Every finding on record at Apple Rehab Guilford

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #3) reviewed for abuse, the facility failed to ensure a resident was protected from mistreatment when Resident #1, with known intrusive and sexual behaviors was witnessed to touch Resident #3 inappropriately. The findings include:1. Resident #1's diagnoses included vascular dementia, adjustment disorder, and anxiety. 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 moderately impaired cognition and ambulated independently. The Resident Care Plan dated 8/11/2025 identified Resident #1 had a history of verbally abusive and sexually inappropriate behaviors (2/12, 6/21 and 12/8/2024). Interventions directed to monitor behaviors, attempt to redirect, remove from public areas when behavior is disruptive/unacceptable and psychiatric follow-up as needed. 2. Resident #3's diagnoses included dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a BIMS score of nine out of fifteen (9/15), indicative of moderately impaired cognition and ambulated independently. The Resident Care Plan dated 8/11/2025 identified Resident #3 had dementia. Interventions directed to provide reminders and consistent daily routines. A facility incident report and investigation dated 8/12/2025 identified Resident #1 was observed with his/her hand on Resident #3's chest area. The incident report was classified as a Class E. The facility plan of correction directed medication changes for and one-to-one (1:1) monitoring until psychiatric clearance. Although attempted, an interview with SPN #1 (LPN Student) was unable to be obtained during the survey. A written statement by SPN #1 dated 8/12/2025, without a specified timeframe, identified SPN #1 was coming from a nursing unit, when she saw Resident #1 with his/her hand under Resident #3's shirt, touching his/her upper chest area. SPN #1 directed Resident #1 to stop, moved Resident #3 in his/her wheelchair away from Resident #1 and notified the charge nurse. APRN #2 progress note dated 8/12/2025 at 1:34 PM identified Resident #1 was seen via telehealth platform for risk assessment and evaluation of impulsive/behavior after an alleged inappropriate sexual behavior on unit. Resident #1 was not at baseline and was making more bizarre impulsive comments. Presented with mild anxiety/hypomania during exam; answered all questions but had difficulty focusing and remaining on task, difficulty grasping seriousness of conversation, and joked intermittently. Thought content was disorganized and denied any memory of alleged incident though is grossly oriented to everything except situation. No signs/symptoms of psychosis, denied thoughts of wanting to harm self/others or make any physical contact with others. New orders for antipsychotics for behaviors. No imminent risk to self/others and directed to discontinue the 1:1 monitoring. Interview with APRN #1 on 10/16/2025 at 12:15 PM identified Resident #1required behaviors monitored by staff, and re-directed as needed for inappropriate behaviors. Interview with the DON on 10/16/2025 at 1:25 PM identified for the incident observed by SPN #1 on 8/12/2025 was inappropriate behavior. The DON stated the nursing staff should have been vigilant monitoring Resident #1's location and behaviors to prevent the incident. Interview failed to identify Resident #3 had the capacity to consent, and why the staff did not monitor Resident #1's location to prevent the incident. Review of the undated facility Abuse Policy and Procedure directed in part, sexual abuse was any form of sexual harassment, coercion, or assault, including unwanted touching between residents.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1 and #3) reviewed for abuse, the facility failed to report an allegation of abuse to the State Agency in a timely manner. The findings include: 1. Resident #1's diagnoses included vascular dementia, adjustment disorder, and anxiety. 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 moderately impaired cognition and ambulated independently. The Resident Care Plan dated 8/11/2025 identified Resident #1 had a history of verbally abusive and sexually inappropriate behaviors (2/12, 6/21 and 12/8/2024). Interventions directed to monitor behaviors, attempt to redirect, remove from public areas when behavior is disruptive/unacceptable and psychiatric follow-up as needed. 2. Resident #3's diagnoses included dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a BIMS score of nine out of fifteen (9/15), indicative of moderately impaired cognition and ambulated independently. The Resident Care Plan dated 8/11/2025 identified Resident #3 had dementia. Interventions directed to provide reminders and consistent daily routines. A facility incident report and investigation dated 8/12/2025 identified Resident #1 was observed with his/her hand on Resident #3's chest area. The incident report was classified as a Class E. The facility plan of correction directed medication changes for and one-to-one (1:1) monitoring until psychiatric clearance. Although attempted, an interview with SPN #1 (LPN Student) was unable to be obtained during the survey. A written statement by SPN #1 dated 8/12/2025, without a specified timeframe, identified SPN #1 was coming from a nursing unit, when she saw Resident #1 with his/her hand under Resident #3's shirt, touching his/her upper chest area. SPN #1 directed Resident #1 to stop, moved Resident #3 in his/her wheelchair away from Resident #1 and notified the charge nurse. Review of CT's Department of Health's FLIS Events Report Tracking System identified the facility failed to submit a reportable event to the State Agency for observed incident that occurred on 8/12/2025 between Resident #1 and Resident #3. Interview with the DON on 10/16/2025 at 1:25 PM identified the facility did not report the incident to the State Agency, as they determined to not meet the level of abuse. DON stated that since the event was witnessed, there was no intention of harm, no injuries, no signs of distress from Resident #3, and the families did not have any concerns. DON identified the facility classified the event as an Class E since the facility did not believe it met the qualifications of an alleged abuse. Review of the undated facility Abuse Policy and Procedure directed in part, sexual abuse was any form of sexual harassment, coercion, or assault, including unwanted touching between residents. The policy further directed, the DON or designee will notify the DPH (Department of Public Health), and local authorities as needed, and submit an online report to FLIS (Facility Licensing and Investigations Section) within two (2) hours of notification.

Based on review of facility documentation, facility policies, and interviews, the facility failed to ensure food temperatures were routinely monitored prior to food service. The findings include: The facility's Cooked Foods Temperature Chart identified food temperatures must be documented when the food item completes the cooking process; supper food items included soup, meat, puree meat, ground meat, potato/starch, puree starch, vegetable, puree vegetable, and other. Review of the Cooked Foods Temperature Charts dated 12/17/24 through 1/4/25 and 1/12/25 through 2/22/25 failed to identify supper temperatures were documented on the following dates: 12/18/24 only soup and meat temperatures were documented, 12/25/24, 12/27/24, 12/30/24, 12/31/24 1/3/25, 1/4/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/20/25, 1/24/25, and 1/30/25. The Cooked Foods Temperature Charts were not provided between 1/5/25 through 1/11/25. The facility's Meal Serving Temperature Chart identified serving temperatures must be taken no earlier than 10 minutes prior to meal service; supper food items included soup, meat, puree meat, ground meat, potato/starch, puree starch, vegetables, puree vegetable, salad, chilled dessert, milk, hot beverage and other. Review of the Meal Serving Temperature Charts dated 12/17/24 through 1/4/25 and 1/12/25 through 2/22/25 failed to identify supper temperatures were documented on the following dates: 12/16/24, 12/17/24, 12/18/24, 12/19/24, 12/20/24, 12/21/24, 12/22/24, 12/23/24, 12/25/24,12/26/24,12/27/24, 12/30/24, 12/31/24, 1/2/25, 1/3/25, 1/4/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/20/25, 1/23/25, 1/24/25, 1/27/25, 1/28/25, 1/30/25, and 2/1/25. The Meal Serving Temperature Charts were not provided between 1/5/25 through 1/11/25. Interview with the Night [NAME] (Cook #1) on 2/24/25 at 1:20 PM identified that food temperatures should be documented before being served to ensure the temperatures are safe so no residents get sick and to ensure hot food temperatures are maintained and not served cold. [NAME] #1 indicated that he always obtains temperatures of all the food items prior to service, but he has forgotten to write them down in the chart, sometimes. Interview with the Director of Dietary on 2/24/25 at 1:39 AM identified that the facility has 5 cooks, four are Servsafe certified, including [NAME] #1, and one new cook is scheduled for Servsafe in March. The Director of Dietary indicated that the cook is responsible to obtain and document food temperatures before food service, and she was aware that there was missing temperature documentation for supper food items; she has been educating the night cooks on the importance of documenting the food temperatures and the documentation has gotten better but remains a work in progress. Inservice education dated 2/24/25 identified education was provided to [NAME] #1 on the topic of documenting cooking temperatures, the procedure for taking temperatures, and reviewing the importance of logging daily temperatures for food. The Procedure for Taking Serving Temperatures policy directs the facility to establish the proper procedure for taking serving temperatures to assure all foods are served at the correct temperatures. The procedure includes measuring internal temperatures of food using a properly calibrated bimetal stem thermometer, recording the temperature on the Serving Food Temperature Chart if the temperature meets the guidelines in the second column, if the food does not meet the minimum/maximum temperature, continue the cooking or chilling process until the proper level is reached by rechecking the temperature periodically, serving temperatures should be taken when food is placed in steam table, no longer than 15 minutes before serving time. The Temperature Control During Food Preparation policy directs for the proper management of time and temperature during food preparation in order to minimize bacterial growth. Except during preparation, cooking, or cooling, food temperatures shall be maintained at 135 degrees Fahrenheit (F) or above or at 41degrees F or below.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Resident #33, 45, 70 and 85) the facility failed to provide care in accordance with professional standards of practice. For 3 of 3 residents, (Resident #33, 45 and 85), reviewed for accidents, the facility failed to ensure neurological assessments were completed according to the facility policy after the residents fell either without a witness or had a head strike, and for 1 of 6 residents (Resident #70) who were at risk for the development of pressure ulcers, the facility failed to ensure the LAL (low air loss) mattress was set according to the manufacturer recommendations, and failed to ensure the Braden Scale and the weekly body audits were completed per facility policy. The findings include: 1. Resident #33 was admitted to the facility in May 2019 with diagnoses that included Parkinson's disease, psychotic disorder with delusions and hallucinations, and repeated falls. A physician's order dated 7/12/24 directed the resident needed assistance of 1 person with a rolling walker for mobility and transfers. The care plan dated 7/16/24 identified Resident #33 was at risk for falls. Interventions included pain management review, a nightlight for adequate light at night, and to declutter the room. The quarterly MDS dated [DATE] identified Resident #33 had moderately impaired cognition, required maximum assistance with toileting, needed moderate assistance to ambulate 50 feet, and has had 2 or more falls with no injury and 2 or more falls with minor injuries such as skin tears or bruises since the prior assessment. a. A Reportable Event Form dated 9/24/24 at 4:30 PM identified Resident #33 was in his/her room picking up dirty clothes at the bottom of the closet when he/she slipped out of the wheelchair and onto the floor. No injuries were noted. Interview with the DNS on 2/25/25 at 9:59 AM identified after a resident has fallen an RN must do the assessment first before moving the resident. The DNS indicated that at the time of this fall Resident #33 had moderately impaired cognition and that the neurological assessment would have to be completed per the facility policy because a staff person did not witness the fall. The DNS indicated that the expectation was that the nurses would follow the neurological assessment policy and reviewing the accident and incident report the neurological assessments were not complete. b. A Reportable Event Form dated 10/11/24 at 11:15 AM identified Resident #33 was found on the floor in front of the recliner chair at the bedside. No injuries noted. Resident #33 indicated that he/she was reaching for the garbage can and slid off the recliner chair. The nurse's note dated 10/11/24 at 1:45 PM identified Resident #33 was found on the floor in front of his/her recliner chair. Neurological assessment within normal limits and initiated post fall vital signs and neurological checks and monitoring for 72 hours. Review of the Neurological checks form dated 10/11/24 at 1:45 PM identified the neurological assessment would include blood pressure, pulse, respirations, resident's level of consciousness, bilateral pupils if reactive or not, and strength of right and left extremities. The form required the neurological assessment to be completed every 15 minutes for the first hour after the fall, then every hour for 4 hours, every 4 hours for the next 24 hours, and every shift for 48 hours after that. The form identified the assessments were completed 6 out of the 20 required times. Staff did not complete 14 required neurological assessments. The interview with the DNS on 2/25/25 at 10:02 AM indicated that on 10/11/24 there was an unwitnessed fall, and the neurological assessment were started but not completed. The DNS indicated that the expectation was that the nurses would follow the neurological assessment policy and would have completed the assessments. c. A Reportable Event Form dated 12/1/24 at 6:30 PM identified Resident #33 was trying to get a hairbrush out from under the bed and slid out of the recliner chair. Resident #3 was noted to have a left knee abrasion, right knee discoloration, and right shoulder pain. The intervention was to educate the resident to call for assistance and staff not to use chuck pads on recliner. Review of the Neurological Checks form dated 12/1/24 at 6:30 PM identified 13 required neurological checks were not completed per the policy. Interview with the DNS on 2/25/25 9:59 AM identified for the unwitnessed fall on 12/1/24 the neurological assessments were started but not completed. The DNS indicated she would have expected them to be completed per policy. Interview with the DNS on 02/25/25 at 10:15 AM indicated that the expectation was the nurses would follow the neurological assessment policy after an unwitnessed fall with a resident that had moderately impaired cognition. The facility's Neurological Checks policy directs neurological checks to be instituted as a nursing measure following a head injury, TIA and seizure disorder. A neurological check flow sheet will be instituted by the nurse and shall include date and time of the assessment, level on consciousness, pupillary response, strength and sensation of the extremities, and vital signs. The checks will be completed as follows: a. Every 15 minutes for the first hour. b. Every hour for 4 hours. c. Every 4 hours for the next 24 hours. d. Every shift for 48 hours. 2. Resident #45 was admitted to the facility on [DATE] with diagnoses that included dementia, post-traumatic stress disorder, and history of falls. The annual MDS dated [DATE] identified Resident #45 had moderately impaired cognition, required setup assistance (helper assists only prior to or following an activity) with sitting to standing and walking 50 feet with two turns, was independent walking 10 feet, and had sustained two falls with no injury, two falls with injury, and no falls with major injury since the prior assessment. The care plan dated 5/22/24 identified Resident #45 required assistance with all ADL's and was non-adherent with assistance, at times. Interventions included assisting with transfers out of bed per the physician's order. Resident #45 was at risk of bruising and bleeding due to the use of anticoagulation medication. Interventions included reminding Resident #45 to use caution and to be aware of extremity positioning when transferring and ambulating. The care plan further identified Resident #45 was at risk for falls due to muscle weakness, dementia, and psychotropic medications, and was not adherent with transfer orders at times, increasing the risk for falls. Interventions included keeping commonly used articles within easy reach, offering music at bedtime to provide a soothing environment, and providing a well-lit, clutter free environment. The nurse's note dated 5/30/24 at 7:49 PM identified that Resident #45 sustained a witnessed fall at 8:25 PM; resident fell on buttocks and hit his/her head, denied headache, no visual disturbances at this time. Resident complained of right clavicle pain, no bruising, no abrasions, no lacerations, or skin tears were observed at this time. No external rotation observed to bilateral lower extremities; no unilateral lengthening observed to lower extremities. Resident is alert and oriented times 2 stated that he/she was trying to walk and fell ; the fall was witnessed by charge nurse who was in the room but wasn't able to get to the resident quick enough to prevent the fall. Resident observed to perform independent transfer from bed took a few steps toward the restroom without walker and fell ; the walker was observed near the window. Staff were educated to keep walker near the resident and within reach at all times. The resident was assisted back to bed, Tylenol was given for the complaint of pain, neurological checks were initiated per facility policy, and resident's family and on call APRN were notified with no new orders. The Reportable Event Form dated 5/30/24 identified Resident #45 had a witnessed fall at 8:25 PM in the bedroom. Resident #45 had gotten out of bed without assistance, took a few steps towards the bathroom, and fell on his/her buttocks, hitting the back of his/her head on the wall. Description of actions taken included neurological checks and vital sign monitoring per facility's protocol, Xray to the right clavicle, pain evaluation and management, change in activity status, PT/OT evaluation, sling to the right upper extremity, and orthopedic, psychiatry, and social services follow-up. Review of the facility's Accident and Investigation documentation and Resident #45's clinical record failed to identify documentation that neurological assessments were completed, per the facility's policy, following the witnessed fall with a head strike, on 5/30/24. Interview with the DNS on 02/25/25 at 8:44 AM identified that while she was not the DNS at the time of the incident, she would have expected neurological assessments to be completed by the charge nurse for 72 hours, per the facility policy, following a fall resulting in the resident hitting his/her head. The facility's Neurological Checks policy directs neurological checks to be instituted as a nursing measure following a head injury, TIA and seizure disorder. A neurological check flow sheet will be instituted by the nurse and shall include date and time of the assessment, level on consciousness, pupillary response, strength and sensation of the extremities, and vital signs. The checks will be completed as follows: a. Every 15 minutes for the first hour. b. Every hour for 4 hours. c. Every 4 hours for the next 24 hours. d. Every shift for 48 hours. The facility's Falls: Minimizing Risk of Injury policy directs that a status post-Accident and Incident (A&I) report will be completed and an interdisciplinary fall assessment in order to identify the potential causes of the fall. A status post A&I assessment and neurological checks will be completed on any resident that experiences an unwitnessed fall and is unable to accurately verbalize if he/she hit their head due to cognitive status or experienced any type of head injury. The post A&I assessment and neurological monitoring will be documented for 72 hours. 