Every finding on record at Apple Rehab Avon

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure staff monitored the resident's whereabouts timely, and the resident was last observed by staff at approximately 6:30 PM and identified missing at 11:48 PM. The findings include: Resident #1's diagnoses included diabetes mellitus and paranoid schizophrenia. Record review identified Resident #1 had a court appointed conservator for person (COP). Review of the Capacity to Meet Minimal Basic Needs assessment dated [DATE] identified Resident #1 did not have the capacity to meet his/her minimal basic needs in the community. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve out of fifteen (12/15), was cognitively intact, had no wandering behaviors and ambulated independently. The Resident Care Plan dated 5/15/26 identified a risk for changes in mood state and behaviors related to paranoid schizophrenia. Interventions directed monitor symptoms, delusions, hallucinations, periods of manic mood and follow up with psychiatry as indicated. Social services note dated 5/18/26 at 1:35 PM by SW #1 identified Resident #1 requested multiple times during the morning to return home. SW #1 attempted to educate Resident #1 regarding safety concerns associated with a leave of absence (LOA) and the need for involvement of his/her COP. Resident #1 adamantly denied needing a COP and became verbally aggressive toward SW #1 while pacing the hallways. A call was made with a message left to request assistance from a family member to obtain personal belongings from the apartment, and a referral was placed for psychiatric follow up. A facility incident report and investigation dated 5/19/26 at 7:00 PM identified Resident #1 went on unauthorized leave. The investigation's timeline identified at 11:48 PM, NA #1 reported to LPN #2 that Resident #1 was not in his/her room they searched the dining room and frequent/common areas. When Resident #1 was not located, a Dr. Hunt (Code for Missing Resident) was called immediately, per facility policy and a wider search including the grounds was conducted without locating Resident #1, and at 11:59 PM, local police were notified. LPN #2 reached Resident #1 by phone at 12:08 AM and Resident #1 stated he/she had called an Uber and was home safe, understood the risks of leaving the facility Against Medical Advice (AMA), and knew how to call 911 if needed. Review of the local police report dated 5/19/26 at 11:55 PM identified Police Officer (PO) #1 and #2 responded to the facility report of missing Resident #1, and was informed Resident #1 was last seen at approximately 6 or 6:30 PM (approximately 5 hours and 18 minutes before identified missing). Resident #1 was located at his/her apartment approximately 11 miles away. The local PO spoke with Resident #1 via phone and Resident #1 indicated he/she left the facility at approximately 7 PM through the front door and was picked up by a friend. A nursing note dated 5/20/2026 at 10:23 AM written by the DON identified Resident #1 was not returning to the facility and was staying at his/her apartment and was choosing an AMA discharge. Local police performed a wellness check and identified Resident #1 was safe. Review of the facility investigation identified facility security video indicated Resident #1 left through the front door at 7:06 PM (4 hours and 48 minutes prior to staff identifying Resident #1 was missing). Interview with the Director of Nursing (DON) and RN #2/Corporate Nurse on 6/5/26 at 1:55 PM identified the expectation was that nursing staff conduct rounds on all residents at least every two hours. Although Resident #1 was reported to last be observed by staff about 6:30 PM, interview failed to identify why staff did not identify Resident #1 was missing until 11:48 PM (5 hours and 18 minutes later). A facility policy on monitoring resident whereabouts was not provided for surveyor review.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for abuse, the facility failed ensure the Resident #1 was free from verbal mistreatment. The findings include: Resident #1 was admitted with diagnoses that included major depression, end stage kidney disease and heart failure. The Resident Care Plan (RCP) dated 3/14/2022 identified Resident #1 often refused treatments, hoarded items and refused out of bed. Interventions directed two (2) staff in attendance when providing care and encourage appropriate storage of items. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was alert and oriented and required extensive assistance for bed mobility. A facility reportable event (RE) form dated 4/28/2022 identified an incident of staff-to-resident abuse without injury. The form identified on 4/17/2022, a staff member (Housekeeper #1) was witnessed to have gotten into an argument with Resident #1 and used curse words towards the resident. A facility RE summary dated 5/18/2022 identified the Housekeeper #1 used profanity towards Resident #1 and the facility terminated her employment. Interview and review of his facility statement with the Director of Maintenance (DM) on 12/05/2025 at 12:45 PM identified on 4/23/2022 he observed Resident #1 became upset with Housekeeper #1, and was yelling that the bedside table had been moved during cleaning demanding it be put back. Housekeeper #1 moved the bedside table as requested. On 4/25/2025, the DM observed Housekeeper #1 in Resident #1's room and Housekeeper #1 told Resident #1 that if he/she treated her the way he/she had treated her the last time (on 4/23/2022) then Housekeeper #1 would no longer clean the room. The DM stated Resident #1 and Housekeeper #1 began to argue, swearing at each other with Housekeeper #1 calling Resident #1 a lazy momma b---ch. The DM requested Housekeeper #1 leave the room and he notified the Administrator the next day (on 4/26/2027)and stated he should have notified the Administrator immediately after his observation as it was considered verbal abuse. Interview and record review with the DON on 12/2/2025 at 1:15 PM identified if a staff member reported they observed a staff member arguing with a Resident and then calling that Resident a lazy b---ch, that it would be considered verbal abuse, and the facility policy should be followed to include suspending the employee. Interview and review of facility investigative documents with the Administrator on 12/5/2025 at 1:25 PM identified that calling Resident #1 a lazy momma b---ch, would be considered an incident of verbal abuse. The Administrator stated they were unable to obtain a statement from Housekeeper #1, and her employment had been terminated. A review of the Housekeeper #1's employee file identified that on 5/5/2022 she identified a notation that she may have used the word b-tch when addressing Resident #1. Additional documentation identified that the incident occurred on 4/25/2025. The facility Abuse Policy, directed in part, that any kind of abuse or mistreatment is strictly prohibited. Verbal abuse was defined as the use of oral, written or gestured language that includes derogatory or threatening terms directed at a resident.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for abuse, the facility failed to ensure an employee was removed from the schedule after she was observed using inappropriate language. The findings include:Resident #1 was admitted with diagnoses that included major depression, end stage kidney disease and heart failure. The Resident Care Plan (RCP) dated 3/14/2022 identified Resident #1 often refused treatments, hoarded items and refused out of bed. Interventions directed two (2) staff in attendance when providing care and encourage appropriate storage of items. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was alert and oriented and required extensive assistance for bed mobility. A facility reportable event (RE) form dated 4/28/2022 identified an incident of staff-to-resident abuse without injury. The form identified on 4/17/2022, a staff member (Housekeeper #1) was witnessed to have gotten into an argument with Resident #1 and used curse words towards the resident. A facility RE summary dated 5/18/2022 identified the Housekeeper #1 used profanity towards Resident #1 and the facility terminated her employment. Interview and review of his facility statement with the Director of Maintenance (DM) on 12/05/2025 at 12:45 PM identified on 4/23/2022 he observed Resident #1 became upset with Housekeeper #1, and was yelling that the bedside table had been moved during cleaning demanding it be put back. Housekeeper #1 moved the bedside table as requested. On 4/25/2025, the DM observed Housekeeper #1 in Resident #1's room and Housekeeper #1 told Resident #1 that if he/she treated her the way he/she had treated her the last time (on 4/23/2022) then Housekeeper #1 would no longer clean the room. The DM stated Resident #1 and Housekeeper #1 began to argue, swearing at each other with Housekeeper #1 calling Resident #1 a lazy momma b---ch. The DM requested Housekeeper #1 leave the room and he notified the Administrator the next day (on 4/26/2027). The DM stated he was unclear as to the specific disciplinary action needed for Housekeeper #1 and stated he did not suspend the housekeeper. When he notified the Administrator, a 3-day suspension be put into place and Housekeeper #1 never returned to the facility. Interview and record review with the DON on 12/2/2025 at 1:15 PM identified if a staff member reported they observed a staff member arguing with a Resident and then calling that Resident a lazy b---ch, that it would be considered verbal abuse, and the facility policy should be followed to include suspending the employee. Interview and review of facility investigative documents with the Administrator on 12/5/2025 at 1:25 PM identified that calling Resident #1 a lazy momma b---ch, would be considered an incident of verbal abuse. The Administrator stated the employee should have been suspended immediately and failed to identify why the employee was not removed from the schedule. A review of the Housekeeper #1's employee file identified that on 5/5/2022 she identified a notation that she may have used the word b-tch when addressing Resident #1. Additional documentation identified that the incident occurred on 4/25/2025. The facility Abuse Policy, directed in part, that any kind of abuse or mistreatment is strictly prohibited. Verbal abuse was defined as the use of oral, written or gestured language that includes derogatory or threatening terms directed at a resident. Further, the Policy directed after an allegation of abuse, an employee was to be removed from the schedule pending the results of the investigation.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for abuse and neglect, the facility failed to ensure staff reported an allegation of abuse/mistreatment timely, and the facility failed to ensure the State Agency was notified timely of an allegation of mistreatment after staff reported an allegation. The findings include:Resident #1 was admitted with diagnoses that included major depression, end stage kidney disease and heart failure. The Resident Care Plan (RCP) dated 3/14/2022 identified Resident #1 often refused treatments, hoarded items and refused out of bed. Interventions directed two (2) staff in attendance when providing care and encourage appropriate storage of items. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was alert and oriented and required extensive assistance for bed mobility. A facility reportable event (RE) form dated 4/28/2022 identified an incident of staff-to-resident abuse without injury. The form identified on 4/17/2022, a staff member (Housekeeper #1) was witnessed to have gotten into an argument with Resident #1 and used curse words towards the resident. A facility RE summary dated 5/18/2022 identified the Housekeeper #1 used profanity towards Resident #1 and the facility terminated her employment. Interview and review of his facility statement with the Director of Maintenance (DM) on 12/05/2025 at 12:45 PM identified on 4/23/2022 (Saturday) he observed Resident #1 became upset with Housekeeper #1, and was yelling that the bedside table had been moved during cleaning demanding it be put back. Housekeeper #1 moved the bedside table as requested. On 4/25/2025 (Monday), the DM observed Housekeeper #1 in Resident #1's room and Housekeeper #1 told Resident #1 that if he/she treated her the way he/she had treated her the last time (on 4/23/2022) then Housekeeper #1 would no longer clean the room. The DM stated Resident #1 and Housekeeper #1 began to argue, swearing at each other with Housekeeper #1 calling Resident #1 a lazy momma b---ch. The DM requested Housekeeper #1 leave the room and he notified the Administrator the next day (on 4/26/2022, Tuesday) because the Administrator was unavailable on 4/25/2022. Further, the DM stated he should have informed the Administrator immediately after his observations as it was considered verbal abuse. Interview and record review with the DON on 12/2/2025 at 1:15 PM identified if a staff member reported they observed a staff member arguing with a Resident and then calling that Resident a lazy b---ch, that it would be considered verbal abuse, and it should be reported immediately. The facility policy should be followed to include reporting the incident immediately. Interview and review of facility investigative documents with the Administrator on 12/5/2025 at 1:25 PM identified that calling Resident #1 a lazy momma b---ch, would be considered an incident of verbal abuse. The Administrator stated theDM should have notified the Administrator immediately when he observed the interaction. A review of the Housekeeper #1's employee file identified that on 5/5/2022 she identified a notation that she may have used the word b-tch when addressing Resident #1. Additional documentation identified that the incident occurred on 4/25/2025. a. Review of the State Agency reportable events identified the State Agency was notified of an incident dated 4/28/2025 that indicated the incident occurred on 4/28/2025 at 11:30 AM. Further review failed to identify the State Agency was notified of the incident that occurred on 4/25/2025 as reported by the DM. Interview and review of his facility statement with the Director of Maintenance (DM) on 12/05/2025 at 12:45 PM identified the incident with Housekeeper #1 occurred on Monday, 4/25/2022 and he notified the Administrator on Tuesday, 4/26/2022 (the day after it occurred). He stated that the incident did not occur on 4/28/2022. Interview and review of facility investigative documents with the Administrator on 12/5/2025 at 1:25 PM identified although the incident between Resident #1 and Housekeeper #1 occurred on 4/25/2022 and the DM notified the Administrator #2 of the incident on 4/26/2022, the State Agency was not notified until 4/28/2022 (3 days after the incident occurred and 2 days after it was reported to Administrator #2). The Administrator stated the State Agency should have been notified as soon as it was reported by the DM. The facility Abuse Policy, directed in part, that any kind of abuse or mistreatment is strictly prohibited. Verbal abuse was defined as the use of oral, written or gestured language that includes derogatory or threatening terms directed at a resident. After an allegation of abuse, an employee was to be removed from the schedule pending the results of the investigation. Further, the Policy directed an online report will be submitted to the State Agency within two (2) hours of notification.

