Every finding on record at Apple Rehab Shelton Lakes

Based on review of the clinical records, facility documentation, facility policy, and staff interviews, for 8 of 8 residents (Residents #4, Resident #5, Resident #7, Resident #70, Resident #81, Resident #109, Resident #110, and Resident #112) reviewed for advance directives, the facility failed to ensure the medical records contained appropriate provider documentation to support a physician's order authorizing a Registered Nurse (RN) to pronounce death. Specifically, the medical records lacked provider documentation indicating the residents' deaths were anticipated and that RN pronouncement of death was appropriate. The findings include:1.Resident #4's diagnoses included hemiplegia, type 2 diabetes mellitus, and dysphagia.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was severely cognitively impaired.A physician's order dated 6/11/26 directed staff to perform chest compressions, administer intravenous fluids (IVF), provide artificial nutrition, and transfer Resident #4 to the hospital if resuscitation was required as a life saving measure. A physician's order dated 6/11/26 also authorized a Registered Nurse (RN) employed by the facility to pronounce Resident #4's death should it occur.Review of the clinical record failed to provide documentation by a provider indicating Resident #4's death was anticipated and that an RN pronouncement of death was appropriate.Subsequent to surveyor's inquiry, a physician's order dated 7/15/26 at 11:25 AM discontinued the authorization for a Registered Nurse (RN) employed by the facility to pronounce Resident #4's death should it occur.2. Resident #5 diagnoses included high blood pressure, hip fracture healing, and generalized weakness.The quarterly MDS assessment dated [DATE] identified Resident #5 was severely cognitively impaired.A physician's order dated 5/8/26 authorized a RN employed by the facility to pronounce Resident #5's death should it occur. A physician's order renewed on 7/15/26 at 3:14 PM directed staff to perform chest compressions, administer intravenous fluids (IVF), provide artificial nutrition, and transfer Resident #5 to the hospital if resuscitation was required as a life saving measure.Review of the clinical record failed to provide documentation by a provider indicating Resident #5's death was anticipated and that an RN pronouncement of death was appropriate.Subsequent to surveyor's inquiry, a physician's order dated 7/15/26 at 11:26 AM discontinued the authorization for a Registered Nurse (RN) employed by the facility to pronounce Resident #5's death should it occur.3. Resident #7 diagnoses included chronic kidney disease with dialysis dependence, heart failure, and type 2 diabetes.The quarterly MDS assessment dated [DATE] identified Resident #7 was cognitively intact.A physician's order dated 6/11/26 directed staff to perform chest compressions, administer intravenous fluids (IVF), provide artificial nutrition, and transfer Resident #7 to the hospital if resuscitation was required as a life saving measure. A physician's order dated 6/11/26 also authorized a Registered Nurse (RN) employed by the facility to pronounce Resident #7's death should it occur.Review of the clinical record failed to provide documentation by a provider indicating Resident #7's death was anticipated and that an RN pronouncement of death was appropriate.Subsequent to surveyor's inquiry, a physician's order dated 7/15/26 at 12:01 PM discontinued the authorization for a Registered Nurse (RN) employed by the facility to pronounce Resident #7's death should it occur.4. Resident #70 diagnoses included intellectual disabilities, post-traumatic stress disorder (PTSD), and depressive episodes.The quarterly MDS assessment dated [DATE] identified Resident #70 was moderately cognitively impaired.A physician's order dated 6/11/26 directed staff to perform chest compressions, administer intravenous fluids (IVF), provide artificial nutrition, and transfer Resident #70 to the hospital if resuscitation was required as a life saving measure. A physician's order dated 6/11/26 also authorized a Registered Nurse (RN) employed by the facility to pronounce Resident #70's death should it occur.Review of the clinical record failed to provide documentation by a provider indicating Resident #70's death was anticipated and that an RN pronouncement of death was appropriate.Subsequent to surveyor's inquiry, a physician's order dated 7/15/26 at 11:45 AM discontinued the authorization for a Registered Nurse (RN) employed by the facility to pronounce Resident #70's death should it occur.5. Resident #81 diagnoses included hemiplegia, epilepsy, and type 2 diabetes.The annual MDS assessment dated [DATE] identified Resident #81 was cognitively intact.A physician's order dated 6/9/26 directed staff to perform chest compressions, administer intravenous fluids (IVF), and transfer Resident #81 to the hospital if resuscitation was required as a life saving measure. A physician's order dated 6/9/26 also authorized a Registered Nurse (RN) employed by the facility to pronounce Resident #81's death should it occur.Review of the clinical record failed to provide documentation by a provider indicating Resident #81's death was anticipated and that an RN pronouncement of death was appropriate.Subsequent to surveyor's inquiry, a physician's order dated 7/15/26 at 12:04 PM discontinued the authorization for a Registered Nurse (RN) employed by the facility to pronounce Resident #81's death should it occur.6. Resident #109 diagnoses included hemiplegia, dementia, and difficulty swallowing.The quarterly MDS assessment dated [DATE] identified Resident #109 was cognitively intact.A physician's order renewed on 6/8/26 at 1:17 PM directed staff to perform chest compressions, administer intravenous fluids (IVF), provide artificial nutrition, and transfer Resident #109 to the hospital if resuscitation was required as a life saving measure. A physician's order dated 6/8/26 also authorized a Registered Nurse (RN) employed by the facility to pronounce Resident #109's death should it occur.Review of the clinical record failed to provide documentation by a provider indicating Resident #109's death was anticipated and that an RN pronouncement of death was appropriate.Subsequent to surveyor's inquiry, a physician's order dated 7/15/26 at 11:26 AM discontinued the authorization for a Registered Nurse (RN) employed by the facility to pronounce Resident #109's death should it occur.7. Resident #110 diagnoses included brain cancer, morbid obesity, and fibromyalgia.A physician's order dated 7/3/26 authorized a RN employed by the facility to pronounce Resident #110's death should it occur.The annual MDS assessment dated [DATE] identified Resident #110 was moderately cognitively impaired.A physician's order dated 7/15/26 directed staff to perform chest compressions, administer intravenous fluids (IVF), provide artificial nutrition, and transfer Resident #110 to the hospital if resuscitation was required as a life saving measure.Review of the clinical record failed to provide documentation by a provider indicating Resident #110's death was anticipated and that an RN pronouncement of death was appropriate.Subsequent to surveyor's inquiry, a physician's order dated 7/15/26 at 11:13 AM discontinued the authorization for a Registered Nurse (RN) employed by the facility to pronounce Resident #110's death should it occur.8. Resident #112 was admitted to the facility on [DATE] with diagnoses that included heart dysrhythmia with pacemaker, type 2 diabetes, and prostate cancer.A physician's order dated 7/7/26 authorized an RN employed by the facility to pronounce Resident #112's death should it occur.APRN note dated 7/7/26 at 9:06 PM identified Resident #112 was alert and oriented to self and person.A physician's order dated 7/15/26 directed staff to perform chest compressions, administer intravenous fluids (IVF), provide artificial nutrition, and transfer Resident #112 to the hospital if resuscitation was required as a life saving measure.Review of the clinical record failed to provide documentation by a provider indicating Resident #112's death was anticipated and that an RN pronouncement of death was appropriate.Subsequent to surveyor's inquiry, a physician's order dated 7/15/26 at 11:18 AM discontinued the authorization for a Registered Nurse (RN) employed by the facility to pronounce Resident #112's death should it occur.Interview with the Director of Nursing Services (DNS) on 7/15/26 at 9:45 AM identified residents with a physician's order authorizing a registered nurse (RN) to pronounce death should also have corresponding provider documentation indicating the resident's death is anticipated and that RN pronouncement is appropriate. The DNS stated she was not aware that Residents #4, #5, #7, #70, #81, #109, #110, and #112 had physician orders authorizing RN pronouncement of death. The DNS stated she would review the medical records to locate the corresponding provider documentation supporting anticipated death and the appropriateness of the RN pronouncement orders.Interview with Advanced Practice Registered Nurse (APRN) #1 on 7/15/26 at 10:15 AM identified RN pronouncement orders were typically entered by the nursing supervisor as part of the admission order set for provider signature. APRN #1 identified she did not usually include additional provider documentation indicating that a resident's death was anticipated or that an RN pronouncement was appropriate.Interview with the Director of Nursing Services (DNS) on 7/15/26 at 2:00 PM identified she was unable to locate provider documentation indicating the residents' deaths were anticipated or supporting the appropriateness of the physician orders authorizing registered nurse (RN) pronouncement of death for Residents #4, #5, #7, #70, #81, #109, #110, and #112. The DNS stated she consulted with the covering Medical Director (MD #1), who, based on the absence of supporting provider documentation, directed the physician orders authorizing RN pronouncement of death for Residents #4, #5, #7, #70, #81, #109, #110, and #112 be discontinued.Review of facility's undated Death of a Resident- RN Pronouncement policy, directed in part, an RN may pronounce the death of a resident when the resident's death is anticipated, and appropriate provider documentation is present in the medical record. The policy further directed that the provider should document that the resident's death is anticipated and that RN pronouncement is appropriate.

Based on review of the clinical records, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #9 and Resident #81) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to submit a request for a Level II screen subsequent to Resident #9 and Resident #81's new psychiatric diagnoses. The findings include: 1.Resident #9 was admitted to the facility on [DATE] with diagnoses that included adjustment disorder with mixed anxiety and depressed mood, chronic pain, and heart failure. The PASARR Level I Screen dated 5/23/23 identified Resident #9 did not have an intellectual disability (ID) or a serious behavioral health condition. The PASARR Level I Screen identified that if changes occurred or new information refuted the findings, a new screen must be completed. The PASARR Level of Care (LOC) assessment dated [DATE] identified Resident #9 was approved for an additional 120 days and long term placement at the facility. The assessment outcome identified long term approval for a nursing facility level of care. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #9 was cognitively intact, was dependent on toileting, showering/bathing and lower body dressing. A psychiatrist progress note dated 12/11/25 identified Resident #9 was evaluated for anxiety, sadness, Post traumatic stress disorder (PTSD), and medication review. The note identified Resident #9 had psychiatric diagnoses of adjustment disorder with mixed anxiety and depressed mood and PTSD. The Resident Care Plan (RCP) dated 12/25/25 identified Resident #9 was at risk for complications related to PTSD. Interventions included maintaining a calm environment, administering medications as ordered, avoiding confrontation, argument, or denial of the resident's expressed thoughts, and following up with psychiatric services as needed. A psychiatrist progress note dated 1/22/26 identified Resident #9 was evaluated for mood and behavior. The note identified Resident #9 had psychiatric diagnoses of adjustment disorder with mixed anxiety and depressed mood and PTSD. Review of Resident #9's medical record identified on 1/22/26 a diagnosis of Post traumatic stress disorder (PTSD) was added to the medical record. A psychiatrist progress note dated 4/20/26 identified Resident #9 was evaluated for anxiety, sadness, PTSD, and medication review. The note identified Resident #9's had psychiatric diagnoses of adjustment disorder with mixed anxiety and depressed mood and PTSD. Review of the clinical record failed to identify the PASARR contracted agency was notified of the new psychiatric diagnosis of PTSD from 1/22/26 through 7/16/26 in order to conduct an additional Level 1 and Level 2 screen. Interview and clinical record review with Social Worker (SW) #1 on 7/16/26 at 2:18 PM identified she was unaware Resident #9 had been diagnosed with PTSD. SW #1 identified Social Services was responsible for notifying the contracted PASARR agency when a resident received a new psychiatric diagnosis. SW #1 identified she was typically informed of new diagnoses or changes in psychiatric status by the MDS nurse or during weekly psychiatric rounds. SW #1 identified that once she was notified of a new psychiatric diagnosis, she submitted a referral to the PASARR agency, which then contacted the facility to schedule an onsite Level II evaluation. SW #1 identified Resident #9's PTSD diagnosis was missed, she was unable to identify why she had not been informed of the diagnosis, and no referral was made to the PASARR agency. 2. Resident #81 was admitted to the facility on [DATE] with diagnoses that included depression and anxiety. The PASARR Level I Screen dated 7/27/23 identified Resident #81 had diagnoses of adjustment disorder with mixed anxiety and depressed mood and no diagnosis of dementia. The assessment outcome identified Resident #81 was excluded from Level II screening due to no evidence of intellectual/developmental disability or a serious behavioral health condition. The assessment outcome further identified that if changes occurred or new information refuted the findings, a new screen must be submitted. A psychiatrist progress note dated 12/3/23 identified Resident #81 had diagnoses of anxiety and depressive symptoms. A psychiatrist progress note dated 3/19/24 identified Resident #81 received a new diagnosis of major depression. Review of Resident #81's medical record identified on 3/19/24 a new diagnosis of major depression was added to the medical record. A physician's order dated 4/9/24 directed administration of Buspirone Hydrochloride (used to treat anxiety) 7.5 milligrams (mg) by mouth twice daily and Sertraline Hydrochloride (used to treat depression) 50 mg tablets, give 150 mg by mouth in the morning. A psychiatrist note dated 7/11/24 identified Resident #81 received a new diagnosis of Post Traumatic Stress Disorder (PTSD). Review of Resident #81's medical record identified on 7/11/24 a new diagnosis of PTSD was added to the medical record. The quarterly MDS assessment dated [DATE] identified Resident #81 had intact cognition and diagnoses of anxiety, depression, and PTSD. The RCP dated 10/22/24 identified Resident #81 was at risk for changes in mood state due to diagnoses of anxiety, major depressive disorder, and PTSD. Interventions included being aware of and reporting changes in mental status, monitoring mood changes when new medications were added, encouraging Resident #81 to express feelings, and following up with psychiatry as recommended and needed. Review of the clinical record failed to identify the PASARR contracted agency was notified of the new psychiatric diagnoses of major depression and PTSD from 3/19/24 through 7/14/26 in order to conduct an additional Level 1 and Level 2 screen. Interview and clinical record review with SW #1 on 7/14/26 at 1:39 PM identified she was responsible for reviewing new admission Pre admission Screening and Resident Review (PASARR) evaluations and updating the contracted state agency when a resident had a mental health change. SW #1 indicated nursing was required to report new mental health diagnoses to her after the resident was evaluated by the physician or psychiatrist. SW #1 identified she depended on nursing to inform her of new mental health diagnoses during morning report, and psychiatry also provided her with a form listing the residents seen that day. SW #1 identified the PASARR completed in the hospital for Resident #81 included only the diagnoses of anxiety and depressed mood. SW #1 identified Resident #81's diagnosis list reflected a new diagnosis of major depression on 3/19/24 and a new diagnosis of post traumatic stress disorder (PTSD) on 7/11/24. SW #1 identified the state agency should have been updated following each diagnosis on 3/19/24 and 7/11/24, and she did not complete the updates. SW #1 identified she should have updated the contracted state agency, but nursing did not inform her of Resident #81's new diagnoses. SW #1 indicated she would complete a status change for Resident #81 and notify the state agency. Review of the facility's undated Preadmission Screening and Resident Review (PASARR) Policy, directed in part, to ensure all residents admitted to the facility meet federal PASRR requirements and are appropriately screened for serious mental illness and/or intellectual disabilities and receive the necessary services when a resident has a change in the level of care notify the appropriate parties of any denial or change in level of care. For changes in level of care Social Services is responsible for PASARR coordination, tracking, and compliance.