3. Resident #85 was admitted to the facility on [DATE] with diagnoses that included ataxic cerebral palsy, epilepsy, and history of falling. The quarterly MDS dated [DATE] identified Resident #85 had intact cognition, was always continent of bowel, frequently incontinent of bladder, required partial staff assistance with toileting and bathing, and supervision with transfers. The care plan dated 11/28/24 identified Resident #85 had a history of falls. Interventions included to notify the physician of pain and bruising, and to complete neurological checks per protocol. Review of the clinical record identified Resident #85 had unwitnessed fall on 12/22/24. A reportable event form dated 12/26/24 identified Resident #85 had a fall at 9:15 PM on that date. Resident #85 reported attempting to ambulate to the bathroom, losing balance, and falling but denied a head strike. The form was signed as completed by RN #6. A change of condition assessment note completed by RN #6 on 12/26/24 at 10:21 PM identified that Resident #85 had an unwitnessed fall with no injuries and denied a head strike. The note further identified that the on-call provider was notified, and treatment orders included to start neurological checks. Review of the clinical record failed to identify any post accident/incident assessment documentation related to Resident #85's fall on 12/26/24. Review of a neurological check documentation flowsheet dated 12/26/24 identified neurological checks were initiated at 9:15 PM. Further review identified neurological checks were completed for the following dates and times: 12/26/24 at 9:30 PM. 12/26/24 at 9:45 PM. 12/26/24 at 10:00 PM (15 minutes x 4). 12/26/24 at 11:00 PM. 12/27/24 at 12:00 AM. 12/27/24 at 1:00 AM. 12/27/24 at 2:00 AM (every hour x 4). 12/27/24 at 6:00 AM. 12/27/24 at 10:00 AM. 12/27/24 at 1:00 PM. 12/27/24 at 5:00 PM. 12/27/24 at 9:00 PM (every 4 hours x 5). A reportable event form dated 12/27/24 identified Resident #85 had a fall at 10:00 PM on that date. A nurse's note dated 12/27/24 at 10:03 PM by RN #6 identified Resident #85 had an unwitnessed fall. The note identified Resident #85 was observed on the floor sitting on his/her buttocks and that Resident #85 reported falling after an attempt to self-transfer. The note further identified Resident #85 sustained a linear scratch to the back of the right buttock, a superficial abrasion to the right top of the thigh measuring 15.5 inches in length, and a bruise above the left elbow measuring 6.0 cm x 5.0 cm. The note also identified RN #6 attempted to reach the on call provider regarding the fall but was unsuccessful. Review of the clinical record failed to identify any post accident/incident (A&I) assessments were initiated or that any neurological monitoring was initiated following the 12/27/24 fall at 10:00 PM. Review of a neurological check documentation flowsheet dated 12/26/24 identified a neurological check completed on 12/28/24 at 1:00 AM, approximately 3 hours after Resident #85's most recent fall on 12/27/24 at 10:00 PM. No other neurological checks were documented, with a handwritten note MLOA (medical leave of absence) written in the 12/28/24 3:00 PM - 11:00 PM shift assessment area. A change of condition assessment note completed by RN #3 on 12/28/24 at 11:54 AM, 13 hours after the fall, identified Resident #85 had altered mental status which included sleepiness and lethargy, right lower extremity redness and warmth, and complaints of left hip pain. The note identified the on-call provider was notified and Resident #85 was sent to the hospital for evaluation of increased lethargy, left hip pain, and bilateral pitting edema with right lower extremity redness and warmth. Interview with the DNS on 2/25/25 at 12:30 PM identified that Resident #85 should have had post A&I assessments completed following the 12/26/24 unwitnessed fall, and that neurological checks should have been completed following the 12/27/24 unwitnessed fall, especially due to Resident #85's history of epilepsy and multiple recent falls. The DNS identified that neurological checks should have been reinitiated beginning at every 15 minutes per the facility policy following the 12/27/24 fall and that post A& I assessments should have been done every shift following each fall and documented on the forms for each. The DNS identified that she was aware there was an issue related to neurological checks being completed and was developing a plan to educate the nursing staff. Although attempted, an interview with RN #3 and RN #6 was not obtained. The neurological check documentation form directed that neurological checks were to be done following a head injury, unwitnessed fall, seizure disorder, and any situation that may alter neurological status. The facility neurological check policy key, included on the form, directed vital signs and neurological checks to be done every 15 minutes for the first hour, every hour for 4 hours, every 4 hours for 24 hours, and every shift for 48 hours. The post A&I assessment form directed that the form should be completed every shift for 72 hours following an accident or incident, and the physician should be notified for any new or worsening symptoms. The facility policy on falls directed that any resident who experienced an unwitnessed fall and is unable to accurately verbalize if he/she hit their head due to cognitive status or experienced any kind of head injury would have post fall A&I assessments and neurological monitoring completed for 72 hours. 4a. Resident #70 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy and dementia. Braden Scale dated 8/14/24 identified Resident #70 was at moderate risk of developing a pressure ulcer. The quarterly MDS dated [DATE] identified Resident #70 had moderately impaired cognition, was always incontinent of bowel and bladder and was totally dependent for bed mobility, eating, toileting, bathing, dressing, transfers, and personal hygiene. Additionally, Resident #70 was at risk for developing a pressure ulcer, but did not have a pressure ulcer on admission. A physician's order dated 8/14/24 directed to complete a Braden Scale (Braden Scale is a tool used to assess a resident's risk of developing a pressure ulcer) on admission and every week for 4 weeks on Saturday during the 7:00 AM to 3:00 PM shift. Braden Scale due the week of 8/24/24 was not completed. Braden Scale dated 8/31/24 identified Resident #70 was at mild risk of developing a pressure ulcer. Braden Scale dated 9/7/24 identified Resident #70 was at moderate risk of developing a pressure ulcer. The care plan dated 9/11/24 identified Resident #70 was at risk for skin breakdown. Interventions included Braden Scale as per facility protocol. Braden Scale due the week of 9/14/24 was not completed. Interview with the DNS on 2/24/25 at 10:00 AM identified when a resident is admitted to the facility, the Braden Scale is to be done on admission and weekly for 4 weeks following admission and then quarterly. After review of the clinical record, the DNS indicated that staff did not complete a Braden Scale the weeks of 8/24/24 or 9/14/24 per the physician order. b. A physician's order dated 8/16/24 directed licensed staff to complete a body audit on admission and weekly thereafter. Review of the clinical record dated 8/14/24 to 2/24/25, 27 weeks, identified a weekly body audit was not completed 9 times, on 8/23/24, 9/6/24, 9/13/24, 9/20/24, 10/25/24, 12/13/24, 1/17/25, 1/31/25, and 2/21/25. Interview with the DNS on 2/24/25 at 10:00 AM identified that staff complete a body audit on residents' admission, readmission, and weekly based on their shower schedule. The DNS a physician's order will indicate when a resident is to have the weekly body audit and what shift. The DNS indicated that the body audits are to be completed weekly by the charge nurses to identify any new skin issues on a resident and the charge nurses are responsible to fill out the body audit form each week. After clinical record review, the DNS indicated that not all of the weekly body audits had been completed between August 2024 to current. c. The quarterly MDS dated [DATE] identified Resident #70 had severely impaired cognition, was always incontinent of bowel and bladder and was totally dependent for bed mobility, eating, toileting, bathing, dressing, transfers, and personal hygiene. Additionally, Resident #70 was at risk for developing a pressure ulcer, but did not have a pressure ulcer. The care plan dated 12/27/24 identified Resident #70 has impaired cognition and was on hospice services. Hospice to provide mattress. A Weight Report Summary dated 2/7/25 identified Resident #70 weighed 100.0 lbs. A Weight Report Summary dated 2/18/25 identified Resident #70 weighed 110.0 lbs. Observation on 2/23/25 at 9:40 AM and 2:00 PM identified Resident #70 was lying in bed on a Low Air Loss (LAL) mattress which was set at 210 lbs., 100 lbs. more than the resident's 2/18/25 weight. Observation of the LAL mattress pump identified the dial starts at 50 lbs. and increases in increments of 30 lbs. until the maximum weight of 350 lbs. There is also an on/off switch and a switch for static on/off. Observation on 2/24/25 at 7:31 AM identified Resident #70 was lying in bed on the LAL mattress which was set at 210 lbs. Interview with RN #2 (Corporate [NAME] President Clinical Operations) on 2/24/25 at 9:30 AM identified that the facility uses 2 primary LAL mattresses and based on manufacturer booklets the air mattresses were to be set to the resident's weight. RN #2 indicated that he would provide the manufacturer booklets. Interview with RN #9 (Vice President of Clinical Operations) on 2/24/25 at 10:43 AM indicated that within the last one hour, she went around to the LAL mattresses in the facility and set the pump dials to the resident's weights and placed duct tape over the dial so no one would be able to change the dial setting. RN #9 indicated that Resident #70 did not have duct tape because she was not aware Resident #70 was on a LAL mattress. Interview with RN #1 (Wound Nurse) with RN #9 (Vice President of Clinical Operations) present on 2/24/25 at 10:44 AM identified RN #1 was responsible to have a list of residents who have a LAL mattress and why the resident has the LAL mattress, however, RN #1 was unable to provide the list. RN #1 indicated that all residents on a LAL mattress will have a physician's order directing the resident is on the LAL mattress and directing to set the mattress to comfort, not weight. RN #1 indicated that Resident #70 was on a LAL mattress because he/she was on hospice. RN #1 indicated that for all LAL mattresses, he puts in the physician's orders, and all are set to comfort. After clinical record review, RN #1 identified there was not a physician's order for the LAL mattress. RN #1 was not able to identify when the LAL mattress was placed on Resident #70's bed. RN #1 identified he would put the order in today for a LAL mattress for Resident #70's and indicated it would be set for comfort. RN #1 indicated that he did not have the manufacturer books for the LAL mattresses that were in the facility. Interview with RN #4 (Hospice Case Manager) on 2/24/25 at 2:06 PM indicated hospice ordered the LAL mattress on 9/17/24 and it was delivered on 9/18/24. RN #4 indicated that the hospice nurse ordered the air mattress because Resident #70 was at risk for skin breakdown, had boggy heels staged as deep tissue injuries and would need relief from pressure due to the difficulty in repositioning him/herself. RN #4 indicated that Resident #70 was not cognitively intact and would not be able to verbalize if the LAL mattress was too hard or too soft. RN #4 indicated that the LAL mattress was to be set at the Resident #70's weight and the staff at the facility were informed of that when Resident #70 received the mattress. RN #4 indicated that if the LAL mattress was set higher than the resident's weight the LAL mattress would not be effective in pressure relief and would put the resident at greater risk of skin breakdown. RN #4 indicated that the physician order should be set per Residents #70's weight and not for comfort because Resident #70 cannot tell you if he/she is comfortable. Interview with the Wound APRN (APRN #3) on 2/25/25 at 9:20 AM identified that LAL mattresses should be used as part of the treatment plan for pressure ulcers, by helping to off-load (reduce pressure) an affected area. APRN #3 indicated that LAL mattresses should be set to a resident's weight, and an order to set a LAL mattress to comfort should be reserved for resident's receiving palliative care or Comfort Measures Only (CMO). Interview with the Wound Nurse (RN #1) on 2/25/25 at 9:18 AM identified the prior Interim DNS instructed him to set everyone's LAL mattress to comfort. Further, RN #1 identified that for all LAL mattresses, the physician's orders direct to set the mattresses to comfort. RN #1 could not recall the time that the directive from the Interim DNS was given, but he was told to in-service the nursing staff to use the resident's weight as a jumping off point and adjust the setting to the resident's preference/comfort. RN #1 further indicated that resident's mattress comfortability was assessed every shift; alert and oriented residents were asked by nursing staff about the comfort level of their mattress and residents who had impaired cognition were assessed for non-verbal cues for pain. Interview with APRN #1 on 2/25/25 at 9:25 AM identified that she was unaware that all residents with a LAL mattress had a standard order to set to the mattress to comfort, as the Wound Care Team typically places those orders. APRN #1 indicated that LAL mattresses were designed to be set to the resident's weight and that is the standard practice. APRN #1 identified that LAL mattresses require an order from the medical provider and are used as an intervention for residents with pressure ulcers or for residents at high risk for developing a pressure ulcer. Interview with the DNS on 2/25/25 at 12:53 PM identified that all LAL mattress orders should not be set to comfort. The DNS indicated that the orders should be set to the resident's weight, but the orders should also be looked at individually and take into account the resident's comfort. Review of the Wound and Skin Care Protocols identified the purpose was to prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions. All residents will be assessed by the nurse for risk of skin breakdown, utilizing the Braden Scale upon admission, readmission and every week for the first 4 weeks. Weekly body audits will be completed on shower day by a licensed nurse and all skin areas will have weekly documentation until healed. The Med-Aire Melody Alternating Pressure Low Air Loss Mattresses Replacement System Operators' Manual directs the control unit to be set to the patient's determined weight. The [NAME] Relief Alternating Pressure System with Low Air Loss Operation Manual directs to set the weight button according to the patient's weight and adjust the weight setting if the mattrass is too soft or firm to suit each patient's needs. 46040 47457

Based on review of the clinical record, facility policy, and interviews for 3 residents (Resident #16, 54, and 85) the facility failed to notify the physician and/or the resident representative with a change in condition. For Resident #16, reviewed for dignity, the facility failed to ensure the Psychiatric APRN was immediately notified when the resident that expressed suicidal ideation, for Resident #54, reviewed for nutrition, the facility failed to ensure the resident representative was notified of a weight loss and the implementation of a supplement, and for Resident #85, reviewed as a closed record, the facility failed to ensure the physician was notified following an unwitnessed fall. The findings include. 1. Resident #16 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, mood disorder due to known physiological condition with mixed features, major depressive disorder, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #16 had intact cognition, had little interest or pleasure in doing things, felt down, depressed, or hopeless 2 - 6 (several) days, and felt social isolation often. The care plan dated 8/7/24 identified Resident #16 had accusatory and manipulative behaviors and voiced delusions and hallucinations. Interventions included frequent documentation of all abnormal behaviors, episodes of confusion, yelling out, and delusions to help assess what medication interventions are needed, per the APRN. The care plan identified Resident #16 could be impulsive and not always able to control his/her behavior. Interventions included if staff see Resident #16's mood changing, offer to assist him/her to another area and spend a few minutes in quiet conversation until the anger subsides. The care plan further identified Resident #16 was at risk for potential adverse effects of psychotropic drug use. Interventions included reporting any mood state/behavior changes to the physician or APRN, monitoring for a wide range of unpleasant side effects of antidepressants including but not limited to agitation, irritability, and anxiety and report to the physician or APRN, and monitoring his/her mental status functioning on an ongoing basis. The Social Services Assessment - Quarterly dated 10/22/24 identified Resident #16 reported feeling down, depressed, or hopeless, was having trouble falling asleep or staying asleep, feeling tired or having little energy, having a poor appetite or overeating, and having thoughts that he/she would be better off dead or harming oneself with a 2 - 6-day frequency of symptoms. The document's summary/review since last assessment identified Resident #16 remains long term with a DNR status, no signs or symptoms of distress or concerns notes. Resident #16 was encouraged to attend activities of his/her preference, psychosocial supports will be provided as needed and psychiatric services will be provided as needed for anxiety, depression, and PTSD. The Social Services note dated 10/22/24 at 5:54 PM identified that Resident #16 reported to the Social Service worker during the quarterly assessment that he/she did not feel suicidal today, but she does other days, this was reported to nursing. The Social Services noted dated 10/22/24 at 5:56 PM identified that the writer noted in the Psychiatric APRN referral book that Resident #16 feels suicidal at times. Review of the nurse's notes dated 10/22/24 through 10/23/24 failed to identify that the physician or APRN was immediately notified that Resident #16 verbalized feeling suicidal at times. The Psychiatric APRN note dated 10/24/24 at 1:50 PM identified that Resident #16 reported suicidal ideation (SI) to the social worker. Upon entering the room, the patient was calm, cooperative, and pleasant, and appeared surprised to hear the reason for our visit today. Resident #16 denied any active thoughts or plans of self-harm, and stated that he/she must have interpreted the social worker's question incorrectly, further explaining that he/she had thoughts of dying only in reference to his/her current medical condition and does not have thoughts of killing him/herself. Interview with APRN #2 on 2/25/25 at 9:53 AM identified that the facility's social worker identified the concern during Resident #16's quarterly social service assessment, and that when she went in to talk to Resident #16 a day or two later, the resident emphasized that any thoughts of death were due to his/her multiple comorbidities but was not feeling suicidal. APRN #2 indicated that if a resident makes a suicidal comment, it should be reported to the psychiatric provider right away, and that she would have expected to have been notified of Resident #16's comments of SI. APRN #2 indicated the SI should not have been documented in the Psychiatric APRN book. APRN #2 further indicated that if she wasn't in the building, at the time of the incident, she would have had a telework visit with Resident #16 to have a conversation about the statement that was made, determine a risk assessment, and then determine if Resident #16 needed to go the hospital or was safe to stay. APRN #2 identified that after the telehealth visit, she would have followed up in person if no risk of self-harm was identified, but if an immediate concern was identified, Resident #16 would have been placed on 1:1 supervision until he/she was transferred to the hospital. APRN #2 indicated that after her visit with Resident #16 there was no need for 1:1 supervision or transfer to a higher level of care. Interview with SW #1 on 2/25/25 at 11:05 AM identified that she remembered completing Resident #16's quarterly assessment, but she could not recall exactly what was said. SW #1 indicated that Resident #16 reported suicidal ideation, in the past, and that it had been a long time since he/she had any thoughts of suicide. SW #1 could not recall the timeline for when Resident #16 had thoughts of suicide, but she did not feel like it was recent. SW #1 indicated that after she completed Resident #16's quarterly assessment, she notified the nursing staff that Resident #16 was having those thoughts in the past, but SW #1 was unable to recall which nurses she had spoken with. SW #1 indicated that she could not recall what she discussed with the nursing staff, but that after speaking with the nursing staff, she felt that adding Resident #16 to the Psychiatric APRN book instead of calling the APRN, was appropriate because she did not feel like Resident #16 was in imminent danger, as the SI was not current and she felt like Resident #16 was safe. In an interview with the DNS and the [NAME] President of Clinical Operations (RN #2) on 2/25/25 at 12:33 PM, the DNS identified that the facility does not have a policy on suicidal ideation. The DNS further identified that she would have expected a suicide risk assessment to have been completed at the time of Resident #16's comments of feeling suicidal. RN #2 indicated that he would have expected the social worker to have obtained more information to figure out when the suicidal ideation had occurred, and he also would have expected the nurse to notify the provider. The facility's Change in Resident Condition/Family/MD Notification policy directs a significant change in the condition of the resident's physical, mental, or emotional status, or in the event of an accident involving the resident, will be reported to the physician and family. 