Every finding on record at Apple Rehab Farmington Valley

Based on observation, clinical record reviews, facility documentation, facility policies, and interviews for one of nine residents (Resident #1) reviewed for accidents, the facility failed to provide adequate supervision to prevent a resident from obtaining a restricted dietary food item per their dietary orders, from the nursing units refrigerator. The failure resulted in a choking event. The findings include: Resident #1's diagnoses included Parkinson's disease, dementia, dysphagia, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen (11/15), indicative of moderate cognitive impairment, had behaviors directed toward others (hitting, kicking, pushing) and rejection of care one (1) to three (3) of the prior seven (7) days, required supervision for mobility with a manual wheelchair, had the ability to self-propel in the wheelchair at least 150 feet in the corridor, and required a mechanically altered diet (change in texture of food or liquids). The Resident Care Plan dated 9/30/2025 identified impaired decision makings skills related to dementia, at risk for complications related to dysphagia, and required a mechanically altered diet. Interventions directed offer one step directions at a time, and provide diet as ordered, provide minced and moist diet and set up for meals with assist as needed, and watch for increased difficulty swallowing, holding food in mouth, increased drooling and food spillage. Nursing note dated 9/17/2025 at 5:37 AM identified Resident #1 was up around 5 AM and wondering in other resident's room to look for food, a sandwich, chips, soda, and crackers were given to him/her. He/she was put in a wheelchair in front of nurses station. Resident got up and tried to run away, nurse reoriented resident back to chair. Nursing note dated 9/17/2025 at 8:41 PM, written by LPN #1, identified Resident #1 was seen going into nursing unit's fridge. Nursing note dated 9/19/2025 at 10:58 PM, written by LPN #1, identified Resident #1 was seen going into nursing unit's fridge multiple times, sandwich offered. Physician orders dated 10/1/2025 directed regular diet, dysphagia/level 2 texture, and thin liquids consistency. Allow IDDSI (International Dysphagia Diet Standardization Initiative) level 5 (minced and moist). Resident #1 requires set-up assistance, provide inner lip plate and Kennedy cup, and directed Resident #1 requires supervision for diet. The Facility Reported Incident Form and Investigation dated 10/6/2025 at 7:15 AM identified Resident #1 was observed by staff holding his/her throat and was not able to verbally respond. The Heimlich maneuver was performed and Resident #1 cleared food from the passageway/expelled food. Additional information identified Resident #1 stated he/she obtained a sandwich from the refrigerator without staff assistance, and the sandwich was regular consistency. A nursing note dated 10/06/2025 at 9:41 PM by LPN #1 identified she observed Resident #1 holding throat area and look panicked. Resident #1 was asked if he/she is okay with no response. LPN #1 immediately performed the Heimlich maneuver to clear airway of turkey meat and was successful, and Resident #1 was back to baseline with stable vital signs. Resident #1 in bed resting for remainder of shift. Observation and interview with the DON at 10:15 AM of Resident #1's nursing unit on 10/8/2025 at identified a kitchenette area with a refrigerator located on the side of the unit hallway in an open alcove, available to all residents/staff/visitors. The alcove had a counter area with two (2) double cabinets under the counter, a microwave on the wall, and a sink. To the right of the cabinet/counters there was a full-size refrigerator/freezer. The DON stated the refrigerator was stocked daily by dietary staff with snacks and sandwiches for the evening and night shift. At the time of the observation, a lock was noted in place on the refrigerator. The DON stated the lock was a new intervention after Resident #1's choking event. Interview with LPN #1 on 10/8/2025 at 1:00 PM identified on 10/6/2025 during the 3:00 PM to 11:00 PM shift, LPN #1 had noted Resident #1 was in his/her wheelchair and had a sandwich in his/her possession. LPN #1 stated as she went to intervene, Resident #1 was noted to be not responsive toward LPN #1. The Heimlich maneuver was immediately initiated and LPN #1 called out for immediate assistance. Resident #1 successfully cleared what appeared to be turkey meat after the Heimlich maneuver. LPN #1 stated she was aware that in the past Resident #1 had opened the refrigerator door, but had not taken any food out. LPN #1 stated Resident #1 required supervision when out of bed to his/her wheelchair, and required an assist of one person if utilizing a walker. LPN #indicated the refrigerator was mainly utilized by the nursing staff, but it can also be accessed by family if they want to store any food for residents. LPN #1 stated the refrigerator stores mostly snacks and sandwiches for the residents. Interview identified Resident #1 was not observed until after he/she had accessed the sandwich and had taken at least one (1) bite of the sandwich without staff supervision. Interview with the DON, ADON, RN #1, RN #2, and Administrator on 10/8/2025 at 2:10 PM identified residents are supervised by the nursing staff at the nurse's station, due to the layout of the unit and indicated the nursing station's overall structure helps with supervision and keeps everyone within eyesight. Interview identified the expectation for supervision was all residents are visualized every two (2) hours, unless physician orders directed increased intervals. Resident #1 was identified as an assist of one (1) with a rolling walker and wheelchair. On 10/6/2025, the nursing team immediately intervened when Resident #1 had a change in condition noted. LPN #1 performed a successful Heimlich maneuver and Resident #1 returned to baseline with follow-up medical interventions negative for any changes. Interview identified Resident #1 should not have been able to access the sandwich independently, and after the incident, the refrigerator had a lock mechanism installed for further safety to prevent resident access. Although requested, the facility did not have a policy regarding supervision of residents.

Based on facility documentation, facility policy and interviews for 4 of 5 employee files (Registered Nurse (RN) #4, RN #5, Nurse Aide (NA) #1 and NA #5) reviewed, the facility failed to ensure pre-employment references were obtained per facility policy. The findings include: 1. RN #4's date of hire was 5/8/25. No pre-employment references were identified in the employee's personnel file. Although requested, the facility could not provide pre-employment references for RN #4. 2. RN #5's date of hire was 11/1/23. No pre-employment references were identified in the employee's personnel file. Although requested, the facility could not provide pre-employment references for RN #5. 3. NA #1's date of hire was 12/2/24. No pre-employment references were identified in the employee's personnel file. Although requested, the facility could not provide pre-employment references for NA #1. 4. NA #5's date of hire was 10/26/23. No pre-employment references were identified in the employee's personnel file. Although requested, the facility could not provide pre-employment references for NA #5. Interview and review of facility documentation with the Human Resources Director (HRD) on 6/3/25 at 10:06 AM identified she was responsible for obtaining pre-employment references for new employees. The HRD indicated that although she was not working in her current position when RN #5, NA #1 and NA #5 were onboarded, the facility should have obtained pre-employment references at that time. In addition, the HRD identified she should have obtained pre-employment references when RN #4 was onboarded, and she was unsure why it was not done. The HRD indicated it was facility policy to obtain pre-employment references for all new employees. Review of the facility policy, Abuse, undated, directed to ensure all residents are treated with kindness, compassion, and dignity, as part of the employee screening/pre-hire procedure the facility would conduct reference checks which included previous employers.

Based on the tour of the Nourishment Rooms and staff interviews, the facility failed to ensure 1of 2 ice machines (West Wing) were clean and sanitary. The findings included: On 6/2/25 at 9:50 AM a tour of the Nourishment Rooms with the Dietary Director identified that the ice machine in the [NAME] Wing nourishment room was unclean, and had a black substance around the drain spout, around the drip tray and along the front side of the machine. On 6/2/25 at 10:05 AM an interview with the Maintenance Director identified a company provided services to clean the ice machine on the [NAME] Wing which was last serviced in April 2025. Also, identifying the ice machine did not look clean and the policy was for the machine to be cleaned every 3 months. On 6/3/25 at 10:33 AM an interview with LPN #3 identified that she usually works on the unit the west wing ice machine was contained and that the machine was used daily. Although a policy for cleaning the ice machine was requested the facility failed to supply one. Subsequent to the surveyor's inquiry, the vendor for cleaning the ice machine was called to the facility and the ice machine was cleaned.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 7 residents (Resident #16) reviewed for falls, the facility failed to notify the state agency of an injury of unknown origin. The findings include: Resident #16 had diagnoses that included vascular dementia, cerebral infarction, and nutritional anemia. 1. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 00), required setup or clean-up assistance with eating, partial/moderate assistance with bed mobility, and required substantial/maximal assistance with bed/chair transfers. The Resident Care Plan (RCP) in place at the time identified Resident #16 was at risk for bruising/bleeding related to blood thinning medication. Interventions included to monitor and report signs/symptoms (s/sx) of bleeding and remind Resident #16 to use caution and be aware of extremity positioning when transferred. The RCP further identified Resident #16 had a fracture to the right arm that required placement of a brace to the area due to a fall on 3/22/2023. Interventions included weight bearing of affected limb as ordered and transfers per physician orders. A review of facility documentation dated 6/20/2023 at 8:30 PM identified bruising was observed on Resident #16's right breast by the nurse aide (NA) during bedtime care. The form identified the Advanced Practice Registered Nurse (APRN) and responsible party were notified of the event, and the bruising on Resident #16's right breast would be monitored. Review of all facility documentation related to the 6/20/2023 incident failed to identify a conclusion/summary of the event which identified an origin for the bruising on Resident #16's right breast. Review of the State Agency reportable event website identified the State Agency was not notified of the bruising to Resident #16's right breast identified on 6/20/2023 as an injury of unknown origin. Interview with Director of Nursing Services (DNS) on 6/2/2025 at 1:30 PM identified she was not the DNS in June of 2023 but that she had reviewed the documentation for the event on 6/20/2023. DNS identified Resident #16 had increased agitation during the time of the event, was on Eliquis, and had recently used a brace to his/her right arm which could have contributed to formation of the bruising. DNS further identified that if the investigation did not reveal supporting evidence for injury then it should be reported as an injury of unknown origin. 2.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 00), and had no physical behaviors directed toward others (hitting, pushing, scratching, grabbing) or behavioral symptoms not directed toward others (hitting or scratching self). The MDS assessment further identified Resident #16 was dependent with eating, required substantial/maximal assistance with bed mobility, and was dependent with bed/chair transfers. The Resident Care Plan (RCP) dated 12/21/2023 identified Resident #16 was at risk for bruising/bleeding related to blood thinning medication with a history of a bruise to the right chest on 6/20/2023. Interventions included to monitor and report signs/symptoms (s/sx) of bleeding and remind Resident #16 to use caution and be aware of extremity positioning when transferred. Review of the RCP failed to identify any focus(es), goal(s) or intervention(s) related to Resident #16 having behaviors of scratching his/her upper body. Review of nursing progress notes in the electronic medical record (EMR) from 2/25/2024 through 3/2/2024 failed to identify a nursing progress note that identified Resident #16 was restless, had s/sx of restlessness, or was observed scratching his/her upper body. Review of facility documentation dated 3/2/2024 at 9:50 AM identified bruising was observed across Resident #16's breasts and chest by the nurse aide (NA) during morning care in Resident #16's room. The Advanced Practice Registered Nurse (APRN) and responsible party were notified of the event, the evening dose of Eliquis (blood thinner) was to be held on 3/2/2024 at 5:00 PM, the affected area was to be monitored, and an investigation was initiated. A late entry nursing progress note by Licensed Practical Nurse (LPN) #4 dated 3/2/2024 at 1:07 PM (written on 3/8/2024 at 1:11 PM) identified bruising was observed to Resident #16's bilateral breasts and bilateral flanks during care. The note identified the bruising was dark purple in color on each side of the outer breasts and greenish-yellow in color across the chest. The note identified Resident #16 denied pain and was unable to recall acquiring the bruising. The note identified the nursing Supervisor was notified, a call was placed to the APRN, a voicemail was left for the responsible party, and an order was received to hold Resident #16's evening dose of Eliquis. Review of facility documentation related to the 3/2/2024 incident failed to identify a conclusion/summary of the event which identified an origin for the bruising on Resident #16's bilateral breasts and bilateral flanks. Review of the State Agency reportable event website identified the State Agency was not notified of the bruising to Resident #16's bilateral breasts and bilateral flanks identified 3/2/2024 as an injury of unknown origin. Interview with Director of Nursing Services (DNS) on 6/2/2025 at 1:30 PM identified she was not the DNS in March of 2024 but that she had reviewed the documentation for the event on 3/2/2024. The DNS identified Resident #16 had notes from the psychiatry group indicating Resident #16 had dementia with instances of sundowning. DNS further identified Resident #16 had thin skin and her care plan showed she had scratching behaviors which could have potentially have caused injury. The DNS was unable to identify how scratching could result in bruising without also having documentation of scratches to the same area. DNS identified the criteria for suspicion of abuse would be considered if there was no explanation for an injury. Review of the Abuse Prevention Program 2025, effective on 10/1/2011 and last revised on 3/1/2022, directed, in part, the purpose to ensure an environment free of abuse included description of an investigative process to be used in instances of suspected abuse, including bruising of unknown origin. The policy directed all injuries of unknown etiology including bruises and skin tears must be reported to the nursing supervisor and must be investigated and appropriately reported if investigation fails to yield likely etiology.