Based on observations, review of the clinical records, facility documentation, facility policy, and interviews, for 1 of 2 residents (Resident #5) reviewed for nutrition, the facility failed to obtain and document weekly weights as ordered by the physician for a resident who had a diagnosis of malnutrition, and for 1 of 1 resident (Resident #38) reviewed for quality of care, the facility failed to conduct weekly skin assessements for a resident with skin breakdown. The findings include: 1. Resident #5's diagnoses included protein calorie malnutrition, vitamin D deficiency, intertrochanteric fracture of the right femur, and cognitive communication deficit.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, was independent with eating, had no swallowing disorder, and had experienced a weight loss of five percent (5%) or more in the last month or ten percent (10%) or more in the last six months.A physician's order dated 05/22/2026 directed weights be obtained weekly in the morning every Tuesday and Wednesday for four weeks.The Resident Care Plan (RCP) dated 07/01/2026 identified Resident #5 was at risk for malnutrition due to chronic or acute illness. Interventions included diet as ordered, monitoring for physical signs of malnutrition, and weights as ordered.Review of Resident #5's Treatment Administration Record (TAR) identified although the weight task was signed off indicating weights were obtained, weekly weight documentation was missing for the following dates: 5/26/2026, 5/27/2026, 6/02/2026, 6/03/2026, 6/09/2026, 6/10/2026, 6/16/2026, and 6/17/2026. A total of 8 of 8 required weekly weights were not obtained.Review of the nurse's notes from 5/26/2026 through 6/17/2026 failed to identify Resident #5 refused weights.Interview and clinical record review with Licensed Practical Nurse (LPN) #4 on 07/16/2026 at 9:34 AM identified both nurses and nurse aides (NA) were responsible for obtaining resident weights. LPN #4 indicated nurse aides obtained most of the resident weights, and nurses were responsible for documenting the weights in the resident's electronic medical record (EMR). LPN #4 was unable to explain why Resident #5's weights were not obtained for the identified missing dates despite the Treatment Administration Record (TAR) indicating the tasks were completed.Interview with the Assistant Director of Nursing (ADNS) on 07/16/2026 at 10:48 AM identified nurse aides are responsible for obtaining resident weights and reporting the results to the nurse for documentation in EMR. The ADNS was unable to locate documentation of Resident #5's weights or refusals in the progress notes or the electronic health record for 5/26/2026, 5/27/2026, 6/02/2026, 6/03/2026, 6/09/2026, 6/10/2026, and 6/17/2026. The ADNS identified Resident #5's weight should have been obtained as required by the physician's order.Interview with the Director of Nursing Services (DNS) on 07/20/2026 at 11:10 AM identified weights should be obtained and documented in the EMR prior to being checked off as completed on the TAR. The DNS further identified facility policy requires weights to be entered into the resident's EMR after they are obtained.Review of facility Weight Monitoring Policy identified, directed in part, residents should be weighed as ordered by the physician/provider or recommended by the Registered Dietician. Weights shall be recorded in the medical record according to facility practice.2. Resident #38's diagnoses included type 2 diabetes, peripheral vascular disease, and hypertension.A physician's order dated 11/17/2025 directed a body audit be completed upon admission and then weekly by licensed nurses on the resident's shower day and document on the Body Audit form every Monday on day shift for monitoring.The annual MDS assessment dated [DATE] identified Resident #38 had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment, was dependent on toileting hygiene, required maximal assistance with showering/bathing and bed mobility, and was at risk for pressure ulcers.The RCP dated 1/09/2026 identified Resident #38 was at risk for skin breakdown. Interventions included inspecting skin when providing care for signs and symptoms of breakdown, treatment as ordered, and incontinent care per policy.A physician's order dated 1/10/2026 directed to cleanse bilateral buttocks with normal saline and apply Triad paste daily and as needed.Review of Resident #38's clinical record and Treatment Administration Record (TAR) from 2/01/2026 through 7/13/2026 identified missing documentation of skin assessments/body audits with no documented resident refusal for the following dates: 2/02/2026. 2/09/2026, 2/16/2026, 2/23/2026, 3/02/2026, 3/9/2026, 3/16/2026, 3/23/2026, 3/30/2026, 4/06/2026, 4/13/2026, 4/20/2026, 4/27/2026, 5/04/2026, 5/11/2026, 5/18/2026, 5/25/2026, 6/01/2026, 6/08/2026, 6/15/2026, 6/22/2026, 6/29/2026, 7/06/2026, 7/13/2026 ( 24 missed skin assessments/body audits).Interview with Licensed Practical Nurse (LPN) #5 on 7/20/2026 at 9:53 AM identified the facility did not have a Body Audit form for documenting skin assessments. LPN #5 indicated she documented changes only for wounds in the progress notes. LPN #5 identified she could not locate any documentation for Resident #38's skin condition, skin assessments, or wound history. LPN #5 identified she did not know how to document skin changes.Interview with the Director of Nursing (DNS) on 7/20/2026 at 10:48 AM identified wound rounds are performed every Tuesday; however; Resident #38 had not been included in wound rounds in months. The DNS identified nurses should have documented on Resident #38's skin condition weekly.Observation on 07/20/2026 at 11:44 AM of Resident #38's buttocks with the DNS identified excoriation and redness measuring approximately 5.0 inches by 4.0 inches on each buttock. Resident #38 stated his/her buttocks were painful. The DNS informed the resident that he/she would be repositioned following incontinence care.Review of facility's Wound and Skin Management policy, directed in part, weekly skin observations/body audits will be completed by a licensed nurse during the resident's bath, shower, or other scheduled skin observation opportunity. All wounds shall be reviewed during the facility at risk meeting. Skin alterations and wounds shall be monitored, documented, and reassessed until resolved or healed

Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 sampled resident (Resident #3) reviewed for positioning, the facility failed to ensure a device was applied for foot contractures. The findings include:Resident #3's diagnoses included hemiplegia and hemiparesis of the left side, contracture of the right foot and left foot, and vascular dementia.The Resident Care Plan (RCP) dated 5/06/2026 identified Resident #3 wore bilateral ankle/foot splints. Interventions included Physical Therapy and Occupational Therapy as ordered, and apply splints as ordered.Physician's orders dated 5/12/2026 directed bilateral ankle/foot splints to be applied after AM care and removed prior to PM care daily, and skin assessments while splints are in use daily on the day shift.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment, did not display behaviors of rejection of care, and was dependent for putting on/taking off footwear.Observation on 7/13/2026 at 10:33 AM identified Resident #3 was in bed with both feet elevated on a pillow without the benefit of the bilateral ankle/foot splints in place.Observation on 7/14/2026 at 10:55 AM identified Resident #3 was in bed with both feet elevated on a pillow without the benefit of the bilateral ankle/foot splints in place.Interview and observation with LPN #1 on 7/14/2026 at 12:43 PM revealed Resident #3 was not wearing the prescribed bilateral ankle/foot splints. LPN #1 identified although she documented on the Treatment Administration Record at 10:59 AM that Resident #3's splints had been applied, she had neither applied the splints nor verified the Nurse Aide (NA) had done so. LPN #1 stated she should not have documented the treatment as completed without first confirming that the bilateral ankle/foot splints had been applied. Subsequent to surveyor inquiry, Resident #3's bilateral ankle/foot splints were applied.Interview with Occupational Therapist (OT) #1 on 7/14/2026 at 1:13 PM identified Resident #3 should have ankle/foot splints applied daily and she had never been notified Resident #3 had refused to wear the splints. OT #1 further identified failure to wear the ankle/foot splints placed Resident #3 at risk for developing plantar flexion contractures.Interview with the Assistant Director of Nursing Services (ADNS) on 7/14/2026 at 1:21 PM identified nurses are responsible for verifying that prescribed splints have been applied before documenting the treatment as completed on the TAR. The ADNS further identified if a resident refuses to wear a splint, the nurse should document the refusal in the resident's medical record.Interview with the Director of Nursing Services (DNS) on 7/14/2026 at 1:41 PM identified the nurses are expected to personally observe that a resident's splint has been applied before documenting in the medical record that the splint was in place. Review facility's undated Splints and Orthotic Devices policy, directed in part, devices shall be applied according to physician/provider orders and rehabilitation recommendations.

Based on review of employee files, interviews, and policy review for 3 of 5 of Nurse Aides (Nurse Aide #1, Nurse Aide #2, and Nurse Aide #3) who were reviewed for annual performance evaluations, the facility failed to ensure that yearly performance evaluations were completed at least every 12 months. The findings include: 1. Review of employee file identified Nurse Aide (NA) #1 had a hire date of 2/20/2020 and the last performance evaluation was completed on 8/7/2024. No annual performance evaluations completed during 2025 or during 2026, through the survey date of July 20, 2026, were found in the employee's personnel record. 2. Review of employee files identified NA #2 had a hire date of 9/23/2020 and the employee the last performance evaluation was completed on 7/18/2024. No annual performance evaluations completed during 2025 or during 2026, through the survey date of July 20, 2026, were found in the employee's personnel record. 3. Review of employee files identified NA #3 had a hire date of 12/7/2022. Review of the employee file identified the last performance evaluation was completed on 7/18/2024. No annual performance evaluations completed during 2025 or during 2026, through the survey date of July 20, 2026, were found in the employee's personnel record. Interview with the Administrator on 7/20/26 at 10:20 AM indicated the Human Resources (HR) Director was responsible each month for providing the Director of Nursing Services (DNS) with a list of employees who were due for their annual performance evaluations. The Administrator identified the DNS was responsible for ensuring annual performance evaluations were completed for all nursing department employees with assistance from the Assistant Director of Nursing Services (ADNS) and nursing supervisors. The Administrator identified nursing supervisors completed the evaluation questions with assistance from the charge nurses who worked directly with the nurse aides. Interview with Registered Nurse (RN) #5, corporate nurse, on 7/20/26 at 11:01 AM identified last year as part of the annual education and competencies she added a section indicating an annual evaluation was completed. RN #5 indicated the annual evaluation in the electronic system was a form titled core competencies, which required the employee to indicate that all required education and competency skills had been completed. RN #5 indicated she was attempting to use the electronic core competencies form as part of the annual performance evaluation. RN #5 identified the electronic form did not include evaluation elements such as time and attendance, appearance, whether the employee attended meetings and participated in committees, demonstrated professional competencies, cooperated with others, or completed workload timely and professionally. RN #5 indicated if concerns existed in any of those areas, the DNS would issue written corrective actions and placed in the employee's Human Resources file. Interview with HR #1 on 7/20/26 at 11:31 AM identified she is responsible for providing department heads with a monthly list of employees due for annual performance evaluations. HR #1 indicated she provides the nursing supervisors with a list of nurse aides due for annual performance evaluations, along with the evaluation forms. HR #1 identified the nursing supervisor completes the evaluations with input from the charge nurses who work directly with the NAs and then forward the completed evaluations to the Director of Nursing Services (DNS) for signature. Once signed, the evaluations are filed in the employee's personnel record. HR #1 identified NA #1's most recent annual performance evaluation was completed on 8/7/24, NA #2's on 7/18/24, and NA #3's on 7/18/24. HR #1 further identified no annual performance evaluations were completed for these employees during 2025 or through the date of the interview in 2026. Interview with the DNS on 7/20/26 at 12:18 PM identified HR #1 kept track of when nursing employees were due for their annual performance evaluations. The DNS identified she was responsible for ensuring all nursing staff received an annual performance evaluation. The DNS indicated the Assistant Director of Nursing Services (ADNS) and nursing supervisors completed the nurse aide annual performance evaluations with input from the Licensed Practical Nurses (LPNs) who worked directly with the nurse aides. The DNS identified nurse aides completed an electronic evaluation related to their education and competencies, and she completed the annual performance evaluations that the employee signed, and she signed before sending the evaluations to HR #1 for filing in the employee's record. The DNS identified she did not have any annual performance evaluations in her office at that time and believed all annual performance evaluations had been completed. Interview with the Assistant Director of Nursing Services (ADNS) on 7/20/26 at 12:33 PM indicated Human Resources (HR) #1 brought the annual performance evaluation form each month identifying which employees were due for completion. The ADNS identified HR #1 was responsible for maintaining the schedule of when employee evaluations were due and responsible for ensuring new hires had performance evaluations completed at 30 days, 60 days, 90 days, and then annually. The ADNS indicated supervisors and nurses completed the nurse aide performance evaluations, and she assisted if needed. The ADNS identified she was responsible for completing the Licensed Practical Nurse (LPN) performance evaluations, and the Director of Nursing Services (DNS) was responsible for the Registered Nurse (RN) evaluations and the ADNS evaluation. The ADNS indicated that once she completed the LPN evaluations, she provided them to the DNS to sign. The ADNS identified all completed nursing annual performance evaluations were reviewed and signed by the DNS before being provided to HR #1 for filing in the employee's record. The ADNS further identified staff development completed an evaluation that addressed employee education and competencies which were separate from the annual performance evaluation. The ADNS stated the annual performance evaluation had two separate evaluations that must be completed. Review of the facility's undated Nursing Assistant Evaluations policy, directed in part, certified nursing assistants will participate in periodic performance evaluations in accordance with facility practice. Evaluations may include assessment of clinical skills, job performance, professionalism, resident care practices, attendance, teamwork, and compliance with facility policies and standards. Performance concerns identified outside of the annual evaluation or competency process will be addressed separately in accordance with facility policies, education processes, and corrective action practices. Nurse aides' evaluations and/or competency reviews will be completed at intervals determined by the facility. Nurse aides will be provided with the opportunity to review and discuss evaluation findings with supervisory staff. Education, counseling, corrective action, or additional training may be implemented as indicated based on evaluation findings. Completed evaluations, competency validations, counseling, and related follow up actions will be maintained in the employee personnel file or education file as appropriate.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 8 sampled resident reviewed for medication administration the facility failed to ensure Resident #52, who was prescribed a controlled substance (Methadone) for substance use disorder (SUD) was administered Methadone per physician's order when the licensed nurse administered Resident #52 another resident's Methadone resulting in a significant medication error. The findings include: Resident #52's diagnoses included orthopedic aftercare following surgical amputation, long term use of opiate analgesic, and opioid dependence.The Resident Care Plan (RCP) dated 5/28/2026 identified Resident #52 was on Methadone maintenance therapy. Interventions included monitor for changes in condition, mood/behavior and report to MD/APRN.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and was receiving five high-risk drug classes including a diuretic, opioid, antiplatelet, hypoglycemic, and anticonvulsant.A physician's order dated 6/19/2026 directed to administer Methadone HCL oral solution 5 milligrams (mg) per 5 milliliters (mL), give 90 mg by mouth in the morning for substance use disorder (SUD) and supervise self-administration.Review of the Medication Administration Record identified on 7/12/2026 at 9:00 AM the Methadone HCI oral solution 5 milligrams (mg) per 5 milliliters (mL), give 90 mg by mouth for SUD supervised administration was signed off by Licensed Practical Nurse (LPN) #3 indicating it was administered.An Advanced Practice Registered Nurse (APRN) note dated 7/12/2026 at 12:00 PM identified Resident #52 had inadvertently received the incorrect dose of Methadone and was given another resident's 55 mg Methadone bottle instead of his/her own 90 mg Methadone bottle. The APRN identified Resident #52 was present during the video call, was aware of the medication error, and declined to receive the remainder of his/her dose if it were made available.A nurse's note dated 7/12/2026 at 1:23 PM written by Registered Nurse (RN) #1 (nursing supervisor) identified Resident #52 was inadvertently administered another resident's 55 mg Methadone dose. RN #1 indicated Resident #52 remained in stable condition after the medication error was identified.A nurse's note dated 7/12/2026 at 1:25 PM written by Licensed Practical Nurse (LPN) #3 identified RN #1 notified her on 7/12/2026 at 11:46 AM Resident #52 was administered another resident's Methadone dose on 7/12/2026 at 10:45 AM, receiving 55 mg Methadone instead of his/her ordered 90 mg Methadone dose. LPN #3 identified Resident #52 was alert and oriented, exhibited no signs of acute distress or respiratory depression, and remained under close nursing observation.Interview on 7/20/2026 at 10:29 AM with RN #1 identified on 7/12/2026 she had multiple envelopes containing resident Methadone prescriptions on the counter in the supervisor office. RN #1 identified on 7/12/2026 she did not look carefully at the envelope when preparing to remove Resident #52's Methadone bottle from his/her envelope and inadvertently pulled another resident's Methadone bottle out in error. RN #1 identified on 7/12/2026 she provided the wrong Methadone bottle to LPN #3 to administer to Resident #52. RN #1 indicated she became aware of the error during the narcotic count of the Methadone after Resident #52 had already been administered another resident's Methadone dose. RN #1 identified she did not perform the five rights of medication administration when giving the Methadone bottle to LPN #3. RN #1 indicated she did not perform the five rights because she was distracted by the voices of multiple people in and around the Supervisor's office. RN #1 identified the error would not have occurred if she had performed the five rights.Interview on 7/20/2026 at 10:36 AM with the Director of Nursing Services (DNS) identified that on 7/12/2026, RN #1 should have verified the bottle of Methadone was intended for Resident #52 and confirmed the correct dose prior to providing it to LPN #3 for administration. The DNS further identified LPN #3 should have ensured the bottle of Methadone she brought to Resident #52 was intended for Resident #52, was the correct dose, and she should have verified with Resident #52 his/her name and dose of Methadone at the bedside prior to handing the bottle to Resident #52 for administration. The DNS stated both nurses should have followed the five rights of medication administration. The DNS was unable to explain why RN #1 and LPN #3 did not follow the facility policy for Methadone administration and the five rights of medication administration.Although attempted, an interview with LPN #3 was not obtained.Review of the facility's undated Medication Administration policy, directed in part, medication administration shall be performed safely and accurately utilizing the principles of medication, including the right resident, right medication, right dose, right route, and right time.Review of the facility's undated Methadone Maintenance policy, directed in part, prior to administration, the licensed nurse will verify resident identity, methadone dose, physician/provider order, medication label, and Medication Administration Record.

