Every finding on record at Apple Rehab Watertown

Based on clinical record review and staff interviews for 1 of 2 residents (Resident # 10) reviewed for Pressure Ulcers, the facility failed to ensure staff accurately review the clinical record and code the pressure ulcer stages on the Minimum Data set assessment to reflect the resident's condition. The findings include: Resident # 10's diagnosis includes dementia. The wound care physician progress notes dated 3/3/20206 and 3/10/2026 indicated Resident #10 had a stage 3 pressure ulcer on the coccyx (center of lower back) and a stage 3 pressure ulcer of the thoracic spine which had reopened and indicated the wound was previously a stage 3 wound). The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was at risk of pressure ulcer, had unhealed pressure ulcers, 1 stage 2 pressure ulcer, 1 stage 3 pressure ulcer and 1 stage 4 pressure ulcer all of which was not present on admission. Resident #10's care plan dated 3/16/2026 indicated Resident #10 had a potential for skin breakdown related to limited mobility and incontinence. Interventions included providing a low air loss mattress (to reduce pressure), to encourage repositioning side to side when in bed, incontinent care after each episode of incontinence. An interview and clinical record review on 3/25/2026 at 2:25 PM with Registered Nurse( RN #2) and Licensed Practical Nurse( LPN #12) indicated even though RN #2 viewed the wound with the nurse caring for the resident both had concluded it was a stage 2 pressure ulcer; the wound physicians progress notes should have been looked at as well to make the determination as how to code the MDS. LPN #12 indicated the MDS would be modified to reflect the correct pressure ulcer status for the resident at that time.

Based on observations of medication administration, review of policy and staff interviews for 3 of 11 residents (Residents #37, #47, and #48) reviewed for medication administration, the facility failed to identify residents prior to administering their medications in accordance with facility policy. The findings included: 1.Resident # 37's diagnoses included Transient Ischemic Attack (TIA), depression, cerebrovascular disease, hyperlipidemia and hypertension.The physician's orders and Medication Administration Record (MAR) for February 2026 and March 2026 directed licensed staff to administer the following: acidophilus probiotic, 1 billion IU's, daily for supplementationEliquis 5.0 Milligrams (MG) by mouth twice a day Folic Acid 1.0 MG by mouth daily Levetiracetam 500 MG by mouth twice a day antiseizure medicationSenna Plus 8,6-50 mg one tablet by mouth twice a day for constipationVitamin B-1, 100 milligrams, daily for supplementationObservations made during medication administration identified the following:On 3/23/26 at 10:28 AM, Resident #37 was administered the following medications:-One tablet of acidophilus probiotic, 1 billion IU's, daily for supplementation-One tablet of Eliquis, 5 milligrams, twice daily for atrial fibrillation-One (1) tablet folic acid, 1 milligram, daily for supplementation-One (1) tablet Levetiracetam, 500 milligrams, twice daily for seizures-Two (2) tablets Senna Plus, 8.6-50 milligrams, twice daily for constipation-One (1) tablet Vitamin B-1, 100 milligrams, daily for supplementationHowever, upon administering the medications to Resident #37, LPN #6 identified him/her by name only. Interview with LPN #6 on 3/23/26 at 10:32 AM identified the facility's standard of practice was to identify the resident prior to administering their medication(s) by either verifying their name on their identification bracelet, asking their name, and/or verifying their date of birth . LPN #6 further indicated he/she did not identify Resident #37 prior to administering his/her medications because he/she already knew him/her.2. Resident # 48's diagnoses included depression, Transient Ischemic Attack ( TIA), cardiac pacemaker, hypertension and atrial fibrillation.The physician's orders dated February 2026 through March 2026 directed the licensed staff to administer the following:Eliquis 2.5 mg by mouth twice a day for atrial fibrillationMetoprolol 100 mg by mouth twice a day for high blood pressureOn 3/24/26 at 10:21 AM, Resident #48 was administered the following medications:-One tablet of Eliquis, 2.5 milligrams-One tablet of metoprolol, 100 milligramsHowever, upon administering the medications to Resident #48, LPN #7 identified him/her by name only.Interview with LPN #7 on 3/25/26 at 4:00 PM identified