Based on observation, review of facility documentation, facility policy and interviews for bi-monthly narcotic audits, the facility failed to maintain and keep records of bi-monthly narcotic audits. The findings include: Based on observation, review of facility documentation, facility policy and interviews for bi-monthly narcotic audits, the facility failed to maintain and keep records of bi-monthly narcotic audits. The findings include: During the onsite review of the medication storage room on 9/25/25 at 12:29 PM, the most recent documented bi-monthly narcotic audit log was dated September 1, 2025. Observation of the bi-monthly narcotic audit logs identified the months for April 2025, May 2025, June 2025, July 2025, and August 2025 were not available. Interview with the Director of Nursing (DNS) on 9/25/25 at 1:56 PM identified that bi-monthly narcotic audit logs were not located prior to her start date in August 2025. Interview with the DNS on 9/25/25 at 2:45 PM identified the bi-monthly audit logs prior to September 2025 were completed by the previous DNS and could not be located. Further identified the bi-monthly audit logs should be kept and stored for 3 years and the DNS was responsible. Review of the Controlled Medications Policy dated 2025 directed, in part, when completed, audit and accountability records are submitted to the Director of Nursing and kept on file for three years at the facility.

Based on tour of the Dietary Department, staff interview and review of facility policy, the facility failed to ensure proper hair covers were worn while in the kitchen, they also failed to ensure items in the kitchen were consistently dated and labeled. The findings include: The tour of the Dietary Department on 9/22/25 at 9:24 AM with the Director of Dietary identified the following:a. The Dietary Manager was observed with a full beard, standing over the food preparation area that contained a tray of uncovered ham, and carrots with no beard covering on to cover his beard. Interview with the Dietary Manager on 9/22/25 at 9:24 AM identified that a hair covering should be worn by all persons in the kitchen but did not provide a reason his beard was not covered while in the kitchen and near food. Facilities Dress Code Policy indicated in part that Hairnets or Hats must be work at all times, hair restraints must completely cover the hair line at all times, beard guards needed to be worn as appropriate. b. Observation on 9/22/25 at 9:32 AM with the Dietary Manager identified that the meat freezer had 1 open bag of a meat like substance described by Dietary Manager to be chicken cutlets with no label to identify the item, and no date to indicate when it was first opened. There were also 3 additional unopened bags of (chicken cutlets according to Dietary Manager) with no labels to indicate the size/ounces of the bag, expiration date or what the item was. Additionally, 1 unopened bag of breaded meat described by Dietary Manager to be fish patties, which did not have labels to indicate what the item was or an expiration date. Prior to observation of the refrigerators and freezers, the Dietary Manager reported that all items were expected to be dated and labeled of what the item was (if removed from original package) and when it was opened.Subsequent to surveyor inquiry, the Dietary Manager began dating and labeling the bags he described as chicken cutlets.c. Observation on 9/22/25 at 9:38 AM of the Pastry fridge noted one 10 inch weight 10.13 lb Strawberry Cream Pie and 1 pound cake( size unknown) with no use by date/expiration date.d. Observation of the Dry storage room at 9:52 AM on 9/22/25 noted 3 cans (6 pound 3 ounces) of shredded sauerkraut with no expiration date and observation at 9:55 AM of an open pack of chocolate cake with no open date or use by date. Interview with the Dietary Manager on 9/22/25 at 9:38 noted he was unable to provide why the cans did not have an expiration date. Subsequent to inquiry Dietary manager contacted the food service distributor of the cans to receive the self-life of the aforementioned items. Review of Facilities perishable dating Policy indicates in part, all items stored in the refrigerator will be dated the date opened.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 4 residents reviewed for mistreatment, the facility failed to ensure that the residents were free from a resident-to-resident altercation. The findings include: 1. Resident #20 's diagnoses included dementia with other behavioral disturbance, anxiety disorder, adjustment disorder and depressed mood. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was cognitively impaired, having behavioral history of rejecting evaluation or care. The MDS further identified Resident #20 required assistance for sit-to-stand transfers and supervision or touching assistance for bed mobility.The Resident Care Plan dated 6/27/24 identified Resident #20 could be physically and/or verbally aggressive toward staff members or other residents. Interventions included to approach Resident #20 slowly and from the front, attempt to involve Resident #20 in 1 to 1 recreational activity, be sure to have his/her attention before speaking or touching him/her, offer a consult with psychiatric services and to use consistent routines (timing and sequencing) for Activities of Daily Living. A physician's order dated 7/26/24 directed to give 25 milligrams (mg) Trazodone (a medication to treat depression) by mouth (PO) every day as needed (PRN) for anxiety for 14 days. 2. Resident #46 's diagnoses included chronic diastolic (congestive) heart failure, type 2 diabetes mellitus and paranoid schizophrenia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 was cognitively intact. The MDS also indicated Resident #46 exhibited behavior of delusional symptoms and was independent with transfers and lower body dressing. The Resident Care Plan dated 7/1/24 identified Resident #46 had paranoid schizophrenia disorder and was at risk for changes in mood state and behaviors. Interventions included to watch for and report new onset or increase in symptoms, delusions, hallucinations, impaired communication and speech, bizarre or unusual behavior, symptoms of depression, periods of manic mood and follow up with the psychiatrist as scheduled or as needed. A nursing note dated 8/5/24 at 4:01 PM identified, the nurse was called by the Nurse Aide (NA) at 2.30 PM. Summoned to the hallway where Resident #20 had fallen. Resident #20 was observed in a semi-lateral position with mild bleeding from an open area to the scalp. He/she denied pain and discomfort. Upon assessment, Resident #20's neurological vital signs were at baseline, pupils were equal and reactive to light, hand grasps equal and weak. Resident #20 was not able to give correct information because of confusion. According to another resident (Resident #46), he/she slapped Resident #20, kicked him/her and Resident #20 fell on the floor. The APRN was informed, a new order was obtained to send Resident #20 to the emergency room for evaluation, activated 911 and Resident #20 was transferred to the hospital for further evaluation. Nursing notes dated 8/5/24 at 10:40 PM identified Resident #20 returned to the facility from the hospital having had a neurological and vital sign evaluation; as well as, an assessment indicating resident was not a current danger to themself or others and had no injuries. No new orders were received upon Resident's #20 return to the facility. A facility obtained statement dated and signed on 8/5/24 from Nurse Aide (NA) #1 (7:00 AM to 3:00 PM shift) indicated I sat down to chart at the NA station, I heard someone yelling 'help' I got up and saw Resident #46 hurrying back into his/her wheelchair and Resident #20 was on the floor. NA #1 asked Resident #46 what happened and he/she said Resident#20 kicked him/her, so he/she retaliated. A facility obtained statement signed and dated 8/6/24 by Registered Nurse (RN) #1 indicated a NA called for help and RN #1 saw Resident #20 on the floor, in a semi-lateral position, with mild bleeding coming from the wound (open area). Resident #20 was not giving accurate statements because of his/her baseline confusion. According to Resident #46, Resident #20 kicked him/her and so Resident #46 pushed Resident #20 and both fell on the floor.A facility Accident and Incident report dated 8/5/24 indicated an unwitnessed incident in which Resident #46 stated Resident #20 was kicking him/her. Resident #46 reported standing up and pushing Resident #20 off of him/her. Both residents were found on the floor. Resident #46 reported that he/she crawled back to his/her chair.Injuries noted on Resident #46 at time of incident was an abrasion to the left kneeInterview with Resident #46 on 9/22/25 at12:20 PM did not provide any additional details related to the incident and only stated it's good now. Interview with NA #1 on 9/24/25 at 11:07 AM indicated that she called the nurse over and waited with Resident #20 as the resident remained on the floor to be evaluated. She reported the residents were not separated at the time after the incident. She reported she didn't recall anything being in the hallway that resident could have hit while falling.Attempts to contact the RN on shift that day were made but unsuccessful.Interview with the Administrator on 9/26/25 at 10:33 AM indicated she was familiar with the incident, though she was off that day. She reported that Resident #20 was sent to the emergency room as a result of the resident-to-resident altercation. She reported due to the pushing, and this altercation would be considered a form of abuse. She reports their policy indicated that residents are immediately separated, seen by psychiatric services and offer room change if applicable. Facilities Abuse policy indicated in part that all residents are treated with kindness, compassion and dignity. abuse or mistreatment of any kind towards a resident is strictly prohibited.

Based on clinical record review and interview for the only resident reviewed for edema (Resident #61), the facility failed to ensure staff submitted Minimum Data Set (MDS) assessments timely. The findings include: Resident #61's diagnosis included heart failure, depression and Hypertension.A quarterly MDS assessment dated [DATE] indicated Resident #61 had moderate cognitive impairment.On 8/28/25 Resident #61 was admitted to the hospital.On 9/4/25 Resident #61 was readmitted to the facility.The facility scheduled and was in the process of completing an annual MDS assessment combined with a discharge return anticipated assessment when Resident #61 was admitted to the hospital on [DATE]. (The facility can complete assessments earlier but no later than 90 days after the date of the last assessment).On 9/24/25 at 9:40 AM an interview and MDS review with Registered Nurse (RN) #2 who completed the MDS', indicated the MDS assessments for Resident #61 had not been completed as of this date and were not completed timely: Entry MDS dated [DATE] to be completed by 9/11/25(13 days late),The annual discharge return anticipated (DRA) assessment along with the care plan decisions should have been completed by 9/20/25 (4 days late), the entry assessment dated [DATE] was to have been completed by 9/21/25 (3 days late), RN #2 indicated he/she was behind in completing the assessments, was the only nurse completing MDS assessments at the facility and at times assists on the units to complete other duties when needed. RN #2 indicated the corporate managers for the facility could be made aware that assistance was needed and planned to do so, subsequent to surveyor inquiry. RN #2 further indicated he/she was told the MDS assessments for September were due on September 15th but would refer to the RAI manual for CMS guidance.The facility policy labeled MDS dated as reviewed 8/19/25 indicated in part the MDS will be completed according to the procedures and directives outlined in the MDS RAI Manual. The Resident Care Coordinator (RCC or MDS Nurse) shall determine the schedule of the MDS assessments to be completed and notify disciplines responsible for completing the MDS. The MDS assessments will be submitted to the QIES data base by an automated MDS submission process through the facility electronic documentation system within 14 days of the completion date of the MDS.MDS Validation Reports were requested but not provided.

Based on review of the clinical record, facility documents, interviews and facility policy for 1 of 4 residents (Resident #24) reviewed for nutrition, the facility failed to ensure weights were documented monthly according to physician orders. The findings include:Resident #24 's diagnoses included having a Stage 4 pressure ulcer to the sacrum, hypotension and neuromuscular dysfunction of the bladder.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 24 was cognitively intact and was dependent with eating, oral hygiene and chair to bed transfer.The Resident Care Plan dated 7/3/25 identified Resident #24 did not have any behaviors of refusing care.A physician's order dated 10/1/24 directed to obtain Resident #24's weight on the first shower day of the month; every day shift starting on the 1st and ending on the 7th every month.Review of the monthly weights failed to identify monthly weights had been documented as physician ordered from May 2025 through September 2025.The Treatment Administration Records (TAR) for March 2025 indicated a weight was obtained on 3/2/25, however, the weight was not documented in the weights/vitals tab, nor does the TAR identify what the weight was that was obtained that day.The TAR for June 2025 indicated weights were taken on 6/1/25, 6/5/25 and 6/7/25 but failed to identify what the weights were from those dates.The TAR for July 2025 indicated on 7/6/25, a weight was obtained but failed to identify what the weight was.The August 2025 TAR indicated on 8/6/25 a weight was obtained; however, the weight was not documented.The September 2025 TAR indicated on 9/5/25 a weight was obtained; however, a weight was not documented.Review of Resident #24's paper chart does not reveal any weights documented for the missing months.Interview with the DNS on 9/24/25 at 10:13 AM indicated all weights should be documented in the weights/ vital tab, during the shift it was taken. She indicated that all refusals should be documented in notes section each time and if the resident had refusal behaviors then it should be care planned for. The DNS was unsure of the reason weights were not consistently taken or documented. She reported acknowledging that weights were an issue for the facility.