Based on review of facility documentation, facility policy, and interviews reviewed for infection surveillance, the facility failed to ensure infection surveillance and tracking included Multidrug- resistant organisms (MDRO). The findings include:Interview with the Director of Nursing Services (DNS) (former Infection Preventionist) and the Administrator on 7/15/2026 at 6:39 AM revealed that the facility had residents with multidrug-resistant organisms (MDROs) in both the past and present; however, the DNS did not maintain an infection surveillance log or other tracking system for MDROs. The DNS indicated the facility created a new list each month identifying current residents with MDROs but did not maintain a cumulative list, spreadsheet, or electronic tracking system to monitor historical MDRO data for discharged residents. The DNS further indicated current residents with MDROs were identified on the Bed Board; however, residents who no longer had an MDRO or who were discharged from the facility were removed from the Bed Board. As a result, the Bed Board could not be used to identify trends or analyze MDRO infections over time. Additionally, the DNS indicated the former Infection Preventionist maintained an Excel spreadsheet that may have contained MDRO surveillance data; however, the DNS did not have access to the spreadsheet, and it had not been updated since 5/26/2026, when the former Infection Preventionist left the facility.Although requested, the facility was unable to provide copies or printouts of the former Infection Preventionist's MDRO surveillance spreadsheets, including documentation identifying the last revision date.Review of the facility's undated Infection Criteria Surveillance policy directed, in part, the Infection Preventionist will maintain an Infection Surveillance Log that includes the resident's name, type of infection, date of onset, diagnostic testing and results as appropriate, treatment and isolation measures as appropriate, and outcome/resolution. The policy further directed infection trends will be reviewed to identify patterns and opportunities for prevention.

Based on clinical record review, facility documentation review, facility policy review, and interviews for 1 of 5 residents (Resident #52) reviewed for immunizations, the facility failed to administer the COVID 19 vaccine as requested by the resident and his/her conservator upon admission. The findings include:Resident #52 diagnoses included surgical amputation, type 2 diabetes, and asthma.Review of the COVID-19 Immunization Consent form dated 5/30/2026 identified Resident #52 and his/her conservator provided consent for the facility to administer the COVID-19 vaccine.Clinical record review identified Resident #52's COVID 19 vaccination status was recorded as pending on 5/30/26.The admission Minimum Data Set (MDS) dated [DATE] identified Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition.Review of Resident #52's clinical record from 5/30/26 through 7/16/26 failed to provide documentation the COVID 19 vaccine was administered as requested by Resident #52 and his/her conservator.Interview with the Assistant Director of Nursing (ADNS) on 7/16/2026 at 10:32 AM, who was the Infection Preventionist during Resident #52's admission identified Resident #52 did not receive the COVID-19 vaccine despite having provided consent. The ADNS identified she was responsible to ensure residents who consented to vaccination received the vaccine and confirmed there were no vaccine supply shortages at the pharmacy during or following Resident #52's admission. The ADNS indicated on 7/15/2026, 46 days after Resident #52 consented to receive the COVID-19 vaccine, Resident #52 changed his/her mind when the facility was preparing to administer the pneumococcal and COVID-19 vaccines. The ADNS further indicated she forgot to document the resident's refusal of the COVID-19 vaccine.Review of facility's undated COVID-19 Vaccination policy, directed in part, the facility would offer residents the COVID-19 vaccine, document that education was provided, document any refusal, and re-offer as appropriate.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for discharge, the facility failed to maintain resident privacy when they discharged a resident with his/her roommate's medication labeled with the resident name and drug name. The findings include: Resident #1's diagnoses included Alzheimer's, urinary tract infection, and diabetes. The discharge Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen, indicative of severe cognitive impairment and was dependent for ADLs, and required assistance with ambulation. The Resident Care Plan (RCP) dated 2/9/2026 identified admitted for short term rehabilitation. Interventions directed to establish a discharge plan and arrange for home care services, social services will facilitate discharge planning when appropriate and arrange for any equipment needed at home. 2. Resident #2's diagnoses included dementia, anxiety and restlessness and agitation. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a BIMS score of three out of fifteen, indicative of severe cognitive impairment and had a psychiatric/mood disorder. A physician order (for Resident #2) dated 3/2/2026 directed Quetiapine Fumarate (Seroquel - antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) Oral Tablet 50 milligrams (mg), give two (2) tablets one time a day for mood disorder. Review of facility census identified Resident #1 and Resident #2 were located on the same unit and shared the same resident room (were roommates). Nursing note dated 3/31/2026 at 2:13 PM, written by the DNS indicated Resident #1 was discharged to home at 2 PM with his/her family member. The family member signed the discharge paperwork, and Resident #1 was assisted into car by staff member. Social service note dated 4/2/2026 at 15:40 (3:40 PM) identified Resident #1 was discharged to home on 3/31/2026 and the discharge plan was reviewed with the spouse who reported understanding. No concerns noted at the time of discharge. Review of facility Accident and Investigation report dated 4/1/2026 identified Resident #1 was discharged to home on 3/31/2026, and on 4/1/2026 the facility received a call from a family member who reported Resident #1 took the wrong medication and was lethargic. The facility APRN was notified of the error after being discharged home, and the APRN advised to send Resident #1 to the hospital for evaluation. The facility initiated an investigation. Record review identified Resident #1 was not prescribed Quetiapine Fumarate (Seroquel). Review of facility Medication Error Report dated 4/1/2026 identified a medication error occurred on 3/31/206 at 10:30 AM. Resident #1 was sent home with someone else's medications (at discharge). The error reason indicated: the nurse overlooked the medications and the actual error was made by the family member. The family called to report the error. The report identified to prevent future occurrences the plan was to check medications twice before handing them to a patient. Record review identified a statement by LPN #1 indicated she did not check the medications given to Resident #1's family member at the time of discharge. The statement indicated she should have checked the medications. Interview and record review with Home Care Nurse (HCN) #1 on 5/19/2026 at 1:23 PM identified she visited Resident #1 on 4/1/2026 and identified Resident #1 was not lucid and dozing off. The family member indicated Seroquel was given to patient, and Emergency Medical Services were called. Review of medications discharged with Resident #1 identified a blister card labeled Seroquel. The blister card of Seroquel had another patient/resident's name on the pack, and the family member had stated he/she gave the Seroquel the night before. On 5/20/2026 at 10:20 AM interview and record review with LPN #1 identified that on 3/31/2026 she was assigned Resident #1, though she typically did not work on that shift or that unit, Resident #1 was scheduled to be discharged to home and a family member came to the facility to pick up Resident #1 for discharge to home. LPN #1 indicated she gathered Resident #1's medication blister packs out of the facility medication cart and was attempting to review the discharge instructions and medications when the family member was focused on finding resident's clothes and had several interruptions. LPN #1 stated Resident #1 was not on Seroquel, however when she later learned Resident #1 had been sent home with Seroquel, it was identified that Resident #1's roommate (Resident #2) was on Seroquel oral 50 mg, two (2) tabs at bedtime and that medication must have gotten mixed in with Resident #1's discharge medications. LPN #1 further indicated she should have double checked the medications she was sending home with Resident #1. Interview and record review on 5/20/2026 at 12:53 PM with the DNS identified when staff discharge a resident, the nurse should review the discharge instructions and review the medications being sent home with the resident. The DNS further stated the nurse is responsible to ensure the person being provided the education is attentive/focused on the directions provided. The family had indicated the Seroquel blister pack was labeled with Resident #2's name. Medications are stored in the medication cart by room number and Resident #2's Seroquel was likely picked up in error; Resident #2's medications should not have been sent with Resident #1. Review of the facility Resident Rights Policy directed in part, residents have the right to privacy and confidentiality regarding all personal and health information kept by the facility, as provided by federal and state laws governing the facility's use and disclosure of this information.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for discharge, the facility failed to ensure the resident medications were reviewed prior to discharge to ensure the correct medications were sent with the resident upon discharge to the community to prevent a medication error. The findings include: 1. Resident #1's diagnoses included Alzheimer's, urinary tract infection, and diabetes. The discharge Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen, indicative of severe cognitive impairment and was dependent for ADLs, and required assistance with ambulation. The Resident Care Plan (RCP) dated 2/9/2026 identified admitted for short term rehabilitation. Interventions directed to establish a discharge plan and arrange for home care services, social services will facilitate discharge planning when appropriate and arrange for any equipment needed at home. 2. Resident #2's diagnoses included dementia, anxiety and restlessness and agitation. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a BIMS score of three out of fifteen, indicative of severe cognitive impairment and had a psychiatric/mood disorder. A physician order (for Resident #2) dated 3/2/2026 directed Quetiapine Fumarate (Seroquel - antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) Oral Tablet 50 milligrams (mg), give two (2) tablets one time a day for mood disorder. Review of facility census identified Resident #1 and Resident #2 were located on the same unit and shared the same resident room (were roommates). Nursing note dated 3/31/2026 at 2:13 PM, written by the DNS indicated Resident #1 was discharged to home at 2 PM with his/her family member. The family member signed the discharge paperwork, and Resident #1 was assisted into car by staff member. Social service note dated 4/2/2026 at 15:40 (3:40 PM) identified Resident #1 was discharged to home on 3/31/2026 and the discharge plan was reviewed with the spouse who reported understanding. No concerns noted at the time of discharge. Review of facility Accident and Investigation report dated 4/1/2026 identified Resident #1 was discharged to home on 3/31/2026, and on 4/1/2026 the facility received a call from a family member who reported Resident #1 took the wrong medication and was lethargic. The facility APRN was notified of the error after being discharged home, and the APRN advised to send Resident #1 to the hospital for evaluation. The facility initiated an investigation. Review of facility investigation statement written by the DNS, dated 4/1/2026, indicated the family member called and reported Resident #1 was lethargic. The family member stated medications were given to Resident #1 and after the mediation was administered he/she realized the medication was not for Resident #1. The family member reported that he/she had given Resident #1 two (2) tablets of Seroquel. The statement indicated the family member was advised the Seroquel was not prescribed for Resident #1 and to take Resident #1 to the hospital for evaluation. Plan for facility social worker to update home care agency that Resident #1 was referred to the hospital. Review of social worker investigation statement dated 4/1/2026 indicated she received call from former Resident #1's family member, lethargic, difficult to arouse, and stated Resident #1 had taken the wrong medication. Advised to call 911 and take to emergency room (ER). SW called the home care agency and notified them of the incident. Review of home care agency note dated 4/1/2026, identified former Resident #1 was not admitted to home care service due to the wrong medication was given to the patient on last night 8 PM, Seroquel 100 mg. The (home care agency) RN assessed the patient sleeping on the couch, vital signs were normal, was not speaking and was very lethargic. A call was placed to 911, EMS (Emergency Medical Services) arrived at 12:15 PM and transferred to the ER. EMS run sheet dated 4/1/2026 indicated dispatched for prescription mistake, found patient sitting in a chair inside the home, in care of family and home health nurse. The patient was alert but confused, as normal for level of dementia, not showing obvious signs of distress. Family member stated gave the patient the wrong medication last night, and patient was more lethargic than normal. Review of facility Medication Error Report dated 4/1/2026 identified a medication error occurred on 3/31/206 at 10:30 AM. Resident #1 was sent home with someone else's medications (at discharge). The error reason indicated: the nurse overlooked the medications, and the actual error was made by the family member. The family called to report the error. The report identified to prevent future occurrences the plan was to check medications twice before handing them to a patient. Record review identified Resident #1 was not prescribed Quetiapine Fumarate (Seroquel). Record review identified a statement by LPN #1 indicated she did not check the medications when they were given to Resident #1's family member at the time of discharge. The statement indicated she should have checked the medications. Interview on 5/19/2026 at 8:40 AM with Home Care Supervisor (HCS #1) identified during a visit on 4/1/2026 Resident #1 was lethargic and had taken the wrong medication (took Seroquel that belonged to another resident). HCS #1 stated Resident #1 was subsequently admitted to the hospital. Interview and record review with Home Care Nurse (HCN) #1 on 5/19/2026 at 1:23 PM identified she visited Resident #1 on 4/1/2026 and identified Resident #1 was not lucid and dozing off. The family member indicated Seroquel was given to patient, and Emergency Medical Services were called. Review of medications discharged with Resident #1 identified a blister card labeled Seroquel. The blister card of Seroquel had another patient/resident's name on the pack, and the family member had stated he/she gave the Seroquel the night before. On 5/20/2026 at 10:20 AM interview and record review with LPN #1 identified that on 3/31/2026 she was assigned Resident #1, though she typically did not work on that shift or that unit, Resident #1 was scheduled to be discharged to home and a family member came to the facility to pick up Resident #1 for discharge to home. LPN #1 indicated she gathered Resident #1's medication blister packs out of the facility medication cart and was attempting to review the discharge instructions and medications when the family member was focused on finding resident's clothes and had several interruptions. LPN #1 stated Resident #1 was not on Seroquel, however when she later learned Resident #1 had been sent home with Seroquel, it was identified that Resident #1's roommate (Resident #2) was on Seroquel oral 50 mg, two (2) tabs at bedtime and that medication must have gotten mixed in with Resident #1's discharge medications. LPN #1 further indicated she should have double checked the medications she was sending home with Resident #1. Interview and record review on 5/20/2026 at 12:53 PM with the DNS identified when staff discharge a resident, the nurse should review the discharge instructions and review the medications being sent home with the resident. The DNS further stated the nurse is responsible to ensure the person being provided the education is attentive/focused on the directions provided. The family had indicated the Seroquel blister pack was labeled with Resident #2's name. Medications are stored in the medication cart by room number and Resident #2's Seroquel was likely picked up in error; Resident #2's medications should not have been sent with Resident #1. Review of facility Medication & Discharge Safety Education Nursing Responsibility for Safe Practice The 5 Rights of Medication Administration directed in part, the 5 Rights of a Safe Discharge - Right Patient: verify using three (3) identifiers, Right Medication: ensure only correct medications are sent, Right instructions: provide clear instructions and use teach-back, Right Documentation: ensure all paperwork is complete, Right Handoff: communicate with receiving caregiver/facility. Sending a resident home with another resident's medication is a serious medication error and a HIPAA (Health Insurance Portability and Accountability Act) violation of sharing PHI (Personal Health Information). Always double check medications prior to discharge.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for ADLs, the facility failed to ensure a resident that required assistance with showers was offered or provided showers at least once a week in accordance with the plan of care. The findings include: Resident #1's diagnoses included dementia, cerebral infarction (stroke) and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five out of fifteen (5/15), indicative of severe cognitive impairment, ambulated independently and required set-up assistance for showers. The Resident Care Plan dated 10/12/2025 identified Resident #1 required assistance with ADLs. Interventions directed Resident #1's ability to perform ADLs may fluctuate due to cognitive status, set up and allow to do for self as able, and directed to assist with ADLs as needed. Review of Resident #1's care card identified he/she was scheduled to receive a shower on Thursdays during the 7:00 AM to 3:00 PM shift. The care card further identified Resident #1 was independent with bathing and preferred showers. Review of the shower/bathing documentation for the period of September 2025 through November 2025 revealed out of nine (9) weekly opportunities, only two (2) dates (10/30 and 11/1/2025) identified Resident #1 received a shower. Documentation for seven (7) remaining scheduled shower days lacked any indication that a shower was provided or was refused. Additional clinical record review failed to identify documentation to indicate Resident #1 refused showers during the seven (7) dates scheduled (September through November), nor documentation that showers were rescheduled or that alternative hygiene measures were provided.Interview with the DON on 12/10/2025 at 12:50 PM identified if a resident refuses to take a shower, the nursing staff should always re-attempt at a different time or the following day after the refusal. Additionally, the nursing assistants (NAs) should notify the resident's nurse. The DON stated she was not aware of any complaints regarding showers, or lack of showers from the resident, conservator, or family. The DON stated showers are documented in the electronic charting system (Point Click Care - PCC), and if the shower was not documented to indicate it was given or refused, then it was considered staff did not provide the shower; it was not performed. Review of the undated facility Bathing/Shower Policy directed each resident will be offered a full bath/shower at least weekly. The nursing staff will assist in preparing the shower for a resident and ensure safety throughout the process.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for change in condition, the facility failed to facilitate the inclusion of the resident and/or resident representative in the development and implementation of his or her person-centered plan of care. The findings include: Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for change in condition, the facility failed to facilitate the inclusion of the resident and/or resident representative in the development and implementation of his or her person-centered plan of care. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, and depression. Record review identified Person #1 was Resident #2's responsible party, Power of Attorney, and substitute decision maker. The Resident Care Plan (RCP) dated 2/1/2023 identified Resident #2 had a psychiatric diagnosis. Interventions directed family involvement with care. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of six out of fifteen (6/15), indicative of severe impaired cognition and was dependent with personal care. Record review failed to identify any interdisciplinary team (IDT) meetings were conducted from admission during 1/2023 through 4/19/2023. Although requested, the facility was unable to provide any documentation that any IDT meetings were conducted from admission during 1/2023 through 4/18/2023. A social services note dated 4/19/2023 at 10:21 AM, written by Social Worker (SW) #1 identified a telephone care plan meeting was held on 4/19/2023 with Person #1. Review of the IDT Care Plan Meeting document dated 4/21/2023 without a time frame noted, identified the care plan meeting was attended by Person #1, the Recreation Director, Dietary Director, and SW #1. The document failed to identify if Resident #2 or Person #1 were present during the meeting, or if they were invited. Interview with RN #1 and the Administrator on 9/2/2025 at 2:25 PM identified the facility performs a baseline and comprehensive care within seven (7) days of admission to the facility. The facility then holds an IDT care plan meeting within twenty-one (21) days from admission, and then quarterly meetings thereafter. RN #1 and the Administrator were unable to provide documentation that an admission care plan meeting was held within seven (7) days of admission to the facility on 1/27/2023, or any additional care plan meetings before 4/19/2023. RN #1 and the Administrator stated the facility should have conducted the meetings as described and should have included both Resident #2 and Person #1, and were unable to explain why that did not occur. Review of the facility Care Plan Policy dated 10/30/20 directed in part, the resident and/or family/responsible party will be invited to attend all care plan conferences. Further, the Policy directed a comprehensive care plan will be developed in collaboration with the resident and/or family/responsible party. A Care Conference to discuss the plan of care will be held on or before day twenty-one (21) from admission and then at least quarterly.