the facility's standard of practice was to identify the resident by their name band prior to administering their medication(s) and if the resident did not have a bracelet on, to ask their name and verify their date of birth . LPN #7 further indicated he/she had only asked Resident #48's name prior to administering his/her medication(s) as she was nervous.3.Resident # 47's diagnoses included vascular dementia with behavior disturbances , anxiety, adjustment disorder, depression and bilateral knee pain.The physician's orders dated February 2026 directed the licensed staff to administer the following medication quetiapine 25 mg by mouth three times a day for dementia with behavioral disturbanceOn 3/25/26 at 11:38 AM, Resident #47 was administered the following medication:-One tablet quetiapine, 25 milligrams, three times daily However, upon administering the medication to Resident #47, LPN #8 identified him/her by name band only.Interview with LPN #8 on 3/25/26 at 11:40 AM identified the facility's standard of practice directed to identify the resident by their name band and date of birth but only verified his/her name on Resident #47's name badge as he/she did not have a computer close by to verify the resident's date of birth had he/she asked. Interview with the Regional Clinical Director on 3/26/26 at 3:22 PM identified the facility's standard of practice directed to identify the resident using two (2) identifiers (name bracelet, picture on electronic medical record, resident to self-identification if able, or two (2) staff that could confirm the resident's identity) prior to administering the resident's medication.The Medication Administration policy directed to confirm the resident's identity by using at least two (2) identifiers (e.g.name and date of birth ) before administering the medication and to ensure the right resident, right medication, right dose, right route and right time.

Based on clinical record review, facility policy and staff interviews for 1 of 2 residents (Resident # 91) reviewed for nutrition, the facility failed to reweigh a resident with a significant weight discrepancy in a timely manner and failed to implement interventions in a timely manner after a confirmed weight loss. The findings include: Resident #91's diagnoses included arthritis of the knee, anxiety, and depression.A physician's order dated 10/1/2024 directed the resident be weighed monthly on the 1st of the month.A quarterly MDS assessment dated [DATE] identified Resident #91was moderately cognitively impairment and was dependent for eating and oral hygiene. The MDS assessment further identified Resident #91 had not experienced significant weight loss.A care plan dated 11/24/2025 identified Resident #91 had potential for nutritional decline. Interventions included providing fortified foods and supplements as ordered and weighing the resident as ordered.A review of documented weights for Resident # 91 identified the following: On 1/1/2026, Resident #91 weighed 160 pounds (lb.) and had been weighed by wheelchair. On 2/1/2026, Resident #91 weighed 151.6 lb. by wheelchair, which was an 8.4 lb. weight loss, or 5.2% loss in one month.A review of nursing progress notes failed to identify documentation of any resident refusals of weights and failed to identify interventions for the potential weight loss of 5.2% on 2/1/2026.A review of provider orders identified a physician's order for an immediate (STAT) reweight dated 2/12/2026 at 1:16 PM.On 2/12/2026, Resident #91 weighed 149.9 lb. by wheelchair, which was a 10.1 lb. weight loss or 6.3% loss from the initial 1/1/2026 weight.A dietician's note dated 2/19/2026 (identified that Resident #91 had a significant weight loss of 6.3% over one month) based on the 2/12/2026 weight of 149.9 Lb. The note further identified a house supplement twice daily was recommended, as well as to monitor intake and weight.On 3/24/2026 at 12:52 PM, an interview with Licensed Practical Nurse (LPN#11) indicated when a resident had a 5 lb. weight loss, then the nurse should tell the provider, dietician, or supervisor. LPN #11 indicated he did not remember who he had notified regarding the suspected weight loss on 2/1/2026. LPN #11 further indicated on 2/12/2026, he was requested to reweigh Resident #91.On 3/25/2026 at 1:09 PM, an interview with the Dietician identified she did not recall being notified of a weight discrepancy on 2/1/2026 or of a confirmed weight loss on 2/12/2026. The Dietitian indicated that she found out about the weight loss when she