2. Resident #54 was admitted to the facility in March 2022 with diagnoses that included dementia. The weight record summary dated 10/5/24 identified Resident #54 weighted 102.0 lbs. The quarterly MDS dated [DATE] identified Resident #54 had severely impaired cognition, required total assistance for eating and had no known weight loss in the last month or 6 months. The dietitian progress note dated 10/9/24 identified Resident #54 was on a puree diet with a house supplement of 4 oz twice a day. Resident #54 required total assistance to be fed meals. Residents #54's current weight is 101.1 lbs., and the ideal body weight is 110 lbs. plus or minus 10%. The care plan dated 10/24/24 identified Resident #54 had the potential for a nutritional decline related to dementia and a history of weight loss. Interventions included providing diet and supplements as ordered, weights as ordered, encourage fluids, assist with meals as needed and watch for signs of aspiration. The weight record summary dated 11/7/24 identified Resident #54 weighed 99.2 lbs., a 2.8 lbs. weight loss. A physician's monthly order dated November 2024 directed to provide a puree diet with thin liquids and house supplement 4 ounces twice a day. The weight record summary dated 12/1/24 identified Resident #54 weighed 95.0 lbs., a 4.2 lbs. weight loss. The dietitian progress note dated 12/4/2024 at 6:14 AM noted Resident #54 weight was 94 lbs. on 12/1/24. This reflects a 7.2% weight loss over the past month. Resident #54 is tolerating his/her meals with variable intake but needs assistance at mealtime. No therapeutic diet restrictions in place. House supplement 4 oz twice a day for increased calories offered. Continue to encourage food/fluids as able. Review of the clinical record failed to reflect the resident representative had been notified of the weight loss or the increase in the house supplements. The APRN progress note dated 12/5/24 by APRN #1 (placed in the medical record after surveyor inquiry on 2/25/25 at 10:06 AM) identified Resident #54 was seen for a weight loss of 5 lbs. in 1 month. Resident #54 has advanced dementia. The plan is to recheck weight and ordered labs. The weight record summary dated 12/6/24 identified Resident #54 weighed 93.0 lbs. The weight record summary dated 12/7/24 identified Resident #54 weighed 93.4 lbs. A physician's order dated 12/9/24 directed to give house supplement 4 ounces three times a day. The dietitian progress note dated 12/11/24 at 11:39 AM identified Resident #54's weight was 93.4 lbs. on 12/7/24. Resident #54 needs assistance/encouragement with meals. House supplement in place to help meet needs. The dietitian progress note dated 12/19/24 at 6:46 AM identified the house supplement increased to three times a day to help meet needs. The annual MDS dated [DATE] identified Resident#54 had an unplanned weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Interview with the DNS on 2/25/25 at 7:10 AM identified the charge nurse was responsible to notify the resident representative of the weight loss when it was identified and to notify the resident representative of the new order for supplements on 12/9/24. Interview with the Dietitian on 2/25/25 at 7:15 AM he indicated that he has a communication book for nursing to notify him of a resident's weight loss. The Dietitian indicated that all residents are weighed in the first 10 days of a month. The Dietitian indicated that all reweights are due by the 15th of the month if noted to have a 5% weight loss or gain. The Dietitian indicated that it was the charge nurse's responsibility to determine if there was a 5% difference and have the nurse's aide get another weight. The Dietitian indicated that he is in the facility 2 days a week every Thursday and Friday. The Dietitian indicated that if a weight loss is noted on a Saturday it will go into his communication book, and he will see it on Thursday when he comes into the facility. The Dietitian noted if he identifies a resident has had a weight loss, he will write it in the APRN's communication book with any recommendations so she will see it the next time she is in the facility. The Dietitian indicated that the nurse was responsible to notify the resident representative of the weight loss and the increase in the supplements. The interview with APRN #1 on 2/25/25 at 10:00 AM indicated she had seen Resident #54 for a weight loss but does not recall the date. APRN #1 indicated that she documents in a different system and her notes are not in the resident's electronic medical record. APRN #1 indicated that she will transfer her notes over now. Interview with APRN #1 on 2/25/25 at 10:27 AM indicated she had seen Resident #54 on 12/5/24 for the weight loss of 5 lbs. in a month and placed Resident #54 on weekly weights for 4 weeks and ordered labs. APRN #1 indicated that she had seen Resident #54 on 12/19/24 for follow up and the labs that were within normal limits and the resident was stable from the last visit on 12/5/24. Review of the clinical record identified the weekly weights were not documented on 12/13/24, 12/20/24, and 1/3/25. Interview and review of the clinical record with DNS on 2/25/25 at 10:40 AM failed to reflect the resident representative was updated with the weight loss and the new physician order to increase the house supplements. Review of the Weight Monitoring Policy identified weights will be taken and recorded on the weight sheet in the EMR. If there is a 5 lb. weight discrepancy plus or minus a reweight should be obtained. The charge nurse should review then weight and compare this to the previous weights to determine a 5% weight change in 30 days or a 10% weight change in 180 days. Significant weight changes will be reported to the physician or APRN, resident representative, and dietitian. Review of the Change in Resident Condition Notification to Physician and Resident Representative identified all significant changes in resident's condition will be reported to the physician and resident representative. The nurse will document in the nurses notes that the physician and resident representative have been notified of the change in condition. 3. Resident #85 was admitted to the facility in November 2018 with diagnoses that included ataxic cerebral palsy, epilepsy, and history of falling. The quarterly MDS dated [DATE] identified Resident #85 had intact cognition, was always continent of bowel, frequently incontinent of bladder, required partial staff assistance with toileting and bathing, and supervision with transfers. The care plan dated 11/28/24 identified Resident #85 had a history of falls. Interventions included to notify the physician of pain, bruising, and to complete neurological checks per protocol. Review of the clinical record identified Resident #85 had unwitnessed falls on 12/22/24 and 12/26/24. A reportable event form dated 12/27/24 identified Resident #85 had a fall at 10:00 PM on that date. The form, signed as completed by RN #6, identified an on call provider was notified of the fall, however, the form failed to identify the provider's name, title or when the notification was made. A nurse's note dated 12/27/24 at 10:03 PM by RN #6 identified Resident #85 had an unwitnessed fall. The note identified Resident #85 was observed on the floor sitting on his/her buttocks and that Resident #85 reported falling after an attempt to self transfer. The note further identified Resident #85 sustained a linear scratch to the back of the right buttock, a superficial abrasion to the right top of the thigh measuring 15.5 inches in length, and a bruise above the left elbow measuring 6 cm x 5 cm. The note also identified RN #6 attempted to reach the on call provider regarding the fall but was unsuccessful. A change of condition assessment dated [DATE] at 10:26 PM completed by RN #6 identified no provider notification was done. Further review of the clinical record failed to identify documentation of additional attempts to notify Resident #85's physician of the fall on 12/27/24 at 10:00 PM. A change of condition assessment note dated 12/28/24 at 11:54 AM by RN #3 identified Resident #85 had altered mental status which included sleepiness and lethargy, right lower extremity redness and warmth, and complaints of left hip pain. The note identified the on call provider was notified and Resident #85 was sent to the hospital for evaluation of increased lethargy, left hip pain, and bilateral pitting edema with right lower extremity redness and warmth. Interview with the DNS on 2/25/25 at 12:30 PM identified that the facility policy directs that when a resident has any change of condition, which includes falls, the nurse assigned to the resident or the RN supervisor should make attempts to contact the on call provider. The DNS identified if the on call provider is unable to be reached, the nurse should then contact the medical director. The DNS identified that RN #6 should have made attempts to contact the medical director following the failed attempts to reach the on call provider, especially given that Resident #85 sustained some injuries with the fall and Resident #85's history of recent multiple falls within a 4 day period. Although attempted, an interview with RN #3 and RN #6 was not obtained. The facility policy on change of condition directs that the resident's attending physician or covering provider would be notified of any significant change of condition or accident involving the resident. The policy further directs if the physician or covering provider were not available, the medical director would be called and notification would be documented in the clinical record. 46040 47457

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 residents, (Resident #25 and 37) reviewed for infection control, the facility failed to develop and implement policies to ensure a resident with a history of colonized multidrug resistant organism (MDRO) and a surgical wound was provided care in accordance with infection control practices and failed to implement policies regarding the use of personal protective equipment (PPE) while providing direct care and for Resident #37 the facility failed to ensure enhanced barrier precautions (EBP) were initiated for a resident with an indwelling medical device. The findings include: 1. Resident #25 had diagnoses that included cutaneous abscess of the groin requiring aftercare following surgery. The care plan dated 1/21/25 identified Resident #25 had a surgical wound, and a history colonized Methicillin-resistant Staphylococcus aureus, MRSA (bacteria resistant to many antibiotics) requiring advanced barrier precautions. Interventions included to instruct visitors and caregivers to wear a disposable gown and gloves during physical contact with the resident and provide treatments as ordered. The quarterly MDS dated [DATE] identified Resident #25 was cognitively intact and required one person assist with bed mobility, two person assist with transfers and had a surgical wound requiring wound care. a. Observation on 2/23/25 at 9:38 AM identified Resident #34 was in a semi-private room with no signage or accessible PPE nearby and no other identifiable indicators on the door or name plate signifying the resident was on enhanced barrier precautions (EBP). An interview with RN #1 on 2/23/25 at 2:33 PM identified he was the Infection Preventionist (IP) for the facility. RN #1 identified only residents with specific novel/targeted MDRO's required enhanced barrier precautions. RN #1 further identified that while Resident #25 had a history of MRSA and an open surgical wound, he/she did not require any special precautions. If required, a resident would have signage, or an orange sticker placed on the name frame indicating the resident on EBP and PPE would be placed outside the room. An interview with the DNS on 2/23/25 at 2:45 PM identified it would be her expectation that a resident with a known history of any colonized MDRO and wound be placed on enhanced barrier precautions. Resident #25 was subsequently placed on EBP. A review of the facility policy for enhanced barrier precautions directed the facility to adhere to the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid (CMS) guidelines related to enhanced barrier precautions to prevent transmission of MDRO's. The facility will implement EBP when contact isolation does not apply for high contact resident care activities and will include unhealed surgical wounds regardless of MDRO colonization or infection. b. An observation on 2/24/25 at 11:12 AM identified signage on the door identifying Resident #25 was on EBP and directing the use of PPE when providing care with a bin outside the door containing PPE. The observation further identified NA #5 entered the room responding to a call light without first donning PPE and exited six minutes later. An interview on with NA #5 on 2/24/25 at 11:18 AM identified she had provided Resident #5 with a bed pan. A subsequent observation of NA #5 on 2/24/25 at 11:30 AM identified her donning PPE before entering Resident #25's room. An interview with NA #5 on 2/24/25 at 12:09 PM identified she had not initially donned PPE when first entering Resident #25's room to provide the bed pan as she was not thinking of it at the time she was providing direct care. Observation on 2/25/25 at 6:40 AM identified NA #8 placing Resident #25 on a bedpan without the benefit of PPE. An interview with NA #8 on 2/25/25 at 6:40 AM identified that although she was aware of the need to don PPE prior to providing direct care, she forgot. An interview with the DNS on 2/25/25 at 6:45 AM identified NA #8 should have been wearing PPE prior to providing direct care. A review of the facility policy for enhanced barrier precautions directed the facility to adhere to the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid (CMS) guidelines related to enhanced barrier precautions to prevent transmission of MDRO's. The facility will implement EBP when contact isolation does not apply for high contact resident care activities and will include unhealed surgical wounds regardless of MDRO colonization or infection. Appropriate signage for EBP will be visible and appropriate PPE and sanitizer will be readily accessible for use. 2. Resident #37 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis. A physician's order dated 10/29/24 directed to check dialysis site (right central venous catheter) upon resident's return to the facility every Monday, Wednesday, and Friday and a physician's order dated 11/15/24 directed to monitor the right central venous line double lumen permacath site for signs and symptoms of infection, every shift, and report changes to the physician. The quarterly MDS dated [DATE] identified Resident #37 had intact cognition, required partial/moderate assist with tub/shower transfers, was dependent for toileting and personal hygiene, and the following treatments, procedures, and programs were performed within the last 14 days: dialysis and IV (intravenous) access. The care plan dated 1/29/25 identified Resident #37 received dialysis due to chronic kidney disease (CKD), 3 times per week, and was at risk for bleeding, infection, and septic shock. The care plan further identified Resident #37 had a right central line dual-lumen tunneled catheter (inserted on 10/24/24) through which he/she received dialysis treatments. Interventions included observing the right central venous catheter for any signs and symptoms of infection and notifying the physician immediately; interventions failed to include EBP (enhanced barrier precautions, a CDC recommendation to provide guidance for use of personal protective equipment in facilities to prevent the spread of MDRO's). The care plan identified Resident #37 required assistance with ADL's status post recent hospitalization for respiratory failure and end-stage renal disease (ESRD) now requiring dialysis. Interventions included incontinence care per facility policy and assisting with ADL's when needed. Observation and interview with LPN #2 on 2/23/25 at 10:38 AM failed to identify signage for EBP in an area that was visible and failed to have PPE readily accessible for use. LPN #2 identified that she was aware that Resident #37 required EBP because of his/her dialysis access and that she does wear PPE while providing care, but she [NAME] the PPE from another room down the hall. LPN #2 was not sure why there was no signage for EBP on Resident #37's door or why PPE was not readily available, but she would place appropriate EBP signage and put a PPE bin outside his/her room. Interview with NA #1 on 2/23/25 at 10:45 AM identified that she was not told that Resident #37 was on enhanced barrier precautions, and as a result she has not worn PPE while providing him/her with care. NA #1 indicated that she did not know why Resident #37 would require enhanced barrier precautions, and there was no sign directing staff to wear PPE while providing care or a bin outside his/her room with PPE. Interview with the Infection Control Nurse (RN #1) on 2/23/25 at 2:33 PM identified that residents with indwelling devices, wounds, and history of MDRO's should be on enhanced barrier precautions. RN #1 indicated that the nursing staff was educated on EBP in April of 2024, and staff would be able to identify residents on EBP by signage on the door and an orange sticker near their name on the wall plate. RN #1 indicated that Resident #37 should be on EBP, due to his/her permacath for dialysis. RN #1 was unsure why Resident #37 had not been on EBP, but he would put him/her on EBP. Observation of Resident #37's name plate on 2/23/25 at 2:49 PM failed to identify an orange sticker identifying the need for EBP. Subsequent to surveyor inquiry, a physician's order dated 2/24/25 directed for enhanced barrier precautions due to indwelling medical device, every shift. Interview with the DNS on 02/25/25 at 8:42 AM identified that she would expect Resident #37 to have been placed on enhanced barrier precautions, due to his/her dialysis permacath. The DNS indicated that upon admission the RN supervisor should have placed Resident #37 on EBP, but it would also be up to the Infection Control Nurse to ensure a resident on dialysis with a permacath was identified and placed on EBP. The Enhance Barrier Precautions policy directs the facility to implement enhanced barrier precautions during high-contact resident care activities, for those residents per the current CDC Novel Targeted MDRO list and with indwelling medical devices. Examples of high-contact resident care activities include dressing, bathing/showering/providing hygiene, transferring, changing linens, changing briefs or assisting with toileting. The facility will implement enhanced barrier precautions to include any resident with an indwelling medical device or chronic wounds regardless of MDRO colonization or infection status. Enhanced barrier precautions will remain in effect for the duration of the resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at a higher risk. The policy further directs that appropriate signage for EBP will be visible and appropriate PPE and hand sanitizer will be readily accessible for use. Staff will perform hand hygiene and don PPE before providing high-contact care to the resident and doff PPE and perform hand hygiene after providing high-contact care to the resident. 47457