Based on observations of the environment, review of facility policy and interviews, the facility failed to maintain a safe, clean homelike environment. The findings included: 1. An observation on 12/02/24 at 10:45 AM identified the following: a) room [ROOM NUMBER] Discolored and stained toilet seat. Stained tile and walls around toilet. b) room [ROOM NUMBER] Marred walls. c) room [ROOM NUMBER] - stained [NAME] in the bathroom, marred walls. d) room [ROOM NUMBER] marred closet door, large amount of brown staining on curtain next to bed #1. e) room [ROOM NUMBER]- Marred walls, exposed sheetrock next to bed #1. f) room [ROOM NUMBER]- Large smeared brown stain above garbage in front of bed #2, missing closet baseboard rusted commode seat, brown dried stain drops along wall. g) room [ROOM NUMBER]- Rusted metal trim in bathroom, brown buildup in corners and on side of closet in front of bed #1. Stained toilet seat. h) room [ROOM NUMBER]- Marred walls, hole in sheetrock next to bed #1, discolored and stained toilet seat, screw holes under soap dispenser, unpainted sheetrock next to entry door with screw holes, marred closet door and sides. i)room [ROOM NUMBER]-Marred walls along baseboard. A subsequent observation and interview with the Director of Maintenance on 12/09/24 at 10:10 AM identified he was responsible for the oversight of maintenance and housekeeping staff to identify and address environmental cleanliness and damage in resident occupied areas. This is typically accomplished through environmental rounds and as identified by the interdisciplinary team. The Director of Maintenance further identified environmental concerns were being addressed annually and in a going manner but was unable to provide supporting documentation/environmental rounds that detailed the plan for completion for some of some of the environmental concerns, i.e. toilet set cover, replacement molding. The Director of Maintenance further identified housekeeping staff should be addressing the cleanliness in an ongoing manner. An interview with the Administrator on 12/09/24 at 10:10 AM identified she would expect the environment be maintained in a safe, clean and sanitary manner. Although requested, a policy for maintaining a clean environment was not provided. A review of the facility policy for Infection Control Surveillance and Safety Rounds dated 1/2/23 directed surveillance rounds tube conducted on a regular basis by the infection control nurse/designee. Each department head will be responsible for correcting issues identified during the surveillance process and document these corrections on the surveillance rounds form. 2. Concerns were received by the state agency online reporting system on 1/5/2024. Concerns noted the facility had stained ceiling tiles and mold in the ceiling registers. On 12/4/24 at 9:35 AM a tour of the facility identified scattered stained tiles. In the chapel, near the back door, a cracked ceiling tile was observed to be tapped. In the resident lounge that housed a small piano and located off of the hallway leading to the long term care wing, a stained tile by the window and exit door was observed. In the hallway directly outside of room [ROOM NUMBER] three ceiling tiles were observed to be stained. No black staining nor black substances were observed on the ceiling or on ceiling registers. The state agency Building Fire and Safety inspection team also conducted its own inspection and found no indication of mold, but did indicate scattered stained tiles in resident areas. The infection control surveillance and safety rounds policy indicated that each department head will be responsible for correcting issues identified during the surveillance process. 48880

Based on clinical record review and staff interviews for 1 sampled resident (Resident #23) reviewed for edema, the facility failed to consistently conduct weights according to physician orders. The findings include: Resident #23 's diagnoses included Congestive Heart Failures (CHF), localized edema and type 2 diabetes mellitus. A physician's order dated 9/25/24 directed daily weight in AM one time a day for CHF. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #23 as cognitively impaired and requires supervision/ touching assistance with personal hygiene and maximal assistance with dressing and toileting hygiene. The Resident Care plan dated 10/18/24 identified CHF. Interventions directed to watch for any increased edema (lower extremities, abdomen, sacrum and generalized swelling) and to report to MD/ Advanced Practice Registered Nurse (APRN). Review of clinical record of Resident # 23's weight for daily weights for for months of October, November and December 2024 identified the following : The facility conducted 4 out of 8 daily weights for the month of December 2024 The facility conducted 7 out 30 daily weights for the month of November 2024 The facility conducted 14 out of 31 weights for the month of October 2024 Interview with RN #8 Assistant Director of Nursing Services (ADNS) on 12/9/24 at 9:23AM identified weights are only documented in the facility electronic records. The ADNS further explained, the first seven days of the month weights are collected on paper then documented in the electronic records under weights, Medication Administration Records (MAR) or Treatment Administration Records (TAR). The ADNS also identified if a resident refuses, the refusal would be documented in the progress notes. A follow up interview with the ADNS on 12/9/24 at 10:32 AM identified if the MAR or TAR is signed off, it reflects the work/ task was completed and indicated the expectation is that weight are documented. The charge nurse, ADNS and DNS are responsible for overseeing that signed off tasks are completed. however, the ADNS was unable to explain why daily weights were signed off as completed but not documented in the clinical record

Based on clinical record reviews, facility documentation, facility policy and interviews for 5 of 5 sampled residents (Residents #16, #18, #23, #76 and #83) reviewed for quality of care, the facility failed to ensure residents receive proper treatement to maintain adequate hearing. The findings included: 1. Resident #16's diagnoses included dementia and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 as severely cognitively impaired and required two person assist with activities of daily living (ADL). The Resident Care Plan (RCP) dated [DATE] identified Resident #16 was hearing impaired, wore a hearing aid and refused at times. Interventions directed to offer hearing aids daily, offer audiology consult as needed and if resident refuses, offer at a later time and utilize family member if available. A social service progress note dated [DATE] identified per request of Resident #16 and responsible party, a contracted community specialty service was contacted and placed the resident on a list for an audiology visit on [DATE] for a hearing aid evaluation. An audiology consult dated [DATE] identified Resident #16 was evaluated after noting new verbal communication difficulties, such as having commands repeated, not turning when spoken to, having difficulty understanding speech with a request for hearing aids. Clinical findings identified hearing loss could not be established in both ears due to cerumen (ear wax) remaining in both ears after instrument removal. Recommendations were made for wax removal in both ears. A subsequent social service progress note dated [DATE] identified the contracted community specialty service was contacted, and Resident #16 was to be seen on the next visit for hearing aid evaluation per responsible party request. A review of the social worker progress notes, nursing progress notes and physician orders and facility documentation failed to reflect Resident #16 was treated and revaluated for hearing loss/hearing aids. An interview and clinical record review with Social Worker, SW #1 on [DATE] at 9:03 AM identified she was responsible for overseeing medical specialty services for the residents. SW #1 identified for any service; a request was sent with consent to the contracted service provider which would include requests for hearing aids. SW #1 submitted a request to the contracted service provider on [DATE] for [DATE] and again on [DATE] for the resident to be seen on [DATE]. SW #1 identified that she assumed it would be her responsibility to follow up on the provider requests but had not done so on behalf of Resident #16. SW #1 further identified she did not offer any alternative community services for audiology to Resident #16 or responsible party. An interview and facility documentation review with Person #1, the Customer Care Coordinator for the community service providers on [DATE] at 9:16 AM identified she coordinated specialty visits with the facility. Once a consent with request for services was received, the provider would request orders and clinical information for the resident. Following each facility visit, the Director of Nursing Services, DNS and SW #1 would receive an After Visit Summary detailing the treatment provided to each resident, and reason, if any, a resident was not seen. Person #1 identified Resident #16 was initially seen on [DATE] for audiology. Recommendations were made for wax removal which was included on the After Visit Summary sent to the DNS and SW #1. It was expected the facility contact the community provider once treatment was completed so the resident could be evaluated. Person #1 identified she had not been contacted by the facility at any time regarding the status of Resident #16's treatment and that audiology services had been provided to facility residents on (8) occasions between [DATE] and present. Person #1 further identified on [DATE], (21) scheduled residents were not seen due physician orders not being received prior to the appointment which was also detailed in the after-visit summary. Person #1 also indicated there have been ongoing issues with the facility in following recommendations for residents to be seen. An interview with the DNS on [DATE] at 11:06 AM identified she, in coordination with SW #1 and Assistant Director of Nursing Services oversaw community provider services. Once identified, a request with consent would be sent to the community provider to add the resident to a list to be seen at the next scheduled visit. Any clinical information and orders were to be obtained and sent to the provider prior to the visit. All information was communicated to her through email fax and phone calls from the provider. The DNS identified any recommendations should be reviewed by the APRN and that nursing staff should be following up on the status of the recommendations. The DNS further identified that although she received correspondence from the community provider, she was unaware there were any concerns related to residents not being seen, recommendations not being followed, and was unable to explain how the systemic issue occurred. An interview with the Administrator on [DATE] at 10:44 AM identified she would expect that if a resident required specialty services, orders are obtained, residents seen timely, recommendations followed, and the facility follow up on any resident not seen. 2. Resident # 18 's diagnoses included anxiety disorder, arteriosclerosis, and Adult Failure to Thrive, A physician's order dated [DATE] directed to provide Dental, Ophthalmology, Podiatry, and Audiology services as needed through Health Drive. The annual Minimum Data Set assessment dated [DATE]/24 identified Resident #18 as cognitively intact and dependent for toileting, personal hygiene, and lower body dressing. The care plan dated [DATE] identified Resident #18 required assistance with ADL. Interventions included assistance of 2 for care. Review of the facility contracted vendor documentation indicated Resident #18 refused services on [DATE] and was rescheduled for [DATE]. The contracted vendor documentation for [DATE] indicated they could not evaluate Resident #18 as they did not have a physician's order. In an Interview with Administrator and DNS on [DATE] at 11:07 AM identified the contracted vendor appointments are initiated upon admission. The Resident/Family will sign a consent for contracted vendor services if they wish to receive services from them. The services will then be added to contracted vendor schedule. The resident will be seen by the next available date. The DNS, ADNS, and Social Worker are involved in the process. The facility is notified if more information is required prior to the appointment such as MD orders. The DNS will provide the information to contracted vendor. In an interview with the Administrator on [DATE] at 10:40 AM identified the expectation is that appointments are made timely and there is timely follow up. The DNS should be overseeing the process. 3. Resident #23 's diagnoses included dementia, and cataracts. A physician's order dated [DATE] directed for vision, dental, podiatry, audiology and psychiatric services as needed. A care plan dated [DATE] identified Resident #23 had difficulty understanding and/or expressing speech related to a decline in cognitive status. An attending physician's request for services/consultation dated [DATE] identified the family or staff had noticed recent decreased in the resident responsiveness and a request for an audiological consultation by the facility audiologist. The quarterly MDS assessment dated [DATE] identified Resident #23 as severely cognitively impaired and had adequate hearing and did not use a hearing aide. Facility documentation dated [DATE] identified that although Resident #23 was on the schedule to be seen by audiology, the resident was unable to be seen due to no physician's orders noted for treatment. A review of the medical record from [DATE] through [DATE] failed to identify if Resident #23 had been evaluated by an audiology specialist. On [DATE] at 2:44 PM an interview with the audiologist customer care representative (Person #2), indicated that a resident is placed on the schedule to be seen after the facility has submitted a request for services and every visit from audiology required a new physician's order. On [DATE] at 11:07 AM an interview with the Administrator and DNS identified that consents for the facility audiology specialty services are obtained on admission and signed by the resident or resident representative and requests for services are submitted when the resident is requesting to be seen or there is an issue that require an evaluation. The DNS was unable to indicate what had prompted a request for service on [DATE] and why there was no physician's order noted on [DATE]. Although, the DNS indicated she was responsible for following up on visit summaries from audiology services she was unable to indicate why follow ups were not being completed. Although the facility did not have an audiology policy for Consultation for Outside Medical Appointments which identified the facility must communicate the outcomes and recommendations from outside healthcare providers to the resident, family, and relevant staff. 4. Resident #76 's diagnoses included hypertension, anxiety and Alzheimer disease. A physician's order dated [DATE] directed to have Vision, Dental, Podiatry, Audiology and Psychiatric Services as needed. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #76 as cognitively impaired and required supervision for eating and maximal assistance for oral and toileting hygiene. The care plan dated [DATE] identified Essential Support Person. Interventions included following facility policy and procedures for essential support persons. Resident's #76 on [DATE] care conference signs off sheet indicate nursing staff was not in attendance. Review of records indicated a recommendation from audiology visit from the facility contracted vendor for wax removal on [DATE]. Subsequent to recommendation on [DATE] there were no physician's order indicating to remove wax post recommendation. Interview with the DNS and Administrator on [DATE] at 11:15 AM indicated on admission residents and/or representative sign consents to receive treatment from facility contracted vendors for services. The DNS reported once recommendations are made, the APRN is informed and is responsible for following up with recommendations. The DNS indicated once the APRN is informed, the expectation is the APRN should follow up with recommendations in a timely manner. The DNS further identified it is her responsibility to ensure follows up appointments are followed through , however, she/he was unable to explain why this was not done. Facility Consultation for Outside Medical Appointments policy in part directed the facility is responsible for ensuring residents receive timely and coordinated care for outside medical appointments and to review instructions or recommendations provided by outside healthcare providers. 5. Resident #83's diagnoses included cerebral infarction (stroke) and dementia. The annual MDS assessment dated [DATE] identified Resident #83 as severely cognitively impaired and (1) to (2) person assist with ADL. The RCP dated [DATE] identified Resident #83 had progressive intellectual decline related to dementia and needed social interaction/mental stimulation. Interventions directed to assist as needed to meet needs and to offer activity supplies of preference/ interest including movies, music and offer social visits. An audiology consult dated [DATE] identified Resident #83 was being evaluated after family/staff noted recent deceased responsiveness. Hearing loss could not be evaluated as ear wax remained in both ears following instrument removal. Recommendations made for wax removal to the right ear. A review of the social worker progress notes, nursing progress notes and physician's orders and facility documentation failed to reflect Resident #16 was treated and revaluated for hearing loss/hearing aids. An interview and clinical record review with Social Worker, SW #1 on [DATE] at 9:03 AM identified she was responsible for overseeing medical specialty services for residents. SW #1 identified for any service; a request was sent with consent to the contracted service provider. SW #1 further indicated she assumed it was her responsibility to follow up on the provider requests but had not done so. An interview and facility documentation review with Person #1, the Customer Care Coordinator for the community service providers on [DATE] at 9:16 AM identified she coordinated specialty visits with the facility. Once a consent with request for services was received, the provider would request orders and clinical information for the resident. Following each visit the facility, the Director of Nursing Services ( DNS) and SW #1 would receive an After Visit Summary detailing the treatment provided to each resident, and reason, if a resident was not seen. The expectation for not being seen would required the facility to contact the community provider once treatment was completed for a resident so the resident can be evaluated. Person #1 further identified on [DATE], (21) scheduled residents were not seen due physician orders not being received prior to the appointment which was also detailed in the after-visit summary. Person #1 further indicated there have been ongoing issues with the facility in following up on recommendations so residents can be seen. An interview with the DNS on [DATE] at 11:06 AM identified she in coordination with SW #1 and Assistant Director of Nursing Services oversaw community provider services. Once identified, a request was sent to the community provider who would place the resident on a list to be seen at the next scheduled visit. Any clinical information and physician's orders were to be obtained and sent to the provider prior to the visit. This information was communicated to her through email fax and phone calls from the provider. The DNS identified any recommendations should be reviewed by the APRN and nursing staff should be following up on the status of the recommendations. The DNS further indicated although she received correspondence from the community provider, she was unaware there were any concerns related to residents not being seen, recommendations not being followed, and was unable to explain how the systemic issue occurred. An interview with the Administrator on [DATE] at 10:44 AM identified she would expect that if a resident required specialty services, physician's orders are obtained, residents seen timely, recommendations followed, and the facility would follow up on any resident not seen. A review of the facility policy for Consultation for Outside Medical Appointments (no date) directed to identify the need for an outside medical consultation, schedule an appointment with the appropriate provider, prepare any necessary documents and history for the appointment, document details in the medical record and update the medical record with any new information or recommendations from the consultation, review any instructions from the outside provider, revise the care plan as necessary or follow up appointments and to communicate any outcomes to the resident, responsible party and relevant staff. 48792 48880 49100