reviewed the resident weights weekly and then addressed the weight loss during the facility's weekly at-risk meetings. The Dietician indicated on 2/5/2026, she reviewed Resident # 91's 2/1/2026 weight discrepancy and indicated during the at-risk meeting Resident #91 needed to be reweighed. The Dietician further indicated on 2/12/2026, she identified Resident #91 needed a reweight to confirm weight loss. The Dietitian indicated she reviewed the 2/12/2026 reweight on 2/19/2026 and ordered a house supplement at that time. The Dietician was unable to identify a rationale for starting interventions on 2/19/2026, which was 7 days after a weight loss was confirmed and 18 days after an initial weight discrepancy was identified.On 3/25/2026 at 1:45 PM, an interview with the Director of Nursing (DNS), the Assistant Director of Nursing (ADNS), and the Administrator were conducted. The administrator identified the facility policy did not specify how soon a reweight should be performed and that it depended on the significance of the weight loss. The Director of Nursing Services indicated a 5% weight loss in one month would be considered significant. The administrator further identified Resident # 91's 2/1/2026 weight discrepancy was discussed during the facility's at-risk meetings on 2/5/2026 and then again on 2/12/2026.A review of the facilities minutes for the Weekly At-Risk Meeting dated 2/5/2026 on 3/24/26 identified Resident #91 needed a reweight related to weight loss. A review of the facility's minutes for the Weekly At-Risk Meeting dated 2/12/2026 identified Resident #91needed a reweight related to weight loss.A review of the facility policy for Weight Monitoring identified that residents will be weighed monthly unless otherwise indicated by a Medical Doctor (MD) order and/or recommended by the registered dietician. Additionally, the policy indicated that if there was a 5 lb. discrepancy, a reweight should be obtained and the charge nurse should review the weight and compare it to the previous weights to determine a significant weight change. A significant weight change would then be reported to a provider, responsible party, dietician, Director of Nursing Services, and care plan coordinator.

Based on review of the clinical record, facility policy and staff interview for 1 of 2 residents for (Resident #52) reviewed for Respiratory Care, the facility failed to ensure the individualized settings needed for the resident's Continuous Positive Airway Pressure (CPAP) machine were reflected in the physician's orders. The findings include: Resident #52's diagnosis includes obstructive sleep apnea. The physician's orders dated 2/14/2026 directed to provide a Continuous Positive Airway Pressure (CPAP) machine already programmed with settings to use every night, to apply the CPAP at bedtime after filling the water chamber with sterile or distilled water and to remove the CPAP in the AM upon waking, and to clean the facemask used with the CPAP machine with soap and water daily then place to air dry on clean surface, once dry place in the provide oxygen treatment bag. The admission Minimum Data Set assessment dated [DATE] indicated Resident #52 used a CPAP machine. The care plan dated 3/02/2026 indicated Resident #52 had sleep apnea. Intervention directed to apply and remove the CPAP as ordered. A discharge summary from the hospital dated 3/13/2026 at 3:00 PM indicated Resident #52 should continue CPAP every evening set at Positive End- Expiratory Pressure(PEEP) 9. An interview, clinical record review and facility policy review with the Director of Nursing Services (DNS) on 3/26/2026 at 2:30 PM identified the lack of individualized settings for the CPAP machine within the physician orders. The DNS indicated the settings were put in by Respiratory Therapy (RT), the nurse's do not change them as they are set on the inside. The DNS also indicated she/he did not have the settings, and the respiratory physician would have the required settings. Resident #52's CPAP settings were identified within the hospital Discharge summary dated [DATE]. The DNS indicated staff need to obtain a physician's order for the required settings as the resident could be transferred to another medical facility. The facility policy and procedure labeled CPAP/ Bilevel Positive Airway Pressure (BIPAP) indicated a CPAP/BiPAP order must be initiated upon receipt of a written order from the resident's physician and need to include the settings(pressure levels, mode of therapy) and any specific instructions for use.