Based on review of the clinical record and facility documentation, interviews and facility policy for 1 of 3 residents (Resident #61) reviewed for falls, the facility failed to ensure supervision was provided in the bathroom, resulting in Resident #61 falling without injury. Additionally, the facility failed to ensure staff remained with food items while re-heating in a microwave to prevent the occurrence of smoke that required the activation of a code red and the fire alarm resulting in the fire department being dispatched. The findings include: 1. Resident #61's diagnosis included congestive heart failure, constipation, history of urinary tract infection and history of falls. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #61 had intact cognition and required partial/moderate assistance for toileting, upper/lower body dressing and personal hygiene. Additionally, the MDS identified Resident #61 had a fall in the last month prior to admission and had 1 fall since the prior MDS assessment.The Resident Care Plan (RCP) dated 4/7/25 indicated Resident #61 was at risk for falls due to multiple risk factors including impaired balance, unsteady gait and pain. The RCP indicated Resident #61 had a fall on 3/21/25 with an intervention to place a walker within reach. The RCP indicated Resident #61 had another fall on 4/10/25 with an intervention added to remind Resident #61 to wear proper footwear/nonskid socks when out of bed. Other interventions already in place were to encourage the resident to transfer and change positions slowly, encourage Resident #61 to use handrails or assistive devices properly, physical and occupational therapy to help increase strength and endurance, offer to organize personal items so they are within reach, to wear slipper socks while in bed and provide transfers per the physician's orders. The care plan indicated Resident #61 was at risk for constipation with interventions in-place including to assist resident #61 to meet toileting needs and provide incontinent care as needed. A physician's order dated 4/15/25 directed to transfer Resident #61 with the assistance of 2 persons and no device while another physician order of the same date directed to use a rolling walker with transfer. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #61 had a severe cognitive impairment and was dependent on staff for toileting, toileting hygiene, and transferring from bed to chair. A facility Reportable Event (RE) form dated 5/29/25 at 10:15 PM indicated Resident #61 after being walked to the bathroom by a Nurse Aide (NA) using the resident's walker, was instructed by the NA (Resident #61 was severely cognitively impaired) to use the call light when done in the bathroom and was left in the bathroom by the NA. Resident #61 was witnessed walking out of the bathroom by him/herself, not having utilized the call light for assistance and fell while trying to use the wall mounted hand sanitizer. The RE indicated Resident #61 was not injured and was able to get up and get back to bed. A facility RE dated 6/14/25 at 9:14 AM (16 days after the last fall) indicated Resident #61 had a witnessed fall after NA #4 walked Resident #61 to the bathroom with a walker, NA #4 stood in the doorway of the bathroom and Resident #61 attempted to go toward the toilet, tripped over his/her own feet and fell sitting on the floor. The RE indicated Resident #61 required the assistance of 1 person with a walker but did not reflect the current physician's transfer order for 2-person assistance for transfer and to use a rolling walker for transfers. An intervention entry on the fall RCP dated 6/16/25 (2 days after the fall) indicated to utilize a gait belt when ambulating Resident #61. An interview, facility document review, clinical record review and facility policy review on 9/25/25 at 12:10 PM with the Administrator, the DNS and RN #2 present, reviewed the falls sustained by Resident #61 on 5/29/2025 and 6/14/25, During review of the fall of 6/14/25 the fall investigation found the NA #4 was standing in the doorway while Resident #61 was in the bathroom attempting to turn towards the toilet and the physician orders indicated 2 person transfer assistance with the use of a walker, the DNS indicated the NA should have had hands on the resident and another person assisting the transfer and the orders should have been on the care card to follow. The DNS and Administrator clarified the NA Care cards were written in pencil without dates and were erased when changed, no copies of each care card were kept when changes were made further indicating when an order was written it was transcribed to the care card. At the end of review of each fall with the Administrator and DNS, it was noted the falls were related to Resident #61 going to the bathroom unassisted, not utilizing the call bell and waiting for assistance. The DNS who had not worked at the facility during the time Resident #61 had the recurrent falls noted Resident #61 had some cognitive fluctuations. While discussing Resident #61's cognitive status over the time period of the falls the DNS indicated to remind and expect Resident #61 to use the call bell would not have been an appropriate intervention as Resident #61 would not have been able to remember to use the call bell and the staff would have had to intervene to toilet the resident. On 9/25/25 at 9:56 AM an interview with NA #3 indicated having worked as a regular aide on the unit and was assigned to Resident #61 when the falls occurred, indicated the assignment indicated Resident #61 required 1 person assistance (a discrepancy with the physician orders dated 4/15/25 directing to transfer Resident #61 with the assistance of 2 persons), the call light within reach but the resident would not use the call bell, would get up unassisted and sometimes the roommate would ring the call bell to alert staff Resident #61 was on the floor. NA #3 indicated when Resident #61 was awake he/she was less confused but if just awoke he/she would be confused. Sometimes NA #3 indicated he would ask Resident #61 if he/she wanted to go to the bathroom or he would change the incontinent brief if it was soiled but the assignment did not say to wake Resident #61 with every 2-hour round on the third shift. When NA #3 was read the statement written after a fall on 6/23/25 indicating no care was provided prior to the fall and resident was asleep, NA #3 added he checked Resident #61's incontinent brief each round and changed it if incontinent. NA #3 indicated at times Resident #61 would use the call bell other times not as his/her mentation varied. NA #3 further indicated once the resident got up on his/her own, Resident #61 never used the walker. On 9/26/25 at 9:45 AM an attempt to reach RN #9 (the RN on duty during the fall that occurred on 6/14/25 at 9:24 AM) was unsuccessful. On 9/25/25 at 12:46 PM, an interview with NA #4 (who was the NA assigned to and who walked Resident #61 to the bathroom on 6/14/25 and stood in the door way while Resident #61 attempted to turn onto the toilet and then fell), indicated she assisted the resident with the walker, had to stand in front of the walker (in the door way) as there was little room in the bathroom, it seemed Resident #61's leg twisted, having no hold on the resident, the resident fell. NA #4 indicated she refers to the care card for information needed to transfer and care for a resident further indicating the care card indicated Resident #61 required the assistance of 1 person (and not 2 persons per physician orders dated 4/15/25). On 9/29/25 at 8:27AM an interview with RN #9 who worked as the charge nurse on Resident #61's unit on 6/14/25 (when Resident #61 had a witnessed fall in the bathroom with NA #4) indicated only working Per Diem (as needed) on the weekends and could vaguely recall the incident, was unaware how the nurse aides obtained the information they needed to care for each resident and could not recall Resident #61's transfer order status on that day but did indicate the NAs carried a sheet of paper with them but was not sure what was on the paper.The facility policy labeled Falls, dated as reviewed on 8/19/25, indicated in part the purpose of the policy is to identify residents at risk for falls,, minimize fall related injuries and to develop and revise interdisciplinary care plans to address falls and injury risk. The policy indicated that all falls would be documented, investigated and used to inform care planning. An Accident and Incident Report would be completed for each fall obtaining staff statements for every fall event, the resident's care plan would be updated with individualized interventions and injury prevention strategies after every fall including updating the resident's care card with the fall risk and corresponding precautions. The policy also indicated all fall would be reviewed regularly in the facility at risk meetings to identify trends or recurring risk factors. 2. On 9/26/25 at 8:20 AM, upon entry into the facility a fire truck, without sirens activated pulled into the facility parking lot and up to the front door. The surveyor was met at the front entrance by the DNS who indicated there was a smoke issue with a microwave, staff pulled the fire alarm and were awaiting the fire men to initiate and all clear before anyone can enter or leave the building. On 9/26/25 at 8:25 AM the announcement of all clear was made in the facility and the DNS opened the front door to the facility. On 9/26/25 at 8:28 AM, an interview and observation with the Administrator of the microwave in the nourishment area on the [NAME] Wing. The microwave was found to be unplugged, warm to touch and a brown discoloration was noted on the interior. The Administrator indicated the microwave would be removed momentarily once cooled down and had indicated some pizza was being reheated by staff, the incident was actively investigated and once the incident report was completed a copy would be provided to the team leader of the survey. On 9/26/25 at 8:30 AM an interview with Administrator #2 indicated it was unlikely that prior in service training of nursing staff was completed regarding proper use of the nourishment room microwaves and further indicated there was no policy or procedure for the use of this microwave (heating, re-heating, staying with food during the heating process), but the facility would develop one. On 9/26/25 at 8:42 AM, the State Agency was notified by the facility Administrator of an event of smoke at the facility. Staff had observed smoke and a burning smell on the [NAME] Wing resulting in the fire alarm being pulled and emergency services activated. A Code RED (a term for the need of all staff to respond to a fire situation) emergency was activated and the facility initiated the Code RED protocol. On 9/26/25 at 11:40 AM an interview and facility document review with the Administrator identified Nurse Aide (NA) #8 placed a piece of pizza in the [NAME] Wing nourishment area microwave, left it unattended while heating, resulting in smoke noted and the need for the fire alarm to be activated. On 9/26/25 at 1:10 PM an attempt was made to interview NA #8 but was unsuccessful.

Based on medical record review, staff interviews and review of the facility policy for the only resident reviewed for dialysis (Resident #8), the facility failed to ensure that a resident on dialysis and with a fluid restriction had fluid intake consistently monitored and documented as per facility policy. The findings include: Resident #8's diagnoses included end-stage renal disease and dependence on renal dialysis.A physician order dated 6/13/25 directed a 1500 milliliter (ml) fluid restriction.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was severely cognitively impaired, required partial/moderate assistance with oral hygiene and was dependent for toilet and personal hygiene. The MDS further identified Resident #8 was receiving dialysis since admission.A hydration risk assessment dated [DATE] identified that Resident #8 was on fluid restrictions and that intake and output (I&O's) had been initiated for at least 72 hours. A physician order dated 8/1/25 directed a 1500 ml fluid restriction.Hospital discharge records dated 8/19/25 indicated that Resident #8 was admitted to the hospital on [DATE] for acute hypoxic respiratory failure due to volume overload and underwent urgent dialysis. Resident #8 was then discharged back to the facility on 8/19/25. A physician order dated 8/19/25 directed a 1,500 ml fluid restriction.A Resident Care Plan dated 8/21/25 identified that Resident #8 had a potential for nutritional decline related to a recent hospitalization from 8/12/25 to 8/19/25. Interventions included recording intake and output (I&O) as ordered. The care plan did not identify any fluid restrictions despite physician orders directing a 1500 ml fluid restriction. A Nutritional assessment dated [DATE] indicated that Resident #8 was on a renal diet and on a 1500 ml per day fluid restriction. The nursing care card failed to identify a fluid restriction or Intake/Output monitoring. The Intake/Output Report located in the paper chart from 7/14/25 to 9/23/25 identified that the Intake/Output Report was not consistently filled in for every shift, and all days were missing a total 24 hour calculated intake. Additionally, for 7/14/25, 7/15/25, 8/3/25, 8/6/25, 8/21/25, 8/22/25, and 8/29/25, there was no recorded intake on any of the three shifts, and there was no calculated 24-hour total documented.Nursing notes from 7/13/25 to 8/30/25 and a review of physician orders identified that Resident #8 was in the facility with an active fluid restriction order during those dates. On 9/24/25 at 2:20 PM, an interview and I&O record review with Licensed Practical Nurse (LPN) #1 identified that no I&Os were recorded for 7/14/25, 7/15/25, 8/3/25, 8/6/25, 8/21/25, 8/22/25, and 8/29/25, that the Intake/Output Report was not consistently filled in for every shift and all days were missing a 24-hour total calculated intake. LPN #1 indicated that the regular staff were very good at documenting I&O's, but that some agencies might not know how to document them. LPN #1 indicated that there was no list on the unit of residents who were on I&O's or on fluid restrictions, but that residents on dialysis would automatically have I&O's documented. LPN #1 further indicated that the only place for documenting Intake/Output was on the paper Intake/Output Report and not in the electronic health record. Subsequent to the surveyor's inquiry, a physician order for Intake/Output was obtained on 9/24/25. On 9/25/25, an interview with the DNS identified that the policy for hemodialysis indicated to only record I&O's for residents who were non-compliant. Further, the DNS indicated that to track a fluid restriction of 1500 mL, staff would need to be monitoring intake and that when filling the Intake/Output Report, staff should be documenting every shift and totaling every day. A review of the facility policy for Intake and Output Monitoring identified that I&O monitoring was not automatically initiated for all residents upon admission, and I&O would be initiated only when clinically indicated based on the results of hydration risk screening. Additionally, the I&O policy indicated that staff were to total 24-hour I&O and notify the provider of abnormal findings. However, a review of the facility policy for Hemodialysis identified that staff were to maintain fluid restrictions as ordered. The Hemodialysis policy also indicated staff were to monitor I&O and notify the physician and dialysis if the resident is non-compliant with fluid restrictions.

Based on review of the clinical record, facility documents, interviews and facility policy for 1 of 5 residents (Resident #32) reviewed for unnecessary medication, the facility failed to ensure facility staff/pharmacy completed monthly medication reviews for 3 months. The findings include: Resident #32's diagnosis included Type 2 diabetes, depression, anxiety anemia hypothyroidism, hypertension and bipolar disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 received insulin injections, antidepressants, antianxiety medication, anticonvulsant medication, and hypoglycemic medications. The Resident Care Plan (RCP) dated 11/13/24 indicated Resident #32 was at risk for adverse effects of hypothyroidism with interventions that included to provide medication and obtain lab work as ordered while observing for adverse signs and symptoms. The RCP also indicated Resident #32 was at risk for complications related to diabetes and the risk for low or elevated blood sugar levels. Interventions included to administer medications, check blood sugars levels and lab work as ordered and to watch for adverse effects of the medications as well as other medical complications. The RCP further indicated Resident #32 was at risk for potential adverse effects from the use of psychotropic medication with interventions that included to provide medications as ordered, observe for medication side effects, monitor vital signs and obtain lab work as ordered. A quarterly Minimum Data Set (MDS) assessment dated [DATE], 5/3/25 and 8/1/25 indicated Resident #32 received insulin injections, antidepressant, antianxiety, and hypoglycemic medications and the care plan at this time remained unchanged.Review of pharmacy medication monthly reviews failed to identify Resident #32's monthly medication regimen was reviewed by the pharmacist for November 2024, February 2025 and June 2025. On 9/25/25 at 8:27AM, an interview with the DNS indicated the facility had transitioned to a new pharmacy months ago and when the DNS started working at the facility mid-August 2025 she did not find monthly pharmacy regimen reviews and recommendation forms were blank. The DNS further identified after meeting with the current pharmacy, a plan was made to provide the review/recommendations to the DNS and a new APRN for the facility had been in place for a few weeks who would address the recommendations timely. On 9/25/25 at 3:10 PM attempts to reach the previous pharmacy consultant, (Pharmacy Consultant #1), were unsuccessful. The facility policy labeled Drug Regimen Review- With Consultant agreement only dated reviewed 08/19/2025 indicated in part A Drug Regimen Review reviews, analyzes prescribed medications therapy and use including nursing documentation of medication ordering and administration of which the consulting pharmacist reviews every residents medication Regimen at least monthly, findings and recommendations are forwarded to the Administrator, Director of Nursing Services, the primary care physician, and the medical director where appropriate. The consultant pharmacist documents the date each review is completed on the appropriate form and notes the findings further indicating that every resident must have a drug regimen review along with a medical record review monthly. The policy further indicated the facility is to maintain copies of the drug regimen review reports and physician signed pharmacy recommendations for at least one year.

