admitted with admitted with [MEDICAL CONDITION] and severe [MEDICAL CONDITION]ly related to volume depletion. The initial blood work at the hospital on [DATE] identified a BUN of 58 and a creatinine of 2.0 with Sodium of 157. At the time of admission a palliative consultation was requested and a decision was made for Hospice care. Resident #4 expired on [DATE]. 2. Resident #10's [DIAGNOSES REDACTED]. On admission to the hospital on [DATE], Resident #10's creatinine was 4.0 and at time of discharge to the skilled nursing facility the creatinine was 1.9. The Nurse Admission assessment dated [DATE] identified Resident #10 was alert and oriented, a urinary catheter, recent and/or current nausea and diarrhea. The admission care plan dated [DATE] identified Resident #10 with a history of dehydration. Interventions directed to provide diet as prescribed, encourage fluids, document intake and respect individual likes and dislikes. The nutritional assessment dated [DATE] identified that the estimated fluid need for Resident #4 was ,[DATE] cc. Review of the I&O records from [DATE] through [DATE] failed to reflect consistent documentation of the resident's intake and output and the twenty-four hour totals. The APRN's progress note dated [DATE] identified that Resident #10 was hypovolemic with a BUN of 73 and a Creatinine of 1.7. A physician's orders [REDACTED]. Review of the I&O documentation dated [DATE] through [DATE] failed to reflect documentation that included the total amount of intravenous fluids and oral fluids Resident #10 had consumed in a twenty-four period. A physician orders [REDACTED]. Review of the I&O records from [DATE] through [DATE] failed to reflect documentation of the twenty-four hour totals that would include the increase of fluids, the intravenous fluids and/or the daily intake of fluids. Review of the basic metabolic panel dated [DATE] identified a BUN of 46 and a creatinine of 1.9. Review of facility policy directs that an accurate record of Intake and Output be maintained whenever a resident is at risk for fluid imbalances. All new admissions shall have Intake and Output monitored for 72 hours. Residents shall have their Intake and Output monitored if the resident is receiving an antibiotic, is on encourage fluids, has consistently poor intake or receives intravenous fluids. Interview with the Director of Nursing on [DATE] at 8:30 AM identified that the facility did not have a formal dehydration risk assessment but the expectation was that the nursing staff review the hospital discharge summary, review the laboratory data and follow orders from the physician and/or APRN and document in the nurse's notes. The nursing staff should be assessing and documenting their ongoing findings in nurse's notes for those residents at risk for dehydration and/or receiving intravenous therapy. If a resident is receiving therapy complete intake and output should be documented. Interview and review of Resident #10's intake and output totals with the charge nurse and the Director of Nurses (DON) failed to identify a consistent method from data entered on the nursing flow sheet. The DON indicated that the current flow sheet was not clear as to how to calculate accurate twenty-four hour totals. Interview and review of the clinical record with the DON identified that the intake and output was not completed on admission, when fluids were to be encouraged, when ordered by the APRN and when IV fluids were administered. 3. Resident #11's [DIAGNOSES REDACTED]. The resident care plan dated [DATE] identified that the resident was readmitted to the facility after a hospitalization [MEDICAL CONDITION] related to a urinary tract infection. Interventions directed to monitor the resident's Intake and Output (I&O) while on an antibiotic. The care plan dated identified that the resident was at risk for nutrition and hydration problems. Interventions directed to encourage fluid and document the intake. A physician's orders [REDACTED]. The nutritional progress note dated [DATE] identified the resident's estimated fluid requirement was ,[DATE]cc per day. Review of the clinical record from [DATE] through [DATE] identified that antibiotic therapy was administer daily. The nurse's notes from [DATE] through [DATE] identified that the resident was encouraged and/or coaxed to take fluids and the resident was tolerating the fluids fair. The clinical record failed to reflect documentation that the resident's intake and output and/or was monitored for dehydration. Upon further review, from [DATE] through [DATE] the clinical record failed to reflect consistent documentation of the fluid intake to determine the actual twenty-four hour total. The nurse's note dated [DATE] at 10:00 AM identified that the resident was lethargic, had a temperature of 100 degrees, the blood pressure of ,[DATE], and dry mucous membranes were noted. The note identified that the supervisor was notified. At 11:00 AM the resident's temperature increased to 101.7 and the APRN was notified. Review of APRN #2's progress note dated [DATE] identified that the Resident #11 was febrile, had normal skin turgor and the resident was mildly hypotensive (normal blood pressure ranged between ,[DATE]-,[DATE]). Review of Resident #11's physician's orders [REDACTED]. Review of the clinical record from [DATE] through [DATE] identified that Resident #11 had increased stools, a poor to no meal intake and fluids were encouraged. Although the resident's intake was documented the record failed to reflect that the total intake and output were consistently calculated to determine the resident's actual twenty-four hour intake and output and/or failed to identify that the resident was assessed for dehydration. The nurse's note dated [DATE] at 2:00 PM identified that Resident #11 had increased lethargy, the color was pale, skin was warm and dry, appetite remained poor, fluid intake was fair and the resident had a large mucousy stool. The note identified that APRN #2 was notified and directed to obtain a Complete Blood Count (CBC), Basic Metabolic Panel (BMP) and a stool specimen for C- Diff. Review of the laboratory report dated [DATE] identified that the BUN was 49 (normal range ,[DATE]), creatinine was 0.9 (normal range 0XXX,[DATE].0), Sodium was 133 (normal ,[DATE]) and Potassium was 3.0 (normal 3XXX,[DATE].1), and white blood count 24.8 (normal range 4XXX,[DATE].5). Review of APRN #2's progress note dated [DATE] identified that the resident's laboratory results were reviewed, the resident had decreased intake, and the resident was assessed with [REDACTED]. The APRN #2 directed to administer intravenous fluids at 50 cc per hour times two liters for dehydration. Review of the APRN's progress note dated [DATE] identified that although the resident's BUN decreased to 26, the WBC had elevated to 30.5 even though [MEDICATION NAME] 500 mg every six hours had been initiated for [MEDICAL CONDITION]. APRN #2 directed to transfer the resident to the hospital for an evaluation and the resident was admitted for treatment of [REDACTED]. The findings must be documented in a nursing note and if the resident is showing any signs of dehydration the physician must be notified for appropriate action. Additionally, the facility's Intake and output policy identified that it is the facility policy to maintain an accurate record of the resident's Intake and Output whenever a resident is at risk for fluid imbalances. The policy directed that residents shall have their intake and output monitored when receiving antibiotics.

Based on review of the clinical record, review of facility documentation and interviews for one of three sampled residents (Resident #20) who were reviewed for accidents, the facility failed to ensure a safe mechanical lift transfer. The findings include: Resident #20's [DIAGNOSES REDACTED].#20 had no cognitive impairments, required extensive assistance with activities of daily living and was totally dependent of staff for transfers in and out of the bed and chair. The resident care plan dated 7/3/13 identified an alteration in mobility related to [DIAGNOSES REDACTED]. The readmission physician's orders [REDACTED]. The nurse's note dated 8/31/13 identified that on the 3:00-11:00 PM shift Resident #20 fell from the mechanical lift to the floor. Resident #20 was transferred to the emergency department for an evaluation. The hospital Inter-Agency Referral Report dated 8/31/13 identified that Resident #20 had sustained right side rib fractures of the 8th and 9th posterior ribs, the CT scan of the head and cervical spine was normal and the resident returned to the facility on [DATE] at 12:30 AM. Review of the Reportable Event Form dated 8/31/13 identified that Nurse Aide (NA) #1 and NA #2 transferred Resident #20 from the wheelchair to the bed via a mechanical lift. Resident #20 was lifted from the wheelchair, the wheelchair was pushed out of the way into the hallway, the hoyer pad came unhooked and the resident fell two to three feet to the floor. Review of the hoyer lift policy directs to check the