Based on review of the clinical record, review of facility documentation, review of policy and staff interviews for 1 of 2 residents (Resident #3) reviewed for dialysis, the facility failed to ensure consistent communications between the facility and dialysis clinic were maintained regarding the resident's dialysis treatments, pre and post treatment weights, vitals, medications administered and/or any concerns. The findings included: Resident #3 was admitted to the facility in October 2025. The residents' diagnoses included end stage renal disease, dependence on renal dialysis, and Type 2 diabetes mellitus.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 as cognitively intact (Brief Mental Interview for Mental Status (BIMS) of 15) and dependent with toileting, lower body dressing and noted the utilization of a wheelchair for transport.The Resident Care Plan (RCP) dated 1/29/26 identified Resident #3 received dialysis three times weekly due to chronic renal disease. Interventions directed to contact the dialysis center with questions regarding care.Review of the Dialysis Communication Book (a notebook used for communications between the dialysis facility and long-term care facility regarding Resident #3's treatments, pre and post treatment weights, vitals, and medications administered) failed to identify entries for treatments administered in February 2026 and March 2026.Although requested, the facility did not have additional notes/communications with the dialysis facility for February 2026 and March 2026 treatments to provide.Interview with LPN #2 on 3/26/26 at 11:02 AM (who was assigned to Resident #3 on dialysis days dated 2/2/26, 2/13/26, 2/16/26, 2/27/26, 3/9/26, 3/11/26, and 3/16/26) identified Resident #3 received dialysis treatments on Mondays, Wednesdays, and Fridays at the dialysis facility and would return to the facility during first shift (7:00 AM to 3:00 PM) following treatment. LPN #2 identified she/he would check the dialysis communication book following Resident #3's treatments and if nothing was logged, she/he would follow-up with a phone call to the facility, document the call, and inform the provider of any issues of concern. However, review of the Dialysis Communication Book failed to identify entries for any dialysis treatments administered in February 2026 and March 2026, and review of nursing notes failed to indicate calls were made to the dialysis facility regarding the resident's treatments.Interview with the Director of Nursing Services (DNS) on 3/26/26 at 12:52 PM identified the dialysis clinic had the responsibility of communicating any information regarding Resident #3's treatment, vitals, weight, medications or concerns with the facility following her/his treatment. However, the DNS did indicate if the treatment was not logged into the Dialysis Communication Book, he/she did expect staff to call the dialysis facility to request Resident #3's vitals, weight, medications, and/or any changes that may have occurred during Resident #3's dialysis treatment that day. Interview with LPN #11 (who was assigned to Resident #3's care on 2/4/26, 2/6/26, 2/9/26, 2/11/26, 2/18/26, 2/20/26, 3/4/26, 3/6/26, 3/13/26, 3/18/26, 3/20/26, and 3/23/26) on 3/26/26 at 3:40 PM identified she/he was not aware of a Dialysis Communication Book and did not recall being told to check it following Resident #3's dialysis treatments.The Hemodialysis policy directed a completed Intra- Agency Report ( W-10) and/or communication sheet, current medication list, and any other pertinent information such as concerns, laboratory, diet, weight, vital signs, etc. were sent with the patient/resident for each dialysis treatment and the dialysis center would communicate with the facility using the communication tools listed above or the center's post dialysis form to communicate information with the facility post dialysis treatment.