Based on interviews, observations, policy and record reviews for 1 of 5 residents (Resident #85) sampled for nutrition, the facility failed to develop a comprehensive person centered dietary care plan. The findings include : Resident #85's diagnoses included pneumonitis due to inhalation of food and vomit, dysphagia, and protein calorie malnutrition. A Speech Language Pathologist Evaluation and plan of care dated 5/7/25 identified recommendations for Resident #85 to receive 1 to 1 supervision/assist to feed as needed and ensure full oral clearance to reduce risk of choking. A physician's order dated 5/7/25 directed for Resident #85 to receive a carbohydrate-controlled diet, puree level 1 texture (watery consistency) with 1 to 1 feeding, small bites, small sips, and checking for pocketing due to aspiration risk. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 85 was severely cognitively impaired, was independent for eating and required substantial/maximal assistance for oral hygiene, dressing and toileting. Additionally, the MDS identified Resident #85 was holding food in the mouth/cheeks or residual food in mouth after meals. The Resident Care Plan dated 5/27/25 identified Resident #85 had a potential for nutritional decline related to medications, multiple medical problems, need for therapeutic diet, need for altered consistency diet, and a recent hospitalization. Interventions included encouragement to eat as much of the meal independently as possible and assists with completion of the meal, offer to set up the meal and weigh as ordered. (The care plan did not provide a resident specific plan of care to reflect special dietary goals and interventions put forth by the speech therapist regarding 1 to 1 feeding, small bites to ensure full oral clearance). Observation and interview with Nurse Aid (NA) #2 on 5/29/25 at 8:34 AM identified NA #2 sat Resident #85 up in bed, and attempt to feed him/her breakfast, which Resident #85 refused. Additionally, she identified that she usually feeds Resident #85, identifying resident care instructions that are on the Resident Care Card located in a binder by the nurse's station. Interview and record review with Licensed Practical Nurse (LPN) #3 on 5/29/25 at 10:08 AM identified that it was facility policy to have a dietary order in the physician's order, instructions on the meal ticket and on the resident care card. Additionally she identified the charge nurse at the time the order was put into place was responsible for updating the resident care card, which is where the NA's checked for care instructions. A review of the resident care card for Resident #85 failed to identify any dietary instructions regarding 1 to 1 feeding, small bites to ensure full oral clearance, checking for pocketing. Subsequent to surveyor, inquiry LPN #3 updated the Resident Care Card for Resident #85 to reflect Assist 1:1 feed, small bites, small sips, check for pocketing. Interview and in-service review with the Speech Therapist (ST) on 5/29/25 at 11:41 AM identified she evaluates residents upon admission and conveys any special instructions by discussing it with the nurse, supervisor and providing education to staff; however she does not update the care plan, that was the responsibility of the nursing department. A review of the in-service dated 5/7/25 on Resident #85's safe swallowing strategies identified only 1 LPN and 9 NA's were inserviced on special feeding instructions regarding Resident #85. The ST further identified that it was hard to catch everyone for the education, but anyone that did not get the education could refer to the meal ticket for the instructions. A review of Resident #85's meal ticket with ST identified special instructions as 1:1 (without the benefit of including instructions to provide small bites, small sips, and check for pocketing). The ST further identified the instructions were not printed in its entirety due to lack of space on the meal ticket, that 1:1 did not reflect Resident #85's full dietary instructions and 1:1 does not always reflect a need small bites, small sips, check for pocketing. Additionally, the ST failed to identify how staff who did not receive the education would know to provide Resident #85 with 1:1 feeding assistance, small bites, small sips, check for pocketing. (the special dietary instructions were not on the Resident Care Card, meal ticket, nourishment roster or included in the Resident Care Plan). Interview with MDS Registered Nurse (RN) #2 on 5/29/25 at 12:05 PM identified she was notified of changes with resident care through morning report and daily 24 hour look back and she would not expect Resident #85's special dietary instructions of assist 1:1 feed, small bites, small sips, check for pocketing to be in the care plan because Resident #85 was already care planned to receive set up and assist as needed during meals. Interview with the Dietician on 5/29/25 at 1:30 PM identified she was at the facility three days a week, reviews the electronic health record for weights and assessments daily, then institutes interventions and updates the care plan as needed. However, she identified she would not expect Residents #85's special dietary instructions of assist 1:1 feed, small bites, small sips, check for pocketing to be care planned because the care plans were usually more general in nature. Review of the Care Planning policy directed in part that a comprehensive and individualized plan of care will be developed for each resident. The care plan will guide caregivers to assist residents to achieve or maintain their highest practical level of well being. Additionally the resident care cards will be updated as needed to reflect changes made to the resident's plan of care.

Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #43) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure personal hygiene care and services were provided to a dependent resident. The findings include: Resident # 43's diagnoses included dementia, diabetes and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 was severely cognitively impaired and dependent on oral hygiene, toileting, showering, dressing and personal hygiene. Also identifying Resident #43 required maximal assistance for transfers. The Resident Care Plan dated 4/4/25 identified Resident #43 required assistance with Activities of Daily Living. Interventions included providing a full bed/sponge bath if a shower was declined, assist with mouth/dental care, and assist with feeding as needed. Physician orders dated 4/25/25 directed to provide a weekly shower on Monday evening shift along with a full body audit. Nursing notes dated 5/19/25 identified that Resident #43 was provided with a shower and had a full body audit. An observation of Resident #43 on 5/27/25 at 2:04 PM identified soiled, long nails. A second observation made on 5/28/25 at 1:00 PM, noted Resident #43 continued to have soiled, long nails. Review of Treatment Administration Record identified Resident #43 had a full body audit completed on 5/28/25. Interview on 5/29/25 at 12:01 PM with Nurse Aid (NA) #4 identified that she provided morning care to Resident #43 which consisted of washing and dressing Resident #43. Also identifying Resident #43 needed his/her nails trimmed and cleaned but she had not provided nail care that morning. Interview on 5/29/25 at 12:14 PM with Licensed Practical Nurse (LPN) #2 identified Resident #43's nails did not appear clean and needed to be trimmed. Also Identifying the policy was to have nails cleaned on shower day or as needed and Resident #43's shower day was on Mondays. Review of the facility policy dated 12/9/14 for AM Care/Activities of daily Living was to provide individualized assistance to residents in preparation for daily activities, according to their wishes and plan of care. Also, identifying fingernail care including trimming was to be provided. Subsequent to the surveyor's inquiry the nursing notes dated 5/29/25 identified Resident #43's nails were cleaned and trimmed.

Based on interviews, observations, policy and record reviews for 1 of 5 residents (Resident #85) sampled for nutrition, the facility failed to address the nutritional needs of an at-risk resident.The findings include: Resident # 85 diagnoses included pneumonitis due to inhalation of food and vomit, dysphagia, and protein calorie malnutrition. A physician's order dated 5/7/25 directed for Resident #85 to receive a carbohydrate-controlled diet, puree level 1 texture (watery consistency) with 1:1 feeding, small bites, small sips, and checking for pocketing due to aspiration risk. The admission Nutritional Assessment written by the dietician dated 5/8/25 identified Resident #85 was pocketing food and required limited and extensive assistance with feeding. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 85 was severely cognitively impaired, was independent for eating and required substantial/maximal assistance for oral hygiene, dressing and toileting. Additionally, the MDS identified Resident # 85 was holding food in the mouth/cheeks or residual food in mouth after meals. The Resident Care Plan dated 5/27/25 identified Resident #85 had a potential for nutritional decline related to medications, multiple medical problems, need for therapeutic diet, need for altered consistency diet, and a recent hospitalization. Interventions included encouragement to eat as much of the meal independently as possible and assists with completion of the meal, offer to set up the meal and weigh as ordered. A review of Resident #85's weight identified he/she weighed 143 pounds (lbs.) on 5/6/25, 5/7/25 and 5/11/25, 145.3 lbs. on 5/17/25 and 124.7 lbs., on 5/25/25 (a significant weight loss of 18.3 lb./12.80 % in 19 days). A review of Resident #85's meal intakes between 5/6/25 and 6/1/25 identified that he/she refused 14 meals, had a meal intake documented as 0-50% for 33 meals and a documented meal intake of 51-100% for 33 meals. Observation of Resident #85 identified he/she was in bed sleeping on 5/28/25 at 8:34 AM with the breakfast meal covered and uneaten on the bedside table. Observation of Resident #85 identified he/she was in bed on 5/29/25 at 10:32 AM and refused breakfast when prompted by a Nurses Aid (NA). Observation of Resident #85 identified he/she was in bed sleeping on 6/3/25 at 8:46 AM with breakfast meal covered and uneaten on the bedside table. Interview and record review with Registered Nurse (RN) #1 on 5/29/25 at 1:45 PM identified it was facility policy to follow physician's orders for weights, they were obtained by the NA and entered into the electronic health record by the charge nurse. Review of Resident #85's record identified that a reweight was not obtained for the 5/25/25 weight of 124.7 lbs. (a significant weight loss of 18.3 lb./12.80 % in 19 days), but should have been. Furthermore, the electronic health record failed to identify the provider, dietician or responsible party were updated of the weight loss. Subsequent to surveyor inquiry a reweight was obtained on 5/29/25 identifying a re-weight of 141.5 lbs., (a 3.8 lb./2.62 % weight loss in 12 days), with the provider, dietician and family updated. Interview with the Dietician on 5/29/25 at 1:30 PM identified she is at the facility three days a week, reviews the electronic health record for weights and assessments daily, then institutes interventions and updates the care plan as needed. In addition to the daily review the interdisciplinary team meets and reviews residents with weight fluctuations at the weekly at- risk meeting. The dietician identified she was not aware of Resident #85's weight loss on 5/25/25, if she had been she would have started him/her on supplements. Subsequent to surveyor inquiry, the dietician note on 5/29/25 at 4:04 PM identified Resident #85 was assessed and was to be started on a diabetic supplement and fortified potatoes in hopes of optimizing calorie and protein intake due to variable intake ( the previous assessment by the dietician was upon admission on [DATE]). Interview and record review with the Assistant Director of Nursing (ADNS) on 5/29/25 1:56 PM identified weekly at risk meetings are held to review and track weights and wounds, he identified Resident #85's weight loss was not discussed and that the dietician and provider were not updated. He could not identify why Resdient #85's weight loss was not reviewed. Subsequent to surveyor inquiry the provider assessed Resident #85 for poor oral intake and confirmed weight loss (first and only assessment by a provider pertaining to weight loss/poor intake). Review of the Weight Monitoring policy directed in part that accurate and timely measurement of weight changes in all residents is an important tool in assessing their nutritional status. Additionally iff there is 5 lb. weight discrepancy, a reweight should be obtained.

Based on interviews, observations and record reviews for 1 of 1 residents (Resident #287) sampled for dialysis, the facility failed to provide oxygen per physician's order.The findings include: Resident # 287 diagnoses included chronic congestive heart failure, sleep apnea and acute respiratory failure with hypoxia. The admission Minimum Data Sets (MDS) assessment dated [DATE] identified Resident #287 was cognitively intact, and required partial/moderate assistance for dressing, transfers, and changing position in bed. Additionally the MDS identified Resident #287 was receiving oxygen therapy. The Resident Care Plan dated 3/31/25 identified Resident #287 had cardiovascular disease. Interventions included to check oxygen saturation as ordered/as needed/per policy and to administer oxygen as ordered. A physician's order dated 5/22/25 directed to administer oxygen continuously every shift at 3 liters per minute (Lpm). Observation on 5/28/25 at 10:02 AM identified Resident #287 awake in bed, wearing oxygen, with the oxygen concentrator set at 5L/pm, positioned by the privacy curtain approximately 3 feet away from the Resdient #287's bed. Observation on 5/29/25 at 8:15 AM identified Resident #287 asleep in bed, wearing oxygen, with the oxygen concentrator set at 5 L/pm, with the concentrator positioned by the privacy curtain approximately 3 feet away from the Resdient #287's bed. Observation with Licensed Practical Nurse (LPN) #3 on 05/29/25 at 10:23 AM identified Resident #287 awake in bed, wearing oxygen, with the oxygen concentrator set at 5 liters, with the concentrator positioned by the privacy curtain approximately 3 feet away. LPN #3 questioned Resident #287 if he/she had trouble breathing overnight, to which Resident #287 responded no. Interview and record review with LPN #3 identified Resident it was facility policy to follow physician's orders for oxygen administration, and it was the nurses responsibility to check the oxygen setting on the concentrator. Record review with LPN #3 identified that Resident #287 had an order to be on 3 lpm of oxygen, but failed to identify why Resident #287 was on 5 Lpm of oxygen. Subsequent to surveyor inquiry LPN #3 turned Resident #287's oxygen concentration to reflect the physician's order of 3 Lpm. Interview with APRN #1 on 5/29/25 at 12:39 PM identified that although Resident #287 did not have ill effects from receiving the prescribed oxygen lpm, he/she is compromised and probably should have had an order for tirating oxygen from the start. Subsequent to surveyor inquiry a physician's order dated 5/29/25 at 3:00 PM was initiated for Resident #287's oxygen to be titrated to maintain oxygen saturation above or equal to 93% every shift. Review of the Oxygen Administration policy directed in part that a physician's order is necessary for the administration of oxygen.