Based on observation and interviews for the only resident (Resident #32) reviewed for environment, the facility failed to ensure bureau drawer knobs were in place to ensure resident access to the use of a facility supplied bureau. The findings include: Resident #32's diagnosis included anxiety and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 was cognitively intact and required set up or supervision for dressing, walking and wheeling the wheelchair. An observation and interview with Resident #32 on 9/22/25 at 11:11 AM noted two lower bureau drawers with the knobs missing and the screws exposed (sticking out) where the knobs once were, rendered the drawers unusable to the resident. An observation, interview and review of facility documentation with the Director of Maintenance on 9/25/25 at 1:45 PM indicated the unit Resident #32 resided on had older bureaus and nightstands and frequently the drawer knobs come off and had to be glued back on. The Director of Maintenance indicated when there was a repair needed on the unit, staff members were to write it in the maintenance book on the unit, then maintenance staff look in the book, repair the issue and sign it off. Review of the entries in the maintenance book found no entries made for Resident #32's missing bureau knobs. Observation of Resident #32's roommate's bureau also noted knobs of the lower drawers missing, with some of the screws sticking outward. The Maintenance Director indicated he/she would replace the knobs for both residents immediately. The Maintenance Director further indicated every resident room was looked at during quarterly Environmental rounds and that a logbook was created which identified all of the bureau knobs already replaced, but was unable to produce the logbook. An interview and facility document review on 9/25/25 at 2:00 PM with the Infection Preventionist (LPN #4), indicated Environmental rounds were conducted quarterly with the supervisor of the area being looked into as well as the maintenance director and documented.Review of the most recent facility Environmental rounds dated 6/2/25 listed night stands were looked at but did not identify the bureaus were observed and indicated no issues for the nursing areas. LPN #4 indicated not remembering seeing any knobs missing off the bureaus during the 6/2/25 rounds. On 9/25/25 at 2:10 PM the Administrator along with LPN #4 present was made aware of the bureau knobs missing and indicated he/she would look into the issue. Interviews with Nurse Aide (NA) #9, #10 and #11 on 9/26/25 at 9:23 AM who were working the [NAME] Wing indicated not having noticed knobs missing off bureaus or nightstands or residents asking for them to be repaired. NA #9 indicated if he/she noticed a repair was needed or a resident made a request he/she would inform the maintenance worker in person when on the unit. An interview on 9/26/25 at 9:23 AM with LPN #1 who was Resident #32's charge nurse indicated not having noticed knobs missing and was surprised to see them missing. LPN #1 indicated in the event a resident informed him/her of something being broken/needing repair he/she would verbally report the incident to maintenance and could write it in the maintenance logbook as well. Subsequent to surveyor inquiry, an observation on 9/26/25 at 1:15 PM noted the drawer knobs were provided and put in place on the lower drawers of the bureaus located in the shared room of Resident #32.

Based on review of the clinical record, facility documentation and interviews for 1 of 1 sampled resident (Resident #15) reviewed for hospice services, the facility failed to accurately code the quarterly Minimum Data Set (MDS) assessment to reflect Resident #15 receiving hospice services. The findings include: Resident #15 was admitted to the facility in 2020 with diagnoses that included malignant neoplasm (cancerous growth) of the breast, transient cerebral ischemic attack (temporary blockage of blood flow to the brain that causes stroke-like symptoms), aphasia (affects a person's ability to communicate), atrial fibrillation and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was severely cognitively impaired, required the assistance of 2 or more with toileting hygiene, showers, upper/lower body dressing, personal hygiene, and required maximal assistance with transfers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was severely cognitively impaired, required the assistance of 2 or more with toileting hygiene, showers, upper/lower body dressing, personal hygiene, and transfers. The Resident Care Plan (RCP) dated 6/25/25 identified Resident #15 was receiving hospice level of care from a contracted hospice agency and death was expected due to illness. Interventions included to control pain, symptoms, maintain dignity and arrange clergy visits as requested. A physician's order dated 8/14/25 directed hospice services effective from 8/19/24. On 9/26/25 at 11:45 AM, interview and review of the 2/26/25 and 6/20/25 MDS' with Registered Nurse (RN) #5 failed to identify the MDS' were coded to reflect Resident #15 entering into hospice services from 8/19/24. Interview with RN #6 on 9/26/25 at 12:16 PM identified Resident #15 was already on hospice services when the MDS dated [DATE] was coded incorrectly. Review of the MDS Policy directed, in part, the MDS 3.0 will be completed according to the procedures and directives outlined in the MDS RAI Manual. Section O of the MDS relates to special treatments, procedures and programs and code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for wound care, the facility failed to ensure the record was complete and accurate to include a verbal treatment order and failed to include timely documentation of wound care provided. The findings include:Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for wound care, the facility failed to ensure the record was complete and accurate to include a verbal treatment order and failed to include timely documentation of wound care provided. The findings include: Resident #1's diagnoses included panniculectomy (removal of excess fat/skin in lower abdomen) during 2024, infection following surgical procedure and wound dehiscence (reopened). Physician order dated 7/7/2025 directed to change wound vac dressing three (3) times per week on Monday, Wednesday and Friday. The Resident Care Plan (RCP) dated 7/7/2025 identified Resident #1 was at risk for skin breakdown and had a wound vac to the lower back related to a surgical wound dehiscence (reopened). Interventions directed to provide wound care as ordered and notify wound specialists as ordered/needed. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact, and had a surgical wound. Review of the MAR/TAR (medication administration/treatment administration record) dated 7/21/2025 identified RN #1 had documented wound treatment as hold/held and see nursing progress notes. A nursing note dated 7/21/2025 at 3:16 PM by RN #1 identified wound vac dressing change was on hold, and an alternate dressing was applied until wound vac machine is replaced. Order was placed and estimated to arrive today. Review of the physician orders failed to identify an order for an alternative dressing in replacement of the wound vac on 7/21/2025 through 7/23/2025. Interview and clinical record review with RN #1 on 8/25/2025 at 12:10 PM identified Resident #1's wound vac had stopped working on 7/21/2025 and RN #1 had notified the DON #2 to order a new wound vac. RN #1 stated he had notified APRN #1 regarding the issue and received a verbal order to place a wet to dry dressing until the new wound vac was delivered to the facility. RN #1 was unable to provide documentation that the verbal order was placed in the electronic medical record (EMR) but indicated he should have entered the order in the record. RN #1 stated he must have forgotten to document in the EMR. Interview with APRN #1 on 8/25/2025 at 12:25 PM identified RN #1 notified her that Resident #1's wound vac had stopped working. APRN #1 gave a verbal order for a wet to dry wound dressing (treatment) until the new wound vac was received, for Resident #1's wound and to follow-up with APRN #2 accordingly if there were any other changes noted. APRN #1 identified verbal orders should be placed in the EMR. Review of the facility undated Physician Orders Policy directed in part, written and/or verbal orders may be obtained. When taking verbal/telephone orders write down the complete order and read-back to verify. Verbal/telephone orders must have the abbreviation T.O. documented followed by the provider's name and credential and authorized person receiving the order (i.e., T.O. Dr. Brown/J. [NAME], RN). Review of the facility undated Nursing Documentation Policy directed in part, documentation should be completed as soon as possible after care is provided, assessments are conducted, or any significant event occurs, ideally within the same shift.

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #3) who were required supervision during meals, the facility failed to follow the physician's order and provide the one to one (1:1) supervision when food was delivered to Resident #3 to prevent a choking episode. The findings include: Resident #3's diagnoses included bipolar disorder, diabetes mellitus, asthma, depression and anxiety. The initial Resident Care Plan dated 2/7/25 identified non-compliance related to diet, drinking thin liquids when on a nectar thick liquid diet. Interventions directed to educate the resident on the importance of following the physician's order while respecting resident rights and observing any untoward effects of non-compliance, document and report to the provider. The admission Minimum Data Set assessment dated [DATE] identified Resident #3 had no memory recall deficits and required supervision with eating. The speech therapy evaluation and plan of treatment dated 4/14/25 identified Resident #3 was referred secondary to a recent onset of oropharyngeal dysphagia status post an Anterior Cervical Discectomy and Fusion (ACDF), a surgical procedure to treat neck pain and nerve compression by removing damaged discs and fusing the vertebrae. The clinical impression from the swallow evaluation revealed Resident #3 presented with mild oropharyngeal dysphagia and cognitive deficits, delay in recall, attention, executive functioning and language fluency. The swallow evaluation recommendations were as follows: dysphagia level 3 diet, thin liquids, 1:1 supervision and assist for feeding with cues for small bites, small sips and slow rate. A physician's order dated 4/14/25 directed to provide a carbohydrate-controlled diet, Dysphagia Advanced/Level 3 texture (foods are soft enough to be chewed and swallowed with minimal difficulty), thin liquids consistency with one to one (1:1) supervision, and assist for feeding with small bites, small sips and alternate solids with liquids. The nurse's note dated 4/20/25 at 1:21 PM identified at 11:55 AM Resident #3 was noted to be having a hard time breathing. The note indicated staff sat Resident #3 up with the head of the bed at ninety (90) degrees however Resident #3 continued to struggle, and was not able to speak when asked if he/she had eaten the dessert (cake) that had been served with lunch. The note identified abdominal thrusts were given with no progress, 911 was called, the ambulance arrived, and Resident #3 was transferred to the hospital. The nurse's note dated 4/21/25 at 3:52 AM identified Resident #3 returned to the facility at approximately 12:10 AM with no new orders. The facility summary report dated 4/23/25 identified on 4/20/25, after being boosted up in bed, Resident #3 was given a piece of moist cake prior to lunch being served, Resident #3 was noted to be having a hard time breathing and was transferred to the hospital. The summary report identified Resident #3 had a hospital diagnosis of aspiration. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 5/7/25 at 12:04 PM identified Resident #3 had an order in place for supervision during meals. LPN #1 explained when a resident required 1:1 supervision with meals, a staff member must be present during the entire meal. LPN #1 identified at the time of the event on 4/20/25, staff were in the process of passing out the lunch meal beginning with the dessert, which the nurse aide left in front of Resident #3 and staff were going to provide supervision after all the lunch trays were delivered. Interview with 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 5/7/25 at 1:37 PM identified on 4/20/25 she passed out the dessert (a piece of cake) to Resident #3 and left it on the overbed table. NA #1 explained she did not stay with Resident #3 after she put the piece of cake on the overbed table and continued to pass out desserts to other residents on the unit. Interview and clinical record review with the Director of Nursing (DON) on 5/7/25 at 1:45 PM identified on 4/20/25, Resident #3 was provided with a piece of cake without the benefit of a staff member present for supervision. The DON indicated that when a resident has an order for 1:1 feeding, the facility policy is a staff member needs to always be in the room during a meal. The DON identified the facility policy and physician's order were not followed. Review of the facility policy titled Feeding, last updated 12/7/23, directed, in part, if a resident is a 1:1 feed, a staff person must always be with this resident when feeding and follow any specific feeding techniques that are recommended. Review of facility documentation identified the facility implemented an action plan: staff education was initiated on 4/21/2025 and included directing staff that all residents' diets to be reviewed and consistency checked during each meal tray disbursement, all residents who require supervision will have supervision provided, and random audits of all residents identified as a dysphagia level 3 diet who require supervision will receive the appropriate diet and supervision. Audits will continue for at least 30 days, and all data will be reviewed at the next facility QAPI meeting. Based on review of facility documentation, past non-compliance was identified.

Based on clinical record review, facility documentation, facility policy and interviews for one of three residents (Resident #6) reviewed for abuse, the facility failed to ensure the State Agency was notified timely of an allegation of abuse. The findings include: Resident #6 was admitted with diagnoses that included borderline personality, post-traumatic stress disorder. A resident care plan (RCP) dated 7/25/2024 identified Resident #6 exhibited accusatory behaviors and poor impulse control towards staff's care. Interventions directed to approach in a clam manner, explain all procedures and medications before administering and do not engage if resident escalates or becomes accusatory. A quarterly MDS assessment dated [DATE] identified Resident #6 had a BIMS of 15 meaning he/she was alert and oriented, and was independent with ALDs and mobility. A facility grievance form dated 8/25/2024 identified Resident #6 reported that the weekend supervisor had recorded her/him on his cell phone saying Resident #6 had psychological problems. Interview and review of the grievance with the DON on 10/28/2024 at 11:30 AM identified that she had reviewed and investigated the grievance reported by Resident #6 on 8/25/2026. The DON stated she did not consider the grievance to be an allegation of abuse and she did not report that allegation to the State Agency. Subsequent to inquiry, the facility submitted the allegation to the State Agency. The facility policy Protecting Resident Privacy and Prohibiting Mental Abuse directed in part, each resident had the right to be free from all types of abuse included mental abuse. The Policy further indicated, related to photos and audio/video recordings by staff, that the facility defined mental abuse to include abuse that is facilitated or caused by nursing home staff taking or using recordings in any manner to demean a resident. The facility policy Abuse/Resident in part, directed that upon reports of an allegation of abuse or mistreatment, the DON, Administrator or designed will immediately conduct an investigation and submit a notification to the state survey agency within two (2) hours.

Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #2) reviewed for grievances, the facility failed to ensure interventions were put into place timely to prevent a wandering resident from entering another resident room. The findings include: Resident #1 had a diagnosis of dementia. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had moderate cognitive impairment and used a wheelchair. The Resident Care Plan (RCP) dated 2/29/2024 identified Resident #1 had wandering behaviors. Interventions directed to redirect and engage in activities. Record review identified Resident #1 was self-mobile in a wheelchair. Resident #2's diagnoses included panic disorder, anxiety, and post-traumatic stress disorder (PTSD). The quarterly MDS assessment dated [DATE] identified Resident #2 as alert and oriented and was independent with ADL care. The RCP dated 2/17/2024 identified PTSD, anxiety, and panic disorder. Interventions directed to provide emotional support, give adequate time to process requests and respect residents right to refuse. Clinical record review identified Resident #2 had a designated emergency contact person. Review of facility grievance dated 3/5/2024 identified Resident #2 alleged another resident entered his/her room over the past few days and a prior occasion the same resident had blocked his/her access to the room doorway. Resident #2 reported he/she felt unsafe, was offered a room change, and Resident #2 declined the room change. The grievance further identified although the 11 PM to 7 AM staff attempted to redirect the resident from Resident #2's room, he/she had to wait for staff to respond to her request. The grievance identified a new plan was to apply a stop sign to the doorway, and was applied on 3/5/2024. A social worker's note dated 3/5/2024 at 8:51 AM identified SW #1 spoke with Resident #2's emergency contact person regarding another resident (Resident #1) entering Resident #2's room during the night on 3/2, 3/3 and 3/4/2024. The note identified Resident #2 awoke to Resident #1 sitting on his/her bed, and on another occasion Resident #1 tried to block Resident #2 from using the door. A social worker's note dated 3/5/2024 at 12:29 PM identified SW #1 met with Resident #2 to discuss his/her concerns regarding a resident wandering in his/her room for the past three (3) evenings. SW #1 discussed room change options were semi-private rooms, Resident #2 chose to remain in current room, and indicated to SW #1 that the 11 PM to 7 AM aides redirect the other resident, but it takes time for staff to remove the other resident because the aides are caring for other residents. Review of nursing notes from 2/29 to 3/5/2024 failed to identify Resident #1 entered Resident #2's room. Interview with Administrator on 3/28/2024 at 12:08 PM indicated that Resident #1 wandered into Resident #2's room twice, that Resident #2 declined moving to another room on the opposite side of the building. The Administrator stated Resident #1 was moved closer to nurse's station for more frequent monitoring due to Resident #1's concerns, and a stop sign was placed on Resident #2's door on 3/5/2024. Interview with the Administrator and SW #1 on 3/28/2024 at 1:18 PM identified although nursing staff were aware Resident #1 had wandered into Resident #2's room and removed had removed Resident #1 from the room on 3/2, 3/3 and 3/4/2024, the Administrator was unable to provide documentation that interventions were put into place to prevent wandering into Resident #2's room until 3/5/2024 (three days after the first incident). Although attempted, an interview with DNS #1, RN #1, RN #2, RN #3, NA#3 were not obtained during survey. The facility did not provide a policy for surveyor review regarding timely interventions for wandering residents.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 4 residents (Resident #20, #36, #202, and #302) reviewed for accidents, the facility failed to ensure the baseline care plan was completed in a timely manner. The findings include: 1. Resident # 20 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, chronic pain syndrome, and diabetes type 2. The admission MDS assessment dated [DATE] identified Resident #20 had intact cognition, spinal stenosis, lumbar region with neurogenic claudication, and polyneuropathy. Resident #20 had 2 care plans, one from dietary with a focus on obesity, not following diet at home, and the Activities Director with a focus on orientating to the facility with interventions that included a controlled carbohydrate diet, one to one visits and activities calendar activities introduced respectively. An interview with the DNS on 2/27/24 at 10:00AM identified it is her expectation that baseline care plans are established within 48 hours of the admission to the facility. 2. Resident #36 was admitted to the facility on [DATE] with diagnoses that included malnutrition, gastrotomy, and diabetes. Review of the hospital discharge documentation identified Resident #36 hospitalized from 10/24/23-1/17/24 and required multiple open abdominal surgeries, tracheostomy placement and decannulation, and gastrostomy tube placement during the hospitalization . The hospital discharge documentation also identified Resident #36 required tube feedings and insulin daily. The admission MDS assessment dated [DATE] identified Resident #36 had intact cognition, was always incontinent of bowel and bladder, was fully dependent on staff for toileting, dressing, and bathing, and required set up for eating. Review of the clinical record identified a blank form labeled Baseline Care Plan within Resident #36's paper chart. Further review of the clinical record failed to identify any additional documentation related to a baseline care plan for Resident #36 within 48 hours of admission to the facility on [DATE]. 3. Resident #202 was admitted to the facility on [DATE] with diagnoses that included dementia, falls with fracture, and diabetes. The baseline care plan dated 2/16/24 identified dietary indicated to maintain weight and fluids but did not indicate the diet, restrictions, food preferences, nutritional goals and if resident needed adaptive equipment. The baseline care plan was not completed by nursing, therapy, social services departments and reviewed with the resident or resident representative. Interview with the MDS coordinator (RN #3), on 2/26/24 at 2:57 PM indicated the licensed nursing staff was responsible to do the baseline care plan on admission and MDS department then oversees it to do the comprehensive care plan. RN #3 indicated the baseline care plan must be done within 48 hours of admission. RN #3 indicated that Resident #202's baseline care plan was not completed due to lack of staff to do it. Interview with the DNS on 2/26/24 at 3:48 PM indicated the baseline care plans were to be completed within 72 hours of admission. The DNS indicated she was aware that the baseline care plans on admission were not being done. The DNS indicated the charge nurses were responsible to do the baseline care plans and MDS RN #3 was responsible to follow up and make sure they were completed. 4. Resident # 302 was admitted to the facility on [DATE] with diagnoses that included Covid 19, cerebral palsy, and sepsis. The nursing admission assessment dated [DATE] identified Resident #302 had no issues with cognition, was continent of bowel and bladder, and required the assistance of 2 staff members with transfers, walking, and repositioning. Review of the clinical record identified a blank form labeled Baseline Care Plan within Resident #302's paper chart. Further review of the clinical record failed to identify any additional documentation related to a baseline care plan for Resident #302 within 48 hours of admission to the facility. Interview and clinical record review with RN #3 (MDS coordinator) on 2/26/24 at 3:05 PM identified she was the staff member responsible for ensuring a comprehensive care plan into a resident's clinical record. RN #3 identifed that the licensed nursing staff were responsible to do the baseline care plan on admission and MDS department would ensure that the base line care plans were completed, and that the baseline care plans were located on paper in the resident's paper chart. RN #3 identitifed that the baseline care plans were not completed for Resident #36 and #302, and that there had been issues with staffing and the workload in the MDS department which resulted in things getting pushed to the side. Interview with the DNS on 2/26/24 at 3:38 PM identified that all residents of the facility should have a baseline care plan completed within 72 hours of admission. The DNS further identified that while the baseline care plan documentation was on paper, it was individualized to each resident's plan of care needs upon admission to the facility, it was the responsibility of the charge nurse to complete the baseline care plan, and that RN # 3 (the MDS Coordinator) was responsible to follow up and ensure the baseline care plans had been completed. The DNS identified that she was aware that there had been issues with the care plans not being completed and had provided in-services of the licensed nursing staff and audits of resident records related to care plans to address the issue. Review of the facility Baseline Care Plans identified the facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.The care plan will guide caregivers to assist residents to achieve or maintain their highest practical level of wellbeing. The baseline care plan must be developed with in 48 hours of a resident's admission, include the minimum information necessary to properly care for a resident including but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy orders, and social services. The facility must provide the resident or resident representative with a written summary of the baseline care plan when the comprehensive set of care plans is completed at the care plan meeting. 43032 Resident #4 [NAME] & [NAME] Res #4 was a readmission and upon request for documents, Res #4's care plans were reactivated . Res #20 had 2 careplans one by dietary, the created by the 2nd Activities Director. #4's F655 needs to change to Resident #20. 46040