Based on observations of the facility medication carts and storage rooms, review of facility policies and staff interviews, the facility failed to dispose of expired medications in 1 of 3 medication carts and1 of 2 medication storage rooms. The findings included: 1.Observation of the medication cart on Crestbrook on 3/24/26 at 10:27 AM identified the following:Narcan ( used to reverse the effects of a life-threatening opioid emergency ) two (2) single dose nasal spray devices, 0.003 fluid ounces (0.1 milliliters each) with an expiration date of 3/2026.An opened bottle of Gericare Milk of Magnesia ( laxative), 16 fluid ounces, with an expiration date of 10/2025Interview with LPN #7 on 3/24/26 at 10:30 AM identified medications that are dated with month and year only expired as of the first of the month listed on the box/container therefore the medications should have been removed from the medication cart prior to their expiration. 2. Observation of the medication room located central to the [NAME] and Crestbrook wings on 3/24/26 at 10:50 AM identified the following:A container of Bisacodyl ( laxative), 5 milligrams, 100 tablets with an expiration date of 9/2024A container of geri-dryl, ( antihistamine) 25 milligrams, 100 tablets with an expiration date of 10/2025A container of stool softener, 100 milligrams, 200 tablets with an expiration date of 8/2025Interview with RN #4 on 3/24/26 10:57 AM identified expired medications should be disposed of prior to their date of expiration. She/he further indicated it was the responsibility of the Director of Nursing Services or Assistant Director of Nursing Services to evaluate the medication storage rooms and dispose of the expired medications.Interview with the Regional Clinical Director on 3/26/26 at 3:25 PM identified expired medications should be removed from circulation and discarded by the expiration date, and if the expiration date listed only the month and year of expiration, the facility staff was directed to dispose of the expired medication the first day of the month listed on the medication package. The Expired Medications and Medications with Shortened Expiration Dates identified the Director of Nursing Services or other authorized personnel would delegate to appropriate personnel the task of ensuring that all outdated or expired medications (with the exception of controlled substances, refer to controlled substances policy) were removed from the medication cart or other area where medication may be stored.

Based on clinical record review, facility documentation review, facility policies review, and interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to ensure an RN assessment was completed timely after staff identified a change in condition that resulted in a transfer to the hospital, and failed to ensure an RN assessment was completed timely after a return to the facility from the hospital. The findings include: Resident #1 was admitted to the facility with diagnoses that included stroke, thyroid disorder, and hypertension. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, moderate cognitive impairment, had no behaviors, required assistance with ADLs and transfers, and received no antianxiety or antidepressant medication. A Resident Care Plan (RCP) dated 9/12/2024 identified Resident #1 had cardiovascular disease due to bradycardia and hyponatremia. Interventions directed to obtain vital signs and provide medications as ordered. A nursing change in condition note (Situation, Background, Assessment, Recommendation - SBAR) written by LPN #1 dated 12/30/2024 at 8:38 PM identified Resident #1 had become combative, and no intervention was improving the behavior, and identified the behavior was worsening noting Resident #1 was now a danger to self. A one-time antianxiety medication was obtained and administered, although Resident #1 spit it out. A nursing note dated 12/30/2024 at 11:59 PM written by LPN #1 identified the day shift nurse, LPN #2, reported Resident #1 was very agitated and became more agitated as the afternoon proceeded and found Resident #1 standing and wanting to climb out of the window to see a man and a baby. Upon redirection, Resident #1 began to hit, scratch and yell at staff. The APRN was notified and when Resident #1 spit out the ordered antianxiety medication, the APRN ordered Resident #1 to be transferred to the hospital for evaluation. Person #1 (Resident #1's responsible party) was notified and refused the transfer until Person #1 was able to see Resident #1. Resident #1 became more agitated with Person #1 in attendance, verbally threatening to hit Person #1 and Resident #1 was transferred to hospital for evaluation. Record review failed to identify an RN assessment was completed when staff identified a change in condition on 12/30/2024. B. Review of EMS (Emergency Medical Services) run sheet dated 12/30/2024 identified