chains and S/hooks to make sure they are properly positioned. The policy failed to reflect direction to check the sling. Interview and review of facility documentation with NA #1 on 10/3/13 at 12:06 PM identified that one of the hooks on the lift pad was loose that caused the resident to jerk when lifted off the chair. NA #1 indicated that the transfer was initiated in the hallway, the wheelchair was pushed away and while the resident remained elevated the lift was pushed into the resident's room and the resident fell before they could reach the bed. NA #1 identified that there was not enough room to maneuver the lift in Resident #20's room and if the transfer was attempted closer to the resident's bed the fall may not have occurred. Interview and review of the clinical record and facility documentation with the Director of Nurses (DON) on 10/1/13 at 10:30 AM identified after that the incident the mechanical lift and the lift pad were checked for safe operating condition and a small tear was noted in one area near one of the hooks. The DON indicated that the nurse aides should have checked for safety prior to lifting the resident. Subsequent to the incident the mechanical lift pad was replaced, the nurse aides were inserviced on proper mechanical lift procedure and NA #2 received a job performance violation for not following the facility's hoyer lift policy.

Based on observations, clinical record reviews, review of facility policy and interviews for one of five residents reviewed for accidents (Resident #120) and/or for four of six residents (Residents #124, #157, #194, #198) reviewed for smoking and/or for one of five resident lounges (Unit Two), the facility failed to ensure the environment remained free of hazards. The findings include: 1. Resident #120's [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated long and short term memory loss, moderately impaired cognitive skills and extensive assistance for bed mobility, transfers and personal hygiene. A care plan dated 3/22/11 identified a risk for skin breakdown related to a [DIAGNOSES REDACTED]. Occupational Therapy notes dated 4/13/11 and 4/15/11 indicated the resident exhibited fear with transfers, was fearful of falling, was very rigid and would continue to require a Hoyer lift for transfers with the maximum assistance of two staff. A nurse's note dated 4/16/11 identified after the removing the waffle boot a deep 4.0 centimeters (cm) by 2.7 cm V- shaped skin tear laceration was found on the left lower extremity. The physician was notified and directed to transfer Resident #120 to the emergency room for an evaluation. The nurse's note dated 4/16/11 identified five sutures were required to approximate the laceration on the left lower extremity. Physician orders [REDACTED]. Interview with the Director of Nurses (DNS) on 7/19/11 at 9:00 AM indicated the resident had fragile skin and when the left foot slipped during transfer, the metal part of the wheelchair calf rest hit the left foot causing the laceration. Interview with Nurse Aide (NA) #3 and NA #4 on 7/20/11 at 3:30 PM indicated after the resident was transferred to the wheelchair via the Hoyer lift, the left foot rest was attached to the wheelchair by NA #3 and the resident's left foot was placed on the foot rest with the calf rest in the open position. NA #3 indicated that while putting the right foot rest onto the wheelchair, the resident's left foot fell off the foot rest and the foot rest assembly shifted away. NA #3 indicated the left foot rest was not properly engaged and " did not click" into place prior to placing the resident's left foot on the foot rest. Upon removing the waffle boot on the left foot, a skin tear and blood was noted on the waffle boot and the Registered Nurse Supervisor was immediately notified. Interview with the Occupational Therapist on 7/21/11 at 9:45 AM indicated if the foot rest on an adapted custom wheelchair is not properly engaged it may move causing the foot to slip between the gaps of the foot rest. 2. Resident #124's [DIAGNOSES REDACTED]. A Smoking assessment dated [DATE] indicated the resident was physically capable of smoking with supervision and did not require a smoking apron. The care plan dated 5/9/11 indicated the resident was observed smoking independently on 3/15/10 and was re-educated on the safety precautions of smoking with supervision. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated independence for decision-making skills, no behaviors, non-ambulatory and extensive assistance for all activities of daily living. Observation on 7/18/11 at 6:10 PM identified the resident smoking in a non-designated smoking area without staff present and without a receptacle for cigarette butts in the area. Observation with the Assistant Director of Nurses (ADNS) at the time noted a trash can in area with a cigarette butt in the trash can. Interview with Resident #124 and the Administrator on 7/18/11 at 6:15 PM indicated the resident was given the cigarette that was lit by a visitor. Interview with the ADNS on 7/19/11 at 9:40 AM indicated a room search of the resident ' s room was conducted the previous evening with the DNS and a cigarette was found in the resident's drawer. The ADNS indicated the resident had stated he/she was not aware the cigarette was in the drawer. A reeducation of the smoking policy was conducted and a first violation of the smoking policy was issued to the resident. 3. Resident #157's [DIAGNOSES REDACTED]. A Smoking Agreement dated 4/9/10 and signed by the responsible party indicated Resident #157 agreed to smoke only in designated areas under supervision of a facility designated monitor. Review of the Assessment for Residents Who Smoke indicated Resident #157's last assessment was competed on 1/2/11. The resident was evaluated to be a safe smoker with supervision. The care plan dated 6/29/11 indicated the resident wished to smoke. Interventions included educating the resident/family on the smoking policy and a smoking assessment will be reviewed quarterly and as needed. Observation of Resident #157 on 7/19/11 at 2:45 PM indicated the resident was with a family member in a non-designated smoking area with no receptacle for the disposal of cigarette butts. Interview with the Assistant Director of Nurses (ADNS) and the resident at that time indicated the resident planned to snuff out the butt and take it into the facility for disposal. The resident further indicated he/she was not aware that the area was not designated for smoking. Interview with Registered Nurse (RN) #2 on 7/19/11 at 2:50 PM indicated the cigarette was provided by staff and the resident was allowed to smoke with a family member present. RN #2 further indicated the resident was aware of the designated smoking areas. 4. Resident # 194's [DIAGNOSES REDACTED]. The care plan dated 7/5/11 indicated Resident #194 wished to smoke. Interventions included educating the resident and family on the facility policy and procedures, all cigarettes and lighting materials will be kept at the nurses ' station and the resident will be allowed to smoke only during facility smoking times. The nurse's note dated 7/4/11 on the 11-7 AM shift identified the Resident #194 was found outside the facility smoking with another resident during a non-designated smoking time. Interview with the Director of Nurses (DNS) on 7/21/11 at 11:30 AM and 12:30 PM indicated she could not explain why the resident was found smoking unsupervised. The DNS further indicated the licensed staff on the evening shift had educated the resident on the facility's smoking policy and procedures. 5. Resident #198 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The Nursing Admission Care Plan dated 7/13/11 indicated the resident was on a Nicoderm Patch for smoking cessation. An Assessment for Residents who Smoke was completed on 7/14/11 and indicated the resident wished to continue smoking and was compliant with the facility policy to not give cigarettes to other residents, to smoke with supervision and to dispose of cigarette butts in the appropriate receptacle. Observation of Resident #198 on 7/18/11 at 6:10 PM indicated the resident was in a non-designated smoking area with Resident #124 who was smoking without staff supervision. Interview with Resident #124 at that time indicated the cigarette was provided by Resident #198. Interview with the ADNS on 7/19/11 at 9:40 AM indicated Resident #198's room was searched the evening of the incident and a pack of cigarettes was found in the resident's room. Further review of the clinical record lacked documentation of a smoking agreement signed by the resident. Interview with Social Worker (SW) #1 on 7/19/11 at 9:45 AM indicated it was the responsibility of the Social Services department to review the smoking agreement with all new admissions that smoke. SW #1 further stated due to staff vacations, she had not been able to review the agreement with Resident #198. SW #1 also indicated the resident had several admissions and was familiar with the facility ' s smoking policy.