Based on observations, review of facility policy and staff interviews, the facility failed to ensure Intravenous Therapy (IV) supplies located in the medication storage room and the central supply were stored and labeled appropriately and the facility failed to ensure supplies were not expired. The facility also failed to ensure left over resident supplies were returned to the pharmacy after therapy completion, discharge, or transfer from facility. The findings included: 1. An observation and interview with the Infection Preventionist (IP) RN #11 on [DATE] at 12:00PM identified the following : individually wrapped loose Intravenous (IV) heparin and saline flushes in large boxes on the lower shelf, several clear bags containing IV flush syringes ordered to particular residents on top of the individual flushes in the boxes. Each box had a laminated card one indicating heparin flushes and the other Normal Saline flushes. Additionally, other individual supplies such as central line dressings were scattered behind the boxes. The IP (RN #11) indicated the flushes were extra supplies and some of the residents supplies needed to be returned as the residents had been discharged . 2. Observation and interview on [DATE] at 12:15 PM with the IP, RN #11 in the central supply closet identified the following: IV supplies in one box (central line tubing and caps), no labels indicating house stock or resident, another large box containing proximately 100 single unused heparin flushes two randomly selected with an expiration date of 2021. RN #11 indicated she/he was the person responsible for ensuring dates supplies are checked for expiration. After inquiry, RN #11 indicated the supplies would be immediately checked. 3. Observation and interview on [DATE] at 1:30 PM on the short-term unit medication room with the IP (RN #11) and the charge nurse LPN #3 identified the following : one of the boxes identified earlier was removed along with the resident specific supplies. RN # 11 further indicted some of the supplies were sent back to the pharmacy. The surveyor pointed out a large box on the medication room shelf indicated Normal Saline flushes, but the contents were Heparin flushes. RN #11 told LPN #3 to label flushes correctly. The facility policy labeled Returning Medications to the Pharmacy dated revised [DATE] indicated in part unopened unused non refrigerated injectable medications and solutions should be (returned within 5 days of discontinuation) and unopened packages of infusion supplies can be returned to the pharmacy for credit. A facility policy for drug destruction was requested but not provided.

Based on observations of the kitchen steam table during the noon meal, review of facility policy and staff interviews, the facility failed to ensure dietary staff served food in a sanitary manner and the facility failed to ensure that food items were labeled with a date and dented cans in the dry storage room were removed. The findings included: 1. Observation on 12/4/2024 at 12:50 PM of Dietary Aide ( DA) #1 identified DA# 1 using a plate cover for delivery of a meal to a resident room then walked out of the room with the cover. DA #1 covered the next meal with the same cover she/he walked out of the resident's room and place the cover upside down on the top shelf of the steam table in front of Dietary Aide #2 who was plating the food. Dietary Aide #2 then placed his/her bare hand over the edge of the plate cover with fingers inside the cover then moved his/her hand off the cover and proceeded to plate a meal for another resident. Dietary Aide #1 then took the same plate cover turned it right side up, covered the next meal and delivered it to a resident room. When Dietary Aide #1 exited the resident room s/he was holding the inside of the plate cover against his/her clothing and walked back to the steam table. An interview with Dietary Aide #1 and #2 12/4/2024 at 12:55 PM at the time of the observation Dietary Aide #1 indicated she/he did not have enough clean covers for each resident plate and was nervous therefore she/he used the same plate cover held it against his/her clothing. Dietary Aide #2 could not explain why she/he used her/his bare hand and fingers over the edge of the plate cover and indicated she/he was sorry for touching the inside of the plate cover and would tell Dietary Aide #1 not to reuse the plate covers. On 12/4/2024 at 1:00PM an interview with the Dietary Manager who was informed of the food delivery concerns identified she/he just received a call from the Dietary Aide about the breach in service and indicated the dietary aide should have used a different cover . An interview on 12/06/24 at 12:18 PM with the Dietary Manager identified the same plate cover should not be reused when there is break in dietary practice because the facility has enough plate covers for all the residents. The Dietary Manager also indicated the process for using the plate covers is to take one out of the steam table cover for the plate deliver to the room then come out the room with the plate cover and place it on the bottom shelf of the steam table; they are not to be reused. 2. During a tour of the Dietary Department on 12/2/24 at 9:59 AM during the initial walk through the kitchen with the Dietary Manager identified the following: a. Observation of the Walk in Refrigerator identified 2 packs of [NAME] Choice Hamburger Buns, 1 pack of [NAME] Choice Hot Dog rolls, 2 packs of [NAME] Choice Bread, 1 pack of [NAME] Rolls, and 1 pack of [NAME] English muffins opened and without the benefit of a date of opened. Interview with the Dietary Manager on 12/2/2/24 at 10:08 AM identified the above food items should be dated once opened. She indicated all kitchen staff are responsible for dating open items. Facility's Stock Rotation Policy notes in part When food items are removed from original case, date individual contents. All items need to be individually dated when removed from original containers. b. Observation of the dry storage room identified 13 cans of 10 oz Nemco Diced Peaches were dented. Interview with the Dietary Manager on 12/2/24 at 10:25 AM identified all Dented items should be removed from the storeroom and returned to the vendor. The Dietary Manger further indicated she was responsible for ensuring dented cans are not placed in the storeroom but was unable to explain why dented cans were not removed. Facility's Damaged Food Container Policy notes in part cans that contain a deep, angular dent with acute crimping of body wall or end seam, (should be) removed from the storeroom and return to vendor. 49100

Based on observations, clinical record reviews, facility documentation, facility policy and interviews for of 2 of 4 sampled residents (Resident #28 and Resident #32) reviewed for urinary catheter/urinary tract infection, the facility failed to ensure infection control standards were implemented in the management of a urinary catheter device and for 2 of 2 resident reviewed for Infection Control ( Resident # 71 and # 153), the facility failed to post signage to alert staff of the need for Personal Protective Equipment and ensure supplies were readily available for residents with infectious and consistently track/monitor residents with infections and for 1 of 3 residents (Resident # 2) reviewed for pressure ulcer, the facility failed to follow appropriate infection control practices. The findings included: 1. Resident #28's diagnoses included obstructive and reflux uropathy and other disorders of the prostate. The quarterly Minimum Data Set ( MDS) assessment dated [DATE] identified Resident #28 as moderately cognitively impaired and required (1) to (2) assist with Activities of Daily Living (ADL). The Resident Care Plan (RCP) dated 11/12/24 identified Resident #28 had an indwelling urinary device in place. Interventions directed provide catheter care as ordered, change drainage bag as ordered and provide privacy cover for drainage bag. The physician's orders dated 11/13/24 directed catheter care every shift and apply leg bag when out of bed. An observation with the Director of Nursing Services (DNS) on 12/02/24 at 10:58 AM identified Resident #28 in a johnny coat sitting in a wheelchair next to her/his bed with urine collection tube extending out from between h/her legs to a urine collection device full of tea colored urine in a basin on the floor beside h/her and without the benefit of a privacy cover. An interview with the DNS on 12/02/24 at 10:58 AM identified the urinary collection device should be hanging on the side of the wheelchair and she/he was unsure why the bag was placed in a basin on the floor. An interview with Nurse Aide, NA #10 on 12/04/24 at 2:45 PM identified he was assigned to Resident #28 on 12/2/24 during the 7:00 AM to 3:00 PM shift and he routinely left the urine collection device in basin directly on the floor next to h/her. 2. Resident #32 's diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms, Methicillin Resistant Staphylococcus Aureus Infection and Chronic Obstructive Pulmonary disease ( COPD). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #32 as cognitively intact and required maximal assistance for toileting hygiene, bed mobility and personal hygiene. A physician's order dated 1/18/24 directed to Change Foley Catheter bag ever week and ass needed. The care plan dated 9/23/24 identified Foley. Interventions included changing the catheter and bag as needed. Observation on 12/03/24 at 9:50 AM of Resident # 32's Foley bag on the floor uncovered. Observation on 12/03/24 at 11:30 of Resident # 32 'Foley bag on the floor and uncovered. Interview with Registered Nurse (RN #5) on 12/03/24 at 11:35 AM indicated she was unsure of what the privacy bag was, therefore, she informed Resident #32's nurse to obtain a privacy bag. RN #5 noticed it was not done and stated nurses are responsible for ensuring the Foley is covered and not on the floor. A review of the facility policy for Catheter Care (dated 9/30/22) directed that a urinary collection bag should never be paced on the floor and should be hanging lower than the resident's bladder. 3. Resident #71's diagnosis included urinary tract infection and Extended Spectrum Beta lactamase (ESBL) Resistance. A physician's order dated 11/1/2024 directed to provide contact precautions due to ESBL in urine. A physician's order dated 11/1/2024 directed to provide Meropenem Intravenous reconstituted solution providing 1 gram intravenously every 8 hours for 9 days to treat bacteremia (end date of 11/10/2024). The baseline care plan dated 11/3/2024 indicated Resident #71 had urinary tract infection with ESBL and was on enhanced barrier and contact precautions. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #71 had severe cognitive impairment and received Intravenous (IV) antibiotics. The care plan dated 11/6/2024 indicated to use enhanced barrier precautions for residents with medical devices or those colonized or infected with a Multi Resistant Organism (MDRO). The care plan further indicated Resident #71 had a Peripherally Inserted Central Catheter (PICC) with interventions which included placing an EBP sign outside the room, instruction on using EBP, and for Resident #71 to remain on EBP during his/her stay in the facility. A nursing progress note dated 11/29/2024 at 3:48 PM indicated preliminary urine culture results were gram negative rods greater than 100,000 colony count with the antibiotic sensitivities still pending. An observation on 12/2/2024 at 10:50 AM identified Resident #71 in bed, a sign outside the room on the right side of the door indicating EBP and a small bright green dot next to Resident #71's name plate. No protective equipment cart was noted outside of the room. Upon entering the open door to the room another sign indicating Contact Precautions was posted in the middle of the door but no indication of which resident in the shared room the signage applied to. Meanwhile a nurse's aide entered the room to assist the resident's roommate. An observation and interview with LPN #4 on 12/2/2024 at 10:54 AM identified residents requiring EBP don't have a PPE cart outside each person's room as a cart is located on the wing to obtain supplies needed. LPN #4 indicated she/he not knowing which sign applied which resident but knew Resident #71 was on EBP and indicated she/he would ask the Assistant Director of Nursing (ADNS) for clarification. An observation and interview with the ADNS on 12/2/2024 at 11:00 AM indicated Resident #71 had been treated for an infection and no longer needed contact precautions and took the sign down. A provider progress note dated 12/2/2024 at 3:15PM indicated in part Resident #71 had a urinalysis the week prior after reported behavioral changes and the results exceeded 100,000 per ml colony count of ESBL. The progress note further indicated though Resident #71 had completed IV antibiotic therapy on November 10,2024 the plan would be to treated with Meropenem 1 gram IV every 8 hours for 14 days. An observation and interview on 12/3/2024 with the Infection Preventionist (IP) identified no contact precautions sign or Personal Protective Equipment (PPE) cart outside Resident #71's room. After surveyor observation IP indicated proper signage, and a cart would be initiated immediately. 4. Resident 153's diagnosis included urinary retention and wounds involving less than 10 percent of the body surface. Resident #153 was admitted on [DATE]. A nurse's note dated 11/21/2024 at 3:13 PM indicated Resident #153 refused to be assessed during wound rounds indicating his/her preference was to go to the wound clinic for wound care. A nurse's note dated 11/25/2024 at 1:37 PM as a late entry indicated Resident #153's wounds and wound measurements noted 7 wounds 6 of which had a depth of 0.1 Centimeter (CM) and 2 of the wounds having 4 and 10 sutures in place. A practitioner progress note dated 11/27/2024 indicated on 11/25/2024 Resident # 153 was experiencing urinary retention requiring a straight catheterization to empty the bladder and the next day (11/26/2024) an indwelling catheter was placed due to continued urinary retention. A practitioner note dated 11/30/2024 at 2:02 PM indicated in part to continue wound care of the second degree burn on the chest wall and to monitor healing of multiple burn sites and graft areas. Interview and facility document review on 12/3/2024 at 1:40 PM with the Infection Preventionist (IP) RN #11 indicated Resident #153 was on the Enhanced barrier precautions list due to having an indwelling urinary catheter. RN #11 indicated the Foley was placed after admission secondary to many wounds. The further indicated when Resident #153 was admitted with, s/he should have had enhanced precautions in place from admission (14 days ago). Observation of Resident #153's room identified no signage posted indicating Resident #153 required enhanced precautions at this time. RN #11 indicated Resident # 153's signage would be posted immediately. The facility policy labeled Enhanced Barrier Precautions (EBP) indicated in part EBP provides a targeted gown and glove use during high contact resident activities. The procedure directed by the RN or designee competing the admission assessment would review the hospital transfer/discharge documentation to determine the presence of a Multi Drug Resistant Organism (MDRO). The facility will implement enhanced barrier precautions to include any resident with an indwelling medical device such as a central line or urinary catheter or chronic wounds. The policy further indicated appropriate signage for EBP would be visible and the facility would implement appropriate precautions when residents are experiencing an active infection. The facility policy labeled Contact precautions indicated in part the purpose is to ensure appropriate precautions are put in place to prevent the spread of infection from direct and indirect transmission from those residents who have a known or suspected to be infected with microorganisms which can be transmitted by direct or indirect contact. The policy further indicates personal protective equipment (PPE); gloves when entering room, touching the resident and patient's immediate environment or belongings and gowns are to be worn in part if substantial contact with the resident's environmental surfaces or items, or if the resident is incontinent or has wound drainage not contained with a dressing. 5.Resident #2 's diagnoses included Pressure Ulcer (PU) stage 3, local infection of the skin, and diabetes mellitus type 2. A physician's order dated 5/28/24 directed Resident #2 to be placed on enhanced barrier precautions. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 as severely cognitively impaired and was dependent for transfers, eating, and required maximum assistance for toileting. The Resident Care Plan dated 10/17/24 identified right buttock stage 3 PU. Interventions included to follow facility protocol/formulary for treatment of pressure ulcers. Observation of Resident # 2's wound care on 12/5/24 at 10:30 AM with the APRN (Wound Consultant and wound/IP nurse.) identified the residents wound was cleansed and a Calcium Alginate dressing was applied. The wound measured 1.5 CM x 7 CM which is smaller than the last measurements. Further observation of nurses conducting the wound treatment identified they did not gown for the procedure for a resident is on Enhanced Barrier Precautions. Interview with Wound APRN and IP on 12/5/24 at 10:45 AM identified the resident was on EBP and required gloving and gowning. APRN #1 and IP identified they did not follow facility protocol by not gowning during wound treatment. Both APRN and IP stated they usually gown. Review of the Enhanced Barrier Precautions policy dated 5/5/24 directed, in part, staff will perform hand hygiene and don PPE before providing high-contact care to the resident 46046 48792 49100