EMS was called at 9:36 PM and left the facility for the transport to the hospital with Resident #1 at 10:03 PM. A hospital Discharge summary dated [DATE] at 12:51 PM identified Resident #1 was evaluated by psychiatric services initially on 12/30/2024, was determined to be a danger to self and was to be held for a psychiatric admission. Psychiatric services changed with recommendations to decrease Buspar to 5 mg daily for five (5) days and then to discontinue the Buspar, recommended to add Risperidone 0.25 mg (antipsychotic medication) as needed for agitation, and to be followed up by geriatric psychiatric services. A nursing note written by LPN #3, dated 1/1/2025 at 7:49 PM (1 day, 21 hours and 46 minutes after transfer to the hospital) identified Resident #1 returned to the facility from the hospital. Review of the facility twenty-four hour report sheets dated from 12/30/2024 to 1/2/2025 failed to identify any documentation for Resident #1, other than documentation of his/her return to the facility from the hospital on 1/1/2025. Review of Resident #1's medical record failed to identify an RN assessment was completed after Resident #1's return to the facility on 1/1/2025. Interview and record review with RN #3 on 1/8/2026 at 1:47 PM identified she was the RN supervisor working on 12/30/2024 when Resident #1 was transferred to the hospital and she stated she could not recall assessing Resident #1 on 12/30/2024. RN #3 stated if she had assessed Resident #1, she would have documented the assessment. RN #3 stated an RN assessment should be completed for a change in a resident's condition and upon admission/readmission. RN #3 stated assessments should have been completed on 12/30/2024 when the change was identified and on 1/1/2025 when Resident #1 returned from a hospital, and it should be documented in the medical record. RN #3 stated if it was not documented, it would not be considered done. Interview failed to identify why RN assessments were not completed. Interview with the DON on 1/12/2026 at 9:28 AM identified that she would expect an RN to complete as assessment if a resident experienced a significant change in condition that resulted in a transfer to the hospital for evaluation. She did not know why RN #3 did not complete an assessment on 12/30/2024 or why the RN supervisor, RN #2, did not complete an assessment on 1/1/2025. RN #2 (supervisor on 1/1/2025) was unavailable for interview during the survey. The facility Change in Resident Condition Policy dated July 2018, directed in part, when there is a significant change in condition or a resident's physical, mental or emotional status, an RN assessment will be conducted. The facility policy Nursing Documentation directed in part, that documentation should occur as soon as possible after the assessment was completed.

Based on clinical record review, facility documentation review, facility policies review, and interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to ensure the clinical record was complete and accurate to include vital signs were recorded timely after a change in condition was identified. The findings include: Resident #1 was admitted to the facility with diagnoses that included a history of stroke, convulsions, thyroid disorder, and hypertension. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, moderate cognitive impairment, had no behaviors, required assistance with ADLs and transfers, and received no antianxiety or antidepressant medication. A Resident Care Plan (RCP) dated 9/12/2024 identified Resident #1 had cardiovascular disease due to bradycardia and hyponatremia, and had accusatory behaviors at times. Interventions directed to obtain vital signs and provide medications as ordered. A nursing note dated 12/7/2024 identified RN #3 was called to assess Resident #1 who became unresponsive during morning care while moving his/her bowels. Resident #1 was unresponsive to tactile and verbal stimuli with a carotid (neck) pulse of 30 beats per minute. Resident #1 became responsive after a few minutes with vital signs: blood pressure 90/60 (baseline 122 to 132/68 to 74), pulse 50 (baseline 55 to 72), and respiratory rate 14. The APRN was updated. A physician order dated 12/7/2024 directed to obtain vital signs every shift for three (3) days. Record review identified although vital sign monitoring was initiated as ordered on 12/7/2024 at 3 PM, vital signs were not recorded every shift for three (3) days. Review of the Medication Administration Record (MAR) for December 2024, identified all the shifts for the three (3) days (12/7, 12/8, 12/9 and 12/10/2024) were initiated to indicate the vitals signs were obtained. Additional review identified the MAR did not record what the vital signs were. Review of the nursing notes and vital sign records in the clinical record failed to identify the vital signs obtained were recorded. The