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents, (Resident #5) reviewed for nutrition, the facility failed to ensure weights were obtained according to policy. The findings include: Resident #5 had diagnoses that included history of a heart attack and recent influenza. The annual MDS dated [DATE] identified Resident #6 had moderately impaired cognition and was independent with eating. The care plan dated 10/16/24 identified Resident #16 had a potential for nutritional decline related to multiple medical problems. Interventions included to provide diet, supplements and weight as ordered. Physician's order dated 11/14/24 directed to obtain weekly weights. The weight log dated 11/27/24 identified Resident #5 weighed 121.2 lbs. A Nutritional assessment dated [DATE] identified Resident #5 experienced no significant weight change in the past one or six months, had mostly good intake with house supplements in place to help meet needs. A Nutritional progress note dated 12/20/25 identified the monthly weight was pending and that Resident #5 had a history of weight loss. A house supplement was added. A physician's order dated 1/10/25 directed to discontinue weekly weights. Review of the weight log failed to reflect a January 2025 weight had been obtained. The weight log dated 2/21/25 identified Resident #5 weighed 113.2 lbs., an 8lbs. weight loss or 6.60 %. Further review of the weight log identified that between 11/14/24 - 1/10/25, 3 of the 9 weekly weights were not obtained per the physician's order. Interview with the Dietitian on 2/24/25 at 11:34 AM and 2/25/25 at 7:15 AM identified any weight discrepancy greater than 5% requires a reweight, however, he was unable to specify a time frame for when this should occur. The Dietitian identified the aides were self-directed in obtaining a reweight but he would follow up if a reweight was not recorded. The Dietitian identified a monthly weight was not obtained for the month of January and should have been. The Dietitian further identified there were occasions where other resident's monthly weights were not documented. Interview with LPN #4 identified the nurse aide staff were responsible for obtaining resident weights and were self-directed in obtaining and documenting reweights for weight loss greater than 5%. However, she would request a reweight for weight changes of 2 - 3 lbs. Most reweights were obtained immediately, but no later than 24 hours. Once a weight change greater than 5% was confirmed, the dietitian and physician were to be notified. An interview with the DNS on 2/25/25 at 7:43 AM identified she would expect a documented reweight for any weight discrepancy greater than 5% and that weights should be obtained in accordance with policy. Review of the Weight Monitoring policy directed that weights were to be taken and recorded on a weight sheet or electronic medical record. A weight discrepancy (plus or minus) 5 lbs. requires a reweight. The charge nurse will review the weight and compare it to the previous weight to determine if there is a 5% change in 30 days or 10% in 180 days. Significant weight changes would be reported to the DNS, responsible party, dietitian and physician.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #14) who were at risk to develop a pressure ulcer, the facility failed to ensure the Braden Scale and the weekly body audits were done per the physician's order and failed to ensure the LAL (low air loss) mattress was set per the manufacturer recommendations. The findings include: Resident #14 was readmitted to the facility on [DATE] with diagnoses that included fibromyalgia, delirium, and stroke. The admission nursing assessment dated [DATE] identified Resident #14 was noted to have an open area to the top of the coccyx that measured 3.0cm by 3.0cm by 2.0 with a 2.25 cm depth. Further, the assessment indicated the resident had a urinary catheter. A physician's order dated 5/27/23 directed to complete a Braden Scale on admission and every week for 4 weeks. The care plan dated 6/13/23 identified Resident #14 had a stage III pressure injury to the sacrum. Interventions included to assess the resident's risk of skin breakdown using the Braden Scale per policy, checking skin at least weekly on scheduled bath day, and use of a LAL mattress per physician orders. The quarterly MDS dated [DATE] identified Resident #14 had intact cognition and required total assistance with toileting, and extensive assistance with bed mobility, transfers, and dressing. Further, the MDS identified Resident #14 was at risk for pressure ulcers and had one stage III pressure ulcer of the sacral region. a. Review of the clinical record identified the Braden Scale was completed on admission 5/27/23 with a score of 17 which indicated the resident was at risk for pressure ulcer development. Further review identified the Braden Scale was not documented weekly for 4 weeks on 6/3/23, 6/10/23, 6/17/23 or 6/24/23. Facility documentation indicated Resident #14 was transferred to the hospital and returned to the facility on [DATE]. The hospital discharge summary dated 2/6/25 identified Resident #14 was hospitalized for a urinary tract infection and dehydration. The readmission nursing assessment dated [DATE] identified the Braden Score identified the resident was a mild risk for pressure ulcer development. Further review of the clinical record identified the weekly Braden Scale was not completed on 2/13/25 and 2/20/25. Interview with the DNS on 2/24/25 at 10:00 AM identified when a resident is admitted or a readmitted , the Braden Scale is to be done on admission or readmission and then weekly for 4 weeks and quarterly thereafter. After clinical record review, the DNS indicated that staff had not completed a Braden Scale following the readmissions on 5/27/23 and 2/6/25 per the physician order. Interview with RN #7 (Corporate Clinical Nurse) on 2/24/25 at 10:08 AM identified the Braden Scale was to be documented on admission within the admission assessment then weekly for 4 weeks and quarterly thereafter documented on the Braden Scale form. b. Physician's monthly orders for September 2024 (original order date 10/19/23) directed to complete a body audit, using the body audit form, on admission and every week by a licensed nurse on Mondays during the 7:00 AM to 3:00 PM shift. Review of the body audit forms dated 9/22/24 to 2/1/25 identified body audits were not done on 9/23/24, 9/30/24, 10/14/24, 10/21/24, 12/9/24, 12/30/24, 1/20/25, and 1/27/25, 8 out of 19 weeks. Interview with the DNS on 2/24/25 at 10:00 AM identified that residents have a body audit on admission, readmission, and weekly based on their shower schedule and time. The DNS indicated there is a physician's order that indicates when a resident is to have the weekly body audit and what shift. The DNS indicated that the body audits are to be completed weekly by the charge nurses to identify any new skin issues on a resident. The DNS indicated that the charge nurses are responsible to fill out the body audit form each week. After clinical record review, the DNS indicated that weekly body audits were not documented consistently from 9/1/24 to current. Interview with RN #7 (Corporate Clinical Nurse) on 2/24/25 at 10:08 AM identified that approximately 2 weeks ago the facility policy changed. RN #7 identified the licensed nurses will no longer be doing weekly body audits and will only chart by exception. c. A physician order dated 10/24/24 directed the use of a LAL mattress, check function and placement every shift and set to comfort for wound. The annual MDS dated [DATE] identified Resident #14 had severely impLALed cognition, was occasionally incontinent of bowel and frequently incontinent of bladder, required moderate assistance for rolling side to side or transfers and maximum assistance for sitting to lying position on side of bed. Further, Resident #14 was at risk for pressure ulcers and had one stage III pressure ulcer of the sacral region. Review of the Weight Record Summary dated 11/1/24 identified the resident weighed 162.0 lbs. Review of the Weight Record Summary dated 2/8/25 identified the resident weighed 164.2 lbs. Observation on 2/23/25 at 9:10 AM and 10:30 AM identified Resident #14 was lying in bed with LAL mattress set at 200 lbs., 35.8 lbs. more than the resident's weight. Observation on 2/24/25 at 7:32 AM identified Resident #14 was lying in bed with LAL mattress set at 200 lbs., 35.8 lbs. more than the resident's weight. Interview with RN #2 (Corporate [NAME] President Clinical Operations) on 2/24/25 at 9:30 AM indicated that the facility uses 2 primary LAL mattresses and based on manufacturer booklets the LAL mattresses were to be set to the resident's weight. RN #2 indicated that he would provide the manufacturer booklets. Interview with RN #7 on 2/24/25 at 10:15 AM indicated that RN #1, the Infection Preventionist, is responsible for tracking which residents have a LAL mattress, why they have the LAL mattress, and to ensure there is a physician order and a care plan for the LAL mattress. RN #7 indicated that all LAL mattresses are set to a resident's weight unless a resident is cognitively intact and requests the setting to be a little softer or firmer. RN #7 indicated that if the resident requested a different setting than the setting based on their weight, that setting would be added to the care plan and a physician's order would be obtained. RN #7 indicated that every shift the charge nurses are responsible to check that the placement, function and setting of the LAL mattress. Interview with RN #1 (Wound Nurse) with RN #9 (Vice President of Clinical Operations) on 2/24/25 at 10:44 AM identified RN #1 is responsible to maintain a list of LAL mattresses in use, however, RN #1 was unable to provide a list of residents on LAL mattresses currently while in his office. RN #1 indicated that all residents on an LAL mattress will have a physician's order stating they are on an LAL mattress, and it will be set to comfort, not weight. RN #1 indicated that for all the LAL mattresses, he ensures the physician's orders direct the mattresses are all set to comfort. RN #1 indicated that Resident #14 is on an LAL mattress because of a stage III pressure ulcer to the coccyx. RN #1 indicated that the LAL mattress was used to promote healing and prevent any new pressure ulcers. RN #1 indicated that he did not have the manufacturer books for the LAL mattresses that were in the facility, so was not aware if the manufacture recommendations say to set the LAL mattress to a resident's weight. Interview with RN #9 on 2/24/25 at 10:44 AM indicated that Resident #14's LAL mattress was set to comfort or weight and there is a physician order for the LAL mattresses. RN #9 indicated that Resident #14 weighs 165 lbs. and the dial would be set at that range, RN #9 indicated that if the dial was not set to weight and was set because Resident #14 had requested it for comfort to a harder or a softer setting it would be in the physician order and in the care plan. Interview with APRN #3 (Wound APRN) on 2/25/25 at 9:20 AM indicated that LAL mattresses are typically used for the treatment of an existing pressure ulcer, to help with off-loading and should be set to a resident's weight. Review of the Wound and Skin Care Protocols identified the purpose was to prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions. All residents will be assessed by the nurse for risk of skin breakdown, utilizing the Braden Scale upon admission, readmission and every week for the first 4 weeks. Weekly body audits will be completed on shower day by a licensed nurse and all skin areas will have weekly documentation until healed. Review of the Manufacturer Booklet for the LAL mattress on Resident #14's bed directed to obtain the resident's weight and set the control knob to that weight setting on the control unit. Although requested, a facility policy for LAL mattresses was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #33) reviewed for pre-admission screening and resident review (PASARR), the facility failed to notify the State-designated authority when the resident received a new psychiatric diagnosis. The findings include: Resident #33 was admitted to the facility in May 2019 with diagnoses that included Parkinson's disease, depression, anxiety, and repeated falls. The Admission PASARR dated 5/1/19 determination date 5/30/19 identified Resident #33 had no major mental disorder, did not have dementia, Alzheimer's, or psychotic/delusional disorder. The outcome was Resident #33 was approved for long term care for skilled nursing care. Resident #33 is reported to be occasionally disoriented in situations, with deficits noted in memory and judgment at this time. The quarterly MDS dated [DATE] identified Resident #33 had severely impaired cognition, and a diagnosis of depression and anxiety. The MDS did not reflect a diagnosis of psychotic disorder. A psychiatric note dated 10/17/22 identified Resident #33 had mild paranoia. Resident #33 has depression, psychosis, confusion, and memory impairment. Assessment and plan delusional disorder, resident continues with delusions and paranoia and depression due to overall decline. Resident recently trialed on Seroquel due to worsening signs and symptoms of psychosis. The staff report Resident #33 has been more pleasant. Resident #33 appears to be improving on Seroquel and will continue medication. Diagnosis of depression and psychotic disorder with delusions. The quarterly MDS dated [DATE] identified Resident #33 had severely impaired cognition, short and long-term memory problems, and a diagnosis of anxiety and depression. but did not reflect psychotic disorder. The MDS did not reflect a diagnosis of psychotic disorder. The care plan dated 10/26/22 failed to reflect the diagnosis of psychotic disorder. Review of the Diagnosis Record identified Resident #33 had a diagnosis of psychotic disorder with delusions dated 1/30/23. The quarterly MDS dated [DATE] identified Resident #33 had severely impaired cognition, and a diagnosis of anxiety, depression, and psychotic disorder. A physician's order dated 10/25/23 directed to administer Pimavanserin Tartrate (antipsychotic) 34mg once daily and Seroquel (antipsychotic) 25mg daily at bedtime. Interview with SW #1 on 2/25/25 at 8:54 AM indicated she is responsible to update State-designated authority when a resident receives a new psychiatric diagnosis. SW #1 it was the psychiatric providers responsibility to inform the social worker when they give a resident a new psychiatric diagnosis. After clinical record review, SW #1 indicated that Resident #33 received the new diagnosis of psychotic disorder with delusions on 1/30/23. SW #1 indicated that she will submit a new Level 1 to determine if a Level 2 is needed. Interview with APRN #2 (psychiatric APRN) on 2/25/25 at 11:02 AM indicated that she reviewed the clinical record and identified the first psychiatric note that adds the diagnosis of psychotic disorder with delusions was dated 10/17/22 after being trialed on Seroquel. Review of the Preadmission Screening and Resident Review PASARR identified PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for short/long term care. All applications to a Medicare/Medicaid certified nursing facility are evaluated for mental illness and/or intellectual disabilities to ensure they are placed in the appropriate setting and receive the services they need in the nursing home setting. The state agency does the reviewing of PASARR level 1 screens and level of care for individuals who are Medicaid active, eligible, or pending. Conducting a level 2 evaluations for person known or suspected of having serious mental illness that are residing in or applying to a Medicaid Certified nursing facility. All admissions will have an approved PASARR. A level 1 preliminary assessment screens are done to determine if there is mental illness or mental retardation. Those individuals that test positive for level 1 are then evaluated in depth with a level 2 PASARR. All positive level 2 outcomes will have a care plan created.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #17) reviewed for advance directive, the facility failed to ensure the resident or resident representatives wishes for an advance directive/code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops) were obtained and implemented. The findings include: Resident #17 was admitted to the facility in January 2021 with diagnoses that included dementia and Wernicke's encephalopathy. A Transfer Discharge Report dated 1/7/21 identified Resident #17 was transferred from another facility with a code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops) of full code (full code directs the medical team to take all possible measures to save the residents' life in the event of a medical emergency). The admission MDS dated [DATE] identified Resident #17 had moderately impaired cognition. A physician's order dated 5/20/21 directed the resident be full code. A resident care conference note, written by the MDS Coordinator, dated 1/11/22 at 12:30 PM identified a care conference was held with the resident in his/her room. A call was placed to the resident representative for update. MDS Coordinator requested a new signed advance directive consent form, because the DNR form was not found in the medical record and a new form to be signed was placed in the chart. A physician's order dated 3/4/22 directed Resident #17 be do not resuscitate (DNR). Interview and review of the clinical record with RN #3 (day supervisor) on 2/23/25 at 9:50 AM indicated that when a resident is admitted , the RN supervisor is responsible, during that shift, to have the resident sign the advance directive, and the nurse signs as the witness. Further, if the resident is cognitively impaired and has a resident representative, the RN is responsible to call the resident representative and discuss advance directive wishes. RN #3 indicated the APRN, or physician is responsible to sign the advance directive consent form within 24 - 48 hours after admission once signed by the resident or representative. Review of Resident #17's advance directive consent form identified the resident representative's name was typed on the form, but the resident representative did not sign it. RN #3 noted in the progress note dated 1/11/22 there was a care conference that identified there was no an advance directive signed in the clinical record and staff would have to have the resident representative sign one. RN #3 indicated that there were no other notes identifying who attempted to contact the resident representative or inform him/her to come in and sign the advance directive form. RN #3 indicated that the form in the chart was not valid. Interview with the DNS and RN #7 on 2/25/25 at 6:51 AM indicated that it was the admitting nurses responsibility to complete an advance directive consent form at the time of admission. RN #7 indicated that if the resident representative comes in with the resident at time of admission, they sign it then if not then the charge nurse must call the resident representative and discuss their wishes for an advance directive. RN #7 indicated that if the nurse cannot reach the resident representative, then he or she must write a progress note and the next shift must attempt to call until the facility reaches the representative. Further, the advance directive was not found in overflow. Review of the Advance Directive Policy identified the facility provides the resident or residents representative, upon admission notice of the policy of advance directive and the resident's rights regarding refusal of treatment. Licensed nursing staff and/or attending physician will review the advance directive with the capable resident or the appropriate decision maker. The plan of care related to advance directive and withholding life sustaining treatment will be documented on the resident's advance directive consent form and the physician's orders. A physician progress note will address the advance directive and any decisions regarding refusal or withholding treatments. The consent form will be signed and dated by the resident or resident's representative, the physician, and the person (nurse) who explains the advance directive. A physician's order will be obtained regarding the advance directive. The Advance directive consent form will be kept in the resident's medical record. The residents' advance directive will be documented in the residents' care plan and will be reviewed on a quarterly basis and as needed for any changes.