Based on observation, review of facility documents and staff interviews, the facility failed to ensure the call bell system on the rehabilitation wing was functioning properly and relayed calls directly to the centralized nursing station. The findings include: A concern was received by the state agency on 1/5/2024. The concern indicated that when a call bell was pushed it would light up above the resident's door but would not ring at the nurse's station. The concern also indicated the person who had spoken to staff about the call bell issues without a resolution. On 12/4/24 at 10:30 AM the call bell system was tested with NA#15. The call light at the head of the bed for room [ROOM NUMBER] and room [ROOM NUMBER] were tested . On both observation with NA#15 the lights outside the rooms lit up, and there was no sound at the nurse's station. An observation with NA#15 identified that the call bell system at the nurse's station did not display the room number that was calling; instead, the call bell system displayed the following error message: interface missing units 154 [sat] 01 29 21/09/24. An interview with NA#15 identified that NA#15 did not know what the error message displayed was and indicated the call bells were working the day before and she/he was not aware of any call bell issues or repairs. NA #15 indicated if the call bell did not sound at the nurse's station, she/he would be able to tell if a resident was calling because she/he would be able to see the light outside the room. On 12/4/24 at 10:37 AM an interview with the Director of Maintenance identified that he was not sure how long the call bell system was displaying the error but indicated it was related to a part that was malfunctioning and needed to be replaced. The Director of Maintenance also indicated when the malfunction of the call bell is intermittent and when error message occurs the system needs to be rebooted in a panel located in the Staff Development office. The Director of Maintenance proceeded to reboot the call bell system, and the call bell system resumed functioning with an audible sound. The Director of Maintenance further indicated that around December of 2023 and January 2024 the call bell system malfunctioned, and an electrician repaired it. A review of facility records identified that a work order was signed with a vendor for repair of the call bell system on 9/30/2024. On 10/4/2024 the vendor diagnosed the issue and, according to facility documentation, returned the majority of the system back to full functionality except for an office, lounge and therapy gym. Facility records also noted to finish the repairs a part needed to be ordered. Additionally, the vendor recommended ordering spare parts for any future repairs. On 10/28/2024 the corporate office of the facility followed up with the vendor regarding updates; the vendor responded on 10/31/2024 indicating they were waiting for confirmation of parts shipment. On 11/25/2024 the facility again contacted the vendor for updates, the facility documentation did not indicate a vendor response. On 12/4/2024 after the surveyor inquiry, the facility contacted the vendor again. On 12/4/2024 the vendor indicated they would attempt to expedite shipment of the parts needed for the repair of the call bell system as the additional spare parts were requested by the facility delaying the shipment. The vendor estimated the repair would be completed by 12/20/2024 (2 months and 20 days after the proposal for service was approved by the facility.) Although requested, the facility was unable to provide documentation regarding the repairs done by a corporate regional electrician to the call bell system in the rehabilitation wing around December 2023 and January 2024. On 12/5/2024 at 1:00 PM an interview and review of the 12/4/2024 facility documentation with the Administrator identified she been aware of the need for additional spare parts ordered for potential future repairs were delaying shipment of the spare parts needed for the call bell repair. The Administrator further indicated she would ensure that the required parts are sent, and the call bell repaired. The facility policy for call bells notes any non-functional call bell should be reported to the maintenance in a timely manner. If there is an extended period of downtime anticipated, the residents should be provided with an alternative method of requesting assistance.

Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 2 of 3 sampled residents (Resident #28 and Resident #32) reviewed for resident rights, the facility failed to ensure a resident(s) with a urinary collection device was treated in a dignified manner. The findings include: 1. Resident #28's diagnoses included obstructive and reflux uropathy and other disorders of the prostate. The quarterly Minimum Data Set ( MDS) assessment dated [DATE] identified Resident #28 as moderately cognitively impaired and required (1) to (2) assist with Activities of Daily Living (ADL). The Resident Care Plan (RCP) dated 11/12/24 identified Resident #28 had an indwelling urinary device in place. Interventions directed provide catheter care as ordered, change drainage bag as ordered and provide privacy cover for drainage bag. The physician's orders dated 11/13/24 directed catheter care every shift and apply leg bag when out of bed. An observation with the Director of Nursing Services (DNS) on 12/02/24 at 10:58 AM identified Resident #28 in a johnny coat sitting in a wheelchair next to her/his bed with urine collection tube extending out from between h/her legs to a urine collection device full of tea colored urine in a basin on the floor beside h/her and without the benefit of a privacy cover. Resident # 28 was sitting closest to the entry room door, with the door open, no privacy curtain with full view of any visitors/staff passing by to his/her roommate. An interview with the DNS on 12/02/24 at 10:58 AM identified she was unaware of any privacy cover required for urine collection devices for any resident while in their room. The DNS further identified Resident #28 should have the urinary collection tubing switched to a leg bag if s/he left the room. An interview with Nurse Aide (NA #10) on 12/04/24 at 2:45 PM identified he was assigned to Resident #28 on 12/2/24 during the 7:00 AM to 3:00 PM shift and well known to him/her. NA #10 identified he routinely left the urine collection device in basin directly on the floor next to Resident #28. NA #10 further identified he was instructed earlier in the day by the DNS to connect the urinary collection tubing to a leg bag for privacy (subsequent to surveyor inquiry). A review of the facility policy for Resident Rights (no date) directed that each resident had the right to be treated with consideration, full respect and full recognition of dignity and individuality. A review of the facility policy for Catheter Care dated 9/30/22 directed that for any resident with a urinary collection device, a privacy bag or fig leaf bag be provided to ensure dignity and using a large drainage closed system bag. 2. Resident #32 's diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms, Methicillin Resistant Staphylococcus Aureus Infection and Chronic Obstructive Pulmonary disease ( COPD). A physician's order dated 1/18/24 directed to Change Foley Catheter Bag ever week and as needed. The care plan dated 9/23/24 identified Foley. Interventions included changing the catheter and bag as needed. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #32 as cognitively intact and required maximal assistance for toileting hygiene, bed mobility and personal hygiene. Observation on 12/03/24 at 9:50 AM of Resident # 32's Foley bag on the floor uncovered. Observation on 12/03/24 at 11:30 of Resident # 32 'Foley bag on the floor and uncovered. Interview with Registered Nurse (RN #5) on 12/03/24 at 11:35 AM indicated she was unsure of what the privacy bag was, therefore, she informed Resident #32's nurse to obtain a privacy bag. RN #5 noticed it was not done and stated nurses are responsible for ensuring Foley is covered and not on the floor. Facility Catheter Care policy dated 9/30/22 indicated in part that Privacy bag or fig leaf bag to ensure dignity. 49100

Based on observations, clinical record review and interviews for one of three residents in survey sample reviewed for pressure ulcers (R#34), the facility failed to initiate interventions to prevent pressure from catheter tubing resulting in the development of a pressure ulcer. The findings included. Resident #34's [DIAGNOSES REDACTED]. An annual assessment dated [DATE] identified that R#34 was cognitively impaired, was totally dependent on staff for transfers and toileting, had an indwelling catheter, was always incontinent of bowel and was at risk for developing pressure ulcers. Resident care plan (RCP) dated 2/1/16 identified a risk for skin breakdown and use of an indwelling catheter (suprapubic). Interventions included inspect skin when giving care and change catheter per facility policy. Nurse's notes dated 2/12/16 identified that at 11:00 AM staff reported and noted that R#34 had a blister to the right upper thigh. The note further described the area as linear in shape and measuring 6.0 CM x 3.0 CM following the path of the suprapubic catheter tubing. The risk for skin breakdown care plan updated on 2/12/16 identified the presence of a new stage II pressure area that was a fluid filled blister. The care plan revision included providing use of a leg strap (to hold catheter in the proper position). physician's orders [REDACTED]. Nurse's notes dated 2/13/16 identified that abrasions were observed with three located on R#34's left abdomen and one on the right side. physician's orders [REDACTED]. physician's orders [REDACTED]. Resident care plan (RCP) related to the indwelling catheter was noted revised on 2/13/16 identifying a small abrasion observed on abdomen. Interventions included use tape over suprapubic tube not on skin. Skin /wound tracking record dated 2/19/16 identified the continued presence of stage II pressure area located on right inner thigh that measured 1.6 CM x 0.6 CM. Observation of R#34 on 2/23/16 at 2:23 PM with RN#1 identified the resident's catheter tube was without the benefit and/or utilization of the (Velcro) leg strap. The tubing was noted wrapped around and under the resident's right inner thigh creating deep demarcation/ impression of the tubing laterally across his/her thigh. The valve aspect of the tubing (utilized for flushing) was noted under the right thigh and it impressed a deep impression into the thigh causing a deep red color. Subsequent to RN#1 repositioning the tubing appropriately and using the Velcro leg strap, R#34 was noted to verbalize I feel better now. Interview with LPN #2 on 2/23/16 at 2:47 PM noted s/he was unaware of any special approaches related to R#34's suprapubic catheter tubing.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who was an admission and had acknowledged full Cardio-Pulmonary Resuscitation (CPR) in the Advanced Directive and physician's orders [REDACTED]. The findings include: Resident #1's [DIAGNOSES REDACTED]. The Nursing Admission assessment dated [DATE] identified that Resident #1 was oriented to person, place and time, able to understand and follow commands. The Current Directive Status dated [DATE] at 7:45 PM identified that Resident #1 requested full support except for intubation or mechanical ventilation and/or enteral feeding. The admission physician's orders [REDACTED]. The nurse's note dated [DATE] written at 6:17 AM identified that at 4:00 AM a Nurse Aide (NA) informed the charge nurse Resident #1 did not look good. The note indicated that the charge nurse was unable to obtain vital signs, the pulse was very faint and the Registered Nurse (RN) Supervisor was notified. The nurse's note dated [DATE] written at 8:27 AM identified that at 4:10 AM, the Supervisor assessed Resident #1 and noted no pulse and/or respirations, the family and physician were notified. Review of the [DATE], ,[DATE]AM shift nurse's notes failed to reflect documentation that CPR had been initiated when Resident #1 had no pulse and/or respirations. The Reportable Event Form dated [DATE] at 4:10 AM identified that CPR was not performed on a resident who was a full code. Interview and review of the written statements dated [DATE] and [DATE] with the ,[DATE]AM charge nurse, Registered Nurse (RN) #1 on [DATE] at 12:20 PM identified she had been informed by the nurse aide at 4:00 AM Resident #1 did not look good. RN #1 to assess the resident and noticed that Resident #1 was not arousable even to sternal stimulation, vital signs were obtained and no readings were noted. RN #1 indicated Resident #1's radial pulse was faint and seemed to come and go and stated I think that the resident was dying then. RN #1 stated she called the RN Supervisor, RN #2, reported that she thought Resident #1 had died and RN #2 indicated she would right there. RN #1 identified that she checked quickly the Advanced Directive form waiting for RN #2. RN #1 stated that when RN #2 asked about Resident #1's advanced directives, she told her Resident #1 was not a full code and I would double check the chart. RN #1 identified that when she checked the advanced directive sheet was when she noted that Resident #1 was a full code with no intubation. RN #1 identified that she did not call a Code Blue as directed in the facility policy. Interview and review of the written statements dated [DATE] and [DATE] with the ,[DATE]AM RN Supervisor, RN #2, on [DATE] at 1:00 PM identified she had been informed by RN #1 Resident #1 was unresponsive. RN #2 questioned if a sternal rub had been conducted to which RN #1 responded yes and there was no response from the resident. RN #2 stated that when she arrived on the unit she asked RN #1 what Resident #1's code status was. RN #1 responded with no intubation. RN #2 identified she took the no intubation as no CPR and when RN #1 questioned her about bringing the crash cart and Automated External Defibrillator (AED) device to the room RN #2 answered no. RN #2 identified she and RN #1 went to assess Resident #1 and the resident had no pulse and/or respirations. RN #2 indicated she herself did not check the chart for Resident #1's the code status prior to assessing the resident. In an interview with the attending physician, MD #1, on [DATE] at 2:12 PM he identified the facility did not notify him on [DATE] that CPR had not been initiated. MD #1 identified that he was informed on [DATE], (three (3) days later) and should have been notified on [DATE] when he pronounced the resident's death. The facility's policy Cardiopulmonary Resuscitation (CPR) directs CPR will be initiated per physician orders [REDACTED]. If there is no response and no breathing or no normal breathing (i.e. only gasping), call a code blue (code blue is request for CPR help). When the second person responds, send him or her to activate 911 and get the emergency supply cart (crash cart) and AED. Subsequent to the incident the facility developed an action plan and implemented the plan on [DATE]. The plan included inservice education of all licensed staff regarding the importance of verifying the Advanced Directive document and the physician's orders [REDACTED].

Based on review of facility investigation documentation, interviews and clinical record review for the only sampled resident (R#169) with a significant injury, the facility failed to ensure that the resident received appropriate assessment, and care and services during the night shift and/or appropriate supervision to prevent a significant injury. The findings include: Resident #169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] noted that the resident was confused, totally dependent on 2 staff for transfers, required assistance for eating and was incontinent of bowel and bladder. The skin condition assessment noted "scribbles" and arrows over the lower extremities with no description of what was present except for a note that there were bilateral lower extremity bruises, and skin tears to the right forearm and left wrist. The nursing admission note dated 10/31/14, indicated that there were "excoriations" to both lower extremities with no open areas and skin tears to both upper extremities. No further description or assessment of the extremities was documented. The admission care plan dated 10/31/14 indicated that the resident was at risk for falls, skin breakdown and incontinent of bowel and bladder. Interventions included to turn and position per policy, incontinent care as needed, and to assist with toileting. There were no treatments ordered for the lower extremities. The nursing notes dated 11/3/2014 documented that the resident was sitting up in a wheelchair at the nurses station at 6:15 PM on 11/3/2014 and the resident would yell when repositioning was attempted. The resident was described as being non-compliant with safety and alarms, and had no complaint of discomfort. Nursing note dated 11/4/2014 at 3 AM noted that the resident was out of bed in a wheelchair at the nurse's station and refusing to go to bed. Facility documentation indicated that at 6 AM on 11/4/14, the resident was noted with a large skin tear on his/her right lower leg. Statements from NA#4 and NA#5 at that time indicated that the resident was observed hitting his/her leg on the wheelchair leg rest and yelling during the night. Interview with CNA #5 on 4/16/15 at 6:20 AM noted that the resident was sitting up in a wheelchair at the nursing station when CNA #5 arrived on the unit at 11pm. CNA #5 stated that s/he tried to put the resident to bed but the nurse said not to because the resident was a fall risk and wanted him/her kept out of bed. CNA #5 stated that the resident stayed in the chair all night, was not ambulated, and was not put into bed. CNA #5 described the resident as "wild", swinging the legs and yelling. CNA#5 reported that he/she toileted the resident during first rounds at approximately 12 Midnight with the help of CNA #4, and that was the last time s/he provided any hands on care for the resident for the rest of the night. NA#5 noted that he/she saw blood and alerted the nurse. Interview with CNA #4 on 4/16/15 at 6:40 AM noted that the resident was not on his/her assignment that night. CNA #4 recalled that the resident was in a wheelchair at the nurse's station when s/he came on duty at 11pm. CNA #4 noted that s/he did not assist NA#5 with toileting the resident at all that night. CNA #4 noted that the resident was very loud, agitated and restless, kicking his/her legs during the night. CNA #4 stated that s/he had "boosted" resident up to reposition, but provided no other care during the night. Neither NA#4 or #5 actually saw the resident strike his/her legs on the wheelchair that resulted in the injury as indicated by their original written statements documented at the time the injury was noted. Interview on 4/16/2015 at 9:15 AM with RN #5, the night supervisor on duty the night of the injury, noted that s/he did not recall the resident or providing any care or assessments for the resident. Interview with LPN #4 on 4/16/15 at 10:17 AM noted that s/he never assessed the resident during the night and only saw the aides changing the resident's shirt. LPN#4 called the supervisor when the skin tear was discovered at approximately 6 AM and asked if s/he should send the resident to the hospital but the supervisor declined and said that the wound nurse would look at it later. Interview with the APRN on 4/16/15 at 10 AM noted that s/he saw the resident at approximately 8 AM on 11/4/2014 seated in a wheelchair at the nursing station with a large skin tear that was still actively bleeding. A nurse was starting to rewrap the wound with a dressing. The APRN indicated that s/he put a pressure dressing in place to stop the bleeding but did not see a large hematoma under the skin at that time. The Medication Administration Record [REDACTED]. Interview and clinical record review with the DNS on 4/16/15 at 7:58 AM failed to provide documentation that the resident had been assessed all night by a licensed nurse when found to be agitated and yelling out, and/or had not been repositioned and/or toileted, and/or provided with incontinent care from 12 AM through at least 6 AM, and/or had been protected from the leg rests on the wheelchair when noted to be kicking his/her legs during the night. The record failed to document that the resident had been agitated, screaming and/or thrashing his/her legs either the night of the injury (11/4/14) or prior. Review of photographs taken at the emergency department noted a large bulky dressing the length of the lower leg from below the knee to the above the ankle that was saturated with blood through the dressing and onto a soaker pad. The wound was long and jagged with a large open area containing exposed subcutaneous fat and tissue and a large, black hematoma.