Based on observations and staff interview for 1 of 3 resident dining rooms, the facility failed to ensure medical equipment was not stored in a resident utilized area. The findings include: On 5/27/29 at 12:18 PM an observation of the Annex resident dining room identified 3 custom wheelchairs and 1 wheeled walker were being stored there, however no residents were eating lunch in the dining room at that time. Further, identifying the 3 wheelchairs and 1 walker remained unmoved throughout the day. On 5/28/29 at 10:18 AM an observation of the Annex resident dining room identified 3 custom wheelchairs and 1 wheeled walker. Also, identifying the 3 wheelchairs and 1 walker remained unmoved throughout the day. An observation and interview on 5/29/25 at 11:45 AM with the Assistant Administrator identified the 3 wheelchairs and 1 walker remained in the Annex dining room and said that she would have them removed quickly. On 5/29/25 at 11:53 AM an observation of the Annex dining room which continued to contain 3 custom wheelchairs and 1 walker, 3 residents (Resident #61, #109 and #125) were observed using the dining room. Interview and observation with Nurse Aide (NA) #3 on 5/29/25 at 11:57 AM identified she usually worked on the Annex unit, and the wheelchairs and walker were usually stored in this room. Also, identifying that residents utilize the room every day. Interview and observation with Resident #125 on 5/29/25 at 11:59 AM identified the wheelchairs and walker were usually stored in the Annex dining room. On 5/29/25 at 12:11 PM an interview with Licensed Practical Nurse (LPN) #2 identified the wheelchairs were stored in the Annex dining room to be charged, and 1 of the wheelchairs was not in use as it was a spare chair for a resident who was not in the dining room. Also, identifying that the wheelchairs and a walker need to be removed when the residents utilize the room and the staff remove the wheelchairs and a walker every day. An interview on 6/3/25 at 10:22 AM with Resident #109 identified the wheelchairs and a walker were always stored in the Annex dining room and not removed during mealtime or when residents utilize the room. Subsequent to surveyor inquiry, an observation on 5/29/25 at 12:15 PM noted the wheelchairs and the walker were removed from the dining room. Although requested, a facility policy on the storage of wheelchairs/walkers was not provided.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure a complete and accurate medical record to include a physician order for a foley catheter insertion after a fall, and to include a time duration to wait before reinserting a foley catheter. The findings include: Resident #1 had a diagnosis of retention of urine, after care following surgery of genitourinary system, and neuromuscular dysfunction of the bladder. The Resident Care Plan (RCP) dated 4/16/2024 identified Resident #1 had an indwelling catheter. Interventions directed to provide indwelling catheter care. The admission Minimum Data Sheet assessment dated [DATE] identified Resident #1 had a BIMS of 3 (severely impaired cognition) and had a catheter. The physician order dated 4/18 /2024 directed that if the foley catheter was pulled out to not replace it, and to not send Resident #1 to the hospital. The nursing note dated 4/21/2024 at 3:46 AM identified an unwitnessed fall; Resident #1 was observed lying on his/her back at around 1 AM and no injuries were noted. Resident #1 had baseline mentation, positive range of motion, denied hitting his/her head and Resident #1 had pulled his/her foley catheter out. The note identified a new catheter was inserted by the charge nurse. The APRN and family was updated regarding the fall. Record review failed to identify a physician's order that directed to re-insert the foley. The interview and record review with RN #1 on 4/28/25 at 12:24 PM identified she would not reinsert a foley or instruct the charge nurse to reinsert a foley unless there was a physician order that directed to. RN #1 stated she must have forgotten to write the order, and she should have written an order after speaking with the APRN regarding the fall. Interview and record review with the Administrator, the DNS and Regional RN # 333 on 4/28/25 identified RN #1 should have written the physician order in the clinical record that directed to reinsert the foley catheter. Interview failed to identify why the order was not written. a. The nursing note dated 4/29/2024 at 11:42 AM identified Resident #1's foley was noted to be out, and the supervisor, family, APRN, and ADNS were notified. A new order was obtained that directed to reinsert the foley catheter if Resident #1 did not void. The physician order dated 4/29/2024 directed staff to reinsert the foley catheter if the resident does not void, and if the resident refuses the catheter, to not reinsert. Additional record review failed to identify the order dated 4/29/2024 directed the length of time (example: 4, 6 or 8 hours) to wait for Resident #1 to void, before reinserting the catheter. The nursing note dated 4/29/2024 at 8:35 PM (8 hours, 53 minutes after the note that indicated the foley catheter was out) identified a foley catheter was attempted to be placed but was unsuccessful. The APRN was notified at 6:35 PM (approximately 6 hours and 53 minutes after the foley was noted to be out) and an order was obtained to transfer Resident #1 to the hospital for evaluation. The family was made aware and was in agreement with transferring the resident. Interview with APRN # --- was not obtained during survey. The interview and record review with RN #1 on 4/28/25 at 12:24 PM identified although she thought six (6) hours was an acceptable length of time to wait for Resident #1 to void before attempting to reinsert the catheter, RN #1 was unable to identify the order directed a length of time to wait. RN #1 indicated orders would usually direct the staff how long to wait for the resident to void before reinserting a catheter. Interview and record review with the Administrator, the DNS and Regional RN #1 on 4/28/25 identified although they thought six (6) hours was an appropriate length of time to wait to see if the resident voided before attempting to insert another foley catheter, interview identified the physician order should have included directions that indicated how long staff should wait before attempting to reinsert the catheter. Interview failed to identify why the time frame was not included in the orders. Although requested, a policy was not provided regarding physician orders.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for accidents, the facility failed to monitor the temperature of a hot water source prior to serving the resident a hot beverage resulting in the resident sustaining second degree burns after spilling the hot beverage on him/herself. The finding includes: Resident #1's diagnoses included dementia and type 2 diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a BIMS of ten (10) indicating some memory recall deficits and was independent with eating after set-up. The Resident Care Plan dated 10/20/24 identified Resident #1 required staff assistance with completing activities of daily living (ADL). Interventions directed, in part, for staff to set-up the meals and assist with eating as needed. The nurse's note dated 10/22/24 at 6:00 AM identified the Director of Nursing was called to Resident #1's room after Resident #1 had spilled hot tea on the right leg and thigh. The resident's right groin was noted to have redness, some peeling skin, and the resident was noted to be in pain. The on call Advanced Practice Registered Nurse (APRN) was notified and gave an order to send Resident #1 to the emergency room for evaluation. The nurse's note dated 10/22/24 at 6:55 AM identified Resident #1 was transferred to the hospital. The hospital discharge summary dated 10/22/24 identified Resident #1 presented to the Emergency Department with complaints of acute burns to the right leg. The summary identified Resident #1 was diagnosed with a second degree burn to the right thigh, the burn was approximately twenty-five (25) centimeters (cm) x fifteen (15) cm of skin with open areas. The summary identified Resident #1 would be discharged back to the facility with orders for wound care and pain management. The nurse's note dated 10/23/24 at 3:44 AM identified Resident #1 returned from the hospital. with orders to cleanse the right upper thigh burn with Normal Saline followed by bacitracin and xeroform gauze followed by a non-adherent dressing and cover with cling gauze. Change the dressing every eight (8) hours for right upper thigh burn until healed and change the right upper anterior thigh burn daily and as needed until healed. Review of the Facility Reported Incident form dated 10/22/24 at 6:00 AM identified Resident #1 was drinking hot tea, spilled the cup of tea on the right groin and leg, and sustained a second degree burn on 3% of the right anterolateral thigh. A written statement by the 11PM-7AM nurse aide, Nurse Aide (NA) #1, dated 10/22/24 identified that every morning at 6:00 AM Resident #1 asks for tea and the nurse aides use the hot water from the coffee machine in the staff break room. NA #1 explained Resident #1 was independent with eating and on 10/22/24 she set up the tea on the table and left the room. After leaving the room, NA #1 heard Resident #1 screaming saying he/she spilled the tea on his/her right leg. Interview with the Director of Food Service on 11/14/24 at 11:AM identified the facility does not have a policy that indicates when a liquid is too hot to serve a resident. The Director of Food Service indicated hot coffee and water are typically served from the kitchen machine which has a digital temperature screen built in and they log the temperatures daily. The Director of Food Service identified the standard of practice at the facility was to serve hot liquids between the temperature range of 150-to-160-degrees. The Director of Food Service identified that when the kitchen is closed and residents request coffee or hot water, staff obtain that from the staff break room. The Director of Food Service identified that the machine in the break room does not have a built-in temperature monitor, and the facility did not monitor the temperatures because it was not part of the meal service for residents. An observation was done on 11/14/24 at 11:10AM with the Director of Food Services who tested the hot water temperature from the staff break room coffee from machine which identified an initial hot water temperature of 182 degrees that cooled to 170 degrees after two (2) minutes. Interview with Occupational Therapist on 11/14/24 at 12:45 PM identified she conducted an initial evaluation with Resident #1 on 6/26/24 and identified Resident #1 was able to feed self with assistance for set up only and did not need adaptive equipment. Interview with the Director of Nursing (DON) on 11/14/24 at 1:35 PM identified staff should be getting all hot liquids from the kitchen, and she was not aware that they were getting hot liquids from the staff break room machine. Review of the facility policy Point of Service Dining does not address liquid hot temperature testing or acceptable temperature ranges to serve. Although attempted, an interview with NA #1, the former Director of Nursing, and the former Assistant Director of Nurses was not completed.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure that a physician was informed of a request to repeat X-rays due to increased pain timely. The findings include: Resident #1 was admitted to the facility with diagnoses that included polyarthritis, osteomyelitis vertebra, erosive arthritis, and osteoporosis. An undated face sheet identified that Resident #1 was responsible for him/herself. Physician's orders dated 6/1/23 directed Methadone 5 mg tablet, 3 tablets every 8 hours for pain and Oxycontin 60 mg, 3 tablets every 8 hours for pain. A physician's order dated 6/1/23 directed Oxycodone 30 mg, 2 tablets every 3 hours as needed for pain. Give at least one hour before or after scheduled narcotic. Do not give with scheduled Oxycontin and Methadone. The quarterly MDS dated [DATE] identified Resident #1 had no impairments in cognition, was independent with transfers with set up help only, required no set up or physical help from staff for locomotion on the unit, had impairments on both sides of upper and lower extremities and had no unhealed pressure ulcers or injuries. The care plan dated 7/12/23 identified Resident #1 had a custom wheelchair for proper positioning and comfort with interventions that included to reposition as needed and observe Resident #1 for signs and symptoms of discomfort. It further identified Resident #1 needed staff assistance with activities of daily living (ADL's) and used a custom wheelchair with interventions that included that Resident #1 may fluctuate in his/her ability to perform ADL's due to his/her diagnoses and cognitive status, assist Resident #1 as needed with transfers per physician orders. A Nursing note dated 8/30/23 at 4:48 PM identified Resident #1 banged his/her left leg into the lobby doors. Resident #1 had an abrasion to his/her left leg and skin tear to his/her left lower leg and treatment was initiated. Resident #1 complained of left leg pain. The APRN was updated and a new order was obtained for x-rays to the left lower leg and ankle. Resident #1 had limited range of motion to left ankle. A body audit dated 8/30/23 identified Resident #1 banged his/her left leg on the double doors of the lobby. Resident #1 had left inner thigh bruising, entire left knee ecchymosis of 8.5 cm, a left knee abrasion 2.5 cm x 1 cm, with several pinpoint abrasions, left lower shin ecchymosis 8.5 cm x 8.5 cm and a left lower shin skin tear 6 cm x 2.5 cm. A nursing note dated 8/31/23 at 3:08 AM identified Resident #1's X-rays were negative for fracture and osteomyelitis. Resident #1 refused acetaminophen but requested Ibuprofen. The on-call APRN was updated and a one time order for Ibuprofen 800 mg was obtained. An APRN #1 progress note dated 8/31/23 identified Resident #1 was seen after report of doors closing on him/her while he/she was in the wheelchair hitting his/her left lower extremity. Resident #1's x-rays of left lower extremity identified no acute fracture or osteomyelitis. Resident #1 reported pain to left lower extremity and Ibuprofen 400 mg every eight hours as needed was ordered. A physician's order dated 8/31/23 at 3:15 AM - 9/1/23 directed Ibuprofen 400 mg every 8 hours as needed for pain for 10 days. Review of the MAR dated 9/1/23 at 3:08 AM identified the administration of PRN Oxycodone was effective. At 3:39 AM the administration of Ibuprofen 400 mg was ineffective. A physician's order dated 9/1/23 at 10:50 AM directed Ibuprofen 600 mg every 8 hours as needed for pain for 10 days. A nursing note dated 9/1/23 at 4:33 PM identified a new order was received for Ibuprofen 600 mg every 8 hours for 10 days. Review of the MAR dated 9/1/23 at 8:56 PM identified the administration of Ibuprofen 600 mg was effective. A nursing note written by RN #1 dated 9/9/23 at 1:37 PM identified Resident #1 complained that his/her left leg was not getting better, he/she was not comfortable and Resident #1's pain did not change, the pain medication helped but Resident #1 believed he/she needed a second x-ray. Health drive was called, and RN #1 was waiting on a response. The nurses note failed to identify if the on call physician and/or the medical director was reached. A nursing note dated 9/12/23 at 2:54 AM identified Resident #1's x-ray results identified Resident #1's left ankle with two views was positive for an acute distal fibular fracture. The results were reported to the APRN and an order was obtained to send Resident #1 to the emergency room . A Nursing note dated 9/12/23 at 6:28 AM identified Resident #1 complained of left ankle pain, 6/7 out of 10 and was requesting Motrin. A one time order was obtained for 600 mg at 3:30 AM with good effect. A Nursing note dated 9/12/23 at 6:35 AM identified the writer spoke to Resident #1's family member and the plan was to send Resident #1 to the ED after 8:00 AM per Resident #1's wishes. An APRN #1 note dated 9/12/23 at 10:52 AM identified Resident #1 was seen following repeat x-rays of left ankle due to ongoing pain. Resident #1 had x-rays originally done on 8/30/23 following the facility doors hitting him/her while going through in his/her electric wheelchair. Resident #1 sustained an abrasion/skin tear to left lower extremity and x-rays at the time were negative for acute fracture. On 9/11/23 APRN #1 spoke with the nurse who stated Resident #1 was requesting a repeat x-ray to his/her ankle due to it still hurting. The repeat x-rays of Resident #1's left ankle of two views identified an acute distal fibular fracture. Resident #1 was transferred to the hospital. Review of the progress notes identified Resident #1 x-rays were ordered two days after he/she requested. An Accident & Incident (A & I) form dated 9/12/23 identified on 8/30/23 at 4:15 PM Resident #1 was going through the main entrance double doors in his/her electric wheelchair and Resident #1's left lower extremity banged into the door. The APRN was notified and ordered x-rays to left lower extremities. The immediate action taken was for Resident #1 to have assistance going through the electronic doors in the electronic wheelchair. The summary identified on 9/11/23 Resident #1 complained of continued pain and swelling and repeat x-rays were performed. The repeat x-rays identified an acute distal fibular fracture and Resident #1 was sent to the hospital for treatment on 9/12/23. Review of the hospital discharge summary dated 9/27/23 identified Resident #1 had a transverse fracture of the distal tibial metadiaphysis and an acute impacted transverse fracture of the distal fibular metadiaphysis which required surgical intervention. Interview with Resident #1 on 10/25/23 at 11:30 AM identified on 8/30/23 after his/her accident he/she did not go to the hospital because x-rays could be done in the facility. He identified the x-rays were negative and his/her pain was managed with the order of Motrin. He identified the Motrin would take the sharp, throbbing aspect of pain away, but he/she remained with pain. Resident #1 identified he/she asked staff several times over several days for x-rays to be taken because his/her leg pain was not improving, and Resident #1 did not know why it took so long for the x-rays to be performed. Resident #1 further identified if the facility performed x-rays when he/she initially asked, he/she could have already been to the hospital and getting the treatment he/she needed. Interview with APRN #1 on 10/25/23 at 1:30 PM identified she saw Resident #1 on 9/12/23 when she found out Resident #1's pain was worse, and she ordered a second set of x-rays. She identified she was not aware on 9/9/23 that Resident #1 was requesting repeat x-rays. She identified because it was the weekend, it would go to the on call physician dispatch and then get sent to the on call provider. Although attempted, an interview with RN #1 could not be obtained. Interview with DNS on 10/26/23 at 2:21 identified she does not know why the Resident did not get x-rays until 9/11/23 when requested on 9/9/23 (a 2 day delay). She identified if the on call physician does not call back, staff are to call her and she will call the attending. Review of the change in resident condition policy directed that all significant change in resident's condition will be reported to physician and family. It further directed that if the resident's physician is not available, the covering physician for him shall be notified. If the attending or covering physician is not available, the medical director or his associate shall be called. The nurse will document in the nurse's notes that the physician and family or responsible party have been notified of the change in condition.