47457 Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 3 residents (Resident #25, #39 and Resident #202) reviewed for care planning,the facility failed to ensure quarterly care plan meetings were conducted, the facility failed to update the care plan reflecting the resident's preferences for provision of care and accusatory behaviors and the facility failed to revise the comprehensive care plan after falls. The findings include: 1. Resident #25 was admitted to the facility on [DATE] with diagnoses which included COPD, atrial fibrillation, and hypertension. The resident care plan sign-in sheet identified care plan meetings with the IDT(inter discilplinary team ) , Resident #25, and his/her Resident Representative occurred on 5/20/22, 8/29/22, and 4/7/23. The quarterly MDS assessment dated [DATE] identified Resident #25's cognition was not assessed and was independent with personal hygiene, eating, and walking. The care plan dated 12/6/23 identified Resident #25 was social and needed to stay active in independent and group activities. Interventions included to ensure staff visit Resident #25 for 1:1 visits, provided a weekly and monthly calendar of programs, ensure Resident #25 remained busy with independent pursuits, and ensure Resident #25 attended resident council and entertainment programs. Interview with Resident #25 on 2/25/24 at 8:50 AM identified that he/she had resided at the facility for many years. Resident #25 further identified that he/she did not recall attending recent care plan meetings but recalled attending them in the past. Interview with the MDS Coordinator (RN #3) on 2/26/24 at 1:18 PM indicated that due to her current workload and per diem status, the resident care conferences were not being held quarterly. RN #3 identified that the resident care plan sign-in sheets were up to date, and that all care plan meetings that occurred would have supporting documentation, including the sign in sheet. Interview with the DNS on 2/27/24 at 7:00 AM identified she was aware that the MDS coordinator was busy and had fallen behind with scheduling the resident care conferences. The DNS further identified that the MDS Coordinator was per diem, and the facility was in the process of interviewing for a full-time position. The DNS indicated that resident care conferences were expected to be held every three months and if there was a change in condition; she would also expect the meetings to include members of the interdisciplinary team, the resident, and a resident representative. Interview with SW #1 on 2/27/24 at 8:52 AM identified that resident care conferences were expected to be held quarterly but that had not consistently been happening. SW #1 further identified that she supported the MDS Coordinator with resident care conferences, but there was no formal system in place for scheduling or implementing the conferences. SW #1 indicated that the facility was getting better about having the resident care conferences, but she would discuss additional opportunities for improvement with the MDS coordinator and the Administrator. The facility's Care Planning policy directs a care conference will be held on or before day 21 from admission and then at least quarterly to discuss the plan of care. The resident and/or family/responsible party will be invited to attend all care plan conferences. 2. Resident #39 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, anxiety disorder, and cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident #39's cognition and mood were not assessed, and he/she required supervision or touching assistance with personal hygiene and was dependent with bathing. The care plan dated 1/16/24 failed to identify Resident #39's preferences for provision of care, interventions addressing customer service concerns brought forth to the facility and accusatory behaviors. Interview with Resident #39 on 2/25/24 at 2:35 PM alleged that NA #3 was rude, handled him/her strongly while providing care, and had directed specific expletive language towards him/her. Resident #39 indicated that other concerns with nursing staff were brought to the attention of the facility, within the last few months. Resident #39 indicated that on 1/6/24 he/she notified the police because an unnamed nurse or nurse aide provided him/her with rough care. Resident #39 further indicated that he/she had reported a male nurse aide to the facility for being loud and laughing; Resident #39 felt the facility addressed the concerns with the male nurse aide because his demeanor had improved. Interview with SW #1 on 2/26/24 at 11:01 AM identified that in December, Resident #39 had requested a room change from the [NAME] Wing to the East Wing because he/she did not get along well with the roommate. Subsequent to the East Wing move, Resident #39 requested to move back to the [NAME] Wing because he/she had developed a relationship with a few of the nurse aides and preferred the manner in which they provided care. Resident #39 returned to the west wing and has not brought forth any concerns related to staff since the move. SW #1 identified that Resident # 39 often requires additional time from the nursing staff and does have an expectation for how care is to be delivered. SW #1 further identified that Resident #39 wants to continue doing things for his/herself that he/she can no longer do, resulting in frustration. SW #1 indicated that she has a good rapport with Resident #39 and his/her daughter and that they communicate frequently, face to face or via email. SW #1 indicated that she was unaware of accusations made by Resident #39 towards staff members, but that he/she had communicated customer service concerns related to some nurse aides, and that Resident #39 does prefer specific staff members and the way they provide care. Interview with the Regional Nurse (RN #6) on 2/26/24 at 3:21 PM identified that Resident #39 had a history of reporting allegations, at the facility that he/she previously resided. RN #6 indicated that Resident #39 is not currently care planned for accusatory behaviors but one will be developed. Interview with the DNS on 2/26/24 at 4:22 PM identified that since Resident #39 moved back to the [NAME] Wing, he/she has identified customer service concerns with 4 staff members. The DNS further identified that Resident #39 should have been care-planned for accusatory behaviors and provision of care preferences. 3.Resident #202 was admitted to the facility on [DATE] with diagnoses that included dementia, falls with fracture, and diabetes. A physician's order dated 2/17/24 directed to ambulate with assist of 2 without a device every shift due to a fall risk. The care plan dated 2/19/24 identified the risk for falls. Interventions included to encourage to wear nonskid socks. Furthermore, the care plan did not reflect the fall on 2/18/24 and 2/24/24, and 2/25/24. The care plan did not reflect the interventions from the fall on 2/19/24 to use floor mats and did not reflect an intervention for the fall on 2/24/24 and 2/25/24. a. The nurse's note dated 2/18/2024 at 2:43 identified Resident #202 was ambulated with assist of 2 to the bathroom. Resident #202 attempted to get out of bed once. Resident #202 noted sliding out the end of the bed. Reportable event form dated 2/18/24 at 10:10 PM Resident #202 was observed kneeling on floor in hallway. Resident #18 had an unwitnessed fall. Intervention directed to have resident wear nonskid socks. The nurse's note dated 2/18/24 at 10:41 PM identified Resident was observed on his/her knees in hallway. Resident had self-transferred self from the bed. b. Reportable event form dated 2/19/24 at 1:00 PM Resident #202 was found on floor in resident's room. The intervention was bedside floor mats to both sides of bed. The nurse's note dated 2/19/2024 at 4:27 PM identified Resident #202 found on the floor to his/her room. Resident #18 had an unwitnessed fall. RN assessment reveals neurologically was alert & confused baseline mentation. c. Reportable event form dated 2/24/24 at 6:00 PM identified unwitnessed fall in hallway. The intervention was offer fluids and nutrition and toilet before changing gown and bed. The nurses note dated 2/24/2024 at 6:00 PM identified Resident #202 status post unwitnessed fall on 2/24 at 6:00 PM. Resident #202 observed in hallway, lying on left side near room door. Resident is alert, and at baseline of cognitive, with increase in confusion, stating along the lines of wanting to help someone out there. No evidence of injury, positive range of motion to all extremities. Observation on 2/25/24 at 6:00 AM Resident #202 sitting in wheelchair tilted backwards in front of the nurse's station with Residents feet exposed without the benefit of nonskid socks. Observation on 2/25/24 at 9:22 AM Resident #202 sitting in wheelchair in residents' room with bare feet and without the benefit of nonskid socks. d. Reportable event form dated 2/25/24 at 5:30 AM identified unwitnessed fall in resident's room. The intervention was offering fluids and nutrition and toilet before changing gown and bed (same intervention as the fall on 2/24/24). The nurse's note dated 2/25/2024 at 8:54 AM Resident #202 at the nurse's station in w/c at beginning of shift stats post fall from 6pm evening shift. Resident #202 was alert and oriented and restless this time. Snacks & fluids offered & taken. Neurological assessment was within normal limits. At 5:30am this nurse was called into the resident's room. Observed resident lying on the floor near the bed. No apparent injury noted. Interview with the DNS on 2/26/24 at 11:43 AM indicated that the nurses were responsible to immediately after a fall to put an intervention in place and care plan the intervention. The DNS indicated the next morning the interdisciplinary team will discuss the fall and make sure the intervention was appropriate or change it. The DNS indicated the reason they put an intervention in place right away was to try to prevent future falls. The DNS indicated the fall on 2/18/24 was not reflected on the care plan. The DNS indicated for the fall on 2/18/24 the intervention should have been put Resident #202 back to bed and should have been safety checks between 10:00 PM -10:30 PM every day and document that on the nursing assistant care card so they know what to do and the care plan. The DNS indicated the intervention of non-skid socks wasn't put into place until 2/19/24 and the safety checks was not on the care plan or on the nursing assistants care card for resident #202. Review of the 2/19/24 fall, the DNS indicated the intervention was to place floor mats on the floor on both sides of the bed. The DNS indicated the expectation was the nurse would put it in the care plan and the nursing assistants care card but indicated it was not on either. Review of the fall on 2/24/24 the DNS indicated the intervention was grey it is not specific just says frequent rounding. The DNS indicate the intervention should have been occupy Resident #202 at 6pm with puzzles and a pencil even though he/she may not know what to do with it to occupy him/her. Review of the 2/25/24 fall, the DNS indicated that the intervention listed on 2/24/24 was the same as the 2/25/24 and she felt it was grey and was not an intervention but what was expected of staff. The DNS indicated the care plan was not updated with the falls on 2/18/24, 2/24/24, and 2/25/24 and the interventions were not updated. Interview with MDS coordinator (RN #3), on 2/26/24 at 2:57 PM indicated the nurses were responsible to put interventions in place right after a fall and place it on the care plans to try to prevent future falls. Review of the facility Care Planning Policy identified to ensure residents have a comprehensive and individualized plan of care. The care plan will include a statement of the problem: reasonable and measurable goals: interventions to achieve these goals and the disciplines responsible to carry out the interventions. The care plan is reviewed and updated at least quarterly and as necessary to reflect changes in the resident's status. The nursing assistants care cards will be updated as needed to reflect changes made to the resident's plan of care. Review of the facility Falls: Minimizing Risk of Injury Policy identified an individualized care plan will be developed and updated as needed to identify interventions to prevent falls and minimize injury. Each time a resident falls the care plan will be revised with any interim interventions to minimize risk of injury. The resident care card shall include the fall risk and preventative strategies.

Based on clinical record review, facility documentation and staff interview for 1 of 3 sampled residents reviewed for pressure ulcers (Resident #493) the facility failed to ensure weekly assessments and/ or interventions to prevent the development of a pressure ulcer. The finding includes: Resident #493 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Nursing Admission assessment dated [DATE] identified the resident as alert and oriented, requiring assistance of one (1) person with transfers and positioning, the resident's bilateral heels were dry, there were scabs on the resident's toes and no open areas identified. The admission physician orders [REDACTED]. The admission interim RCP dated 1/9/18 identified to off load heels. Review of the clinical record from 1/9/18 (time of admission) through 1/22/18 failed to identify the resident's heels were off loaded as per the admission plan of care. Review of the Nutrition Admission assessment dated [DATE] identified the resident's daily fluid needs were 1575-1890cc of fluid, and was at moderate risk for skin breakdown. The assessment identified the resident's teeth were in poor condition, and that the resident stated he/she needed increased nutrition/ hydration to gain weight and become stronger. Additionally, the note identified the resident was started on 90cc of house supplement twice a day and to have pudding, yogurt or ice cream with each meal. Review of the Braden Scale assessment dated [DATE] identified the resident was a low risk for the development of pressure ulcers which was inaccurate based on the residents nursing admission assessment that identified the resident required assistance with bed mobility indicating a potential problem with friction and shearing. The admission MDS dated [DATE] identified the resident as alert and oriented, requiring limited assistance of one person for bed mobility, using a wheelchair for mobility, and at risk for pressure ulcers. Nurse's notes dated 1/12/18 at 5:38PM identified the resident complained of toe pain and the residents name was already entered in podiatrist book for the next visit. The clinical record lacked documentation of an assessment of the resident's toes/feet. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) identified although the physician orders [REDACTED]. Further review of the TAR for (MONTH) (YEAR) identified although body audits by a licensed nurse were to be completed every week on Mondays on the 3 to 11 shift, The TAR lacked documentation that it was signed for as completed for 1/15/18. Review of weekly body audit sheets identified although one section was checked off (abrasions/excoriations) the audits failed to identify any date. Additionally, no body audit sheets were completed for 1/15/18, 1/22/18 and 1/29/18 in accordance with facility policy. Review of the Podiatry Consult dated 1/23/18 identified the resident complained of a painful heel and long toenails. The note identified an unstageable pressure ulcer to the right heel that was spongy and painful on the plantar posterior aspect. Additionally, the note identified the heel was irritated and although there was a pillow in the residents bed, the residents feet were not elevated. Review of Resident # 493's clinical record from 1/9/18 through 1/23/18 failed to identify any assessment completed on the resident's feet until the resident was seen by the podiatrist on 1/23/18. Review of Resident # 493's clinical record from 1/23/18 (time unstageable right heel identified by the Podiatrist) until discharge on [DATE] failed to identify the residents heel was assessed and/ or monitored. Interview with RN # 4 on 4/9/18 at 12:50PM stated that Resident # 493 would refuse at times to eat or drink and/ or take his/her supplement and/or not finish it all the time. RN # 4 stated that he could not recall if he notified the physician and/ or dietician that the resident was not taking the supplement and/ or about his/her poor appetite. RN# 4 further identified that he recalled the resident having some kind of heel issue but could not remember if the resident had a low air loss mattress and/or if the feet were elevated. Interview with RN #3 on 4/9/18 at 1:12PM identified that he remembered the resident complaining of something on his/her foot hurting but could not recall what it was. RN # 3 stated that the resident's appetite was poor and could not recall if staff offered alternatives to food and he could not recall if the resident's heels were elevated but stated that usually that is something they sign for as doing in the treatment record. Interview and review of the clinical record with the DON on 4/10/18 at 9:45AM identified the Braden scale, weekly weights and body audits were not completed weekly as ordered. The DON stated that the body audits are to be completed by the licensed nurse on each resident on their shower day. The DON stated that even if a resident refuses a shower a body audit is to still be completed and if the resident refuses the audit the refusal is to be documented in the clinical record. The DON stated she did not know why the Braden scale, body audits and reweights weren't done. The DON identified that after a resident is weighed if there is a discrepancy in the weight a re-weight is to be completed that same day and the MD and dietician are to be made aware. Review of the clinical record with DON, at that time, failed to identify that the resident's heels were offloaded until 1/23/18 when the resident was evaluated by the podiatrist and unstageable right heel was identified. Additionally, review of the clinical record with the DON from 1/23/18 (time unstageable right heel identified by the Podiatrist) until discharge on [DATE] failed to identify the residents heel was assessed and/ or monitored. The DON stated that wound rounds are to be assessed weekly. Please note that the scope and severity of your prior deficiencies under: F686 CFR 483.25 (b)(1)(i)(ii) the resident receives treatment and services to Prevent/Heal Pressure Ulcers has been amended to reflect a change from Immediate Jeopardy (IJ) to health and safety whereby significant corrections are required (J) to an Isolated deficiencies that constitute actual harm that is not IJ whereby significant corrections are required (G).