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #16) reviewed for dignity, the facility failed to ensure staff treated the resident with dignity. The findings include: Resident #16 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, mood disorder, morbid obesity. The quarterly MDS dated [DATE] identified Resident #16 had intact cognition, had upper and lower extremity impairments on both sides, was dependent on rolling left and right, refused chair/bed-to-chair transfers, was on a scheduled pain regimen, and received PRN (as needed) pain medication in the last 5 days. The care plan dated 8/7/24 identified Resident #16 required staff assistance with ADL's due to decreased range of motion to the upper and lower extremities. Interventions included incontinence care per policy and per resident request to be out of bed within half an hour of the specified time and back to bed as needed for naps and incontinent care. Resident #16 had accusatory and manipulative behaviors and voiced delusions and hallucinations. Interventions included frequent documentation of all abnormal behaviors, episodes of confusion, yelling out, and delusions to help assess what medication interventions are needed, per the APRN, assist of 2 for all care, and approach in a calm manner. The care plan further identified Resident #16 could be impulsive and not always able to control his/her behavior. Interventions included if staff see Resident #16's mood changing, offer to assist him/her to another area and spend a few minutes in quiet conversation until the anger subsides. The Social Service note dated 10/3/24 at 3:42 PM identified that Resident #16 reported to the social worker that two nurse aides were unpleasant during a transfer with a hoyer lift. Resident stated that his/her right leg was often sore and during the transfer the leg was bumped, reported the concerns to the DNS. The Reportable Event Form dated 10/4/24 at 2:00 PM identified Resident #16 reported to the social worker that two nurse aides were not pleasant to him/her while they provided assistance with a transfer via mechanical lift. The resident was reassured of safety, nurse aides have been suspended pending investigation. NA #4's statement identified that on 10/3/24 at 1:00 PM, before they entered Resident #16's room, NA #3 indicated to NA #4 that she would remain silent while caring for the resident because of the residents past threats and reported allegations of nurse aide terminations. NA #3 and NA #4 changed the resident's clothes, provided care, and utilized a hoyer lift for the transfer. A third nurse aide, NA #2, assisted with the transfer. The transfer was done safely and with precautions. After securing the resident in the chair, he/she thanked the nurse aides, and all three nurse aides left the room to continue with our duties. NA #3's statement identified that on 10/3/24 at approximately 1:00 PM, she assisted NA #4 with Resident #16's care. Prior to entering the room, NA #3 communicated that she would remain silent because the resident had previously made threats and claimed to have had other nurse aides fired. Resident #16 had expressed no desire for NA #3's termination but for a suspension, which was brought to the Administrator's attention and the attention of the overnight supervisor. Upon entering Resident #16's room, his/her clothes were changed, and care was provided without verbal interaction from NA #3 to the resident. NA #3, NA #4 and NA #2 safely transferred Resident #16 from the bed to the wheelchair. NA #2's statement identified that Resident #16 had asked NA #2 to assist NA #3 and NA #4 with the transfer. After the transfer, Resident #16 was complaining that he/she was not sitting correctly. NA #2 tilted the seat back so they could get Resident #16 into the right place. NA #2 held the resident's foot out of the way while NA #4 pulled him/her back in the chair and NA #3 lowered the resident into it. Once seated, NA #2 adjusted the wheelchair back to the correct position. When NA #2 was about to walk out the door and leave, Resident #16 said, thank you to NA #2. Subsequently, NA #3 stated to the resident, (Thank you NA #2? There were two other people here). NA #2 indicated she heard that as she left the room but heard nothing else. The Reportable Event Summary dated 10/8/24 identified that Resident #16 reported that 2 nurse aides (NA #3 and NA #4) were unpleasant. Resident #16 indicated that NA #3 said let me do my job, and during the transfer his/her leg hit the lift, and it was very painful. Resident #16 later called for assistance from NA #2 because she knew how to accurately position the resident. NA #2 assisted NA #3 and NA #4 and when they were done Resident #16 indicated that he/she said, (Thank you, NA #2), and NA #3 made a comment that 3 nurse aides provided assistance and only NA #2 was thanked. Resident #16 indicated that the comments were full of sarcasm and were not appreciated. Based on the investigation including physical and clinical findings, there was not sufficient evidence that the resident's right leg was injured during the transfer from bed to motorized wheelchair. The physical presentation, chronic condition of the right leg, and findings of pain on light palpation were evidence that the leg was sensitive to light touch, and pain could be aggravated by the slightest movement during transfer, the resident reported that he/she was not in fear. There was no intentional harm or injury to the resident, and the allegation of abuse was unsubstantiated. Social services and the Psychiatric provider would follow up, as needed, for emotional support. Nurse aide staff would be reeducated on proper transfer techniques using mechanical lift, transferring a resident with chronic or acute pain, and customer service. A letter dated 10/17/24 identified that NA #3's employment was terminated as of 10/11/24. A letter dated 10/17/24 identified that NA #4's employment was terminated as of 10/11/24. Interview with Resident #16 on 2/23/25 at 8:00 AM identified that he/she was able to recall the hoyer transfer that took place on 10/3/24. Resident #16 identified that two of the nurse aides that were involved with that transfer were more than rude and did not know what they were doing while transferring him/her from the bed to the chair. Interview with NA #3 on 2/25/25 at 11:57 AM identified that on 10/3/24, another nurse aide, NA #4 had asked for assistance with providing care and transferring Resident #16. NA #3 told NA #4 that she was uncomfortable helping her because Resident #16 had told her that he/she wanted to see her suspended, but she would provide assistance but would remain quiet. NA #3 indicated that she had reported her concerns to the Administrator in the past. NA #3 identified that she greeted Resident #16 upon entering the room but otherwise remained quiet, when she and NA #4 turned Resident #16, the resident stated that she wanted to lose weight and buy more clothes. NA #3 identified that she told NA #4 that she had to assist another resident on her assignment, but Resident #16 indicated that he/she wanted to get up to his/her chair, so they called NA #2 to assist, and all 3 assisted with the hoyer transfer. NA #3 indicated that after Resident #16 was transferred into the motorized wheelchair and properly positioned she left the room. NA #3 indicated that it was NA #4 that made a comment that Resident #16 had only thanked one of the nurse aides while all three had provided assistance. NA #3 identified that after this incident she was terminated and that nobody could tell her who or what was said to result in a termination. Interview with the DNS on 02/25/25 at 12:33 PM identified that she was not the DNS at the time of the incident, but it was disrespectful to laugh at a resident and to suggest that he/she should have thanked the staff members. The DNS further identified that this is the resident's home, and all residents were expected to be treated with dignity and respect, at all times. Although attempted, interviews with NA #2, NA #4 and RN # 6 were not obtained. The facility's Resident's Rights policy directs that residents have the right to be treated with consideration, respect, and full recognition of dignity and individuality.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident, (Resident #34) reviewed for range of motion, the facility failed to ensure appropriate care and use of adaptive devices was provided in accordance with the plan of care and failed to ensure a physician's order was maintained that directed the use of an adaptive device for a resident with limited mobility. The findings include: Resident #4 had diagnoses that included hemiplegia/hemiparesis (weakness and paralysis) following a stroke affecting the right side and was receiving hospice services. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition, had mobility impairment to one side of the body and was dependent with dressing. The care plan dated 1/14/25 (original date 2/16/23) identified Resident #34 was at risk for contractures of the right hand related to right hemiparesis. Interventions included applying a resting hand splint after morning care, remove after evening care and use a rolled washcloth after the splint is removed. Physician's orders 2/1/25 (original order date 8/11/22) directed to apply a right resting hand splint during the 3:00 PM to 11:00 PM shift after evening care and remove after morning care with skin checks. (This is in conflict with the care plan initiated on 2/16/23 that indicates to apply the resting hand splint after morning care, remove after evening care and use a rolled washcloth after the splint is removed). A physician's order dated 2/18/25 directed to discontinue the right resting hand splint application during the 3:00 PM to 11:00 PM shift after evening care and remove after morning care with skin checks. Observation on 2/23/25 at 8:35 AM identified Resident #34 lying in bed, the right hand in a contracted position with no splint and no rolled washcloth applied. (Per the care plan, the resident should have a rolled washcloth after the splint is removed). A second observation on 2/23/25 at 10:12 AM identified Resident #34 was dressed in bed and the right hand was in a contracted position with no splint and no rolled washcloth applied. (Per the care plan, the resident should have the splint applied after morning care). Interview with NA #5 on 2/24/25 at 10:44 AM, Resident #34's nurse aide, identified she had provided and completed morning care for Resident #34. Interview with LPN #3 on 2/24/25 at 11:43 AM identified he was the assigned nurse for Resident #34 during the 7:00 AM to 3:00 PM shift. LPN #3 identified all required morning care had been completed for Resident #34. LPN #3 identified that Resident #34 had no refusals of care that morning and no significant history of refusal of care other than medications at times. A third observation on 2/24/25 at 12:09 PM with LPN #4 identified Resident #34 was in bed with no splint or rolled washcloth applied to the right hand. Interview with LPN #4 on 2/24/25 at 12:09 PM identified Resident #34 was in bed with no splint or rolled washcloth applied to the right hand. LPN #4 identified the assigned nurse aide was responsible for applying the splint. Subsequent to surveyor inquiry, the splint was placed by LPN #4 without difficulty. A subsequent interview with NA #5 on 2/24/25 at 12:10 PM identified, other than meals, Resident #34 did not refuse any care this morning (2/24/25). NA #5 further identified she was not regularly assigned to Resident #34, was unaware the resident required the use of a splint after morning care and had not referred to the care card prior to providing care. NA #5 further identified the Director of Rehabilitation had assisted with morning care this morning and mentioned obtaining something for Resident #34's right hand. Interview and review of the clinical record with the Director of Rehabilitation on 2/24/25 at 1:25 PM identified Resident #34 required a splint due to a contracture of the right hand. The Director of Rehabilitation identified she did assist with care earlier that morning and had observed that Resident #34's right hand was not clean and was going to look into the matter. The Director of Rehabilitation identified that rehabilitation services were responsible for the assessment and recommendation of the right hand splint for Resident #34. The Director of Rehabilitation further identified that the physician order for the right hand splint had been discontinued on 2/18/25, specifically by her, but she was unable to explain why she discontinued the order as Resident #34 needed the splint due to a contracture of the right hand. Interview with APRN #1 on 2/24/25 at 1:27 PM identified the physician order for the right hand splint should not have been discontinued as Resident #34 needed the splint and not having the splint could place the resident at risk for skin integrity issues and further contracture. The physician's order was reinstated on 2/24/25 that directed the application of the resting hand splint to the residents right hand on during the 3:00 PM to 11:00 PM shift after evening care and off after morning care with skin checks. Interview with the DNS on 2/25/25 at 7:54 AM identified she would expect nurse aide staff to ensure the residents right hand would kept clean and dry, and the splint would be applied according to rehabilitation recommendations. Interview with NA #7 on 2/25/25 at 1:27 PM identified she frequently provides care to Resident #34 during the 7:00 AM to 3:00 PM shift and is aware the resident requires the application of a splint on the right hand after morning care. NA #7 further identified she has not previously observed Resident #34 refusing to wear the splint. Additionally, NA #7 indicated she had not previously observed that the splint or washcloth was already in place on the resident's right hand at the beginning of the 7:00 AM to 3:00 PM shift. Interview with APRN #1 on 2/25/25 at 1:38 PM identified she would expect to be notified and have a discussion before splint discontinued. Review of the physician/APRN progress notes and nurses notes dated 2/1/25 through 2/18/25 failed to reflect Resident #34 refused the application of the right hand splint. Review of the Splints and Orthotic Devices policy directed splints were provided to maintain range of motion, ensure proper joint alignment, promote skin integrity and prevent further contracture. Therapy and/or physician will issue the appropriate positioning splint determined by resident need. A physician's order will be obtained for the positioning device and include the wearing schedule. The skin will be observed before and after the removal of the splints and documented on the TAR. The resident care plan and care card will reflect the use of the splint.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents, (Resident #46 and 74) reviewed for hospitalization, the facility failed to provide notice of bed-hold policy upon a hospital transfer specifying the duration of a bed-hold. The findings include: 1. Resident #46 had diagnoses that included type II diabetes, atrial fibrillation an history of acute kidney failure. The admission clinical record identified Resident #46 was self-responsible. Annual MDS dated [DATE] identified Resident #46 had moderate cognitive impairment. Facility documentation identified Resident #46 was hospitalized from [DATE] through 10/10/24, 11/21/24 through 12/1/24 and 12/10/24 through 12/13/24. Review of the clinical record failed to identify that a notice of bed-hold policy was provided to the resident upon each of the 3 transfers to the hospital. Interview and review of the clinical record with RN #7 on 2/25/25 at 12:17 PM identified the charge nurse or nursing supervisor were responsible provide the bed hold policy upon transfer to the hospital and retain a copy for the clinical record. Once admitted , the social worker was responsible to call the resident/representative to inform them of the bed hold policy. RN #7 was unable to provide documentation that the bed hold policy had been provided to Resident #46 or the resident representative at the time of each hospitalization. 2. Resident #74 was admitted to the facility on [DATE] with diagnoses that included hepatic encephalopathy, septic shock, and neuromuscular dysfunction of the bladder. The admission MDS dated [DATE] identified Resident #74 had intact cognition. Facility documentation dated 12/11/24 indicated Resident #74 was sent to the hospital and returned on 12/19/24. Further, Resident #74 was sent to the hospital on 2/7/25 and returned on 2/11/25. Interview and review of the clinical record with RN #7 on 2/25/25 at 12:17 PM identified Resident #74 had gone out to the hospital on [DATE] and 2/8/25 and staff were not able to find a copy of the facility discharge paperwork to the hospital or documentation that the bed hold policy was given to the resident upon transfer. RN #7 identified the charge nurse or supervisor were responsible to give the bed hold notice to the resident just prior to leaving the facility to go to the hospital and make a copy for the resident's clinical record. RN #7 indicated that if the resident is admitted to the hospital, then the social worker is responsible to call the resident or resident representative to inform them of the bed hold policy again and discuss payment. RN #4 indicated she and RN #2 (vice president of operations) were not able to find the facility bed hold policy. Although requested, a facility bed hold policy was not provided.

Based on clinical record review and staff interview for one of three residents (Resident #8) reviewed for care and services, the facility failed to ensure a urine sample was obtained timely in accordance with physician orders, and for one of three residents (Resident #7) reviewed for quality of care, the facility failed to ensure verbal orders were acted upon timely, and failed to ensure vital signs and neurological assessments were completed after an unwitnessed fall. The findings include: 1. Resident #8 had a diagnosis of varicella encephalitis and altered mental status. An admission MDS dated [DATE] identified Resident #8 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderately impaired cognition and required assistance with toileting and showering. The RCP dated 2/11/2023 identified Resident #8 was at risk for falls. Interventions directed to encourage to sit in common areas when restless and to provide activities. Physician order dated 2/13/2023 directed to obtain a urine culture. Nursing note dated 2/14/2023 at 4:24 AM identified unable to obtain urine sample for urinalysis/culture. Record review identified a urine culture specimen was obtained on 2/17/2023 (4 days after the order was given). Additional record review failed to identify additional attempts to obtain the urine sample prior to 2/17/2023. Interview and record review with MD #1 on 9/13/2024 at 11:40 AM identified although the urine order was given on 2/13 and the sample was not obtained until 2/17/2024, he was not concerned that the urine sample was not obtained prior to 2/17/2024. 2. Resident #7 had a history of bacteremia and dementia. Record review identified Resident #7 was readmitted to the facility during April 2024 with a diagnosis of septicemia. The quarterly MDS dated [DATE] identified Resident #7 had severe cognitive impairment, required assistance with transfers, was impulsive and was receiving antibiotics. The Resident Care Plan (RCP) dated 6/27/2024 identified Resident #7 required assistance with ADLs and transfers, and to avoid information overload. Interventions directed to assist with toileting as needed. Nursing note dated 7/12/2024 at 9:56 PM (written by RN #10) identified Resident #7 was sleeping in a chair and not responding to voice. Vital signs were taken, blood pressure was 80/40 (usual BP range was 120/80 for Resident #7). The APRN was notified and directed to put Resident #7 back in bed and elevate her/his legs. Resident #7 then became responsive and went back to baseline. Advanced Practice Registered Nurse (APRN) note dated 7/15/2024 identified new orders for blood work and indicated a urine culture was ordered after the unresponsive incident that occurred on 7/12/2024 and the urine results were not available to review. APRN order dated 7/15/2024 directed to obtain CBC and BMP. APRN note dated 7/16/2024 identified Resident #7's bloodwork was reviewed with stable results, pending urine culture results. Record review failed to identify a urine culture order was entered and failed to identify a urine sample was obtained prior to Resident #7's transfer to the hospital on 7/19/2024. Interview and record review with RN #10/shift supervisor on 8/22/2024 at 10:46 AM identified on 7/12/2024 toward the end of his shift he was called to Resident #7's room because the resident was unresponsive, and he identified Resident #7 had a low blood pressure. RN #10 notified the APRN and was informed that the incident was not uncommon for Resident #7. Further, RN #10 stated he could not recall if APRN #1 gave orders to collect a urine culture. Interview with APRN #1 on 8/22/2024 at 11:08 AM identified she received a was notified that Resident #7 was unresponsive on 7/12/2024. APRN #1 stated the unresponsive episode and low blood pressure was not unusual for Resident #7 due to his/her history of Parkinson's disease. APRN stated she directed to put Resident #7 back to bed and elevate his/her legs, and she was then notified the resident improved. APRN #1 stated she ordered a urine culture because in the past when Resident #7 had a low blood pressure he/she had a urinary tract infection (UTI). Further, she noted on 7/15 and 7/16/2024 the urine culture results were not received, and she did not speak with the nursing staff to inquire about the results. Interview with the Director of Nursing (DNS) and Corporate Clinical Nurse on 8/22/2024 at 1:50 PM identified the urine culture should have been obtained when the APRN gave verbal orders on 7/12/2024. Interview failed to identify why the urine sample was not obtained. Further, the expectation was that the APRN would follow up regarding the lack of results. a. Facility incident report dated 7/12/2024 at 10:45 PM identified Resident #7 was found on the floor by the bed by the maintenance staff (unwitnessed fall), and stated he/she had tried to get up alone. Resident #7 was awake, alert, able to stand