Based on review of facility documentation, facility policy, and interviews for four (4) of four (4) staff (RN #1, LPN #1, LPN #2 and LPN #3) reviewed for competencies, the facility failed to complete and document new hires completed orientation checklist and competencies. The findings include: 1. RN #1 was hired to the facility on [DATE] and was currently in orientation. Review of RN #1's employee file failed to identify an orientation checklist and competencies in process. 2. LPN #1 was hired to the facility on [DATE] and was currently off orientation and working independently. Review of LPN #1's employee file failed to identify a completed orientation checklist and competencies. Interview with LPN #1 on 9/5/23 at 12:40 PM identified she did not receive an orientation checklist and/or documentation of completed competencies. 3. LPN #2 was hired to the facility on [DATE] and was currently in orientation. Review of LPN #2's employee file failed to identify an orientation checklist and competencies in process. 4. LPN #3 was hired to the facility on [DATE] and was currently off orientation and working independently. Review of LPN #3's employee file failed to identify a completed orientation checklist and competencies. Interview and staff record review with the Administrator on 9/5/23 at 3:00 PM identified the orientation process consists of approximately eighty (80) hours, depending on the staff member's experience. He identified the RN supervisor assesses the competencies for the LPN's and RN's. He identified the orientation checklist is the standard for assessing competencies. He further identified there was no documentation of a completed orientation checklist and competencies for RN #1, LPN #1, LPN #2 and LPN #3. Subsequent to surveyor inquiry, the Administrator created a worksheet for new hires to ensure the orientation checklist was provided and completed. The checklist identified LPN #2 started orientation on 9/5/23 and an orientation checklist was provided to LPN #2. The administrator further started in-servicing on completion of the orientation checklist with oversight provided by the DNS to ensure all new hires complete the orientation checklist, Review of the Licensed Staff Orientation Checklist identified the checklist contains skills that are either met or not met including orientation to the unit, infection control, admission procedures, documentation procedures, wound care procedures, pharmacy and medication pass. The checklist to be signed by the employee and preceptor with completion date. Although requested, the facility does not have a staff orientation/new hire policy.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents ,(Resident #1), reviewed for falls, the facility failed to ensure fall assessments were completed in accordance with facility policy. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included nondisplaced fracture of left femur, malignant cancer of left breast, stroke, acute respiratory failure and dementia. Review of the fall risk assessment dated [DATE] identified Resident #1 was at risk of falling. Review of the nursing quarterly/annual evaluation dated 11/21/22 identified Resident #1 was not at risk for falls. The quarterly MDS dated [DATE] identified Resident #1 had no impairments in cognition, required extensive assistance of one staff for activities of daily living (ADL's), had an upper extremity and lower extremity impairment on one side of the body and used a walker and wheelchair. Review of the care plan dated 5/21/23 identified Resident #1 was at risk for falls due to multiple risk factors with interventions that included call bell within reach, encourage the resident to transfer slowly, encourage the resident to use handrails or assistive devices properly and transfer per MD orders. a) Review of the accident and incident (A & I) form dated 6/7/23 at 3:40 PM identified Resident #1 was observed on the floor next to his/her bed and stated he/she was trying to pick up Kleenex off of the floor and slid off the bed with interventions included ED transfer due to left hip pain and to have Resident #1 use the call bell and wait for assistance when there are objects on the floor that need to be picked up. Resident #1's fall care plan was updated on 6/7/23 to include that Resident #1 had a fall resulting in a left hip fracture with the intervention added to encourage the resident to use the call bell and wait for assistance when there are objects on the floor that need to be picked up. Resident #1 was readmitted to the facility on [DATE]. b) Review of the A & I form dated 8/2/23 at 1:00 PM identified Resident #1 had an unwitnessed fall while attempting to ambulate to the commode in his/her room with interventions included x-rays to left shoulder, hip and elbow, ED transfer to offer toilet after lunch and to encourage the resident to use the call bell when needing assistance. Review of Resident #1's medical record failed to identify a fall risk assessment was completed quarterly and annually since the admission fall risk assessment was completed 10/2/22. Interview and record review with the Administrator on 9/5/23 at 3:00 PM failed to identify fall assessments for Resident #1 after 10/2/22. Review of the falls: minimizing risk of injury policy directed that residents shall be assessed for risk of falling upon admission, quarterly, annually and after a significant change in condition.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents, (Resident #1), reviewed for oxygen, the facility failed to ensure the resident had a physician order for oxygen administration and care. The findings include: Resident #1 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included nondisplaced fracture of left femur, malignant cancer of left breast, stroke, acute respiratory failure and dementia. A physician's order dated 10/2/22 directed as needed oxygen at 2 to 3 liters per minute via nasal cannula as needed for respiratory distress and to titrate oxygen via nasal cannula to maintain saturations greater than 92%. The quarterly MDS dated [DATE] identified Resident #1 had no impairments in cognition, required extensive assistance of one staff for activities of daily living (ADL's), had shortness of breath when sitting at rest and when lying flat, and required oxygen therapy. Review of the care plan dated 6/16/23 identified Resident #1 was at risk for shortness of breath related to history of pulmonary embolisms and chronic periods of shortness of breath and used oxygen with interventions that included to monitor and document breathing abnormalities to the physician. It further identified Resident #1 was at risk for cardiac issues with interventions that included oxygen therapy as ordered. A nurses note dated 6/11/23 at 7:55 PM identified Resident #1 was readmitted via stretcher and had 2 Liters of oxygen on. Review of the nursing quarterly assessment dated [DATE] identified Resident #1 required oxygen. Observations conducted on 9/5/23 at 9:40 AM and 12:30 PM identified Resident #1 with 3 Liters of oxygen applied. Review of Resident #1's physician orders dated 6/11/23 through current failed to identify an order for continuous oxygen and oxygen tubing changes . Interview with LPN #1 on 9/5/23 at 12:40 PM identified Resident #1 has always been on continuous oxygen. She further identified she does not sign off in the medication administration record for oxygen use for Resident #1. Interview with APRN #1 on 9/5/23 at 1:29 PM identified Resident #1 is on continuous oxygen and has been since admission on 10/2/22. She identified Resident #1 had been in and out of the hospital and the order may have been dropped in error. She further identified Resident #1 is on comfort measures only and that the oxygen is for Resident #1's comfort. Subsequent to surveyor inquiry, APRN #1 wrote an order for Resident #1's oxygen use. Review of the oxygen policy and procedure manual identified a physician's order is necessary for the administration of oxygen. Review of the oxygen & nebulizer tubing changes policy directed that licensed staff will obtain a physician order for any resident receiving oxygen therapy and/or nebulizer treatments to change tubing once a week and as needed.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) reviewed for a change in condition, the facility failed to complete vital signs and intake and output as per the plan of care. The findings include: Resident #1's diagnoses included Systemic Inflammatory Response Syndrome (SIRS), acute renal failure, pulmonary embolism, diabetes mellitus and urinary retention. The discharge Minimum Data Set assessment dated [DATE] identified Resident #1 was independent in making decisions regarding tasks of daily life and required extensive assistance for bed mobility, transfer, and toilet use. A physician's order dated 6/9/23 directed to draw blood work Basic Metabolic Panel (BMP) and Complete Blood Count (CBC)) weekly, to monitor vital signs and intake and output starting from admission every shift for three (3) days. The Resident Care Plan dated 6/10/23 identified Resident #1 had been re-hospitalized and had a medical condition that was precarious with recent hospitalization due to acute renal failure. Resident #1 was also at risk for cardiovascular disease, on a diuretic, and was at risk for cardiac issues and dehydration. Interventions included monitoring oxygen saturation levels, vital signs, intake and output as ordered or per policy, to notify the physician and/or Advanced Practice Registered Nurse of any changes and watch for and report any renal or respiratory problems. Interview and review of clinical record with the Director of Nurses (DON) on 6/29/23 at 10:20 AM identified Resident #1's clinical record lacked documentation of the ordered every shift vital sign monitoring for six (6) of the required twelve (12) shifts and although documented in the treatment administration record that intake and output was completed for six (6) of the twelve (12) required shifts, the facility was unable to provide documentation of recorded intake and output for three (3) days or twelve (12) shifts. The DON identified that it was the nurse's responsibility to enter the vital signs into the electronic clinical record and she did not know why it was not done as ordered. The DON indicated the intake and output (I&O) was recorded on a separate paper form, the nurse aides enter the information, including incontinent episodes and the nurse was responsible to assure the documentation was done and complete. The DON identified the nurse would also be responsible for determining if the resident was meeting their hydration requirements and to note any significant changes. The DON identified she was not sure why the I&O documentation was not completed or noted in the clinical record. The DON stated the facility's standard was to monitor vital signs and I&O every shift for three (3) days after admission or readmission to the facility.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who had a change in condition, the facility failed to notify the physician of significant abnormal bloodwork results. The findings include: Resident #1's diagnoses included Systemic Inflammatory Response Syndrome (SIRS), acute renal failure, pulmonary embolism, diabetes mellitus and urinary retention. The discharge Minimum Data Set assessment dated [DATE] identified Resident #1 was independent in making decisions regarding tasks of daily life and required extensive assistance for bed mobility, transfer, and toilet use. A physician's order dated 6/9/23 directed to draw blood work Basic Metabolic Panel (BMP) and Complete Blood Count (CBC)) weekly, to monitor vital signs and intake and output starting from admission every shift for three (3) days. The Resident Care Plan dated 6/10/23 identified Resident #1 had been re-hospitalized and had a medical condition that was precarious with recent hospitalization due to acute renal failure. Resident #1 was also at risk for cardiovascular disease, on a diuretic, and was at risk for cardiac issues and dehydration. Interventions included monitoring oxygen saturation levels, vital signs, intake and output as ordered or per policy, to notify the physician and/or Advanced Practice Registered Nurse of any changes and watch for and report any renal or respiratory problems. The laboratory CBC test results dated 6/14/23 at 12:43 PM identified the Nursing Supervisor, Registered Nurse (RN) #1, had initialed the laboratory results and physician's review on 6/14/23. The bloodwork results identified the Blood Urea Nitrogen (BUN) level was 44 milligrams per deciliter (mg/dl) (normal range was 8-21), the Creatinine level was 1.6 mg/dl (normal range is 0.4-1.1) and the previous BUN level on 6/9/23 was 27 mg/dl and Creatinine was 0.7mg/dl. A physician's order dated 6/14/23 directed to administer Iron supplement by mouth two (2) times a day for anemia for fourteen (14) days and to draw a CBC and BMP bloodwork in one (1) week. The nursing situation, background, assessment, and recommendation (SBAR) note dated 6/15/23 at 4:53 PM identified Resident #1 had increased bilateral leg edema, increased pain, increased BUN and Creatinine levels with notification to the attending physician, MD #1, at 4:45PM. MD #1 directed Resident #1 to be transferred to the hospital emergency department for evaluation. Vital signs recorded temperature 97.6, blood pressure 128/72, heart rate 72 and respiratory rate 20. Interview with MD #1 on 6/29/23 at 9:30 AM identified that on 6/14/23 as per his routine, Resident #1's CBC results were faxed to him at his office, he reviewed the results and wrote for Resident #1 to begin an iron supplement, to repeat the labs in one (1) week, and he initialed the CBC results and faxed them back to the facility. MD #1 indicated this was the established process for his lab result reviews as routine lab results come back to the facility in the afternoon, and he normally rounds in the morning. MD #1 identified initialing of the lab results indicated his review and was intended to be kept in the resident's paper clinical record as documentation of his review. MD #1 identified he never received Resident #1's BMP faxed results on 6/14/23 and when he rounded on 6/15/23 in the morning, he did not see Resident #1's chart flagged for his review. MD #1 stated if the chart was in the rack and flagged, he would have seen Resident #1 at that time. MD #1 identified based on Resident #1's complex condition, the change in the BUN and creatinine was significant and could have indicated for example heart failure, or possible clot formation. MD #1 identified had he seen Resident #1 on rounds on 6/15/23 and saw the note the family had increased concerns, he would have transferred Resident #1 to the hospital at that time. MD #1 identified Resident #1's treatment was delayed by at least six (6) hours. Interview and review of the clinical record with the Director of Nurses (DON) on 6/29/23 at 10:20 AM identified when a resident's routine laboratory results are received by the nursing staff, the nurse will fax the lab results to MD #1, which is normally done in the afternoon and was the responsibility of the evening shift RN. The DON indicated after MD #1 reviewed the lab results, he would initial the faxed lab results and then the initialed results would be faxed back to the facility to place in the resident's clinical record. The DON identified the nurse who received the faxed initialed lab results would review the report and enter any orders that may have been requested by MD #1 after his review. The DON indicated this has been the process since she has been at the facility. The DON identified the 6/14/23 BMP lab results lacked MD #1s initials and a sign off by a nursing staff member and RN #1 was responsible to fax Resident #1's lab results to MD #1 on 6/14/23. The DON identified she did not know why RN #1 did not question why the CBC was initialed by MD #1 but not the BMP. The DON explained the BMP results were elevated, indicating a change in Resident #1's condition and she would have expected that RN #1 would have contacted MD #1 to clarify that he had seen all of Resident #1's lab results. The DON identified that the process for a nurse to inform MD #1 a resident needed to be seen on rounds would be to flag and place the record in the rack so MD #1 would know to see the resident. The DON stated when she worked on 6/15/23 on the evening shift, the family had expressed concern to her about Resident #1's lab results and increased complaints of pain, so she went to Resident #1's chart and saw a note on the front of the chart that stated the family had requested MD #1 to call and the flagged 6/14/23 CBC results. The DON identified the 6/14/23 BMP results were filed in Resident #1's chart, the chart was in the rack and flagged appropriately for MD #1 so that he would know to see Resident #1 on rounds on 6/16/23. The DON stated she contacted MD #1 at approximately 4:30 PM on 6/15/23, who identified he did not see Resident #1 when he had rounded in the morning as the chart was not placed in his chart area and he was unaware the BUN and Creatinine were elevated or the family had requested him to contact them. The DON indicated MD #1 then directed her to transfer Resident #1 to the hospital for an evaluation. Interview with RN #1 on 6/29/23 at 11:30 AM identified that she did fax Resident #1's CBC and BMP results to MD #1 in the afternoon on 6/14/23 and she entered the orders in Resident #1's chart as directed by the notation on the CBC results. RN #1 indicated she believed MD #1 had seen the BMP results as MD #1 ordered a repeat of the CBC and BMP in one (1) week in his notation on the CBC results. RN #1 identified that she had not covered the Nursing Supervisor role often as she was the Infection Control Nurse. RN #1 identified she did not realize if MD #1 did not initial both pages that it could have indicated MD #1 did not see the BMP lab results. RN #1 stated she was not alarmed by the increased BUN and creatinine levels as she believed Resident #1 had similar results when he/she was hospitalized and contacting MD #1 directly was not necessary. RN #1 identified the family had expressed concern over the lab results, requested MD #1 call them after his rounds on the next day and she placed a note on Resident #1's chart for MD #1 to call the family and flagged the record so that MD #1 would see the Resident when he rounded in the morning of 6/15/23. RN #1 identified she did not know why MD #1 did not see the flagged chart or note on Resident #1's chart. The hospital discharge summary dated 6/20/23 at 4:18 PM identified a CT scan showed bilateral hydronephroureter (dilation of the upper urinary tract) with a concern for bladder outlet obstruction, Resident #1's presentation was most likely acute kidney injury secondary to postrenal etiology and obstructive uropathy, a foley catheter (catheter to drain urine) was placed and drained 2200 cubic centimeters (ccs) of urine with labs returning to Resident #1's baseline. The facility policy, Change in Resident Condition, in part directs, to notify the Resident's physician of any significant change in condition.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents reviewed for abuse, (Resident #2), the facility failed to report and investigate resident concerns of alleged abuse/neglect. The findings include: Resident #2 had diagnoses that included malignant neoplasm of ovary (cancer), diverticulitis, spinal stenosis, and generalized muscle weakness. The annual MDS dated [DATE] identified Resident #2 had no cognitive impairment, was frequently incontinent of urine and required an extensive assist of one staff for toileting, personal hygiene, and dressing. A care plan dated 5/2/23 identified that Resident #2 was often incontinent of bladder and occasionally stool with interventions that included to encourage and offer toileting as needed and to wear a brief for dignity. The care plan further identified Resident #2 refused/choose not to accept incontinent skin care on the 11:00 PM - 7:00 AM shift with interventions included education provided by staff related to the risks of not having skin care on the 11:00 PM - 7:00 AM shift. Interview with Resident #2 on 5/16/23 at 9:45 AM identified about a month ago he/she was placed into bed for the night and his/her brief was not changed until around 11:00 AM the next morning (approximately 14 hours later). Resident #2 identified his/her brief was wet with urine, and when h/she asked to be changed, a NA raised her voice and yelled at Resident #2 I have so many other patients, you're not the only one. Resident #2 identified he/she told the nurse that he/she did not want that NA taking care of him/her anymore. Interview with NA #1 on 5/17/23 at 12:08 PM identified Resident #2 told her about an incident with NA #3 where NA #3 yelled at Resident #2 and told him/her that he/she was not the only person here. NA #1 identified Resident #2 had already reported it to the nurse, therefore she did not. Interview with LPN #2 on 5/18/23 at 12:01 identified she was aware of the incident that happened with Resident #2 but could not remember when it happened. She identified she came into Resident #2 room and the resident was upset that he/she was not out of bed until 11:00 AM (normally out of bed around 8:30/9:00 AM). She identified NA #3 was abrupt with his/her care and Resident #2 let NA #3 know he/she was upset, and NA #3 responded defensively you're not the only person I take care of, and Resident #2 told NA #3 not to take care of him/her anymore. LPN #2 further identified she notified RN #3, the RN supervisor, and asked her if there was anything else she needed to do. She identified RN #3 told her to just tell NA #3 not to care of Resident #2 anymore. Interview with RN #3 on 5/23/23 at 12:48 PM identified she does not remember a situation happening with Resident #2 not being changed for a long period of time and refusal for NA #3 to care for him/her. She identified if she was aware NA #3 yelled at Resident #2 and/or was left soiled for a long period of time, she would immediately report it to the DNS. Attempts to interview NA#3 were unsuccessful. Interview with the DNS on 5/16/23 at 10:25 AM identified she was not aware of Resident #2's concerns with treatment by NA #3 and being left in bed soiled for approximately 14 hours, and NA # 1 and LPN #2 should have reported Resident #2's concerns. She further identified she would expect to be notified if a resident is refusing care from a particular NA. Review of the abuse/resident policy directed abuse or mistreatment of any kind toward a resident is strictly prohibited. Allegations of abuse, by any individual (staff, family, visitor, resident) toward a resident must be reported immediately to a facility supervisor. All allegations will be thoroughly investigated and acted upon according to the policy. It further directed an A &I will be completed for each resident involved, to document a description of the incident in each resident's nursing notes and to contact the Administrator and the DNS.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents reviewed for activities of daily living, (Resident #4), the facility failed to provide a resident weekly shower. The findings include: Resident #4 had diagnoses that included hemiplegia (paralysis of left side), malignant neoplasm of head, neck and face, and generalized muscle weakness. The care plan dated 10/21/22 identified Resident #4 needed assistance with activities of daily living (ADL's) with interventions that included to assist Resident #4 as needed to meet toileting needs, incontinent care per policy and assist as needed due to cognitive status Resident #4 may fluctuate in his/her ability to perform ADL's. A physician's order dated 4/1/23 directed body audit on shower days by licensed nurse weekly on Wednesdays 3-11 (shower to be given on Wednesdays the 3:00 PM to 11:00 PM shift). The quarterly MDS dated [DATE] identified Resident #4 had no impairments in cognition, was an extensive assist of one staff for dressing and personal hygiene, total dependence on one staff for bathing and the resident always incontinent of bowel and bladder. Review of Resident #4's shower/bath flowsheet dated April 2023 identified Resident #4 had a documented shower on 4/4/23 (total dependence with one staff assistance). Resident #4 did not have a documented shower until 4/25/23 (20 days later). Interview with NA #7 (7:00 AM to 11:00 PM NA on 4/12/23, Resident #4's scheduled shower day) on 5/19/23 at 12:48 PM identified he had never showered Resident #4 before. Interview with NA #8 (7:00 AM - 3:00 PM NA on 4/19/23, Resident #4's scheduled shower day) on 5/19/23 at 12:50 PM identified she did not shower Resident #4 because she thought Resident #4's showers were scheduled on Tuesdays during the 3:00 PM - 11:00 PM shift. Interview with the DNS on 5/17/23 at 3:00 PM identified Resident #4's family members had a complaint about Resident #4 not receiving his/her scheduled showers. The DNS identified she changed Resident #4's shower schedule from Wednesdays during the 3:00 PM - 11:00 PM to Tuesdays on the 7:00 AM - 3:00 PM shift. She identified she did not change the physician order to reflect the change in Resident #4's shower schedule. Review of the bathing/shower policy directed that each resident will be offered a full bath/shower at least weekly.