Based on clinical record review, facility documentation and staff interview for 1 of 3 sampled residents reviewed for weight loss, (Resident # 493) the facility failed to ensure weekly weights were completed and/or the residents fluid needs were met and/or the resident was assessed for dehydration. The findings include: 1.a. Resident # 493 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the physician admission orders [REDACTED]. The interim admission care plan dated 1/9/18 identified the resident was at risk for weight loss and on a regular diet. Review of the facility's policy for monitoring weights identified all residents will be weighed weekly for four (4) weeks on admission. The policy identified if there is a 5 lb. weight discrepancy (plus or minus) a reweight is to be obtained, and the charge nurse should then review the weight and compare to the previous weight to determine if there is a weight change and report to the health care team. Review of the Weights and Vital Signs Summary identified on 1/10/18 the residents weight was 139.7 lbs. The dietary evaluation dated 1/12/18 identified the resident's weight as 139.7 lbs, meal intake varies from 25-100%, and the resident wishes to gain weight and become stronger. The evaluation further identified that the resident's teeth are in poor condition and the resident's diet was changed to a mechanical soft consistency. Additionally, the assessment noted that the resident was started on house supplement 90 cc twice a day and as well as yogurt, pudding or ice cream as extras on meal trays. Review of the Weights and Vital Signs Summary identified on 1/22/18 the resident's weight was 122.2 lbs. (a 17.7 lb or 12.5% weight loss). On 1/29/17 the resident's weight was 125.9 lbs (a 13.8 lbs or 13.8% weight loss), and on 2/5/18 the residents weight was documented at 122.9 lbs (a 16.8 lb or 12% weight loss). Review of Resident # 493's ADL flow sheets identified out of 98 meals (1/10/18 through 2/11/18), 13 meals intake was not documented, 21 times the resident consumed 76-100% of meals, 17 times the resident consumed between 51-75%, 19 times the resident consumed 26-50%, 18 times the resident consumed between 0-25% and 5 times the resident refused meals. Review of the nurse's notes identified from the time of admission (1/9/18) through 2/13/18 (discharge) numerous entries of the resident having a poor appetite and fluid intake, eating only crackers, fluids pushed and refusing meals. The clinical record lacked documentation that substitutes were offered to the resident. Interview and review of Resident # 493's clinical record with the DON on 4/10/18 at 9:45 AM identified that there was a 17.7 lb weight loss (12.5%) from 1/10/18 until 1/22/18 (12 days) and the clinical record lacked documentation that a reweight was completed on 1/22/18 and/or the physician or dietician was made aware. Additionally, further review of the clinical record indicated that after each time the resident was weighed (1/29/18 and 2/5/18) no reweight was completed. The DON stated that it is the facility's policy if there is a discrepancy in the resident's weight of plus or minus 5 lbs. a reweight is to be completed that day and if accurate reported to the physician and dietician. Interview with the Dietician on 4/11/18 at 11:00 AM stated that she completed the initial nutritional evaluation on the resident and placed the resident on supplements to gain weight. The dietician stated that she was on vacation and had fill in dieticians in the building to review resident's. The Dietician stated that she does not think they were made aware because there was no notes written or different interventions implemented to prevent weight loss. The dietician stated that had they been made aware she would have tried different supplements, foods that would appeal to the resident to try to increase the resident's weight. b. Review of Resident #493's physician orders dated 1/9/18 directed to monitor intake and output for 72 hours. The admission nursing assessment dated [DATE] identified the resident's skin as warm and dry. The admission history and physical dated 1/11/18 identified the resident's general appearance as very thin and pale and directed to continue supportive care, encourage PO intake, dietary evaluation and nutritional supplements as needed. Review of lab work dated 1/11/18 identified the residents BUN (blood urea Nitrogen) at 24 (normal 10-24 mg/dl) Sodium at 144 (normal 133-145mmol/L) and Creatinine 1.1 mg/dl (normal 0.7-1.5). Lab work dated 2/6/18 identified the BUN at 32 (up 6 since admission blood work), Sodium 146 (up 2) and Creatinine at 1.2 (up.1). The Nutritional Admission assessment dated [DATE] identified the residents fluid needs between 1575-1890cc per day. Additionally the assessment identified a house supplement of 90 cc twice daily was ordered and to monitor the resident's intake, weights and skin. Review of the nurse's notes identified from the time of admission (1/9/18) through 1/25/18 identified numerous entries of fair fluid intake, poor fluid intake, and fluids offered and encouraged. The clinical record lacked documentation that substitutes and/or different fluids were offered to the resident. Nurse's notes dated 1/26/18 at 10:52 AM identified resident's estimated fluid needs 1575 cc, average daily intake for the past 3 days 955 cc. The resident's eyes appear sunken, mucous membranes are dry and skin turgor is fair. The note identified the resident drank coffee and juice for breakfast, was offered sherbert and accepted. The note further identified the physician and son were updated. Review of the intake and output sheet from 1/9/18 through 1/26/18 identified the resident did not meet his/her fluid needs and only consumed between 720 cc to 1460 cc of fluids daily for 11 out of 18 days. Additionally, 3 shifts were left blank. Review of the clinical record and interview with the DON on 4/10/18 at 9:45 AM failed to identify that dehydration assessments were completed on the resident. The DON stated that when a resident is not meeting there fluid needs the nurse is to complete a dehydration assessment, and maintain intake and output. The DON further stated that when a resident does not meet their fluid needs and is showing signs of dehydration the physician and dietician are to be made aware to determine if changes are to be made to the resident's plan of care. Review of the facility policy for Hydration Protocol identified all residents will receive sufficient fluids to maintain proper hydration and health. The policy identified if a resident does not meet their fluid goals ad does show signs of dehydration the physician, dietician and family will be notified to determine any changes to the plan of care.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who had acknowledged full Cardio-Pulmonary Resuscitation (CPR) in the Advanced Directive and physician's orders [REDACTED]. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had no cognitive deficits. The Advance Directives and Medical Treatment Decisions form dated [DATE] identified the resident requested I do not choose to formulate or issue any Advance Directives at this time, I want efforts to prolong life and want life sustaining treatment to be provided. The form was signed the attending physician. A physician's orders [REDACTED]. The nurse's note dated [DATE] at 9:00 PM identified Resident #1 was alert and oriented. The nurse's note dated [DATE] written at 1:25 AM identified at 11:45 PM, the ,[DATE]AM charge nurse, Registered Nurse (RN) #1, went in to check Resident #1's oxygen saturation level and found the resident deceased . The note identified RN #1 assessed no heart beat after one minute of auscultation, no breathing and the resident's color was pale. RN #1 checked the resident's chart and interpreted the code status as Do Not Resuscitate (DNR), the attending physician, MD #1 was notified and an order for [REDACTED]. directives were interpreted by the RN to be DNR. The investigation identified the ,[DATE]PM charge nurse interacted with Resident #1 at 10:30 PM and there were no apparent signs of distress. Interview with RN #1 on [DATE] at 1:15 PM identified during the routine check of the residents at the beginning of the shift he went in to Resident #1's room at 11:45 PM and noted the resident was pale. RN #1 stated upon assessment there was no heart beat after one minute of auscultation, the resident's skin felt cool to touch and the lower part of the body showed signs of darker discoloration. RN #1 identified he checked Resident #1's chart for the code status and perceived the Advance Directives as DNR. RN #1 stated he notified the attending physician that the resident had expired, requested an order for [REDACTED].#1 identified he has been placed on suspension since [DATE]. In an interview on [DATE] at 1:40 PM, LPN #1 identified on [DATE] about 11:50 PM RN#1 informed him Resident #1 had expired. LPN #1 identified RN #1 had reviewed the physician's orders [REDACTED].#1 suggested to RN #1 to check the Advance Directives sheet because residents change their code status. LPN #1 identified RN 1 did not respond after reviewing the Advance Directive sheet and he was not able to review the Advance Directive sheet himself. In an interview on [DATE] at 2:50 PM, MD #1 identified he received a call after midnight on [DATE] from RN #1 stating that Resident #1 had expired and was requesting an RN pronounce order. MD #1 assumed RN #1 was aware of the resident's code status and did not question giving the order. MD #1 identified when he went into the facility the following day he inquired as to why an RN pronounce was not ordered before and was informed of the Advance Directives sheet misinterpretation by RN #1. MD #1 identified he did not recall that Resident #1 expressed his/her code status to be DNR. Subsequent to the incident the facility developed an action plan and implemented the plan on [DATE]. The plan included in-service education of all licensed staff regarding the importance of verifying the Advanced Directive document. A mock code drill scheduled for [DATE], reformatting the Advance Directives sheet to read Full Code prior to the statement I do not choose to formulate or issue any Advance Directives at this time, I want efforts to prolong life and want life sustaining treatment to be provided and all resident charts were audited for the correct code status.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for medication errors, the facility failed to ensure that a narcotic medication was administered according to the physician's orders [REDACTED]. Resident #1's [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. The physician's orders [REDACTED]. The nurse's note dated 5/31/14 identified that Resident #1 complained of pain to the left abdomen with nausea and had increased lethargy. The physician was notified and Resident #1 was transferred to the hospital and on 6/2/14 returned to the facility. The physician's readmission order dated 6/2/14 directed to administer [MEDICATION NAME] 5mg/5ml via the J-tube every four hours as needed for pain. The 5-day admission Minimum Data Set assessment dated [DATE] identified that Resident #1 was alert and oriented, required extensive one person assistance with activities of daily living, had a feeding tube for nutritional support, weighed 81 pounds, and received pain medications as needed. The nurse's note dated 6/6/14 at 11:30 AM identified that at 11:15 AM Resident #1 was apparently seizing. The pupils were fixed, the resident had a gazed look, jerky movements were noted with all four extremities, the blood pressure was 93/48 (normal range was in 90's/50's), pulse rate 140 beats/minute (normal 64-101), respirations 12 (normal 16-24), the oxygen saturation was 81% on two liters via nasal cannula, the oxygen was increased to five liters via venti mask and with a decrease in saturation the oxygen flow was increased to ten liters. Resident #1 was transferred to the hospital and admitted to the Intensive Care Unit (ICU) with the [DIAGNOSES REDACTED]. The hospital discharge summary dated 6/11/14 identified that Resident #1 was admitted from the skilled nursing facility on 6/6/14 after erroneously given 100mg of [MEDICATION NAME] via the J-tube and subsequently had a tonic clonic [MEDICAL CONDITION]. Enroute to the hospital Versed 2.5mg and [MEDICATION NAME] 0.4mg were administered with minimal effect, the resident upon arrival to the Emergency Department was hypotensive and unresponsive. In the ICU the resident was started on a [MEDICATION NAME] drip and received the [MEDICATION NAME] for a total of twelve hours. Prior to discharge from the hospital all opiate narcotics had been discontinued and only Tylenol was administered as needed which controlled the pain. The Reportable Event Form dated 6/6/14 at 11:00 AM identified a medication error. The report indicated that [MEDICATION NAME] 100mg via the J-tube was administered instead of 5mg. The investigation identified that Registered Nurse (RN) #1 stated to Licensed Practical Nurse (LPN) #1 reported Resident #1 was in pain and LPN #1 suggested giving the [MEDICATION NAME]. LPN #1 indicated that RN #1 asked her "it says give 5ml, I would have to give a couple of syringes, and should I just put 5ml in the med cup?" Review of RN #1's written statement dated 6/6/14 identified that Resident #1 started seizing within a minute or less after the [MEDICATION NAME] was administered. When RN #1 went back and checked the medication order she discovered 0.25 mg sublingual was to be given and not 5mg via the J-tube. Review of the investigation identified that LPN #1 was orienting RN #1. Interview with LPN #1 on 9/16/14 at 2:50 PM identified that after the medication pass was finished, physical therapy came up to the nurses, reported that Resident #1 needed pain medication and RN #1 stated that she would administer the medication. LPN #1 indicated that although she found it odd that RN #1 needed to use a medication cup, she read the order as to administer 5mg/5ml, but did not check it against the medication bottle until after the incident. Interview and review of the clinical record with the Director of Nursing (DON) on 9/15/14 at 11:10 AM identified that when Resident #1 returned from the hospital on [DATE] the nurse transcribed the orders onto the order sheets and kardexes. The nurse had the physician complete the schedule two control sheets and sent the order to the pharmacy. The DON indicated that the 11-7 AM charge nurse (RN #2) identified that the medication that was available was not the right dose and/or concentration and had to recalculate the equation to administer the right dose of [MEDICATION NAME] on 6/5/14 at 5:30 AM and 6/6/14 at 5:30 AM when the resident complained of pain. RN #2 did not notify the physician, write a new order with the correct dose, change the order on the medication kardex, or pass it on to the oncoming shift. The DON identified that when she observed Resident #1, the resident was unresponsive, the pupils were pinpoint and fixed, and the extremities were in a jerking movement.

Based on clinical record review, review of facility documentation and interviews for one of three residents (Resident #14) reviewed for hydration, the facility failed to notify the physician regarding the resident's continued poor fluid intake and/or for one of six residents (Resident#113) reviewed for pressure ulcers, the facility failed to notify the family when the resident developed a Stage 1 pressure ulcer. The findings include: 1. Resident # 14 ' s [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified the resident was oriented to person and required extensive assist of two for bed mobility and transfers, and assistance of one for dressing and personal hygiene. The care plan dated 12/27/2013 identified Resident # 14 ' s medical condition was precarious and was at risk to be re-hospitalized . Interventions directed to record intake and output every shift for 72 hours and to notify the physician of any changes in status. The dietary assessment dated [DATE] identified Resident # 14 ' s estimated daily fluid needs were 1698cc ' s to 2038 cc's per 24 hours. The laboratory results dated [DATE] identified a BUN of 39(normal is 7-17mg/dl) and creatinine of 2.3(normal is 0.5-1.0mg/dl).The nurse ' s note dated 12/31/2013 3:00PM-11:00PM shift identified the physician was notified of abnormal lab results with orders which directed to encourage oral fluids, provide 200 cc of water with each medication pass and to repeat a basic metabolic panel on 1/3/14. A review of the clinical record identified Resident # 14 ' s oral fluid intake on 1/2/2014 was 620cc, 1/3/2014 was 420cc, 1/4/2014 was 900 cc, 1/5/2014 was 1190 cc, 1/6/2014 was 1440 cc, 1/7/2014 was 570 cc, 1/8/2014 was 1210 cc and 1/9/2014 was 990 cc. A review of nurse ' s notes from 1/1/14 to 1/10/2014 and the intake/output record identified that although oral fluids were encouraged, Resident #14 failed to meet his/her estimated daily fluid needs as identified by the dietician from 1/2/14 through 1/9/14. Despite Resident #14's persistent low intake the clinical record lacked documentation of a dehydration assessment between 1/1/14 and 1/8/14. laboratory results dated [DATE] identified a BUN of 62 and creatinine of 3.1. The physician progress notes [REDACTED]. A physician's order [REDACTED].? normal saline at 75 cc hour intravenously for a total of 500 cc per day. The nurse's notes dated 1/11/2014 3:00PM-11:00PM shift identified Resident #14 was not arousable to physical stimuli and was transferred to the Emergency Department for an evaluation. A review of the emergency room record dated 1/11/14 identified a BUN of 62 and creatinine was 2.5 and an admitting [DIAGNOSES REDACTED].# 14's poor fluid intake between 1/2/2014 and 1/9/2014. The DNS further identified that it is the responsibility of the 11:00PM-7:00AM shift to total the intake and output and review the totals to ensure the estimated fluid needs were met. The 11:00PM-7:00AM shift would then inform the 7:00AM-3:00PM shift of those residents who had not met their estimated fluid needs which would require a dehydration assessment and physician notification. The DNS identified based on Resident #14's low intakes he/she would expect the physician to be notified and although an order was given for lab work to be drawn on 1/3/2014 it was not obtained until 1/7/2014. Interview with the Medical Director on 4/10/14 at 9:58 AM identified that he/she would expect the facility to notify the physician if a resident has persistent low fluid intake. The Medical Director further identified that there was a delay in treatment as the lab work ordered for 1/3/14 was not obtained as directed and new orders may have been given based on those results. A review of facility change in condition policy identified that a resident with a change in condition will be reported to the physician. 2. Resident#113's [DIAGNOSES REDACTED]. A Braden Scale for predicting pressure ulcer risk completed on 4/2/14 identified a score of 15. A score of 12 or less represents high risk for developing pressure ulcer. The admission nursing assessment dated [DATE] failed to provide evidence of any alterations in skin integrity to the buttocks. The nurse notes dated 4/6/14 indicated Resident #113 complained of a sore area to the right buttock. Observation at that time identified a 1.5 cm x 0.5 cm purple non-blanch able Stage 1 pressure ulcer. The physician was notified and directed to apply Allevyn 3 x 3 topically and change every three days. Clinical record review and interview with the Infection Control Nurse on 4/10/14 at 12:05PM failed to provide documentation that the family was made aware of the new area on the right buttock and the new treatment order. A review of the facility change in condition policy indicated that family and/or legal representatives are notified of changes in condition and/or treatment changes.