following shifts had initials signed on the MAR to indicate the vital signs were obtained, but no vital signs obtained were documented in the record:12/7/2024 night shift12/8/2024 day, evening, and night shifts12/9/2024 day, evening, and night shifts12/10/2024 day shift Interview with the DON on 1/12/2026 at 9:28 AM identified she expected the nursing staff to follow a physician's order. The physician order was for vital signs every shift for three (3) days and the staff should have obtained and documented the vital signs (temperature, blood pressure, pulse and respirations) in the medical record. The DON stated she did not know why the nursing staff did not document the vital signs as ordered. The facility Nursing Documentation Policy directed in part, that documentation should occur as soon as possible after care was completed.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for change in condition, the facility failed to ensure when changes were made in medications and the plan of care the resident's family was notified. The findings include: Resident #1 had diagnoses that included type 2 diabetes mellitus, liver cirrhosis, dementia, and Alzheimer's disease. The physician's orders dated 1/21/24 directed to administer Tresiba subcutaneous solution (a medication used for diabetes mellitus) 100 unit/ml inject 6 units at bedtime, obtain blood sugars at 6:30 A.M., 11:30 A.M., 4:30 P.M. and administer Humalog (Lispro insulin) injection solution (a medication used for diabetes mellitus)100 unit/ml subcutaneously before meals inject per sliding scale: Blood Glucose (BG) is below 60 or above 401, call MD/APRN BG 151-200 administer 2 units BG 201-250 administer 4 units BG 251-300 administer 6 units BG 301-350 administer 8 units BG 351-400 administer 10 units The admission MDS dated [DATE] identified Resident #1's had a Brief Interview for Mental Status score of seven (7) indicative of severely impaired cognition, frequently incontinent of bowel and bladder, required substantial assistance with ADLs, received insulin injections, and Resident #1 and h/her family participated in the assessment and goal setting. The care plan dated 1/30/2024 identified Resident #1 is at risk for hyperglycemia and/or hypoglycemia related to diabetes with interventions directed to administer medications as ordered, check blood sugar if any of the following signs/symptoms are noted complaints of hunger, sweating, confusion, dizziness, increased thirst, nausea or vomiting, abdominal discomfort or changes in mental status, labs as ordered, watch for any changes in mental status and mood state and report to MD/APRN. A pharmacist medication regimen review dated 3/14/24 identified Resident #1 has an order for insulin to be administered via sliding scale and for Tresiba insulin 6 units daily Resident #1's reported A1C was 6.1 % on 3/11/24 appears to have stable glycemic control. The pharmacist recommendation directed to consider discontinuing Resident #1's sliding scale of insulin and continue to monitor fingerstick blood glucose in a frequency appropriate for Resident #1. A review of Resident #1's laboratory reported dated 3/12/24 identified Resident #1's Hemoglobin A1C (a blood test that measures the average blood sugar levels over the past two (2) to three (3) months reported as a percentage) result was 6.1 % (levels between 5.7 % to 6.4 % indicate prediabetes, levels of 6.5 % or higher suggest diabetes). Review of APRN #1's note dated 3/15/24 at 12:00 A.M. identified Resident #1 had multiple episodes of blood glucose above 250. APRN #1 identified for Resident #1's hyperglycemia will increase Tresiba long-acting insulin from 6 units 10 units at bedtime and can move to blood glucose monitoring once per day instead of three times a day. A physician's order dated 3/16/24 directed to administer 10 units of Tresiba subcutaneous solution 100 unit/ML inject subcutaneously at bedtime. Review of the pharmacist recommendation dated 3/14/24 identified on 3/18/24 APRN #1 accepted the recommendations above, signed, and directed to implement as written. The physician's orders dated 3/18/24 written by APRN #1 directed to discontinue obtaining Resident #1's fingerstick for blood sugars at 6:30 A.M., 11:30 A.M., 4:30 P.M. and discontinue Resident #1's sliding scale of Humalog (Lispro insulin) injection solution (a medication used for diabetes mellitus)100 unit/ml subcutaneously before meals. An interview with APRN #1 on 1/16/25 at 10:40 A.M. identified on 3/12/24 Resident #1's had an A1C level of 6.1 % indicating Resident #1's blood sugars were stable. APRN #1 identified on 3/18/24 the pharmacy monthly medication review recommendations directed to consider discontinuing Resident #1's sliding scale of Humalog insulin. APRN #1 identified on 3/18/24 she discontinued Resident #1's blood sugar checks and sliding scale of Humalog insulin sliding scale. APRN #1 identified when a resident has a change in condition and/or change in the plan of care it is the responsibility of the nurses to notify the resident's next of kin. Interview and clinical record review with DNS on 1/16/25 at 2:30 P.M., the DNS was unable to provide documentation to reflect that on 3/18/24 Resident #1's daughter was notified when APRN #1 discontinued Resident #1's sliding scale of Humalog insulin and discontinued Resident #1's blood sugar checks. Review of facility change in resident condition family/MD notification policy dated July 2018 identified; in part, all significant changes in residents' condition will be reported to the physician and family.