Based on tour of the Dietary Department and staff interview, the facility failed to ensure the kitchen and equipment was maintained in a sanitary manner. The findings include: Tour of the Dietary Department on 3/1/23 at 10:30 AM with the Dietary Manager identified the following: a. The window sill above the 3 bay pot sink was noted to have a heavy accumulation of black crumb like material. The 2 water faucets of the 3 bay sink were in the off position, but dripping water. b. The wall tile below the airconditioner was noted with a heavy accumulation of dirt, drip marks, and grime. c. The kitchen floor was covered with debris, the tile coving perimeter around the entire kitchen was noted with a heavy accumulation of dust, grime and debris. d. The area above the coffee machine was observed with duct tape around the pipes coming out of the wall. e. A 5 tier black metal cart with clean metal mixing bowls on the shelves was observed to be soiled with a heavy accumulation of grime, dust and debris. f. A 4 tier metal rack containing clean coffee dispensers contained crumbs, dust and grime. g. A 4 tiered metal rack shelving unit, which contained dirty pots was observed to be soiled with a heavy accumulation of grime, dust and debris. The soiled metal cart was positioned adjacent to the clean drink cart. h. The 6 drink carts were set up with clean paper napkins, creamers, condiments, mugs, and cups, and were noted to be heavily soiled with grime, debris, and dust. The stack of paper napkins on the end cart were brown stained. i. The 6 overhead fluorescent lights were noted with a heavy accumulation of dust visible coming out from the top and around the upper frame. The light over the bread cart also had an approximate 8 inch by 4 inch spider like crack. j. A black self closing plastic garbage bin located adjacent to the eye station/hand wash station was noted with a heavy build up of a whitish film around the sides. k. The window sill in the dry storage room was noted with a heavy accumulation of dust/debris. l. The dry storage room was observed to contain an opened 10 lb bag that was 1/2 full each of penne, egg noodles, shells, and elbows, that was not labeled/dated when opened. Additionally, 4 clear plastic bags of chocolate cream cookies was dated 2/11. The Director stated 2/11 indicated the open date, but there was no expiration date because the cookies were removed from the original package. m. The floor of the freezer in the dry storage room was noted to contain boxes of biscuits, breads/bagels, frozen fruit, puffed pastry, high calorie ice cream, etc was also observed to be soiled with debris,crumbs and a frozen birthday cake belonging to the Director of Food Service. There was a white, linty film on the inside door and the outside doors were noted to be soiled with an oily substance. n. The dry storage area walls contained drip markings. o. The Dietary Storage room (located in the basement) was noted to have a freezer, whose floor was soiled with debris. p. The Dietary Storage room's (located in the basement) floor was littered with debris, dust especially where the floor meets the wall. q. The ceiling tile in the Dietary Storage room (located in the basement) surrounding the fire indicator was noted to have a brown halo type stain. Interview with Dietary Manager at that time identified that although there was a cleaning schedule for the metal carts, the carts were not cleaned last week. He further identified that he previously did not identify the soiled areas but since it was brought to his attention, he could see the soiling. Additionally, the Dietary Manager identified that for the Dietary Storage room located in the basement, Dietary takes out the trash and Maintenance/Housekeeping was responsible for cleaning of the floors.