with assistance, had no bruises or visible injuries, and stated he/she did not hit his/her head. The incident summary dated 8/14/2024 identified Resident #7 was assessed after the fall, and had no change in mobility or pain; no injury was identified. The nursing note dated 7/12/2024 at 11:24 PM identified maintenance found Resident #7 on the floor. Resident #7 was awake, able to answer simple questions, the bed was in the low position with the side rails up and the call bell in reach. An assessment identified no bruising or injuries were noted. Resident #7 stated he/she did not hit his/her head. Resident #7 was lifted onto his feet and pivoted to bed. The APRN and spouse were notified. Record review failed to identify vital signs and neurological signs were monitored after the unwitnessed fall on 7/12/2024. Interview and record review with RN #10 on 8/22/2024 at 12:52 PM identified although he completed an initial set of vital signs and a neurological assessment at the time of the fall, interview failed to identify any additional vital signs and neurological assessments were obtained after the fall on 7/12/2024 at 10:45 PM. RN #10 was unable to explain why the vital signs and neurological assessments were not completed. Interview and record review with the DNS and Corporate Clinical Nurse on 8/22/2024 at 1:50 PM identified vital signs and neurological assessments should be completed after an unwitnessed fall in accordance with facility policy. The DNS and Corporate Clinical Nurse were unable to provide documentation that vital signs and neurological assessments were completed after Resident #7's unwitnessed fall on 7/12/2024 and were unable to identify why they were not completed. Review of facility Falls Policy dated 8/19/22, directed in part, a resident who experiences an unwitnessed fall and is unable to accurately verbalize if he/she hit their head due to cognitive status, or experienced any type of head injury will have neurological checks instituted. Review of facility (undated) Neurological Assessment Policy, directed in part that any resident that experiences an unwitnessed fall and is unable to accurately verbalize if he/she hit their head or experienced any type of head injury will have neurological checks instituted and neurological checks will be completed every 15 minutes for the first hour, every hour for 4 hours, every 4 hours for the next 24 hours, and every shift for 48 hours after that. Based on review of the clinical record, facility documentation, facility policy and interviews for one of three residents (Residents #1) reviewed for abuse, the facility failed to follow a physician's order directing staff assistance of two (2) for care. The findings include: Resident #1's diagnoses included chronic pain, muscle weakness, difficulty in walking and anxiety disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors and required extensive assistance for bed mobility and total assistance for transfers. The Resident Care Plan dated 1/30/24 identified that Resident #1 required staff assistance with Activities of Daily Living (ADL's). Interventions included to assist as needed to meet toileting needs, incontinent care per policy and side rails per policy to assist with bed mobility. Review of the Concern Form (grievance) dated 5/3/24 and signed by the Social Worker and Administrator, identified that Resident #1 complained about care and when the NA rolled him/her onto their side, it was rough on the 3:00 PM to 11:00 PM shift on 5/3/24. The summary of findings indicated that Resident #1 had an air mattress that made it difficult to roll the resident in bed when the mattress pressure was not at the highest setting. It identified that the NA had to hold the resident up against the rail to change him/her due to the loss of air from the mattress. The actions taken indicated that the NA in question was to no longer care for Resident #1, the resident was to be a 2 person assist with all care and education was provided on air mattress settings while providing care. A physician's order dated 2/2/24 directed that Resident #1 was an assist of 2 for transfers and ADLs, 3 months prior to the Concern Form dated 5/3/24. Interview with Resident #1 on 9/3/24 at 2:23 PM identified that NA #1 was the only staff member in his/her room during the 5/3/24 incident where he/she reported rough care. Interview with NA #1 on 9/3/24 at 3:02 PM identified that on 5/3/24, Resident #1 was incontinent of urine and needed to be changed. She indicated she attempted to turn him/her but that it was very difficult, and he/she started yelling out and stated that she was hurting him/her. She stated that she was only half complete and needed to finish changing him/her, so she pushed him/her on their side again and he/she started yelling that they were going to fall out of bed. She identified that Resident #1 then accused her of throwing him into the bedrail, but she reported that the allegation was false, and she was just trying to provide care and was not forceful. She indicated that she always did Resident #1's care by herself because they were short staffed, despite being aware that he/she required 2 staff for assistance with ADL's. Interview with RN #2 on 9/4/24 at 1:28 PM identified that through his interviews with both Resident #1 and NA #1, NA #1 admitted she was alone giving Resident #1 care and Resident #1 only identified NA #1 as the staff member in the room that was rough with him/her. Review of Resident Care Card identified that Resident #1 was an assist of 2 for care. Interview with RN #3 (Regional DNS) on 9/4/24 at 1:13 PM identified that per physician's order dated 2/2/24, Resident #1 was an assist of 2 for transfers and ADLs, 3 months prior to the incident on 5/3/24 where the intervention was to have 2 staff for all care. She indicated that NA #1 should have had another NA with her in the room on 5/3/24 providing assistance with ADL's and care on Resident #1. Although requested, a policy on following physician's orders was not obtained.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) residents (Residents #1 and #2) reviewed for abuse, the facility failed to investigate allegations of abuse and neglect and failed to ensure an alleged accused staff member was removed from the schedule timely to ensure residents were protected from potential abuse. The findings include: 1. Resident #1's diagnoses included chronic pain, muscle weakness, difficulty in walking and anxiety disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors and required extensive assistance for bed mobility and total assistance for transfers. The Resident Care Plan dated 1/30/24 identified that Resident #1 required staff assistance with interventions that included to assist as needed to meet toileting needs, incontinent care per policy and side rails per policy to assist with bed mobility. Review of the Concern Form (grievance) dated 5/3/24 and signed by the Social Worker and Administrator, identified that Resident #1 complained about care and when the NA rolled him/her onto their side, it was rough on the 3:00 PM to 11:00 PM shift on 5/3/24. It identified that the NA had to hold the resident up against the rail to change him/her due to the loss of air from the mattress. The actions taken indicated that the NA in question was to no longer care for Resident #1, the resident was to be a 2 person assist with all care and education was provided on air mattress settings while providing care. Nursing note dated 5/3/24 at 11:01 PM identified that Resident #1 wanted to make a formal complaint. The note indicated that the resident was interviewed, and the concern form was delivered to the social worker's mailbox. Interview with NA #1 on 9/3/24 at 3:02 PM identified that on 5/3/24, around dinner time, Resident #1 was incontinent of urine and needed to be changed. She indicated she attempted to turn him/her but that it was very difficult, and the resident started yelling out and stated that she was hurting him/her. She stated that she was only half complete with the incontinent care and needed to finish changing him/her, so she continued care and placed the resident on their side and the resident started yelling again that he/she was going to fall out of bed. She identified that Resident #1 then accused her of throwing him/her into the bedrail. NA #1 identified that she was just trying to provide care and was not forceful. Interview and clinical record review with RN #2 on 9/3/24 at 1:06 PM identified that he was the nursing supervisor on the 3:00 PM to 11:00 PM shift on 5/3/24 and he filled out the Concern Form on Resident #1. He indicated that he spoke with Resident #1 who reported that NA #1 pushed him/her up against the bedrail roughly. Although he stated he then notified NA #1 that she was not to enter that room again, changed the assignment so she no longer was caring for Resident #1 and then filled out the Concern Form and put it in Social Worker (SW) #1's mailbox. He was unaware that NA #1 should have been sent home pending investigation. Although requested, neither a facility incident report or an investigation of the allegation was provided for surveyor review. The incident occurred around dinner time, review of the facility punch card for NA #1 identified that she was scheduled to work from 3:00 PM to 9:00 PM on 5/3/24 and her punches indicated she punched in at 3:05 PM and punched out at 9:12 PM. Interview with the Administrator on 9/3/24 at 3:32 PM identified that although he signed the 5/3/24 Concern Form for Resident #1 as complete. He was unsure why NA #1 was not sent home immediately after the allegation was made, and why the allegation of abuse was not fully investigated as it should have been. He stated that he didn't make any assumption as to what rough meant. 2. Resident #2's diagnoses included chronic pain, fibromyalgia (widespread pain, fatigue and cognitive symptoms) and anxiety disorder. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 was cognitively intact, exhibited no behaviors and required extensive assistance for bed mobility and transfers and was dependent on staff for toileting use. The Resident Care Plan dated 3/13/24 identified that Resident #2 required staff assistance with ADLs with interventions included to assist as needed to meet toileting needs and incontinent care per policy. Review of the Concern Form dated 4/25/24 and signed by the Social Worker and Administrator identified that lack of staffing was interfering with care and Resident #2 was made to sit in a wet brief for 5 and 7 hours. The summary/findings section and the recommendations/action taken sections were blank. Review of progress notes for April 2024 through May 2024 failed to identify the above concerns. Interview and facility documentation review with RN #1 (Regional Nurse) on 9/3/24 at 12:22 PM identified that the 4/25/24 Concern Form regarding Resident #2, and the 5/3/24 Concern Form regarding Resident #1 should have been treated as allegations of abuse and should have been fully investigated. She indicated that if a staff member is unsure of how to proceed with an allegation, that they should always reach out to the DNS and/or Administrator for guidance/direction and reported that all staff has been educated on abuse. She identified that she was unable to locate a facility investigation, or a reportable event related to the 4/25/24 Concern Form regarding Resident #2 or the 5/3/24 Concern Form for Resident #1. Interview and facility documentation review with the Administrator on 9/3/24 at 2:50 PM identified that although he signed the 4/25/24 Concern Form for Resident #2 as complete (undated signature) he was unsure why the allegation of abuse was not fully investigated. He identified that his expectation is that all allegations of abuse are taken seriously and investigated thoroughly. Interviews and documentation review failed to identify an investigation was initiated timely after the allegation dated 4/25/24. Review of facility Abuse Policy (undated) directed in part, to complete an investigation. The policy further directed the accused staff will be immediately suspended pending the findings of the investigation, and an investigation will be conducted.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) residents (Residents #1 and #2), reviewed for abuse, the facility failed to ensure the State Agency was notified timely of allegations of abuse or neglect. The findings include: 1. Resident #1's diagnoses included chronic pain, muscle weakness, difficulty in walking and anxiety disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors and required extensive assistance for bed mobility and total assistance for transfers. The Resident Care Plan dated 1/30/24 identified that Resident #1 required staff assistance with interventions that included to assist as needed to meet toileting needs, incontinent care per policy and side rails per policy to assist with bed mobility. Review of the Concern Form (grievance) dated 5/3/24 and signed by the Social Worker and Administrator identified that Resident #1 complained about care and when the NA rolled him/her onto their side, it was rough on the 3:00 PM to 11:00 PM shift on 5/3/24. The summary of findings indicated that Resident #1 had an air mattress that made it difficult to roll the resident in bed when the mattress pressure was not at the highest setting. It identified that the NA had to hold the resident up against the rail to change him/her due to the loss of air from the mattress. The actions taken indicated that the NA in question was to no longer care for Resident #1, the resident was to be a 2 person assist with all care and education was provided on air mattress settings while providing care. Review of the State Agency Reportable Events website on 9/4/24 failed to identify the allegation of abuse/neglect was reported to the State Agency. Interview with the Administrator on 9/3/24 at 3:32 PM identified that although he signed the 5/3/24 Concern Form for Resident #1 as complete (undated signature) he was unsure why the allegation was not reported to the State Agency, stating that he didn't make any assumption as to what rough meant. 2. Resident #2's diagnoses included chronic pain, fibromyalgia (widespread pain, fatigue and cognitive symptoms) and anxiety disorder. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 was cognitively intact, exhibited no behaviors and required extensive assistance for bed mobility and transfers and was dependent on staff for toileting use. The Resident Care Plan dated 3/13/24 identified that Resident #2 required staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. Review of the Concern Form dated 4/25/24 and signed by the Social Worker and Administrator identified that lack of staffing was interfering with care and Resident #2 was made to sit in a wet brief for 5 and 7 hours. The summary/findings section and the recommendations/action taken sections were blank. Review of progress notes for April 2024 through May 2024 failed to identify the above concerns. Review of the State Agency Reportable Events website on 9/4/24 failed to identify the allegation of abuse/neglect was reported to the State Agency. Interview and facility documentation review with RN #1 (Regional Nurse) on 9/3/24 at 12:22 PM identified that the 4/25/24 Concern Form regarding Resident #2, and the 5/3/24 Concern Form regarding Resident #1 should have been treated as allegations of abuse and should have been reported to the Stage Agency within 2 hours. She indicated that if a staff member is unsure of how to proceed with an allegation, that they should always reach out to the DNS and/or Administrator for guidance/direction and reported that all staff has been educated on abuse. She identified that she was unable to locate a facility investigation, or a reportable event related to the 4/25/24 Concern Form regarding Resident #2 or the 5/3/24 Concern Form for Resident #1. Interview and facility documentation review with the Administrator on 9/3/24 at 2:50 PM identified that although he signed the 4/25/24 Concern Form for Resident #2 as complete (undated signature) he was unsure why the allegation of abuse was not reported to the State Agency. He identified that his expectation is that all allegations of abuse are taken seriously, reported to the Stage Agency within 2 hours. Review of facility Abuse Policy (undated) directed in part, to notify the State Agency of allegations of abuse within two (2) hours. The policy further directed the accused staff will be immediately suspended pending the findings of the investigation, and an investigation will be conducted.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure that a resident was free from abuse when care was not stopped upon resident request. The findings include: Resident #1's diagnoses included chronic pain, muscle weakness, difficulty in walking and anxiety disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors and required extensive assistance for bed mobility and total assistance for transfers. The Resident Care Plan dated 1/30/24 identified that Resident #1 required staff assistance with interventions that included to assist as needed to meet toileting needs, incontinent care per policy and side rails per policy to assist with bed mobility. Review of the Concern Form (grievance) dated 5/3/24 and signed by the Social Worker and Administrator, identified that Resident #1 complained about care and when the NA rolled him/her onto their side, it was rough on the 3:00 PM to 11:00 PM shift on 5/3/24. The summary of findings indicated that Resident #1 had an air mattress that made it difficult to roll the resident in bed when the mattress pressure was not at the highest setting. The form identified that the NA had to hold the resident up against the rail to change him/her due to the loss of air from the mattress. The actions taken indicated that the NA in question was to no longer care for Resident #1, the resident was to be a 2 person assist with all care and education was provided on air mattress settings while providing care. Nursing note dated 5/3/24 at 11:01 PM identified that Resident #1 wanted to make a formal complaint. The note indicated that the resident was interviewed, and the concern form was delivered to the social worker's mailbox. Interview with Resident #1 on 9/3/24 at 2:23 PM identified that NA #1 was rough and when he/she asked her to stop pushing him/her, she continued to do so and pushed him/her right up against the bedrail. Resident #1 stated that he/she requested to speak with a nursing supervisor after the incident and stated they told RN #2 that they didn't want NA #1 caring for him/her ever again. Interview with NA #1 on 9/3/24 at 3:02 PM identified that on 5/3/24, around dinner time, Resident #1 was incontinent of urine and needed to be changed. She indicated she attempted to turn him/her but that it was very difficult, and the resident started yelling out and stated that she was hurting him/her. She stated that she was only half complete with the incontinent care and needed to finish changing him/her, so she continued care and placed the resident on their side and the resident started yelling again that he/she was going to fall out of bed. She identified that Resident #1 then accused her of throwing him/her into the bedrail. NA #1 identified that she was just trying to provide care and was not forceful. Interview and clinical record review with RN #2 on 9/3/24 at 1:06 PM identified that he was the nursing supervisor on the 3:00 PM to 11:00 PM shift on 5/3/24 and he filled out the Concern Form on Resident #1. He identified that he spoke with Resident #1 who reported that NA #1 pushed him/her up against the bedrail roughly. He stated he then notified NA #1 that she was not to enter the resident's room again. He changed the assignment so she no longer was caring for Resident #1 and then filled out the Concern Form and put it in Social Worker (SW) #1's mailbox. He identified that he did not assess Resident #1 for injuries and did not report the allegation of abuse to the DNS or the or send NA#1 home. Interview with SW #1 on 9/3/24 at 3:09 PM identified that RN #2 notified her of the allegation of roughness with Resident #1 on 5/4/24, the morning after the incident. She reported she went to see the resident right away and he/she reported that NA #1 pushed him/her roughly in the bed into the siderail. She indicated that the resident reported that NA #1 didn't explain any instructions and just pushed him/her. Interview with the Administrator on 9/3/24 at 3:32 PM identified that although he signed the 5/3/24 Concern Form for Resident #1 as complete (undated signature) he was unsure why NA #1 was not sent home immediately or the allegation of abuse was not fully investigated, stating that he didn't make any assumption as to what rough meant. He identified that his expectation is that all allegations of abuse are taken seriously and investigated thoroughly. Review of facility Abuse Policy (undated) directed, in part, that residents will be free from abuse, and the accused staff will be immediately suspended pending the findings of the investigation.