Based on clinical record, interviews, and review of facility policy and procedure for one of three residents reviewed for pressure ulcers (Resident #25), the facility failed to appropriately assess a pressure sore and/or failed to ensure that TED stockings were appropriately applied and/or fit to prevent a pressure sore and/or failed to discover a wound until it was open and contained 100% slough. The findings include: Resident #25's [DIAGNOSES REDACTED]. The care plan dated 1/29/15 identified a risk for skin breakdown. Interventions included encourage and assist me to reposition every two hours while awake, and pressure redistribution mattress. Physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. The clinical record failed to reflect a wound assessment was completed on 3/4/15 when the resident was identified with an open area on the anterior right ankle. Nursing notes dated 3/5/15 at 11:50 AM noted an unstageable pressure ulcer on the top of the right ankle measuring 2 CM x 2.5 CM with 100% yellow slough and surrounding deep purple area consistent with DTI in appearance. Wound tracking flow sheets dated 3/5/15 identified an unstagable pressure ulcer located on the top of the right ankle measuring 2 CM x 2.5 CM with 100% yellow slough. Facility policy and procedure for wound care protocols identified a complete wound assessment and documentation will be done weekly utilizing the skin/wound tracking record. The documentation will include the site/location, stage of the pressure ulcer, size including length, width and depth, appearance of the wound bed, surrounding skin and if there is any drainage/exudate. Interview and review of the clinical record with RN # 3 on 04/16/2015 at 9:30 AM identified when he/she assessed the wound on 3/5/15 it was identified as an unstageable pressure sore that was caused by the use of the Ted stockings. The APRN was notified and directed to cleanse the wound with normal saline and apply Acticot flex dressing daily. RN #3 indicated when the resident was identified with an open area on the top of the right ankle the clinical record should have reflected documentation of a thorough assessment.

Based on clinical record reviews and staff interviews for two of six residents in the survey sample reviewed for accidents (R # 16, R#35), the facility failed to ensure a resident who was to receive nothing by mouth (NPO) was not served a meal resulting in the resident taking a bite of a sandwich, and/or and/or the facility failed to ensure the resident care plan was reviewed and revised and interventions implemented to prevent bruises and/or skin tears and/or failed to maintain the residents environment in a safe manner and/or for the only sampled resident (R#169) with a significant injury, the facility failed to ensure that the resident received appropriate assessment, and care and services during the night shift and/or appropriate supervision to prevent a significant injury. The findings include: 1. Resident #169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] noted that the resident was confused, totally dependent on 2 staff for transfers, required assistance for eating and was incontinent of bowel and bladder. The skin condition assessment noted "scribbles" and arrows over the lower extremities with no description of what was present except for a note that there were bilateral lower extremity bruises, and skin tears to the right forearm and left wrist. The nursing admission note dated 10/31/14, indicated that there were "excoriations" to both lower extremities with no open areas and skin tears to both upper extremities. No further description or assessment of the extremities was documented. The admission care plan dated 10/31/14 indicated that the resident was at risk for falls, skin breakdown and incontinent of bowel and bladder. Interventions included to turn and position per policy, incontinent care as needed, and to assist with toileting. There were no treatments ordered for the lower extremities. The nursing notes dated 11/3/2014 documented that the resident was sitting up in a wheelchair at the nurses station at 6:15 PM on 11/3/2014 and the resident would yell when repositioning was attempted. The resident was described as being non-compliant with safety and alarms, and had no complaint of discomfort. Nursing note dated 11/4/2014 at 3 AM noted that the resident was out of bed in a wheelchair at the nurse's station and refusing to go to bed. Facility documentation indicated that at 6 AM on 11/4/14, the resident was noted with a large skin tear on his/her right lower leg. Statements from NA#4 and NA#5 at that time indicated that the resident was observed hitting his/her leg on the wheelchair leg rest and yelling during the night. Interview with CNA #5 on 4/16/15 at 6:20 AM noted that the resident was sitting up in a wheelchair at the nursing station when CNA #5 arrived on the unit at 11pm. CNA #5 stated that s/he tried to put the resident to bed but the nurse said not to because the resident was a fall risk and wanted him/her kept out of bed. CNA #5 stated that the resident stayed in the chair all night, was not ambulated, and was not put into bed. CNA #5 described the resident as "wild", swinging the legs and yelling. CNA#5 reported that he/she toileted the resident during first rounds at approximately 12 Midnight with the help of CNA #4, and that was the last time s/he provided any hands on care for the resident for the rest of the night. NA#5 noted that he/she saw blood and alerted the nurse. Interview with CNA #4 on 4/16/15 at 6:40 AM noted that the resident was not on his/her assignment that night. CNA #4 recalled that the resident was in a wheelchair at the nurse's station when s/he came on duty at 11pm. CNA #4 noted that s/he did not assist NA#5 with toileting the resident at all that night. CNA #4 noted that the resident was very loud, agitated and restless, kicking his/her legs during the night. CNA #4 stated that s/he had "boosted" resident up to reposition, but provided no other care during the night. Neither NA#4 or #5 actually saw the resident strike his/her legs on the wheelchair that resulted in the injury as indicated by their original written statements documented at the time the injury was noted. Interview on 4/16/2015 at 9:15 AM with RN #5, the night supervisor on duty the night of the injury, noted that s/he did not recall the resident or providing any care or assessments for the resident. Interview with LPN #4 on 4/16/15 at 10:17 AM noted that s/he never assessed the resident during the night and only saw the aides changing the resident's shirt. LPN#4 called the supervisor when the skin tear was discovered at approximately 6 AM and asked if s/he should send the resident to the hospital but the supervisor declined and said that the wound nurse would look at it later. Interview with the APRN on 4/16/15 at 10 AM noted that s/he saw the resident at approximately 8 AM on 11/4/2014 seated in a wheelchair at the nursing station with a large skin tear that was still actively bleeding. A nurse was starting to rewrap the wound with a dressing. The APRN indicated that s/he put a pressure dressing in place to stop the bleeding but did not see a large hematoma under the skin at that time. The medication administration record for 11/4/2014 noted that Tylenol was administered at 7am for pain. Interview and clinical record review with the DNS on 4/16/15 at 7:58 AM failed to provide documentation that the resident had been assessed all night by a licensed nurse when found to be agitated and yelling out, and/or had not been repositioned and/or toileted, and/or provided with incontinent care from 12 AM through at least 6 AM, and/or had been protected from the leg rests on the wheelchair when noted to be kicking his/her legs during the night. The record failed to document that the resident had been agitated, screaming and/or thrashing his/her legs either the night of the injury (11/4/14) or prior. Review of photographs taken at the emergency department noted a large bulky dressing the length of the lower leg from below the knee to the above the ankle that was saturated with blood through the dressing and onto a soaker pad. The wound was long and jagged with a large open area containing exposed subcutaneous fat and tissue and a large, black hematoma. 2. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge summary dated 12/5/14 indicated R # 16 was NPO with glucerna 1.2 at 50 cc/hour via a gastrostomy tube. An admission nursing assessment dated [DATE] indicated the resident was alert and oriented, was NPO and and had a feeding tube. A physician's orders [REDACTED].@ 50 cc/hour via gastrostomy tube. A nurse's note dated 12/5/14 indicated R # 16 was given a dinner in error and removed by the nurse aide when the error was discovered. The resident was NPO. The pulse oximeter reading was 97% and lungs were clear. The resident was educated on not eating at that time. At 10:30 PM the resident complained there was something stuck in his/her throat and requested to be suctioned. A small amount of secretions were cleared. The resident continued to complain that something was stuck in his/her throat. The Physician was notified at that time and ordered the resident be sent to the emergency room for evaluation. Review of a reportable event form and investigation dated 12/5/14 indicated R # 16 took a bite of a sandwich and later felt something was stuck I his/her throat. The resident had a tracheostomy. The resident was sent to the hospital for evaluation and was admitted to the hospital with [REDACTED]. The investigation indicated R # 16 was recently made NPO and was receiving [DEVICE] feedings. On 12/5/14 the resident was inadvertently given a supper meal by the dietary department. The meal included a ham salad sandwich on a roll. The meal was removed when the staff identified the resident should not have been given a meal. At that time a small piece of roll was missing and the resident had a piece of bread in his/her hand. The resident was assessed and had no choking or coughing. At 11:00 PM the resident complained that something was in his/her throat. The resident was suctioned and no food and/or object was found. The Physician was notified and the resident was sent to the hospital for evaluation at that time. An interview on 4/13/15 at 2:55 PM with the Cook Supervisor indicated he/she was serving the evening meal from the steam table on 12/5/14.. He/she was going through his/her routine and served a regular meal to the resident in room 113 bed 2. Although the diet sheet had indicated that R # 16 had been admitted into that bed and was NPO, he/she did not refer to the sheet and thought he/she was serving to the resident that was previously in the bed. When it was realized that food should not have been given to R # 16, the food was removed. A hospital discharge report dated 12/8/14 indicated on day two of the hospitalization the patient showed no evidence of aspiration and the antibiotics were discontinued and the bronchoscopy plan was aborted. 3. Resident # 35 was admitted to the facility with [DIAGNOSES REDACTED]. An admission nursing assessment dated [DATE] indicated the resident had multiple bruises on his/her lower legs. An annual MDS assessment dated [DATE] indicated the resident had short and long-term memory problems, required total care with all ADLs, and did not walk. A resident care plan dated 11/7/14 identified an alteration in skin integrity related to steroid medications. Interventions included pressure redistribution mattress, assist with repositioning every two hours, inspect skin weekly, and protective skin care with incontinent care. The individualized resident assignment (nurse aide informational sheet) did not include [DIAGNOSES REDACTED] and/or guidelines to prevent bleeding. A review of reportable events noted the following: On 11/10/14 a 1 cm x 1 cm purpura was noted on the resident's left calf. On 11/11/14 the Physician directed dermasavers to the residents lower legs at all times except during care. On 11/20/14 a purpura was noted on the resident's left eye. The nursing staff were educated on using a disposable wipe and using gentle dabbing instead of rubbing when providing care. On 12/1/14 a bruise was noted on the resident's left hand. On 12/1/14 the nursing staff were provided with reeducation on applying the palm guard. On 12/6/14 the resident sustained [REDACTED]. On 12/11/14 the resident was noted to have a skin tear to the left shin. During an interview on 4/15/15 at 1PM with RN # 2, he/she was unable to provide documentation that a preventative care plan was developed to prevent injury for a resident with severe [DIAGNOSES REDACTED] and/or the care plan was not reviewed and/or revised after the identification of the 12/6/14 skin tear and the 12/11/14 skin tear. He/she was unable to provide documentation in the investigation that the dermasavers had been applied to the resident's leg prior to transferring the resident out of bed on 12/11/4. An interview on 4/13/15 at 1:15 PM with NA # 1 indicated he/she could not recall the incident on 12/11/14 and/or if the resident had dermasavers on his/her legs prior to the transfer. 4. During tours of facility on 4/13/15 , 4/14/15 and on 4/15/15 at 10:30 AM with the Director of Maintenance the following was identified: a. Bedrooms 121, 122 and 123 had urinal deodorizer tacked to wall in bathroom and/or adjacent to bedroom door. b. A-wing bath/shower room had urinal deodorizer tacked to wall. c. Bathrooms (4) adjacent to reception area urinal deodorizer tacked to wall. d. A-wing bath/shower room damaged tile (located at baseboard level) at shower entrance. The tile was noted having sharp exposed jagged edges. Additionally the passage into the tub room noted damaged sharp edges at just above baseboard level. Interview with the House keeping manager on 4/16/15 at 6:58 AM h/she indicated that the urinal pads were used in the resident bedrooms that had strong urine odors because h/she could not utilize spray deodorant and had no access to wall or other deodorizers.

Based on clinical record review, interviews, review of facility documentation, and review of facility policy for one of three residents (Resident # 65) reviewed for hydration and/or one of four sampled residents (Resident #116) reviewed for weight loss, the facility failed to notify the physician and/or family when fluid goals were not met and/or when a significant weight loss was identified. The findings include: 1. Resident # 65 [DIAGNOSES REDACTED]. The Significant change MDS dated [DATE] identified severe cognitive impairment, required extensive assistance with eating and experienced a weight loss. The physician orders [REDACTED]. The NA flow sheets dated 4/24/14 through 5/1/14 indicated Resident #65 consumed 0 % and 25 % of meals. In addition, several meal intakes were not recorded during this time frame. A nurse ' s note dated 5/1/14 for the 7:00AM-3:00PM shift identified Resident #65 was noted with a temperature of 97.3, pulse 96, respirations 22 and blood pressure 104/64. Resident #65 was lethargic, had decreased fluid intake and had not met his/her fluid goals for 9 days. The nurse ' s note further identified that tenting was noted to the chest area, the supervisor was notified and an order was obtained by the physician to encourage fluids. A physician's orders [REDACTED]. Physicians order dated 5/4/14 directed to continue the IV fluids for 24 hours. A review of the clinical record from 4/24/14 through 5/1/14 failed to provide evidence that the physician was notified that Resident #65 was not meeting the fluid goals prior to 5/1/14. Interview with LPN # 6 on 6/11/14 at 11:00 AM identified that he/she observed Resident #65 to be lethargic on 5/1/14 and then reviewed the I & O 's which identified that the resident did not meet his/her fluid needs for 9 days . LPN # 6 further identified that although he/she identified Resident #65 had not met his/her fluid goals for nine days on 5/1/14, the clinical record lacked documentation of the Intake and Output (I & O) records for the dates of 4/24/14-5/3/14 . The physician was notified by the nursing supervisor and directed to encourage fluids. LPN # 6 identified on 5/2/14 he/she asked the physician to conduct an assessment of Resident # 65 because LPN #6 was concerned about the resident's hydration status. The physician evaluated the resident and identified IV fluids were required for a [DIAGNOSES REDACTED]. Interview with the ADNS on 6/9/14 at 2:30 PM identified that she was unable to locate the I & O's for the dates of 4/24/14-5/3/14. The ADNS further identified that it is the responsibility of the 11-7 nurse to file the I & O's in the clinical record once the sheet is completed. Interview with the Director of Nurses on 6/11/14 at 9:30 AM identified that it is the responsibility of the 11:00PM-7:00AM nurse to tally the I & O's for the past 24 hours and identify which residents are not meeting their fluid needs to pass onto the next shift. The DNS further identified that it would be her expectation that when a resident is not meeting their fluid goals and is exhibiting signs of dehydration an assessment would be completed and reported to the physician immediately. A review of the facility hydration protocol identified that if a resident does not meet fluid goals and does show signs of dehydration the physician, dietician and family will be notified to determine any changes to the plan of care. 2. Resident #116 ' s [DIAGNOSES REDACTED]. The care plan dated 3/22/14 identified impaired cognition; his/her appetite may fluctuate, required a therapeutic restrictive diet to manage [MEDICAL CONDITION], and was at risk for changes in weight. Interventions directed weights as ordered, offer supplements as needed, offer to set up for meals, cut food into small pieces and provide lip plate. The monthly physician's order [REDACTED]. The 14-day Minimum Data Set (MDS) assessment dated [DATE] identified moderately impaired cognition, short and long-term memory deficits and required limited assistance with eating. A review of weekly weight monitoring audit documentation noted the following weights: 4/3/14- 207 lbs., 4/7/14- 193 lbs., 4/14/14- 193 lbs., 4/28/14- 183 lbs., 5/5/14- 182 lbs., 5/12/14- 182 lbs. (which represents a 5% weight loss since 4/14/14). The dietary progress note dated 4/16/14 identified Resident #116 ' s weight was trending down, now 193 pounds (lbs.) and recommended weekly weights. The physician orders [REDACTED]. A review of the clinical record from 4/14/14 through 6/11/14 failed to identify that the physician and /or family were made aware of the 5% weight loss in a timely manner. Interview and review of facility documentation with the ADNS on 6/11/14 at 12:20 PM identified that the clinical record lacked documentation that the physician and/or family were notified at the time a significant weight loss was identified on 5/12/14. Attempts to contact MD#1 were unsuccessful. A review of the facility change in resident condition policy directed all significant change in resident ' s condition will be reported to the physician and family. The nurse will document in the nurse ' s notes that the physician and family or responsible party have been notified of the change in condition.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of four sampled residents (Resident #116) reviewed for weight loss, the facility failed to implement interventions in a timely manner to a prevent significant weight loss. The findings include: Resident #116 ' s [DIAGNOSES REDACTED]. The care plan dated 3/22/14 identified impaired cognition; his/her appetite may fluctuate, required a therapeutic restrictive diet to manage [MEDICAL CONDITION], and was at risk for changes in weight. Interventions directed weights as ordered, offer supplements as needed, offer to set up for meals, cut food into small pieces and provide lip plate. The monthly physician's order [REDACTED]. The 14-day Minimum Data Set (MDS) assessment dated [DATE] identified moderately impaired cognition, short and long-term memory deficits , required limited assistance with eating and had broken or loosely fitting full or partial dentures . A review of weekly weight monitoring audit documentation noted the following weights: 4/3/14- 207 lbs., 4/7/14- 193 lbs., 4/14/14- 193 lbs., 4/28/14- 183 lbs., 5/5/14- 182 lbs., 5/12/14- 182 lbs. (which represents a 5% weight loss since 4/14/14). The dietary progress note dated 4/16/14 identified Resident #116 ' s weight was trending down, now 193 pounds (lbs.) and recommended weekly weights. The physician orders [REDACTED]. A review of the clinical record from 4/14/14 through 6/11/14 failed to identify that weekly weights were completed as directed by the physician as the weight for 4/21/14 was not completed. The clinical record identified an additional 10 pound weight loss on 4/28/14 and failed to provide evidence that the dietician followed up on the weekly weights and /or was notified of the 5% weight loss in a timely manner. Interview and review of facility documentation with the Dietician on 6/11/14 at 11:20 AM indicated that Resident #116 weight was trending down and he/ she recommended weekly weights on 4/16/14, however he/she was not made aware of the subsequent April weights and continued weight loss until surveor inquiry on 6/11/14( six weeks later). The dietitian indicated he/she would have expected to have been notified of the additional weight loss. Interview with ADNS on 6/11/14 at 11:25 AM identified that it is the charge nurse's responsibility to notify the dietitian of weight loss. Subsequent to surveyor inquiry, Resident#116 was reassessed on 6/11/14 and interventions included to provide Resource 60ml between meals and to continue weekly weights. Review of the facility weight monitoring procedure directed weights to be taken and recorded on the weight sheet. The charge nurse should then review the weight and compare this to the previous weight to determine a 5% weight change in 30 days or 10% change in 180 days. Significant changes will be handled accordingly. Residents who have experienced significant weight loss should be identified to the health care team at morning report, since all departments can play a part in observing resident ' s routines or playing a part in the interventions. .