Based on clinical record review, review of facility documentation, review of facility policy and interviews for two of six residents, (Resident #256 and #606), reviewed for accidents, the facility failed to ensure care was provided safely to prevent an accident with injury, and/or interventions were in place to prevent a fall. The findings included: 1. Resident #256 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Provide assist of two (2) people. An admission evaluation dated 4/5/18 indicated Resident #256 had bruising on the right front shoulder, left front shoulder, right front knee, left front knee, and right antecubital space. He/she was non-weight bearing of the upper extremities, a two person assist for positioning, had pain especially with movement secondary to a fall down the stairs, was able to understand, and was oriented to person, place, and time, and his/her speech was clear. An occupational therapy evaluation note dated 4/5/18 indicated Resident #256 was totally dependent for Activities of Daily Living (ADLs) secondary to bilateral upper extremity non-weight bearing. The resident was a maximum assist for bed mobility. A resident care plan dated 4/6/18 identified a problem with ADLs and falls. Interventions included assist of 2 for transfers and ambulation. Assist with toileting, bathing, grooming, dressing, and mouth care. Encourage transfer and change of positions to be done slowly, and encourage the use of handrails or assistive device. An individualized resident assignment indicated Resident #256 was alert and oriented, was not to be rolled side-to-side, do not pull on shoulders, and assist of 2 for mobility. A nurse's note dated 4/6/18 at 8:15 AM indicated Resident #256 had a new pain in his/her right wrist. The right wrist was warm, slightly reddened, and tender to movement and touch. The Advanced Practice Registered Nurse (APRN) was notified and an x-ray was ordered. An APRN note dated 4/6/18 indicated Resident # 256 had right wrist [MEDICAL CONDITION], decreased range of motion, and pain. The resident had hit his/her wrist on the side-rail. X-rays were pending. The plan noted the resident was to attend an orthopedic appointment 4/6/18. An APRN order dated 4/6/18 directed to increase [MEDICATION NAME] from every 6 hours for pain to every 4 hours for pain x 1 week then reevaluate, ice to the right wrist for 20 minutes on and 20 minutes off, three times a day and as needed for 5 days then reevaluate. A portable x-ray report of the right wrist dated 4/6/18 indicated no fracture and/or dislocation was seen. An orthopedic consult dated 4/6/18 indicated the resident struck his/her wrist against the side of the bed. The right wrist revealed 1-2+ swelling with slight [DIAGNOSES REDACTED]. There was distinct pain on palpation to the distal radius with painful range of motion in all directions. X-rays of the wrist today revealed a nondisplaced radial styloid fracture with considerable [MEDICAL CONDITION] changes noted. The consult note indicated to apply a thumb spica splint to the right wrist at all times and follow-up in 3 weeks. Review of a reportable event form and investigation dated 4/6/18 indicated Resident #256 reported that Nurse Aide #6 was rough when providing care on 4/6/18 at 6:30 AM. The resident complained of right wrist pain. A documented interview with Resident #256 dated 4/6/18 indicated Resident #256 indicated Nurse Aide #6 was rough with him/her during care and bumped his/her wrist on the side rail. The resident informed Nurse Aide #6 that he/she was hurting him/her and Nurse Aide #6 indicated he/she knew. A subsequent interview with Resident #256 indicated Nurse Aide #6 did not mean to hurt him/her and it was not intentional. A documented interview with Nurse Aide # 6 indicated he/she knew Resident # 256's wrist was bumped, but did not think anything happened (not significant). A review of a reportable event and investigation dated 4/6/18 and interview on 1/14/19 at 1:00 PM with Registered Nurse (RN) #1 indicated he/she would have expected 2 people to assist with Resident #256's care if that is what was required by the assessment and/or physician's orders [REDACTED]. An interview on 1/14/19 at 1:10 PM with Nurse Aide #5 indicated he/she was not asked to assist in Resident #256's care at any time the night of 4/6/18. An interview on 1/14/19 at 2:10 PM with Occupational Therapist (OT) #1 indicated he/she evaluated Resident #256 on 4/5/18 and unless he/she changed the resident's status for assistance (assist of 2) that was ordered by the Physician on 4/4/18, the resident would have required assist of 2 for bed mobility on 4/6/18. He/she was unable to provide documentation that Resident #256's status of assist of 2 was changed after his/her evaluation on 4/5/18, therefore Resident #256 should have been provided with assist of 2 people during care. Attempts to contact nurse aide # 6 were unsuccessful. 2. Resident #606's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #606 with severe impairment in cognition, required limited assistance of one staff for transfer, locomotion in room, and toilet use, was not steady, but able to stabilize without staff assistance, and had two recent falls. The care plan for fall risks indicated multiple risk factors such as: impaired balance, unsteady gait with intervention which included to ask and wait for staff assistance for transfers and/or toileting. Additional care plan for ADLs included an intervention of assist to bathroom throughout the day. Physician's monthly orders dated (MONTH) (YEAR) directed to transfer and ambulate Resident #606 with assist of one with rolling walker. The fall risk assessment dated [DATE] identified Resident #606 with score of 9 indicating no risk of falling. Nursing note dated 4/9/18 identified that Resident #606 was observed on the floor of the bathroom, with pain and shortening of the left hip observed. Resident #606 was transferred to the hospital and was admitted with a [DIAGNOSES REDACTED]. Facility investigation identified Nurse Aide (NA) #8 took Resident #606 to the bathroom, Resident #606 stated he/she wanted to have some privacy, Resident #606 shut the door and two seconds later he/she fell down while NA #8 was still in his/her room at the doorway. Interview with NA #8 on 1/14/19 at 11:30 am indicated he/she brought Resident #606 to the bathroom and closed the door so that it was cracked a little open, and it was usual for resident to be left alone in bathroom if door was cracked. In-service education provided to NA # 8 on 4/12/18 instructed to stay with a resident, (even in the bathroom), who is assist of one. Interview and review of the facility documentation with current Director of Nursing Services (DNS) on 1/15/19 at 10:00 indicated that Resident # 606 was an assist of one, and assist of one is physically assisting that person, staying with the person. Facility-wide staff education, date 4/13/18, indicated, A resident who requires assistance to get to the bathroom, must not be left on the toilet alone. These residents require direct supervision at all times during toileting to keep them safe from loss of balance, or attempts to stand independently. Facility policy for falls did not include assistance with toileting activities and the facility does not have a specific toileting policy.

Based on clinical record review, facility documentation, and interviews for 1 of 3 residents reviewed for pain management (Resident #2), the facility failed to ensure that pain management was provided consistent with the comprehensive person-centered care plan and physician orders. The findings include: Resident #2 was admitted to the facility on [DATE] from an acute care facility with [DIAGNOSES REDACTED]. A nursing admission evaluation dated 10/28/16 identified that the resident was alert and oriented, required extensive assistance with Activities of Daily Living (ADL's), and had moderate pain all the time in his/her abdomen. A Resident Care Plan (RCP) dated 10/28/16 identified that the resident had pain with interventions to administer pain medication as ordered. Review of the Medication Administration Record [REDACTED]. admission orders [REDACTED]. Review of a nurse's note written by Licensed Practical Nurse (LPN) #3 on 10/29/16 identified that the resident had complained of increased pain, the physician was notified and directed to have the [MEDICATION NAME] changed to a scheduled dose. Review of physician order [REDACTED]. Review of a nurse's note dated 10/30/16 written by LPN#3 identified that the resident continued to complain of increased pain, with a rating of 8 out of 10. The physician was notified and the [MEDICATION NAME] was increased to 6 mg every four hours around the clock. Further review of physician's orders [REDACTED]. Review of the October 2016 MAR indicated [REDACTED]. Review of the MAR for 10/30/16 identified that the resident received [MEDICATION NAME] 6 mg at 9:00 AM, 1:00 PM , 5:00 PM , 9:00 PM , and on 10/31/ 16 at 1:00AM , 5:00AM, and 9:00 AM. Interview of the review of the [MEDICATION NAME] controlled drug disposition form with the Director of Nursing Services (DNS) on 1/11/17 at 12:00 PM for Resident #2 identified that the form lacked [MEDICATION NAME] doses signed out of the narcotic disposition log for 10/29/16 at 5:00 PM and 9:00 PM, and on 10/30/16 for 1:00 AM, 5:00 AM and 9:00 AM, and 1:00 PM doses. The DNS further identified that he/she had checked the pyxis machine, where extra medication would be stored if they were not available in the medication cart, and there were no doses of [MEDICATION NAME] signed out for Resident #2 on 10/29/16 and/or 10/30/16. The DNS further identified that if the [MEDICATION NAME] was not signed in the narcotic drug disposition log and/or Pyxis, the resident most likely did not receive the [MEDICATION NAME] doses that were missing from the narcotic disposition log (6 doses), although most were signed off on the MAR indicated [REDACTED] Interview with LPN#3 who was Resident #2's charge nurse on 10/29/16 on the 3:00 -11:00 PM shift on 10/30/16 and the 7:00 AM to 3:00 PM shift identified that he/she did not recall Resident #2. LPN #3 further stated if he/she had administered the [MEDICATION NAME] 6 mg scheduled for 5:00 PM and 9:00 PM on 10/29/16, and the 9:00 AM and 1:00 PM doses on 10/30/16, it would have been identified on the narcotic disposition log and/or documented on the form that is used when removing medication from the Pyxis. LPN #3 was unable to explain the omission. Further, Resident #2 continued to report pain as an 8 out of 10 (strong pain) 10/28-10/30/13 however, was not provided the benefit of pain medication. Review of the administration of medication policy identified that the licensed nurse shall administer medication per the facility policy and/or standards of practice. Review of the pain management policy identified that the facility will provide the optimum level of comfort for each resident.

Based on clinical record review, facility documentation, and interviews for 1 of 3 residents reviewed for pain management (Resident #2), the facility failed to ensure a resident with pain was medicated in accordance with physician orders. The findings include: Resident #2 was admitted to the facility on [DATE] from an acute care facility with [DIAGNOSES REDACTED]. A nursing admission evaluation dated 10/28/16 identified that the resident was alert and oriented, required extensive assistance with Activities of Daily Living (ADL's), and had moderate pain all the time in his/her abdomen. A Resident Care Plan (RCP) dated 10/28/16 identified that the resident had pain with interventions to administer pain medication as ordered. Review of the Medication Administration Record [REDACTED]. admission orders [REDACTED]. Review of a nurse's note written by Licensed Practical Nurse (LPN) #3 on 10/29/16 identified that the resident had complained of increased pain, the physician was notified and directed to have the [MEDICATION NAME] changed to a scheduled dose. Review of physician order [REDACTED]. Review of a nurse's note dated 10/30/16 written by LPN#3 identified that the resident continued to complain of increased pain, with a rating of 8 out of 10. The physician was notified and the [MEDICATION NAME] was increased to 6 mg every four hours around the clock. Further review of physician's orders [REDACTED]. Review of the October 2016 MAR indicated [REDACTED]. Review of the MAR for 10/30/16 identified that the resident received [MEDICATION NAME] 6 mg at 9:00 AM, 1:00 PM , 5:00 PM , 9:00 PM , and on 10/31/ 16 at 1:00AM , 5:00AM, and 9:00 AM. Interview of the review of the [MEDICATION NAME] controlled drug disposition form with the Director of Nursing Services (DNS) on 1/11/17 at 12:00 PM for Resident #2 identified that the form lacked [MEDICATION NAME] doses signed out of the narcotic disposition log for 10/29/16 at 5:00 PM and 9:00 PM, and on 10/30/16 for 1:00 AM, 5:00 AM and 9:00 AM, and 1:00 PM doses. The DNS further identified that he/she had checked the Pyxis machine, where extra medication would be stored if they were not available in the medication cart, and there were no doses of [MEDICATION NAME] signed out for Resident #2 on 10/29/16 and/or 10/30/16. The DNS further identified that if the [MEDICATION NAME] was not signed in the narcotic drug disposition log and/or Pyxis, the resident most likely did not receive the [MEDICATION NAME] doses that were missing from the narcotic disposition log (6 doses), although most were signed off on the MAR indicated [REDACTED] Interview with LPN#3 who was Resident #2's charge nurse on 10/29/16 on the 3:00 -11:00 PM shift on 10/30/16 and the 7:00 AM to 3:00 PM shift identified that he/she did not recall Resident #2. LPN #3 further stated if he/she had administered the [MEDICATION NAME] 6 mg scheduled for 5:00 PM and 9:00 PM on 10/29/16, and the 9:00 AM and 1:00 PM doses on 10/30/16, it would have been identified on the narcotic disposition log and/or documented on the form that is used when removing medication from the Pyxis. LPN #3 was unable to explain the omission. Review of the administration of medication policy identified that the licensed nurse shall administer medication per the facility policy and/or standards of practice. Review of the pain management policy identified that the facility will provide the optimum level of comfort for each resident.