Based on review of the clinical record, observation and interviews for one of five residents (Resident #45) reviewed for pressure ulcers, the facility failed to manage the resident's pain during a treatment. The findings include: Resident #45's [DIAGNOSES REDACTED]. The annual Minimum (MDS) data set [DATE] identified the resident was moderately cognitively impaired and totally dependent for activities of daily living including personal hygiene. The physician's orders [REDACTED]. The nurse's note dated 2/27/11 identified when the palm guard was removed a 1.0 centimeter (cm) by 1.0 cm Stage 3 pressure ulcer that "was down to the bone" on the 2nd digit of the right hand. Additionally the palm guard was noted with new and old blood and tissue on it and the staff was unsure how long the pressure ulcer was present. The quarterly Minimum (MDS) data set [DATE] identified the resident was moderately cognitively impaired, totally dependent for activities of daily living including personal hygiene, a functional limitation of the upper extremities, and indicators of pain as evidence by crying and moaning. The physician's orders [REDACTED]. Observation of the treatment to the pressure ulcer on the second digit of the right hand on 4/21/11 at 1:45 PM identified when Registered Nurse (RN) #1 attempted to assess and cleanse the wound the resident cried out repeatedly "It hurts, it hurts, it hurts". LPN #1 who was in the room responded, "We're almost done" as RN #1 continued with the treatment. The resident moaned and cried until the remainder of the treatment was completed. Interview and review of the clinical record on 4/21/11 at 2:00 PM with RN #1 (the facility wound nurse) and LPN #1 identified that the resident always cried out during the treatment and although Tylenol 650 mg was administered that morning, pain medication was not provided prior to the treatment. Interview on 4/21/11 at 2:15 PM with the Director of Nurses (DNS) identified that because of the resident's pain, the treatment should have been stopped and pain medication administered. Subsequent to surveyor inquiry a physician's order [REDACTED].

Based on clinical record review, observation and interviews for one of five sampled residents (Resident #45) reviewed for pressure ulcers, the facility failed to monitor and implement the care plan to prevent the development of a pressure ulcer. The findings include: Resident #45's [DIAGNOSES REDACTED]. The annual Minimum (MDS) data set [DATE] identified the resident was moderately cognitively impaired and totally dependent for activities of daily living including personal hygiene. The physician's orders [REDACTED]. The nurse's note dated 2/27/11 identified when the palm guard was removed a 1.0 centimeter (cm) by 1.0 cm Stage 3 pressure ulcer that "was down to the bone" on the 2nd digit of the right hand. Additionally the palm guard was noted with new and old blood and tissue on it and the staff was unsure how long the pressure ulcer was present. Review of the February 2011 Treatment Administration Record identified licensed staff signed out for weekly skin assessments, the use of the palm guard on the right hand and for washing and checking the resident's skin daily on the 7:00 AM to 3:00 PM shift and the 3:00 PM to 11:00 PM shift. Interview, and review of the clinical record on 4/21/11 at 2:00 PM with the wound nurse (RN #1), identified that no wounds were noted on the skin check that was conducted on 2/26/11, the day before the Stage 3 pressure ulcer was identified. Additionally, licensed staff documented the ordered treatment to the right hand was conducted two times a day and the wound had not been noted until 2/27/11. RN #1 stated that if skin checks were conducted twice a day per the physician's orders [REDACTED]. Interview on 4/25/11 at 9:30 AM with Physician #1 identified that "It was impossible for a stage 3 pressure ulcer to develop in 12 hours" and because of the resident's contractures and pain it was difficult for the staff to see the area. Interview and review of the clinical record on 4/25/11 at 11:30 AM with LPN #1, who conducted the resident's skin check on 2/26/11 identified that the nurse aide was responsible to apply and remove the palm guard and wash the resident's hand every morning and evening. LPN #1 indicated she did not view the hand on a daily basis and was unable to remember if she checked the resident's right hand on 2/26/11. Interview with Nurse Aide (NA) #1 on 4/25/11 at 1:15 PM indicated she provided care to the resident on a regular basis on the 7-3 PM shift. NA #1 indicated she put the palm guard on in the morning, however, noted it was impossible to wash the resident's hand and between the fingers because the resident cried out in pain. NA #1 noted she did not move the fingers to check for pressure areas. NA #1 further indicated she did not inform the nurse of the inability to wash the right hand.

Based on clinical record reviews, facility documentation and interviews for two of five sampled residents (Residents #48 and #79) reviewed for accidents, the facility failed to ensure interventions were in place and/or supervision provided to prevent falls with injuries. The findings include: 1. Resident #48's [DIAGNOSES REDACTED]. The resident care plan dated 5/20/10 identified at risk for falls related to an unsteady gait and a history of falls. Interventions included use of a chair alarm in the wheelchair and/or recliner and to check placement and function every shift. The nurse's note dated 5/20/10 at 1:00 PM identified R #48 was found lying on the floor next to the recliner chair. An assessment identified the left leg was noticeably shorter than the right and the resident was verbalizing pain in the leg. The resident was transferred to the hospital for an evaluation and was diagnosed with [REDACTED]. Interview with Registered Nurse (RN) #2 on 4/25/11 at 11:20 AM identified that the chair alarm was put in place because the resident was confused and had a history of [REDACTED]. Interview with the Maintenance Director on 4/25/11 at 11:25 AM indicated he was walking by R #48's room and saw the resident lying on the floor next to the recliner chair. The Maintenance Director stated he did not see a chair alarm and did not hear an alarm sounding when he found the resident. Interview with Licensed Practical Nurse (LPN) #2 on 4/25/11 at 12:20 PM indicated she was notified that R #48 was on the floor by the Maintenance Director. LPN #2 assessed the resident and identified complaints of pain and that the left leg was visibly shorter than the right leg. LPN #2 indicated that she did not recall if R #48's alarm was on and/or functioning at the time of the fall. Interview with the Director of Nurses (DNS) on 4/25/11 at 11:55 AM indicated the nurse aide is responsible to check alarms at the beginning of the shift for functioning and placement and that the nurse is to check the alarm when rounds are being conducted. 2. Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident care plan dated 4/7/11 identified decreased strength, balance and coordination related to recent fractured hip. Interventions included the use of a chair alarm and assistance with ambulation and transfers. The care plan further identified the resident required assistance with transfers and mobility related to poor safety awareness and decreased strength. Review of nurse's notes from 3/25/11 through 4/21/11 identified that the resident was noted with confusion, increased hallucinations, was unable to follow directions and made attempts to get out of bed and/or the wheelchair without assistance. The nurse's note dated 4/20/11 for the 3-11 PM shift identified the resident had increase restlessness that required Ativan. The nurse's note dated 4/21/11 at 8:35 AM identified R #79 was sitting in the wheelchair outside on the patio alone and fell . An assessment identified impaired range of motion of the left foot due to complaints of pain. The resident was transferred to the hospital for an evaluation and identified with a left femoral fracture. The Reportable event dated 4/21/11 at 8:30 AM identified R #79 was found outside lying on the patio. The investigation identified the resident was weepy that morning, exhibited agitation and was insistent about going outside after reporting having hallucinations. Physical Therapy Aide (PTA) #1 brought the resident outside to the patio and left the resident alone to go back in the facility. R #79 stood up unassisted from the wheelchair and fell landing on the left side. Interview with Nurse Aide (NA) # 2 (assigned to provide care to resident on 4/21/11) on 4/21/11 at 1:00 PM indicated the resident was weepy and confused that morning and made several attempts to get up from the wheelchair without assistance. Interview with PTA #1 on 4/21/11 at 1:40 PM identified that on 4/21/11 the resident was weepy and hallucinating and staff was trying to calm the resident down. R #79 was still agitated when he/she came into the therapy room and wanted to go outside. PTA #1 indicated she brought R #79 outside and sat with the resident for a while. R #79 calmed down and PTA #1went back inside leaving the resident on the patio alone. PTA # 1 noted she was inside at her computer and did not see the resident fall, but heard a noise and when she looked outside the resident was out of view. PTA #1 went outside to the patio and saw the resident lying on the ground. Interview with the Director of Nurses (DNS) on 4/21/11 at 2:20 PM indicated the resident had hallucinations, was weepy and made several attempts to get out of the wheelchair and was not safe to be left outside alone. The DNS was unable to identify why the resident was left without supervision outside.

Based on review of the clinical record, review of facility policy, facility documentation, and interviews, the facility failed to ensure that one resident (Resident #1) received adequate supervision to prevent a fall. The finding includes: Resident #1 had [DIAGNOSES REDACTED]. Review of a care plan dated 7/22/10 identified that the resident was at risk for falls with interventions that included 2 1/2 rails in bed, transfer with the assistance of two staff, and call bell in reach. Review of a nurse's note dated 8/5/10 at 4:00 AM identified that the resident was found lying on the floor, the floor was wet with urine, and the resident didn't have a bed alarm. The resident sustained [REDACTED]. The care plan was updated to remind the resident to use the call bell for assistance. Review of the Minimum Data Set (MDS) assessment dated [DATE], identified that the resident was independent for daily decision making, required physical assistance to stand from a seated position and was non-ambulatory. A nurse's note dated 11/22/10 identified that the resident was observed falling backwards when attempting to stand independently. No injuries were sustained. The care plan was updated to include remind the resident to lock the wheel chair and call for assistance. A nurse's note dated 12/1/10 identified that the resident was found on the bathroom floor at 8:30 PM with contusions of the scalp, hip and forearm. The plan of care was updated to include initiation of a chair alarm. Review of LPN #1's nurse's notes dated 12/2/10 at 1:10 AM and 12/3/10 at 6:00 AM reflected that a bed alarm was placed on the resident's bed for safety. Interview with LPN #1 on 2/18/11 at 2:45 PM stated that the resident would sometimes become confused at night, therefore, they applied a bed alarm on the bed for the resident's safety. Review of the treatment kardex for December 2010 and January 2011 identified that licensed staff signed off on all three shifts that the resident utilized a bed alarm to prevent unsafe ambulation. Review of the February 2011 kardex reflected that "bed" was crossed out and replaced with "chair" alarm, absent of an assessment, that determined the changed needs of the resident. The exact day in February in which this intervention was changed was unknown. Review of the Minimum (MDS) data set [DATE] identified that the resident had prior falls, required extensive assistance for transfers and was non-ambulatory. A follow-up psychiatric assessment dated [DATE] reflected that the resident had advancing dementia with mildly impaired judgement, memory deficit, and poor safety awareness with a goal for "safety". Review of LPN #1's nurse's note dated 2/5/11 at 12:05 AM identified that R #1 was found prone on the floor following a fall from the bed. The resident, sent to the hospital, sustained a head injury and cervical neck fractures resulting in death two days later. Interview with NA #1 (assigned caregiver) on 2/18/11 at 2:20 PM stated that during first rounds on 2/5/11, she heard moaning, observed R #1 lying on the floor beside the bed, and immediately summoned LPN #1 to the room. NA #1 stated she thought R #1 had a bed alarm in place, however, could not recall hearing it sound when she found the resident. Interview with LPN #1 on 2/18/11 at 2:45 PM stated she could not recall if the resident utilized a bed alarm the night of the fall. Interview with RN #2 on 2/16/11 at 2:12 PM stated she thought R #1 utilized a bed alarm, however, could not recall if an alarm was in place during the time of the fall. Review of the clinical record, facility documentation, and interview with the Director of Nurses on 2/22/11 identified that the resident utilized a chair alarm in accordance with the care plan and did not use a bed alarm. Review of Resident #1's clinical record and interviews with direct caregivers identified discrepancies in the plan of care resulting in inconsistent approaches to ensure the safety of the resident.