Based on clinical record review and staff interview for one of three residents (Resident #7) reviewed for quality of care, the facility failed to ensure the medical record was complete and accurate to include vital signs and neurological assessments after an unwitnessed fall. The findings include: Resident #7 was admitted to the facility with diagnoses of dementia. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #7 had severe cognitive impairment and required staff assistance with ADLs and transfers. The Resident Care Plan (RCP) dated 6/27/2024 identified Resident #7 required assistance with ADLs, transfers and was impulsive. Interventions directed to assist with ADLs, and transfers, and to avoid information overload. Facility incident report dated 7/12/2024 at 10:45 PM identified Resident #7 was found on the floor by the bed by the maintenance staff (unwitnessed fall), and stated he/she had tried to get up alone. Resident #7 was awake, alert, able to stand with assistance, had no bruises or visible injuries, and stated he/she did not hit his/her head. The nursing note dated 7/12/2024 at 11:24 PM identified maintenance found Resident #7 on the floor. Resident #7 was awake, able to answer simple questions, the bed was in the low position with the side rails up and the call bell in reach. An assessment identified no bruising or injuries were noted. Resident #7 stated he/she did not hit his/her head. Resident #7 was lifted onto his feet and pivoted to bed. The APRN and spouse were notified. Record review failed to identify vital signs and neurological signs were monitored after the unwitnessed fall on 7/12/2024. Interview and record review with RN #10 on 8/22/2024 at 12:52 PM identified although vital signs and a neurological assessment were completed at the time of the fall, and interview failed to identify the vital signs and neurological assessment obtained was documented in the medical record. RN #10 stated he should have documented the assessment and vital signs in the medical record and was unable to explain why he did not document them in the record. Interview and record review with the DNS and Corporate Clinical Nurse on 8/22/2024 at 1:50 PM identified vital signs and neurological assessments should be documented in the clinical record. Interview identified Resident #7 had dementia, and failed to identify why RN #10 did not document the vital signs and neurological assessment after the fall on 7/12/2024. Interview identified vital signs and neurological assessments should be completed in accordance with the facility policy, and the expectation was for the staff to document the vital signs and neurological assessments in the medical record. Review of facility (undated) Neurological Assessment Policy, directed in part that any resident that experiences an unwitnessed fall and is unable to accurately verbalize if he/she hit their head or experienced any type of head injury will have neurological checks instituted and neurological checks will be completed every 15 minutes for the first hour, every hour for 4 hours, every 4 hours for the next 24 hours, and every shift for 48 hours after that.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) residents (Residents #1 and #2) reviewed for abuse and neglect, the facility failed to ensure the residents were provided social services support timely after an allegation of abuse/neglect. The findings include: 1. Resident #1's diagnoses included chronic pain, muscle weakness, difficulty in walking and anxiety disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors and required extensive assistance for bed mobility and total assistance for transfers. The Resident Care Plan dated 1/30/24 identified that Resident #1 required staff assistance. Interventions included to assist as needed to meet toileting needs, incontinent care per policy and side rails per policy to assist with bed mobility. Review of the Concern Form (grievance) dated 5/3/24 and signed by the DNS and Administrator identified that Resident #1 complained about care and when the NA rolled him/her onto their side, it was rough on the 3:00 PM to 11:00 PM shift on 5/3/24. Review of social service notes for May 2024 failed to identify the 5/3/24 concern until 5/6/24 (3 days later) and failed to indicate further follow-up with Resident #1 on the concern after the 5/6/24 note. 2. Resident #2's diagnoses included chronic pain, fibromyalgia (widespread pain, fatigue and cognitive symptoms) and anxiety disorder. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 was cognitively intact, exhibited no behaviors and required extensive assistance for bed mobility and transfers and was dependent on staff for toileting use. The Resident Care Plan dated 3/13/24 identified that Resident #2 required staff assistance with ADLs. Interventions included to assist as needed to meet toileting needs and incontinent care per policy. Review of the Concern Form dated 4/25/24 and signed by the Social Worker and Administrator identified that lack of staffing was interfering with care and Resident #2 was made to sit in a wet brief for 5 and 7 hours. Review of social service notes for April 2024 and May 2024 failed to identify the above concerns. Interview with Social Worker #1 on 9/3/24 at 3:09 PM identified that following allegations of abuse or neglect, she is responsible to meet with the resident initially and then daily for 3 days to offer support and to evaluate the resident's mood. She is then required to document her interactions in the resident's clinical record. She indicated the documentation should be timely and she was unsure why there was only one entry on Resident #1 for the 5/3/24 allegation and no documentation on Resident #2 for the 4/25/24 allegation. Interview with Social Worker #2 (Regional) on 9/4/24 at 10:07 AM identified that there was no full-time Social Worker employed at the facility during the 4/25/24 and 5/3/24 Concern Form allegations, indicating that Social Worker #1 and herself had been filling in to meet the needs of the residents. She identified that after an allegation of abuse or neglect, the Social Worker is required to meet with the resident initially and then daily for at least 3 days and as needed and that the interactions should be documented in the clinical record timely. She indicated that the Social Worker is also responsible for documenting the resolution of the allegation in the resident's record. Social Worker #2 was unable to explain why the interaction with Resident #1 was untimely and there was no documented follow-up or resolution and why the allegation with Resident #2 was not mentioned in the social service notes. Review of the Director of Social Services job description revised 11/2020 directed, in part, that the Social Worker is responsible for fostering and maintaining inter-department communications and cooperation to ensure that issues are addressed and corrected, follows facility policy in regard to documenting grievances and resident complaints and ensures that the Grievance book is maintained and up to date. Review of the Grievance Procedure policy dated 11/2013 directed, in part, that the Social Worker will address the complaint/concern with the resident and/or responsible party and document in the resident's record in the Social Work section. The Social Worker will document the resolution and notification of the resolution to the resident/responsible party in the resident's record.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who was on a modified diet consistency due to missing teeth causing increased difficulty with chewing, the facility failed to ensure the resident was not served the wrong diet consistency of fruit to prevent the resident from choking. The findings include: Resident #1's diagnoses included schizoaffective disorder. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 required set up assistance for eating. The hospital discharge summary dated 8/5/24 identified Resident #1 was discharged to the facility on a regular diet. The hospital occupational therapy evaluation dated 8/2/24 identified Resident #1 was alert and oriented to person, time, and situation but disoriented to place. The evaluation indicated Resident #1 was completely independent with eating. The diet slip presented to the kitchen dated 8/5/224 identified Resident #1 was on a regular diet with mechanical soft texture and thin liquids. A physician's order dated 8/6/24 directed regular diet with mechanical soft texture and thin liquids. The Speech Therapy evaluation dated 8/6/24 identified Resident #1 preferred soft foods due to missing dentition and a regular diet trial demonstrated minimal to moderate prolonged mastication and bolus formation with moderate diffuse oral residue remaining after swallowing. The evaluation indicated a mechanical soft diet demonstrated reduced chewing time and decreased oral residue after swallowing, there were no signs of aspiration noted during the evaluation, and the recommendation was to continue with a diet of mechanical soft solids and thin liquids. Review if the wekly menu identified the supper meal for 8/6/24 was summer chili, mixed vegetables, cornbread, and fruit salad was the dessert for a regular consistency diet and peaches was the therapeutic substitute for a soft diet. The nurse's note dated 8/6/24 at 6:32 PM identified Resident #1 approached the nurse's station with a mouthful of fruit salad and verbalized I can't breathe. The note indicated staff assisted Resident #1 to spit out the remaining food, but Resident #1 was unable to fully clear the airway. The note identified Resident #1's oxygen saturation level decreased to 80% on room air which stabilized to 90% on four (4) liters of oxygen via nasal canula, the heart rate was in the 140-150s, an audible stridor was present on inspiration, and Resident #1 was unable to cough independently. The note identified the Advanced Practice Registered Nurse was notified and gave order to send Resident #1 to the Emergency Department. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, on 8/15/24 at 12:05 PM identified on 8/6/24 Resident #1 had chili and a cup of fruit for dinner. LPN #1 indicated after dinner Resident #1 approached her at the nurse's station stating, I can't breathe and pointed to his/her throat. LPN #1 explained she assisted Resident #1 to spit out the unchewed fruit, they walked back to the room, and Resident #1 continued to express there was more food in his/her throat, so she and a nurse aide attempted to assist Resident #1 to spit the food out. LPN #1 identified Resident #1's voice became raspy, the nurse aide summoned the Nursing Supervisor, the Heimlich was attempted without success, Resident #1 was unable to cough and became weaker, 911 was called, another nurse responded to assist. LPN #1 stated the two (2) Registered Nurses and she continued to attempt the Heimlich until the Emergency Medical Services arrived and took over care. LPN #1 indicated Resident #1 never lost consciousness. LPN #1 described the food that Resident #1 spit out was ground up chili, orange cantaloupe and green melon and she was not certain of the size of the pieces. Interview with the dietary manager on 8/15/24 at 12:30 PM identified the mixed fruit that was served on 8/6/24 for dinner was honeydew melon and pineapple mix, the size of the pieces was typically one (1) inch, and those items are prohibited on a mechanical soft diet. Interview with the Speech Language Pathologist on 8/15/24 at 12:50 PM identified honeydew melon and pineapple are considered regular texture, they should not be given to someone on a mechanical soft diet, and the peaches would have been an appropriate substitute. Interview with the Director of Nursing on 8/15/24 at 2:15 PM identified the facility staff did not follow the prescribed diet consistency for Resident #1 based on the description LPN #1 gave of the fruit. Although attempted, interviews with the 3-11PM Nursing Supervisor, the 3-11PM nurse aide, and the 3-11PM dietary aide were not obtained.

Based on clinical record review, facility documentation review and interviews for 12 of 27 residents (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) reviewed for medication administration, the facility failed to ensure medications were administered in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #16, #17, #18, #19, #20, #21, and #22) observed during medication administration, the facility failed to ensure medications administered timely. The findings include: A). Review of the facility reportable event dated 7/25/2022 identified while the facility was reviewing nurse performance for the 7/23/2022 evening shift, it was identified that 12 residents lacked signatures from RN #1 (charge nurse) on the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility investigation included an interview with RN #1, and RN #1 indicated if she did not sign off the medications on the E-MAR, then she did not administer the medications. The Medical Director and all residents responsible parties were updated, and RN #1 was removed from the schedule. All residents were assessed by their practitioner on 7/25/2022 with no ill effects noted. 1. A review of Resident #1's clinical record identified that he/ she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 6/2/2022 identified Resident #1 required pain management for moderate to severe pain. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented and required opioid medication. Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 0.25 ml (for moderate to severe pain) identified they were scheduled to be administered at 9:00 PM. Review of the E-MAR identified the [MEDICATION(S)] and [MEDICATION(S)] were not signed off in E-MAR to indicate they were administered. 2. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 4/8/2022 identified Resident #1 took medications to help alleviate anxiety, depression, and adverse behaviors and that Resident #2 was at risk for pain or discomfort due to [CONDITION(S)]. The quarterly MDS dated [DATE] identified that Resident #2 had severe cognitive impairment and required antidepressant medication. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the E-MAR identified the [MEDICATION(S)], [MEDICATION(S)], Senna, [MEDICATION(S)] and Acetaminophen were not signed off in E-MAR to indicate they were administered. 3. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 4/13/2022 identified Resident #3 had history of psychotic behaviors including delusions or hallucination related diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] identified that Resident #3 had mild confusion, and received antipsychotic and antidepressant. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the E-MAR identified the [MEDICATION(S)] and [MEDICATION(S)] were not signed off in E-MAR to indicate they were administered. 4. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 5/12/2022 identified Resident #4 was at risk for respiratory distress and ineffective breathing patterns, and pain related to chronic pain syndrome disease. Interventions directed to administer medications per physician orders. The Quarterly MDS dated [DATE] identified severe cognitive impairment with and Resident #4 received antidepressant and antipsychotic medications. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the E-MAR identified the medications were not signed to indicate they were administered. 5. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #5 had mild to moderate cognitive impairment, had a feeding tube, received a portion of total calories through a tube feeding, and received antidepressant medications. The RCP dated 6/28/2022 identified Resident #5 had a feeding tube to help improve and maintaining nutritional status due to anorexia and failure to thrive (inability to maintain weight and nutritional status), was at risk for dehydration, and had depression. Interventions directed to administer feed, medications, and G-tube flushes as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the E-MAR identified the liquid supplement tube feeding was started at 11:30 PM (two hours after the scheduled time). Further review identified Resident #5 was scheduled to receive [MEDICATION(S)] HCL 5 mg (for dementia) , and [MEDICATION(S)] F/C 15 mg (for depression) at 9 PM and were not signed off in E-MAR to indicate they were administered. 6. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 6/10/2022 identified that Resident #6 had a [CONDITION(S)] disorder and directed to administer medications as ordered. The Quarterly MDS dated [DATE] identified Resident #6 had mild to moderate cognitive impairment with and received antidepressant and antianxiety medication. Resident #6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 5/7/2022 identified Resident #7 was at risk for respiratory compromise related to [CONDITION(S)] and had anxiety or was restless at times. Interventions directed to administer medications as ordered. The Quarterly MDS dated [DATE] identified that Resident #7 had moderately impaired cognition and received antidepressant medications. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS dated [DATE] identified Resident #8 had moderate cognitive and received antidepressant medication. The RCP dated 7/2/2022 identified Resident #8 was at risk for pain [CONDITION(S)] (feeling like pins and needles in hands and feet) and had increased agitation at times. Interventions directed to administer medications as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 9. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] identified that Resident #9 had mild to moderate cognitive impairment and received antidepressant medication. The RCP dated 7/6/2022 identified Resident #9 had dementia and received medications to help alleviate anxiety. Interventions directed to administer medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 10. Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 5/9/2022 identified Resident #10 had decline in memory, judgment, decision making and thought process due to delusional disorder and dementia. Interventions directed to administer medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #10 had moderate cognitive impairment and received antipsychotic and antidepressant medication. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 11. Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS dated [DATE] identified Resident #10 had moderately impaired cognition and antipsychotic and antidepressant medications. The RCP dated 7/20/2022 identified Resident #11 had dementia, was at risk for pain, was unable to verbalize pain due to cognitive impairment and received scheduled mediations for [CONDITION(S)] (pain). Interventions directed to administer medications as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 12. Resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] identified Resident #12 was alert and oriented and received antipsychotic and antidepressant medications. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview, clinical record review and facility documentation review with RN #1 on 8/11/2022 at 11:30 AM identified on 7/23/2022 during the 9 PM medication administration pass she became ill and could not complete the medication pass for all the residents. RN #1 indicated she had given report and her keys to the 3 to 11 PM shift supervisor (RN #2) at approximately 9:30 PM. She notified the DON, and the DON came into work at approximately 10 PM (the DON sent RN #1 home). She further indicated that she had administered one narcotic to one resident during the 9 PM medication pass but did not sign the E-MAR to indicate she had given the medication because she was ill. Interview, clinical record review and facility documentation review with RN #2 on 8/11/2022 at 12:42 PM identified that he called the DNS at approximately 9:30 PM when he noticed that RN #1 was ill. He identified that he took the narcotic and medication cart keys from RN #1 and secured the medications. RN #2 further indicated that RN #1 may not have been able to complete the medication pass, and he gave the unit keys to the DON when the DON arrived at the facility about 10 PM. On 8/11/22 at 1:41 PM interview with RN #3 (oncoming nurse at 11 PM on 7/23/2022) identified there was no discrepancy with the narcotic count, and while doing her usual tour of the unit following report, she noticed the gastric feeding (G-tube feeding) for Resident #5 was not hung (ordered to start at 9:30 PM). She checked the E-MAR, saw that it was not signed off (indicated not started) and initiated the feeding at approximately 11:30 PM. RN #3 further indicated she received report from the DON and was not informed any residents did not receive their scheduled 9 PM and 10 PM medications, which resulted in no additional monitoring for safety and adverse effect, for the 12 residents who had medications omited. Interview, clinical record review and facility documentation review with the DON on 8/11/2022 at 3:08 PM identified RN #1 had told her that she had not completed the medication administration. The DON indicated although the E-MAR shows resident names and medications due during the time frame (9 to 10 PM) and would also show a signature sign off if medications were already administered, she indicated that she could not determine what medications were given by RN #1 and she did not administer any of the medications without signatures on the E-MAR. The DON indicated although she drove RN #1 home due to illness, she did not ask RN #1 if the medications were administered; she indicated she was not sure if RN #1 would be a reliable source since she was not feeling well. The DON further identified although most of the residents could have been asked (9 out of 12 residents were alert and oriented or had mild/moderate cognition impairment), that she did not notify the physician prior to 7/25/2022 because she could not determine if the medications were administered or not. The DON did not inquire or investigate if the medications that were not signed off on the E-MAR were given until 7/25/2022 (2 days later). Twelve resident's medications were not administered timely, including antiseizure, antipsychotic, and antidepressant medications, and a gastric tube feeding was not administered timely. Review of the facility General Dose Preparation and Medication Administration Policy, dated 12/1/2007, directed in part, to document medication administration when a medication is administered, and to administer medications within the time frame specified. B). Observations on 8/22/2022 at 10:20 AM identified LPN #8 was passing resident medications. Interview and review of the resident's Medication Administration Records (MARs) identified the following medications were scheduled and were not yet administered: 1. Resident #14's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #15's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident #16's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. 4. Resident #17's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Resident #18's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Resident #19's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Resident #20's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Resident #21's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 9. Resident #22's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview with LPN #8 identified the listed medications were due to be administered at 9 AM, and they would be considered late if they were administered after 10 AM. She further indicated she was unfamiliar with the residents on the unit and many residents had multiple medications which caused her to be late. LPN #8 indicated she notified her supervisor, and another nurse was helping to complete the remaining medications. An interview with the DON on 8/22/2022 at 3:00 PM identified that scheduled medications should be given as ordered by the physician within the specified time frames for medications, and if a nurse was unable to complete medication administration timely they should ask for help. The DON further indicated that medications should be administered within one hour after the scheduled time to ensure residents receive their medications on time. No facility policy was provided during survey for surveyor review.