Based on clinical record review, facility documentation, and interviews, for 1 of 8 residents reviewed for food allergens (Resident #3), the facility failed to ensure the resident received food products that did not contain allergens. The findings include: Resident #3 had [DIAGNOSES REDACTED]. A 30 day Minimum Data Set (MDS) assessment dated [DATE] identified that the resident was alert and oriented and required extensive assistance with Activities of Daily Living (ADL's). Review of a physician order [REDACTED].#3 had an allergy to shellfish and iodine. Review of a nurse's note dated 11/7/16 written by Registered Nurse (RN) #2, identified that Resident #3 had notified him/her that he/she had a shellfish allergy and had consumed shrimp, Resident #3 identified that he/she immediately stopped eating but noticed some difficulty swallowing. The physician was contacted and [MEDICATION NAME] and Solu-[MEDICATION NAME] (medications that can be used to manage an allergic reaction) were administered. Resident #3 ' s vital signs remained stable, lung sounds were clear, no labored breathing was noted and the resident was free from swelling. Review of a nurse ' s note dated 11/7/16 written by RN#3 identified that he/she was notified by the floor nurse that Resident #3 stated he/she was having an allergic reaction. Resident #3 was assessed and no respiratory distress, wheezing, flushing, swelling in mouth or tongue, and/or hives were noted. The physician (MD#1) was notified immediately and [MEDICATION NAME] 25 milligrams (mg) and a Solu-[MEDICATION NAME] 40 mg injection was administered to Resident #3. One hour after medication administration, the resident was free from respiratory distress and/or trouble swallowing. Review of facility documentation dated 11/7/16 identified that Resident #3 had eaten shrimp in his/her soup and had a shellfish allergy, and identified he/she was having trouble swallowing. Interview with Nurse Aide (NA) #2 on 1/10/17 at 2:00 PM identified that he/she was the NA that delivered the soup to Resident #3 on 11/7/16. NA#2 stated that when he/she delivered Resident #3 ' s meal tray, he/she asked for soup. NA#2 identified that he/she obtained the soup from the server from the dietary department in the café, but could not recall who it was. NA#2 brought the soup to Resident#3, Resident #3 tasted the soup and notified NA#2 that there was shrimp in the soup. NA#2 stated he/she notified the nurse. NA#2 identified that he/she was not aware of the resident's shellfish allergy, nor what type of soup he/she had served Resident #3, but identified that he/she should be aware of allergies and what he/she is serving to the residents. Interview with Cook #1 on 1/10/17 at 1:00 PM identified that on 11/7/16 the soup of the day was shrimp gumbo, and he/she was serving in the café at lunch on 11/7/16, but did not recall giving NA#2 the soup. He/she further identified that if NA#2 had asked for soup, he/she would have checked the diet roster for allergies before giving NA #2 the soup. Interview with RN#3 on 1/10/17 at 1:15 PM identified he/she was notified by RN#2 on 11/7/16 that the resident had consumed shrimp and had a shellfish allergy. Resident #3 was immediately assessed and the physician was called and ordered [MEDICATION NAME] and Solu-[MEDICATION NAME], with-in a minute or so, the resident received the medication and the resident was monitored at the nurse ' s station with no further symptoms of an allergic reaction. Review of physician orders [REDACTED]. Review of a further physician's orders [REDACTED]. Attempts to interview MD#1 were unsuccessful. Interview with the Director of Nursing (DNS) on 1/10/17 at 2:00 PM identified that although the resident's allergy to shrimp was identified on the diet roster in the cafe, it appeared that the diet roster was not checked prior to providing Resident #3 with the shrimp gumbo. The DNS identified that all staff should check for allergies and diets before serving the residents any type of food. The DNS further identified that NA#2 was immediately educated on the proper protocol while serving the residents meals, and allergy bracelets were initiated to identify allergies, green bracelets for food allergies and red bracelets were for medication allergies. Interview with the Food Service Director on 1/10/17 at 2:00 PM identified that on 11/9/16 all dietary staff were educated to ensure to check diet and allergies before serving meals to the residents. Subsequent to surveyor inquiry on 1/10/17 further education was provided to all nursing staff in regards to ensuring to check the diet and allergies prior to serving resident meals. Review of the point of service policy identified that a diet roster list stating name, diet, and allergies, must be utilized while serving meals.

Based on clinical record review, facility documentation, interviews and observations, for 1 of 6 residents reviewed for therapeutic diets (Resident #1) the facility failed to ensure a consultation was completed after a diet was downgraded per facility policy, and/or that food was provided that met the criteria for a therapeutic diet. The findings include: Resident #1 had a [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident needed extensive assistance with Activities of Daily Living, supervision with eating and was receiving a mechanically altered diet. A resident care plan (RCP) dated 9/22/16 identified that the resident was at risk for aspiration due to advanced dementia with interventions that included to assist as needed with meals, to take small bites of food and to encourage the alteration of liquids and solids. Review of an individualized resident assignment card for Resident #1 identified that the resident feeds him/herself, in the room, with set-up and assistance as needed. Physician orders [REDACTED].#1 with a mechanical soft diet. Review of the supper menu on 10/23/16 identified that Ravioli, green beans, and toasted garlic bread were served. Review of a nurses note dated 10/23/16 documented by Registered Nurse (RN) #1 identified that he/she was called to Resident #1's unit by the charge nurse, Licensed Practical Nurse (LPN) #1 and notified that the resident was choking. Resident #1 was noted with circumoral cyanosis, and was unresponsive. The [MEDICATION NAME] maneuver was performed and after several minutes of abdominal thrusts the resident regurgitated small amounts of undigested food. The resident was noted to have a weak cough with a few shallow breaths noted. The nursing staff continued the [MEDICATION NAME] maneuver and finger sweeps, during this time all respirations ceased and no pulse was detected. The paramedics arrived on scene, applied a cardiac monitor which read asystole (indicates no electrical activity or blood flow to the heart). The resident had advanced directives in place for do not resuscitate (DNR) and do not intubate (DNI), no further interventions were performed and the resident was pronounced deceased at 6:06 PM. The physician and family were notified. RN#1 confirmed with staff that the resident was seated in bed at a 90 degree angle, and that the resident received the correct meal consistency. The resident was transferred to the funeral home at 8:40 PM. Review of facility documentation dated 10/23/16 identified that the resident was noted to be choking on food, the [MEDICATION NAME] maneuver was performed and the resident expired at 6:06 PM. Interview with Licensed Practical Nurse (LPN) #1 on 1/9/17 at 1:00 PM identified that he/she was Resident #1's charge nurse on the evening of 10/23/16 and had delivered the resident6 ' s dinner tray. The resident was noted to be sitting in bed at a 90 degree angle, the resident's meal was ravioli, green beans and a piece of garlic bread, all permitted on a mechanical soft diet. LPN#1 cut the ravioli and garlic bread into small pieces but noted that the garlic bread was a little difficult to cut with a knife, and a bit on the tough side, but bread was permitted on R#1's diet so he/she did not question the breads texture. LPN#1 identified that she returned to the resident's room to check on him/her a few minutes later and noted him/her to be choking, and immediately started the [MEDICATION NAME] maneuver and called for help. RN#1 arrived with the crash cart and suction machine, 911 was called and the [MEDICATION NAME], finger sweeps and suctioning were performed until the Paramedics arrived on scene. Upon arrival, the Paramedics applied the heart monitor, which read asystole. LPN#1 further identified that at one point during the [MEDICATION NAME] maneuver R#1 was turned on his/her side and expelled a piece of the Italian bread. Interview with RN#1 on 1/9/17 at 2:00 PM identified that he/she was the nursing supervisor on the evening of 10/23/16. RN#1 identified that he/she responded to Resident #1's room after an emergency call was placed on the overhead paging system. When he/she responded to Resident #1's room, he/she observed the resident to have circumoral cyanosis and appeared to be unresponsive, LPN#1 was performing the [MEDICATION NAME] maneuver. The emergency cart was brought to the room, suctioning and finger sweeps were administered and the [MEDICATION NAME] maneuver continued, and supplemental oxygen was applied. The resident had regurgitated some undigested food, but continued to be unresponsive. The paramedics arrived and placed a heart monitor on the resident which read asystole. He/she stated the resident had orders which indicated, Do not Resuscitate and no further resuscitation attempts were made and the resident was pronounced deceased . RN#1 further identified that the resident had received a mechanical soft diet that was cut properly, and the resident's bed was elevated to a 90 degree angle. Interview with LPN#2 on 1/10/17 at 5:00 PM identified that he/she responded to Resident#1 ' s room when an emergency page was announced over the intercom on 10/23/16 at supper time. He/she arrived at Resident #1's room and noted RN#1 to be performing the [MEDICATION NAME] maneuver. At this time he/she began to suction the resident and small pieces of ravioli and bread were suctioned out of Resident #1's mouth. LPN#2 further identified that after the incident he/she returned to his/her unit and told NA#1 what had happened with Resident #1. LPN # 2 stated that NA#1 informed him/her that he/she had removed the bread from R#13 ' s dinner because it was hard and he/she didn ' t believe the resident, who is a mechanical soft diet could tolerate the bread. Interview with Nurse Aide (NA)#1 on 1/10/16 at 5:05 PM identified the same evening that Resident #1 had choked, he/she delivered dinner to Resident #13, when he/she picked up the garlic bread to cut it for the resident, it was noted to be hard . At this time NA#1 determined that Resident #13 should not have the bread because he/she wasn't sure the resident could tolerate the bread on mechanical soft diet and removed it from the plate. Interview with the Speech Language Pathologist (SLP) on 1/9/16 at 11:00 AM identified that he/she had had Resident #1 on caseload until 10/19/16 to evaluate if the resident's diet could be upgraded due to a new pair of dentures. The SLP trialed the resident on a regular diet, but Resident #1 could not tolerate regular textured foods, because of chewing difficulties, but the resident tolerated a mechanical soft diet with no difficulty. The SLP identified that upon discharge from Speech Therapy on 10/19/16, the resident would remain on a mechanical soft diet. The SLP identified that the resident could be left alone at meal time, as long as the food was cut by staff, cueing could be provided by staff checking in on the resident during meal time. The SLP further identified that from the description given by LPN#1 and NA#1 of the garlic bread on 10/23/16, the resident should not have been served the garlic bread because anything that would be described as difficult to cut and hard would not be appropriate for a resident on a mechanical soft diet, the bread should be soft enough to cut easily with a fork or spoon. Interview with Cook Supervisor #1 (CS#1) on 1/10/17 at 2:00 PM identified that he/she had prepared the garlic bread on the evening of 10/23/16, the bread was baked that day, it started out raw, was then cooked in the oven and then cut into pieces. He/she stated that the bread was soft and doughy when it was placed in the steam table. CS#1 could not identify how the bread could become hard, unless it was sitting out for a while, because when the bread sits in the steam table it will usually become moist from the steam. Interview with the Food Service Director (FSD) on 1/10/17 at 2:00 PM identified that there is a meal breakdown kept on the steam table of the foods being served and what foods can be given to certain diets. Review of the breakdown for supper on 10/23/16 identified that mechanical soft diets can receive ravioli, green beans, and garlic bread, as long the garlic bread is soft. The FSD identified that the choking incident had happened before he had taken the FSD position, but was told by the previous food service director that the Italian bread loaf was not to be purchased and/or served anymore because of a choking incident, but did not give an explanation. The facility now purchases soft rolls instead of the Italian bread loaf. Interview with the Director of Nutritional Services on 1/10/17 at 12:00 PM identified that he/she was aware that the facility was no longer serving the Italian loaf bread, but had not heard there were any issues with the Italian loaf bread. Interview with the Director of Nursing on 1/10/17 at 2:00 PM identified that although he/she conducted an investigation into the choking incident with Resident #1, and determined the correct actions were taken and the resident received the correct diet, he/she had not heard that staff had noted the garlic bread to be hard on the evening of 10/23/16. Review of the mechanical soft diet protocol identified that the mechanical soft diet modifies the consistency of a regular diet when there is difficulty chewing, most foods allowed on a regular diet may be included with mechanical alterations.