Based on facility documentation, clinical record review and interviews for 1 of 3 residents , ( Resident # 65)reviewed for nutrition the facility failed to provide sufficient fluids to maintain proper hydration.The findings include: Resident # 65 [DIAGNOSES REDACTED].The Significant change MDS dated [DATE] identified severe cognitive impairment, required extensive assistance with eating and experienced a weight loss. The physician orders [REDACTED]. The NA flow sheets dated 4/24/14 through 5/1/14 indicated Resident #65 consumed 0 % and 25 % of meals. In addition, several meal intakes were not recorded during this time frame. The nurses note dated 5/1/14 for the 7:00AM-3:00PM shift identified Resident #65 was noted with a temperature of 97.3, pulse 96, respirations 22 and blood pressure 104/64. Resident #65 was lethargic, had decreased fluid intake and had not met his/her fluid goals for 9 days. The nurses note further identified that tenting was noted to the chest area, the supervisor was notified and an order was obtained by the physician to encourage fluids. A physician's orders [REDACTED]. Physicians order dated 5/4/14 directed to continue the IV fluids for 24 hours. Interview with LPN # 6 on 6/11/14 at 11:00 AM identified that he/she observed Resident #65 to be lethargic on 5/1/14 and then reviewed the I & O 's which identfied that the resident did not meet his/her fluid needs for 9 days . LPN # 6 further identified that although he/she identified Resident #65 had not met his/her fluid goals for nine days on 5/1/14, the clinical recod lacked documentation of the Intake and Output (I & O) records for the dates of 4/24/14-5/3/14 . The physician was notified by the nursing supervisor and directed to encourage fluids. LPN # 6 identified on 5/2/14 he/she asked the physician to conduct an assessment of Resident # 65 because LPN #6 was concerned about the resident's hydration status. The physician evaluated the resident and identified IV fluids were required for a [DIAGNOSES REDACTED].Interview with the ADNS on 6/9/14 at 2:30 PM identified that she was unable to locate the I & O's for the dates of 4/24/14-5/3/14. The ADNS further identified that it is the responsibility of the 11-7 nurse to file the I & O's in the clinical record once the sheet is completed.Interview with the Director of Nurses on 6/11/14 at 9:30 AM identified that it is the responsibility of the 11:00PM-7:00AM nurse to tally the I & O's for the past 24 hours and identify which residents are not meeting their fluid needs to pass onto the next shift. The DNS further identified that it would be her expectation that when a resident is not meeting their fluid goals and is exhibiting signs of dehydration an assessment would be completed and reported to the physician immediately.A review of the facility hydration protocol identified that if a resident does not meet fluid goals and does show signs of dehydration the physician, dietician and family will be notified to determine any changes to the plan of care.

Based on clinical record reviews, review of policies and procedures and interviews with facility personnel for one of six sampled residents (Resident #1), the facility failed to ensure that the building was secure to prevent residents from eloping. The findings include: Resident #1's [DIAGNOSES REDACTED]. Review of the cognitive assessment dated [DATE] identified that the resident's seizures appeared to be the contributing factor to his cognitive impairment. In addition, Resident #1's decision-making capacity appeared to be mildly impaired for rational thinking, higher order functioning, memory issues and attention difficulities which indicated that the resident required supervision for health/safety issues. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] identified that the resident was alert/oriented with a cognitive deficit in judgement and had no skin issues. Review of the nursing care plan dated 9/12/13 identified that the resident is independent with activities of daily living and refused care. Review of the physician orders [REDACTED]. On 1/28/14 at 11:10 PM, Resident #1 was found by a nurse aide to be walking down the road away from the facility with no coat on. Interview with Nurse Aide (NA) #1 on 1/28/14 identified that she had left late and while she was driving down the road from the facility, she recognized the resident walking on the road, NA #1 indicated that she stopped her car, opened the car door and called the resident to get him into her car to drive him back to the facility but he instead, the resident ran away into a residential area. NA #1 indicated that she had notified the facility immediately and a search was initiated by staff. Until notified by NA #1, the facility was unaware that Resident #1 had exited the facility. Interview with Registered Nurse (RN) #1 on 1/29/14 identified that she initiated a search on 1/28/14 at 11:15P.M. for the resident by staff and called the police department for assistance in locating the missing resident. On 1/29/14 at 9:30 A.M., Resident #1 was found 2 1/2 miles away at a cafe having a bagel and coffee. Interview with Resident #1 on 1/29/14 at 2:00 PM, identified that he was upset the night before because the evening meal was horrible and there was nothing in the vending machine to eat so he decided to leave the facility to go to his brother's house (the home where he used to live) to get something to eat. Further interview with Resident #1 on 1/29/14 identified that he had exited the building through a clear sliding glass door in the rehabilitation area that did not have a keypad nor was it alarmed to notify staff if the door was opened. Resident #1 indicated that while he was walking down the road, a lady who he did not recognize, tried to get him into her car. Resident #1 stated that he got scared and ran away. Subsequently, the next morning at 9:30 AM, the resident was found by authorities at a cafe, without the slippers he had exited the building with and no coat and was taken to the hospital for an evaluation. Resident #1 sustained frostbite to his feet from being out in the cold for over 10 hours. Review of the readmission Nursing Admission Assessment documentation dated 1/30/14 at 8:20 PM identified that the resident was admitted with a [DIAGNOSES REDACTED]. The readmission skin sheet dated 1/30/14 identified the following: bilateral feet severe frost bite, bilateral feet edema, cool to touch and purple/red discoloration to all digits with swelling noted, the right foot/heel had an area identified as 9.2 centimeters (cm) by 13 cm, the heel was purple and the periphery had blisters, identified as reddish and purple, the bilateral feet had taunt skin, the right foot plantar area had an 11.0 cm by 13.0 cm blister like area, the right great toe had a blister documented as 2.6 cm by 0.5 cm with serous drainage present and there was also a blister to the medial aspect of the right foot that measured 0.4 cm by 1.0 cm that was reddish, purple in color. The left foot had an open area described as 3.0 by 2.2 cm with a depth of 0.2 cm, the left medial heel had a whitish area identified as 6.0 cm by 5.0 cm, the left foot, fourth digit had a 0.7 cm by 2.3 cm blister, the left foot plantar area had a purple discolored area measuring 13.0 cm by 15.0 cm, the underside of the left foot, the 3rd, 4th and 5th digits were described as purple and swollen, while the 2nd digit had a purple area measuring 1.4 cm by 1.4 cm. The treatment was identified as Silvadene followed by Xeroform to the open area on the left foot daily.The readmission fall risk assessment identified that the resident was on bedrest secondary to frostbite of bilateral feet. Upon return to the facility, Resident #1 was identified as an elopement risk and a wanderguard was placed on the resident. Observation of 3 sets of sliding glass doors in the recreation/dining area on the rehabilitation unit on 1/29/14 at approximately 3:00 PM identified that the alarms for the doors had been dismantled due to sharing the same electrical panel as the doors to the ambulance entrance, so residents were able to exit the sliding doors without any staff members being alerted. In addition, observation on 1/29/14 at 2:30 P.M. of the 3 sliding glass doors on the long term side that were linked into the alarm system identified that when the doors were opened by the surveyors, staff failed to respond to the door alarm. Review of the daily checklist for door modules dated 12/01/2013-1/29/2014 failed to identify that the sliding glass doors to exit the facility were listed on the checklist and/or being checked by staff. Interview with the Director of Maintenance on 1/30/14 at 10:30 PM and the Administrator on 1/29/14 at 6:00 PM identified that the facility was aware that the alarms were disengaged from the 3 sliding glass doors on the rehabilitation side for many years due to the noise the alarms where making from the ambulance/employee entrance. Review of facility policy identified that the Department of Maintenance were responsible for testing door alarms and keypads daily. Review of facility documentation identified that an Immediate Action Plan was received from the facility on 1/29/14 and all slider doors will be secured.

Based on review of the clinical record, facility documentation and interviews for one of two sampled residents with a history of falls and/or with poor safety awareness (R#95), and/or one of five sampled residents reviewed for accidents (R#111 ) the facility failed to ensure that assistive devices and/or foot rests were applied to ensure the safety of the resident. The findings included: 1. Resident #95's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident as severely impaired for decision-making skills requiring supervision and/or extensive assistance from staff for walks in the room and in the corridor of the unit, and/or for personal hygiene and dressing. The resident plan of care updated on 7/14/11 identified a problem for fall risk and/or poor safety awareness. Interventions included, utilizing 2 ? side rails on the bed to assist with bed mobility and transfers, call bell within reach when in bed and/or in bedside chair, check functions of chair and/or bed alarm every shift, bed pad and chair pad applied, ensure that motion sensor is working at all times, place floor mats on the floor beside the bed and provide evening care by 9 P.M. Review of facility documentation dated 8/18/11 at 12:30 A.M. identified in part that the resident was found on the floor by NA #10 on the floor along the bedside, fully dressed without receiving evening care (i.e. person hygiene) and/or that safety devices were not in place. Although the resident offered complaints of left flank discomfort after breakfast, an x-ray was obtain on 8/18/11 and the results were negative for fracture and/or injury. On 7/16/12 at 2:10 P.M. an interview and review of the facility documentation with NA #7 indicated that although she recalls putting the resident to bed at 8:30 P.M. she could not remember if she utilized all of the resident ' s safety devices per the resident ' s plan of care prior leaving the resident ' s room. On 7/16/12 at 2:20 P.M. and 2:44 P.M. interview and review of facility documentation with NA #8 and RN #4 indicated that the last time they saw the R #95, he/she was sitting in his/her chair at the bedside fully dressed at 5:30 P.M. and 9:30 P.M. in passing and/or while performing care with other residents. NA #8 indicated that she didn ' t know what type of safety devices the resident utilized at the time because he/she wasn ' t familiar with the resident because she wasn ' t assigned to the resident for care. Although RN #4 indicated that she remembers seeing the resident sitting in his/her chair at the bedside and that she may have seen the box to the resident ' s clip alarm in place she couldn ' t remember it ' s exact position on the resident ' s chair and/or whether or not the device was engaged and/or in the " on " mode. On 7/16/17 at 3:38 P.M. and 3:56 P.M. and on 7/17/12 at 2:42 P.M. interviews and review of the facility documentation with LPN #6, RN #7 and NA #10 indicated that on the night shift (at or around 12:30 A.M.), R #95 was found lying on the floor with his/her blanket and pillow, fully dressed and wearing a pair of sneakers with the door of the resident ' s room more than ? way closed. LPN #6 and NA #10 further noted that the side rails were down, the floor mats were not at the bedside and that the bed and/or chair alarm and/or motion sensors weren ' t being utilized and the call bell was out of the resident ' s reach. 2. Resident #111's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified mostly intact cognition, non-ambulatory, the need for extensive assistance of two staff for transfers and total assistance of one staff for locomotion off unit. The care plan dated 8/9/11 directed the resident be transferred via a hoyer lift with assist of two staff and utilize a wheelchair while out of bed. Accident/incident report dated 9/1/11 at 12:00 PM identified that while NA#4 was pushing the resident in the wheelchair, the resident's left leg got caught under the wheelchair and the resident was noted to say "ow." Nurse's note dated 9/1/11 at 3:15 PM identified that the resident was complaining of pain in the left leg. Additionally, the resident stated that while being pushed in the hallway, her left leg got stuck under the wheelchair. Furthermore, the note identified that the leg was warm, swollen, deformed and after physician notification, the resident was sent to the hospital for evaluation. Interview with RN#3 on 7/9/12 at 11:15AM identified because the resident was on the way to a physician appointment, he/she should have had leg rests on. Interview with PT#1 on 7/9/12 at 12:00 PM identified that although the resident could self propel short distances on the unit, for a physician appointment, I would expect leg rests to be applied. Review of the hospital discharge paperwork dated 9/1/11 identified the resident was diagnosed with [REDACTED]. Review of the facility policy on wheelchairs directs that staffs are to ensure extremities are supported.

Based on review of the clinical record, facility documentation and interviews for one of three sampled residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision was provided to prevent an injury. The findings include: Resident #1's [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified severe impairment and total dependence for activities of daily living. The resident care plan dated 3/1/11 identified that the resident required assistance for daily activities due to cognitive loss and impaired physical ability. The nurse's note dated 5/24/11 at 8:30 AM identified that the resident had four filled blisters to four fingers on ther right hand with the middle finger almost covered with a blister. The physician was notified and the resident was transferred to the hospital for an evaluation. The hospital discharge summary dated 5/24/11 identified thermal burns to right wrist, hand, and 2nd-5th digits with treatment that included Bacitracin, Xeroform and 4 X 4 gauze to each finger followed by a kerlix wrap. Facility documentation dated 5/24/11 identified that on 5/23/11 Resident #1 was at the hairdresser and while under the hairdryer second degree burns were sustained to the right hand. Facility documentation further identified that Resident #1 had a history of [REDACTED]. Hairdresser #1 in an interview on 6/28/11 at 11:00am indicated she transports residents to and from the hairdresser salon for their appointments and she was not aware Resident #1 had burned the right hand in the hairdryer. Hairdresser #1 further identified that she was aware the resident's habit of keeping the right hand on the side of his/her head. Interview and review of a written statement with LPN #2 on 7/1/11 at 9:00am identified that she fed the resident dinner on 5/23/11 and noticed that the tips of the resident's fingers were slightly red but were not swollen. LPN #2 indicated she did not think she needed to report the redness to the Nursing Supervisor or monitor the redness during the shift. Interview and review of the clinical record with LPN #1 on 6/30/11 at 10:00am identified that on 5/24/11 fluid filled blisters were noted on the second, third, fourth and fifth fingers of the resident ' s right hand. LPN #2 indicated the third finger was almost entirely covered by a blister. Interview with the Director of Nurses (DNS) on 6/30/11 at 9:30am identified the resident had been to the hairdresser on 5/23/11 and the hairdryer was used to dry his/her hair. The DNS indicated the facility investigation determined the burns on the right hand were from the resident putting the hand into the bonnet portion of the hairdryer while the hairdryer was on. The DNS indicated she was unaware that the hairdresser was transporting residents to and from the hairdresser salon leaving residents unattended. Review of the manufacturer's recommendations for the hairdryer identified that close supervision was necessary when the appliance is used by, on, or near children or invalids.