Based on clinical record review, facility documentation review and interviews for 12 of 27 residents (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) who were reviewed for medication administration, the facility failed to ensure the physician was notified timely when medication administration due at 9 and 10 PM on 7/23/2022 was not completed timely, in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility reportable event dated 7/25/2022 identified while the facility was reviewing nurse performance for the 7/23/2022 evening shift, it was noted that 12 residents lacked signatures from RN #1 on the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility investigation included an interview with RN #1, and RN #1 indicated, if she did not sign off the medications on the E-MAR, then she did not administer the medications. The Medical Director and all residents' responsible parties were updated, and RN #1 was removed from the schedule. All residents were assessed by their practitioner on 9/25/2022 with no ill effects noted. Additional review of facility documentaiton failed to identify the physician was notified prior to 7/25/2022, two (2) days after the omited medications. 1. A review of Resident #1's clinical record identified that he/she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 6/2/2022 identified Resident #1 required pain management for moderate to severe pain. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented and required opioid medication. Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 0.25 ml (for moderate to severe pain) identified they were scheduled to be administered at 9:00 PM. Review of the E-MAR identified the [MEDICATION(S)] and [MEDICATION(S)] were not signed off in E-MAR to indicate they were administered. 2. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 4/8/2022 identified Resident #1 took medications to help alleviate anxiety, depression, and adverse behaviors and that Resident #2 was at risk for pain or discomfort due to [CONDITION(S)]. The quarterly MDS dated [DATE] identified that Resident #2 had severe cognitive impairment and required antidepressant medication. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the E-MAR identified the [MEDICATION(S)], [MEDICATION(S)], Senna, [MEDICATION(S)] and Acetaminophen were not signed off in E-MAR to indicate they were administered. 3. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 4/13/2022 identified Resident #3 had history of psychotic behaviors including delusions or hallucination related diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] identified that Resident #3 had mild confusion, and received antipsychotic and antidepressant. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the E-MAR identified the [MEDICATION(S)] and [MEDICATION(S)] were not signed off in E-MAR to indicate they were administered. 4. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 5/12/2022 identified Resident #4 was at risk for respiratory distress and ineffective breathing patterns, and pain related to chronic pain syndrome disease. Interventions directed to administer medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #4 received antidepressant and antipsychotic medications. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the E-MAR identified the medications were not signed to indicate they were administered. 5. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #5 had mild to moderate cognitive impairment, had a feeding tube, received a portion of total calories through a tube feeding, and received antidepressant medications. The RCP dated 6/28/2022 identified Resident #5 had a feeding tube to help improve and maintaining nutritional status due to anorexia and failure to thrive (inability to maintain weight and nutritional status), was at risk for dehydration, and had depression. Interventions directed to administer feed, medications, and G-tube flushes as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the E-MAR identified the liquid supplement tube feeding was started at 11:30 PM (two hours after the scheduled time). Further review identified Resident #5 was scheduled to receive [MEDICATION(S)] HCL 5 mg (for dementia), and [MEDICATION(S)] F/C 15 mg (for depression) at 9 PM and were not signed off in E-MAR to indicate they were administered. 6. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 6/10/2022 identified that Resident #6 had a [CONDITION(S)] disorder and directed to administer medications as ordered. The Quarterly MDS assessment dated [DATE] identified Resident #6 had mild to moderate cognitive impairment with and received antidepressant and antianxiety medication. Resident #6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 5/7/2022 identified Resident #7 was at risk for respiratory compromise related to [CONDITION(S)] and had anxiety or was restless at times. Interventions directed to administer medications as ordered. The Quarterly MDS dated [DATE] identified that Resident #7 had moderately impaired cognition and received antidepressant medications. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS assessment dated [DATE] identified Resident #8 had moderate cognitive and received antidepressant medication. The RCP dated 7/2/2022 identified Resident #8 was at risk for pain [CONDITION(S)] (feeling like pins and needles in hands and feet) and had increased agitation at times. Interventions directed to administer medications as per physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 9. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] identified that Resident #9 had mild to moderate cognitive impairment and received antidepressant medication. The RCP dated 7/6/2022 identified Resident #9 had dementia and received medications to help alleviate anxiety. Interventions directed to administer medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 10. Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 5/9/2022 identified Resident #10 had decline in memory, judgment, decision making and thought process due to delusional disorder and dementia. Interventions directed to administer medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #10 had moderate cognitive impairment and received antipsychotic and antidepressant medication. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 11. Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS assessment dated [DATE] identified Resident #10 had moderately impaired cognition and antipsychotic and antidepressant medications. The RCP dated 7/20/2022 identified Resident #11 had dementia, was at risk for pain, was unable to verbalize pain due to cognitive impairment and received scheduled mediations for [CONDITION(S)] (pain). Interventions directed to administer medications as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 12. Resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] identified Resident #12 was alert and oriented and received antipsychotic and antidepressant medications. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview, clinical record review and facility documentation review with RN #1 on 8/11/2022 at 11:30 AM identified that she arrived at work approximately 4:30 PM and about 2 to 3 hours into her shift she started to feel ill. RN #1 indicated during the 9 PM medication administration pass she became ill and could not complete the medication pass for all the residents. RN #1 indicated she had given report and her keys to the 3 to 11 PM shift supervisor (RN #2) at approximately 9:30 PM, she notified the DON, and the DON came into work at approximately 10 PM (the DON sent RN #1 home). She further indicated that she had administered one narcotic to one resident during the 9 PM medication pass but did not sign that she had given the medication because she was ill. Interview, clinical record review and facility documentation review with RN #2 on 8/11/2022 at 12:42 PM identified that he called the DNS at approximately 9:30 PM when he noticed that RN #1 was ill. He identified that he took the narcotic and medication cart keys from RN #1 and secured the medications. RN #2 further indicated that RN #1 may not have been able to complete the medication pass, and he gave the unit keys to the DON when the DON arrived at about 10 PM. On 8/11/22 at 1:41 PM interview with RN #3 (oncoming nurse at 11 PM on 7/23/2022) identified on 7/23/2022 she received report from the DON and was not informed any residents did not receive their scheduled 9 PM and 10 PM medications. Interview, clinical record review and facility documentation review with the DON on 8/11/2022 at 3:08 PM identified RN #1 had told her that she had not completed the medication administration. The DON indicated although the E-MAR shows resident names and medications due during the time frame (9 to 10 PM) and would also show a signature sign off if medications were already administered, she indicated that she could not determine what medications were given by RN #1 and she did not administer any of the medications without signatures on the E-MAR. The DON indicated although she drove RN #1 home due to illness, she did not ask RN #1 if the medications were administered; she indicated she was not sure if RN #1 would be a reliable source since she was not feeling well. The DON further identified although most of the residents could have been asked (9 out of 12 residents were alert and oriented or had mild/moderate cognition impairment), that she did not notify the physician prior to 7/25/2022 because she could not determine if the medications were administered or not. The DON did not inquire or investigate if the medications that were not signed off on the E-MAR were given until 7/25/2022 (2 days later), and the physician was not notified. Interview and clinical record reviews with the Medical Director (attending physician for the residents) on 8/11/2022 at 4:03 PM identified he was notified on 7/25/2022 of the incident on 7/23/2022 (2 days after the medications were not signed as administered), and on 7/25/2022 he performed exams for all the Residents who did not receive their scheduled medications. The Medical Directed indicated that he should have been updated at the time of incident on 7/23/2022 and he would have wanted to know to assess the residents if any adjustments were necessary to ensure the residents safety and continuity of care. Twelve resident's medications were not administered timely, including antiseizure, antipsychotic, and antidepressant medications, and a gastric tube feeding was not administered timely. The physician was not notified until 7/25/2022, two (2) days after the incident. A review of the facility Notification Policy dated October 2015, directed in part, the resident's physician should be made aware of any significant change in condition that may affect the resident's physical, mental, or emotional status. If the physician is not available, then the associate should be called. A review of the undated facility Medication Error Policy directed in part, all medication errors will be reported to the physician.

Based on clinical record review, interviews, review of facility documentation, and review of facility policy and procedure for 2 of 4 residents reviewed for abuse/neglect (R #25 and R #41), the facility failed to ensure that resident's received the necessary care and services to prevent neglect. The findings include: 1. Resident #25's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified the resident without cognitive impairment, required limited assistance with toilet use and extensive assistance with personal hygiene, was frequently incontinent of bladder and occasionally incontinent of bowel. 2. Resident #41's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified the resident with severely impaired cognition, required extensive assistance with toileting and personal hygiene, was frequently incontinent of bladder and always incontinent of bowel. Review of facility reportable event documentation and investigation dated 6/1/16 identified that on 5/29/16 at 7:30 AM, NA #2 and NA #4 reported that before breakfast, residents were found with pads, briefs and beds saturated in urine. This wasn't one or two residents, it was about 10. Further review of NA#4's written statement noted that there was an enormous stench of urine in some of the rooms. The facility investigation noted that when NA #2 went into R #41's room, the resident was noted to be visibly upset, crying and saturated in urine. NA#4 reported that R#25 informed him/her that no one had been in to provide care all night. An interview with R#25 conducted by the former DNS on 6/1/16 and documented in the investigation noted that no one had offered toileting or incontinent care of any kind all night on the 29th. The resident indicated that s/he was very upset at having been left in such a condition. Interview with NA #2 on 12/5/16 at 12:15 PM identified while starting first morning rounds on 5/29/16, he/she went into R #41's room and the resident visibly upset, crying, and saturated in urine. NA # 2 indicated although he/she immediately reported the incident to the nurse, NA # 2 was unable to remember who she/he reported it to. Interview and review of the reportable event with the previous DNS on 12/6/16 at 9:50 AM noted if the allegation of abuse/neglect was reported to him/her, he/she would have initiated an investigation, obtained statements, and removed the alleged staff member pending the investigation. The previous DNS identified she/he could not recall when he/she was notified of the allegation, but indicated if the dates on the reportable event form and facility investigation documentation identified 6/1/16, then that was when he/she became aware of the allegation and initiated an investigation (3 days after the neglect was reported to licensed staff). Multiple Attempts to interview NA #1 (the 11 PM - 7 AM NA assigned to provide care to the residents) were unsuccessful. Interview and review of the reportable event form with the DNS on 12/6/16 at 8:50 AM indicated when an allegation of abuse/neglect is reported, the facility will immediately initiate an investigation, remove the staff member involved, notify the appropriate state agencies, families and/or responsible parties. Additionally if there is an allegation of neglect/care not being provided nursing should conduct a body/skin assessment at that time, and document those findings in the clinical record. The clinical record failed to reflect that a body/skin assessment had been completed subsequent to the allegation of neglect. Facility policy and procedure for abuse identified allegations of abuse by any individual (staff, family, visitor, resident) toward a resident must be reported immediately to a facility supervisor. Anyone witnessing, and/or having knowledge of abuse/mistreatment of [REDACTED]. A accident/incident report will be completed, a description of the incident will be documented in the residents nursing notes, the DNS or designee shall notify the resident's family, physician, Department of Public Health, and local police. The individual accused will be immediately suspended pending the findings of the investigation.

Based on observation, clinical record review and interviews for one of three residents (Resident#32) reviewed for pressure ulcers, the facility failed to provide the necessary treatment and services to prevent the development of a pressure ulcer and/or for one of three residents (Resident#93) reviewed for activities of daily living, the facility failed to provide proper incontinent care. The findings include: 1. Resident#32's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified severely impaired cognitive skills, required total dependence for most activities of daily living and did not have a history of falls. The care plan dated 4/20/15 identified self-care deficit with interventions which included assist of two with mechanical lift for all transfers, non-ambulatory and provide daily personal hygiene needs. The nurse's note dated 6/12/15 at 11:00PM identified Resident #32 was found on the floor with the right leg bent and internally rotated. The resident was transferred to the emergency room for an evaluation and a right closed proximal tibial fracture was identified. The interagency referral form dated 6/15/15 identified the resident was not a surgical candidate and returned to the facility with recommendations to maintain a right leg immobilizer, pain management and follow-up visit with the orthopedic physician in one week. The June 2015 - September 2015 treatment records identified the right leg was elevated on a pillow with the immobilizer was in place. The nurse's note dated 9/22/15 identified the presence of an unstageable pressure ulcer on the right ankle upon removal of the immobilizer. The pressure ulcer measured 7cm by 6.5cm with 95% soft black eschar, 5% slough and was malodorous. The physician directed to cleanse the area with Normal Saline followed by Santyl (a wound debrider) then cover with a AGB dressing daily. Clinical record review and interview with the DNS on 11/13/15 at 9:30AM identified the responsible party declined the orthopedic consultation on 6/23/15 and an X-ray of the right leg was obtained and faxed to the orthopedic physician's office on 6/23/15. Review of the clinical record failed to reflect directions for the care/handling of the right leg immobilizer after 6/23/15 when the resident was to be seen by the orthopedic surgeon. Interview with LPN#2 on 11/12/15 at 3:30PM identified the physician's orders [REDACTED]. LPN#2 identified Resident #32 was provided bed baths, weekly skin checks which did not include checking the skin beneath the immobilizer and was provided daily care including getting out of bed to a wheelchair. Interview with the DNS on 11/13/15 at 9:30AM identified it was the responsibility of the RN Supervisor to follow through on the orders for the right leg immobilizer following the results of the X ray on 6/23/15. The DNS further identified the Infection Control Nurse (ICN) observed the right leg immobilizer on 9/22/15 was still on the resident (three months after being applied) at which time he/she inquired about its removal and care. The DNS identified that follow up instructions were not obtained from the orthopedic surgeon or the attending physician. MD#1(attending physician) was notified and directed to obtain an X-ray of the right leg which identified a healed fracture. MD #1 indicated the pressure ulcer on the right ankle was caused by the right leg splint (immobilizer). Interview with NA #7 on 11/13/15 at 9:55AM identified the right leg immobilizer extended from below the knee to the ankle and was not removed for care from June 2015 through September 2015.Interview with the MD#2 (orthopedic physician) on 11/13/15 at 11:30AM identified if the facility contacted him/her about the care/handling of the right leg immobilizer beyond 6/23/15, he/she would direct the daily opening and closing of the immobilizer to inspect the skin underneath the immobilizer. MD#2 identified daily skin inspections are necessary since soft tissue is vulnerable to the development of pressure ulcers. 2. Resident#93's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified moderately impaired cognitive skills, required extensive assistance for transfers, ambulation, toilet use and personal hygiene, was incontinent of bowel and bladder and the presence of a Stage II pressure ulcer. A care plan dated 11/11/15 identified incontinence with interventions which included assist with peri care as needed after incontinent episodes, utilize a brief for dignity, apply barrier cream after each peri care and check skin for reddened areas for any signs of breakdown and report changes to physician. Observation of incontinent care on 11/9/15 at 2:30PM identified the presence of fecal incontinence with NA#1 providing incontinent care. NA#1 was observed to wipe the resident front to back with moistened wash cloths and once the cleaned, patted the area dry. Further observation identified the resident's scrotal area was reddened and the resident would yell when the area was touched or moved. A pressure ulcer dressing covered the coccyx area and was observed with fecal matter. NA#1 then removed the dressing and indicated the nurse will be notified. However, before a clean brief could be applied, the resident had another episode of fecal incontinence. NA#1 then moistened a wash cloth and wiped the resident front to back once and patted the area dry. Despite obvious signs of fecal matter, NA#1 applied barrier cream on the resident's buttock and started to apply the clean brief. Upon surveyor intervention, the resident was provided incontinent care until all fecal matter was removed and with application of barrier cream followed by a clean brief. Interview with NA#1 on 11/9/15 at 3:15PM identified he/ she was new in her position and was nervous. NA#1 further identified he/she had to finish incontinent care in a speedy manner due to the resident's history of agitation and yelling during incontinent care. Review of the facility's policy on incontinent care identified incontinent care is provided to promote cleanliness, prevent infection, body odor and skin breakdown.

Based on clinical record reviews, review of facility documentation and interviews for 2 of 6 residents reviewed for accidents (R#35, 160), the facility failed to ensure that the resident received adequate supervision and/or appropriate assistance to prevent accidents/injuries. The findings include: 1. Resident #160 ' s [DIAGNOSES REDACTED]. The admission minimum data set ((MDS) dated [DATE] documented that the resident was moderately impaired cognitively, required extensive assistance from staff for toileting, and other activities of daily living (ADL), and had no falls. The fall risk assessment dated [DATE] identified the resident was at high risk for falls. The care plan dated 12/16/11 identified that the resident had a deficit with performing ADLs. Interventions included assisting the resident to a safe position while performing daily dressing and hygiene. The nurse aide care card directed use of bed and chair alarms. Facility investigation dated 1/23/12 indicated that R#160 was alone in the bathroom at 2:30 PM and was found on the floor with complaints of pain. He/she was transferred to the hospital and was admitted to the hospital with [REDACTED]. An interview with NA#6 on 12/12//12 at 1PM indicated that he/she recalls taking the resident to the bathroom and leaving the resident in the bathroom (alone) to answer a call light. An interview with RN #4 on 12/12/12 at 1:30PM indicated that the resident should not have been left alone because the resident was a high risk for falls and that he/she had a tendency to lean forward when sitting up. Interview with the DNS on 12/13/12 at 1PM indicated that the chair alarm was used to alert staff when the resident leaned forward. 2. Resident #35 ' s [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] indicated that the resident was severely impaired cognitively, and was totally dependent on the nursing staff for all activities of daily living (ADL). A nursing assessment dated [DATE] indicated that the resident required two staff to turn in bed and required constant supervision with transfers. Nursing notes dated 4/3/12 indicated that the resident was found with an open area on the left hip. Review of the medication administration record for April 2012 noted that from 4/11 through 4/20/12 the resident complained of severe pain to the left hip. Facility investigation/documentation dated 4/17/12 indicated that the resident was found with a yellow discoloration and pain to the left hip. A radiology report dated 4/20/12 indicated that the resident sustained [REDACTED]. Interview with RN#4 indicated that the resident was completely immobile and rarely ever got out of the bed. RN#4 indicated that the resident was receiving all care in bed up until April 2012 when staff started getting him/her out of bed for weekly showers. RN #4 indicated that the resident started to complain of severe pain to the left lower extremity after the staff started getting the resident out of bed for weekly showers. An interview with MD #1 on 12/13/12 at 4pm indicated that the x-ray indicated a new/recent fracture to the left hip that was a likely caused by trauma and not pathological.

Based on clinical record review and interview for the only sampled resident reviewed for hydration (R# 121), the facility failed to assess the resident's fluid needs appropriately, and/or failed to develop interventions to prevent dehydration, and/or failed to assess the resident for signs and symptoms of dehydration. The findings include: Resident # 121 [DIAGNOSES REDACTED]. A significant change minimum data assessment dated [DATE] identified the resident with a BIMS score of 11 ( moderately impaired cognition), limited assist with eating, and weight loss of 5% in the last month or 10% in the last 6 months. A resident care plan dated 10/17/12 identified a problem with weight loss. Interventions included offer favorite foods and encourage adequate dietary intake. Review of a weight record noted the resident's weight on 7/24/12 (admission) was 165 lbs. On 10/10/12 the resident's weight was 142.4 lbs (14% weight loss in 3 months). A nutritional assessment dated [DATE] noted the resident's estimated fluid needs were 1120 cc in 24 hours. A lab report dated 9/6/12 noted a BUN level of 26 (7-25), creatinine level of 1.09 (.6-.88). Review of Intake and Output reports noted the following: From October 9, 2012 through October 28, 2012 intake and output monitoring was lacking. October 31, 2012 the resident's intake was 540 cc November 1. 2012 840 cc November 2, 3, 4, and 5, 2012 were blank with no intakes recorded A nurse's note dated 10/5/12 noted the resident had no signs or symptoms of dehydration. No further hydration assessments were noted in the clinical record. Meal intake records indicated the residents intake in October 2012 ranged from 0% to 25% on 47 of the 90 occasions. The resident was transferred to a behavioral health hospital for increasing behaviors and the history and physical examination [REDACTED]. The resident had a 22 pound weight loss in the last 30 days. He/she had a significant elevation in BUN and creatinine. He/she was transferred to acute care for further monitoring. The residents BUN was 45 ( 7-25) and creatinine was 1.7 (.6-.88). The resident appeared volume depleted (on admission) and was placed on IV fluids. A hospital discharge [DIAGNOSES REDACTED]. An interview and review of the clinical record with the dietician on 12/13/10 at 10:10 AM indicated residents fluid goal is based on the residents "ideal" body weight and not the actual weight. She decreased the 25 cc of fluid per kilogram of body weight to 20 cc of fluid per kilogram of body weight because the resident had a [DIAGNOSES REDACTED]. At that time she indicated she was aware of the resident's decreased appetite in October 2012, but was not aware the the resident had a decreased fluid intake. Although interventions were in place to address the resident's weight loss, she did not develop a plan and/or interventions to prevent dehydration. An interview on 12/13/12 at 1:18 PM with the DNS indicated there was no I & O documentation from 10/9/12 through 10/28/12 because it had been discontinued. At that time she indicated she was not aware why his/her intake monitoring was discontinued and should have been monitored because his/her intakes were poor. Review of a facility hydration protocol indicated the resident's fluids needs may need to be reassessed following a significant change in status related to hydration/weight. Resident's at risk will have appropriate interventions on their care plan.