Based on clinical record review, review of facility documentation, and interviews for two of four residents reviewed for accidents (Resident #158 and Resident #42), the facility failed to provide adequate supervision and/or assistive devices to prevent an accident and/or for one of two storage supply storage closets in the facility ensure the door was locked. The findings include: a. Resident # 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 12/9/14 Resident Care Plan (RCP) identified that the resident required a mechanical lift for transfers, did not ambulate. It futher identified that the resident required total care with all activities of daily living secondary to status [REDACTED]. A Reportable Event investigation dated 12/29/14 at 9:00 PM identifed that Resident # 42 fell from a Hoyer lift during a transfer resulting in injury to the left side of nose, ecchymotic area above the left orbital area. The interdisciplinary fall risk assessment dated [DATE] post fall identified that the witness discription of the event identified that the Hoyer lift hook unfastened and the resident fell to th floor. The interdisiplinary fall assessment dated [DATE] identified a resolution that included proper mechanical lift transfer competency of staff was indicated.The 12/29/14 investigative report identified a sign statement by Licensed Practical Nurse (LPN) # 4 he/she went into Resident # 42 's room after a nurse aide told him/her about a fall and found the resident lying on the flor on his/her left side with the left side of his/her nose cut and what appears to be an "egg" emerging on his/her left orbital area. Additionally, the patient complained of pain to the left shoulder. The resident was noted to be alert and nonverbal.The 12/29/14 statements from Nurse Aide # 7 and Nurse Aide # 8 and the 12/29/14, 3:00 PM - 11:00 PM nurse's note identified that while both nurse aides were transferring the resident with a Hoyer lift, one of the clips unhooked, causing one strap to be unhooked and the resident fell on to the floor. The nurse's note further identified that the resident was sent to the hospital for an evaluation. The investigation dated 12/29/14 identified that after extensive interviews with the staff who were assisting with the transfers, it was identifed that the mechanical lift straps unsnaped. A nurse's note dated 12/30/14 at 11:00 PM - 7:00 AM identified that the resident returned from the hospital with no new orders. The investigative report dated 12/30/14 identified that the Hoyer lift was checked for functioning on 12/30/14 and was found to be properly functioning. A 12/31/14 inservice education on full body mechanical lift was attended by NA # 7 and NA # 8. Interview on 2/11/15 at 2:30 PM with NA # 7 identified that he/she went in the room and the resident was all hooked up, the left side of the pad snapped and he was lowered to the floor. He/she further added that he/she did not believe it was hooked right. An interview on 2/11/15 identified that two NAs were transferring the resident when one of the clips unhooked. When asked what he/she would do differently NA # 8 responded that he/she would make sure the clips were on. b. R #158 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment identified clear speech, makes self understood, severely impaired vision, Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact range of 13-15), non-ambulatory, extensive assistance of 2 staff for transfers, limited assistance of 1 staff for locomotion on the unit and total dependence on 1 staff for locomotion off the unit; functional limitations in range of motion (ROM) of the upper and lower extremities with impairment on 1 side and occasional moderate pain. Corresponding Resident Care Plans (RCP) dated 03/13/14 identified problems of Activities of Daily Living (ADL), Bruising, Fall/Injury Risk (left sided [DIAGNOSES REDACTED] due to stroke, non-ambulatory), Skin Breakdown (decline in ability to move about independently due to stroke). Interventions included, in part, assist for toileting, identify and correct any environmental concerns, and transfer out of bed (OOB) to custom wheelchair (CWC) with seatbelt and hemi-tray for positioning. Care plans did not address ability to self-propel CWC, use of hemi-tray, and/or safety measures to protect the affected left arm and/or leg from injury. A Physical Therapy Plan of Care/Evaluation dated 04/10/14 identified a medical [DIAGNOSES REDACTED]. R #158 required assist with all activities. Underlying impairments included severely impaired safety awareness limited by the resident ' s inability to perform transfers, bed mobility, and gait. A facility conducted investigation completed 04/17/14 identified that on 04/08/14 at 1:00 PM R #158 the resident was self-propelling out of the dining room when Nurse Aide (NA) #3 pushed the resident ' s wheelchair the remainder of the way to his/her room. In a signed statement, NA #3 identified that, suddenly, the resident ' s arm started shaking and he/she began hysterically crying. After reporting the behavior to LPN #2, NA 3 and NA #4 prepared to put the resident to bed. As NA #3 lifted the resident ' s arm, he/she noted that the tip of his/her left thumb and the nail were missing. In a signed statement dated 04/08/14, LPN #2 identified that R #158 had stated that he/she had caught his/her left hand on something while self-propelling out of the lounge (dining area) after lunch. The investigation identified that R #158 had never had any issues with the lap-tray on the wheelchair. Review of an internal investigation documented by the former Assistant Director of Nursing (ADNS) and dated 04/09/14, identified that the resident was unaware of how the injury was sustained and the investigation was inconclusive. Blood was noted on the wheel of the chair. The resident had been noted to self-propel out of the dining room to the hallway. The Director of Therapy found the tip of the thumb and nail outside of the dining room. Interview with NA #3 on 02/13/15 at 2:30 PM identified that the facility had not provided specific training in caring for a resident with a stroke and did not recall receiving direction regarding individualized care for R #158. Review of the Resident ' s Care did not identify guidance to the NA for monitoring the position of the affected left arm or leg during dining or transport and/or correct positioning including removal and reapplication of the lap-tray and/or ability to self-propel. Review of the facility ' s Care Planning policy identified that an individualized plan of care will be developed for each resident. The care plan will guide caregivers to assist residents to achieve or maintain their highest practical level of well-being. The policy also identified that Care Plan will include a statement of the problem; reasonable and measurable goals; interventions to achieve these goals and disciplines responsible for carrying out the interventions. It will also be reflected on the nurse aide care cards. c. During the initial tour of the facility on 2/9/15 at 10:00AM an unlocked supply storage room on South Unit was noted by the surveyor. The closet door had a key pad on the door, however the door was unlocked. Interview with LPN#1 at the time of the observation identified that this supply closet should be locked. Observation inside the closet identified 45 disposable razors and grooming supplies ie. lotions , shampoo were also stored in bulk in the room. Interview during the time of the observation with Maintenance Staff#1 of the locked closet key pad, identified that the latch in the back of the door was turned open which undid the use of the key pad code. Further interview identified some one turned the latch and the need for the code was disengaged.

Based on clinical record review, observation, and staff interview and facility documentation for one of three sampled residents (Resident #83) reviewed for accidents and for one unit, the facility failed to provide supervision to prevent a fall and/or a hazard free environment. The findings include: 1. Resident # 83 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission assessment dated 6/13/13 that identified that Resident #83 had moderatly impaired cognitive skills for daily decision making and required extensive assist of two for bed mobility, transfers and toileting. The Admission Care Plan dated 6/7/13 identified that the resident required assist of two with transfers and ambulation. Review of a nurses note dated 6/9/13 at 2:15 AM, identified that the resident had been found on the floor by a NA and that the alarm did not go off. The note identified that a 8.5 x 7.0 bruise was noted to the left shoulder and the resident was placed on 15 minute checks for the remainder of the evening. The fall interventions added 6/9/13 identified 15 minute checks at hour of sleep and a physical therapy screen secondary to the fall. Review of the Nursing Notes dated from 6/9/13 through 6/17/13 identified the resident having a chair alarm and every 15 minutes checks in place. Nursing note dated 6/22/13 at 4:00 AM identified the supervisor had been called to the resident's room and the resident was found on the floor with the NA and the charge nurse in the room. The note identified the resident had been able to move all extremities. This nursing note failed to identify if a bed/chair alarm had been utilized. Review of the facility reportable event dated 6/22/13 identified the resident had an unwitnessed fall in attempt to go the bathroom and to keep the bed/chair alarm in place and anticipate needs. The 6/19/13 care plan identified the intervention for non skid socks. Nursing note dated 8/28/13 at 12:30 PM identified the resident had been noncompliant with two assist transfer and had fallen on his/her bottom sustaining a skin tear. The documentation failed to identify if the resident had been utilizing a the chair alarm. Review of the care plan identified the fall from transferring self with the intervention of an activity i.e. folding towels. Nursing note dated 9/8/13 at 1:00 PM identified that the resident had been given Trazadone at 1:15 am for agitation with minimal effect and continued yelling and screaming, had been assisted with toileting, and assisted to the wheelchair with the alarm. The note identified that the resident had been left unattended and had been found on the floor yelling for help. The documentation failed to identify if the chair alarm had been in place.Review of the care plan identified the 4:45 AM fall on 9/8/13 in the South dining room, with the interventions for every 15 minute checks at night. Review of the nursing note dated 9/24/13 at 11:30 PM identified that the resident had been found on the floor at the nursing station at 7:30 PM, hitting his/her head with a large hematoma noted on the forehead, with positive neuro signs and was transferred to the hospital. The documentation failed to identify if wheel chair alarm had had been in place. The note further identified that the hospital reported the CT scan showed a large left forehead hematoma, a large hematoma to the left shoulder and no fracture. Review of the care plan dated 9/26/13 identified the unwitnessed fall from the chair to the floor and the intervention for a PT evaluation for a tilt in space wheelchair. The nursing note dated 9/25/13 identified that the resident had arrived at 11:30 PM to the facility and that Trazadone had been given at 1:00 AM for increase yelling and screaming. The note further identified that the discharge instructions had been faxed to the physician and that the resident slept in the recliner chair with the chair alarm. Nursing note dated 9/25/13 on the 7:00 AM -3:00 PM shift identified that the resident had a large left eye hematoma and edema, eye swollen shut, and increase lethargy. The note identified that the physician had been called and the resident was sent to the hospital. Nursing note dated 3:00 PM-11:00 PM identified the resident had returned, had increased lethargy, and was placed in bed with bed alarm. Review of a CT scan dated 9/25/13 identified the questionable nondisplaced left nasal fracture. Review of physician's order dated 9/25/13 identified the order for Bactrim DS one tablet twice a day for 7 days. Interview with the Assistant Director of Nurses (ADNS) on 12/20/13 at 1:30 PM identified that the resident had been working with physical therapy on the first fall of 6/9/13. The ADNS identified that on 6/22/13 with the unwitnessed fall in the resident's bedroom, the bed/chair alarm had been kept in place and that nonskid socks had been added to the treatment plan. The ADNS identified that the witnessed fall on 8/28/13 had been in the lobby and that an activity such as folding towels had been added. He/she identified that on 9/8/13 the resident had become agitated during the night and from the recliner chair had been placed in the wheelchair and that the resident had propelled him/herself into the dining room where the unwitnessed fall had occurred. He/she identified that 15 minute checks had been put into place. He/she further identified that the fall on 9/24/13 in front of the nurse desk had been unwitnessed and a request for physical therapy evaluation had been for a wheelchair with a tray had been put inplace. The ADNS identified that he/she could not answer to the fact as to why there was no documentation to indicate if the bed/chair alarms had been in place for these falls. Review of the September 2013 medication and treatment kardex failed to identify the documentation of the bed/chair alarm. Interview with the ADNS on 12/23/13 at 10:45 AM identified that the nurses are to sign off in the treatment kardex that bed/chair alarm is checked. He/she identified that sometimes a physician's order is obtained and that it is written on the care cards for the NA to follow if the resident has a bed/chair alarm. Review of the care cards identified the documentation of the bed/chair alarm. He/she further identified that he/she was unsure if the facility had a policy for the bed/chair alarms. Review of the facility policy directed the documenting the placement and function of the alarm on the resident's treatment record. The facility failed to follow their policy. Review of the June, July and August treatment kardexes provided on 12/24/13 failed to identify the documentation ensuring that the bed/chair alarm had been checked per the facility policy. 2. Observation 12/16/13 at 10:00 AM identified that while Resident #3 was watching television in the Annex unit resident lounge, two wheelchair batteries were plugged into the wall charging. Interview with NA #7 on 12/16/13 at 10:05 am identified that the7-3 shift NA usually unplugs the batteries prior to allowing the residents to occupy the lounge. Interview with LPN #9 identified that he/she was unclear why the batteries were not unplugged while the resident was in the lounge. Interview with DNS on 12/19/13 at 2:00 PM identified that he/she was okay with the resident in the lounge while the batteries were charging. A review of the facility's policy indicated that the resident's electric wheelchair will be charged in a non-resident area at night as needed using appropriate battery and outlet.

Based on clinical record review and staff interview for one of four sampled residents with a history of falls (R# 159) the facility failed to provide the supervision necessary to prevent a fall with injury and/or failed to secured hazardous materials to ensure the safety of the residents. The findings include: 1. Resident #159 ' s [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident with short-term memory loss, extensive assistance with transfers, toilet use, and walking in room. A care plan dated 6/01/10 identified the resident at risk for falls related to a history of falls. Interventions included to apply bed alarm and provide a self-release belt with alarm in the wheelchair. However the care plan failed to reflect that the resident was not to be left alone in the bathroom until 7/17/10 after a fall with injury. A fall risk assessment dated [DATE] identified the resident as at risk for falling. A physician's orders [REDACTED]. A nurse ' s note dated 7/17/10 at 2:45 PM identified the resident was assisted into the bathroom by a nurse aide and instructed to ring for assistance when done. The resident attempted to get up and fell on to the floor hitting his/her head. The supervisor assessed the resident and no acute distress was noted. A subsequent nurse ' s note dated 7/17/10 at 7:00 PM identified the resident was unable to plant his/her left foot onto the floor. An x-ray was obtained and a fractured femur was identified. Interview with NA#3 on 9/08/10 at 2:46 PM identified that on 7/17/10 she transferred R #159 onto the toilet, placed the call bell in the resident's hand and instructed him/her to ring the call bell when he/she was done. NA #3 indicated at that time she went to help another resident and when she came back to assist R#159, he/she was already on the floor. NA #3 further indicated that she routinely left R #159 alone on the toilet and the resident would ring when he/she was done. However the resident did not ring for assistance on 7/17/10. Interview with RN # 2 on 9/08/10 at 3:00 PM identified that on 7/17/10 she assessed the resident after the fall and there were no signs or symptoms of injury. RN#2 indicated she did not document an assessment in the clinical record because LPN # 2 wrote in the nurse's note. RN#2 indicated she would not have expected R #159 to be left alone in the bathroom because he/she had a history of [REDACTED]. 2. Observation of equipment storage closets on the Annex, South-1 and North units closets were noted to be unlocked and had disposable razors stored in the closets. Interview with NA #9 on 9/08/10 at 11:50 AM identified that the razors are stored in a storage closet. Upon surveyor request NA#9 opened the storage closet and identified the disposable razors in a bin on the shelf. The door to the storage closet remained unlocked. Interview with NA#10 on 9/08/10 at 12:00 PM identified razors are stored in a storage closet. Upon surveyor request NA#10 opened the storage closet and identified the disposable razors in a bin on the shelf. The door to the storage closet had remained unlocked. Interview with the Director of Nursing (DNS) on 9/08/10 at 12:10 PM the DNS indicated that disposable razors were stored in the nurse aide storage closets on the units and the closets should remain locked.