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for diabetes management, the facility failed to ensure diabetes bloodwork was obtained. The findings include: Resident #1 had diagnoses that included type 2 diabetes mellitus, liver cirrhosis, dementia, and Alzheimer's disease. The care plan dated 10/19/24 identified Resident #1 is at risk for hyperglycemia and/or hypoglycemia related to diabetes with interventions that directed to administer medications as ordered, check blood sugar if any of the following signs/symptoms are noted complaints of hunger, sweating, confusion, dizziness, increased thirst, nausea or vomiting, abdominal discomfort or changes in mental status, labs as ordered, watch for any changes in mental status and mood state and report to MD/APRN. The quarterly MDS dated [DATE] identified Resident #1's had a Brief Interview for Mental Status score of five (5) indicative of severely impaired cognition, always incontinent of bowel, frequently incontinent of bladder, dependent with Activities of Daily Living (ADL's). A physician's note dated 10/23/24 written by MD #1 identified Resident #1's vital signs are stable with no new issues. MD #1 indicated the plan is to check Resident #1's Hemoglobin A1C (a blood test that measures the average blood sugar levels over the past two (2) to three (3) months reported as a percentage). A physician's order dated 12/1/24 directed to administer Tresiba subcutaneous solution (a medication for diabetes mellitus) 100 unit/ml inject 10 units at bedtime. The pharmacist medication regimen review dated 12/7/24 at 12:30 P.M. identified Resident #1 has diabetes but an A1C is not available in the medical record in the past 6 months. The recommendation is to monitor Resident #1's A1C on the next convenient lab day and every 6 months if meeting treatment goals or every 3 months if therapy has changed or goals are not being met. On 12/12/24 APRN #1 agreed with the recommendation to obtain Resident #1's A1C and directed to implement the order. Interview with APRN #1 on 1/16/25 at 10:40 A.M. identified Resident #1's diabetes mellitus should be monitored by obtaining an A1C every 6 months. APRN #1 identified on 12/12/24 the pharmacist's monthly medication review for Resident #1's diabetes management recommendation was to obtain Resident #1's A1C. APRN #1 identified on 12/12/24 she signed and agreed with the pharmacist's recommendation for Resident #1 to have an A1C obtained. APRN #1 indicated when she agrees with a resident's pharmacy recommendation her signature directs the order to be implemented. APRN #1 indicated the nurses are responsible for entering the orders. APRN #1 identified on 12/12/24 it was her expectation Resident #1's A1C would be obtained by the lab. Interview with MD #1 on 1/16/25 at 12:40 P.M. identified on 3/12/24 Resident #1's Hemoglobin A1C was 6.1 % and Resident #1's goal was an A1C of 7 % or lower had been met. MD #1 identified his expectations for Resident #1's diabetes mellitus management was Resident #1's A1C would be monitored every 6 months. MD #1 identified Resident #1's A1C should have been obtained no later than October 2024. Interview and clinical record review with the DNS on 1/16/25 at 2:30 P.M., failed to provide documentation to reflect Resident #1 had an A1C obtained since 3/12/24. The DNS identified the nurses and/or the ADNS are responsible for reviewing the resident's monthly pharmacy medication regimen reviews and implementing the physician's orders per the pharmacy recommendations. The DNS could not explain why on 12/12/24 an order was not implemented directing to obtain Resident #1's A1C. Review of facility physician orders undated policy identified the purpose of the policy is to ensure all physician's orders complete and accurate.

Based on a review of clinical records, facility documentation, facility policy and interviews, for two of 5 residents (Resident #27 and 41) at risk for falls, the facility failed to implement interventions including adequate supervision to prevent falls consistent with the resident's needs resulting in injury. The findings include: 1. Resident #27 was admitted to the facility in June 2021 with diagnoses that included diabetes, atrial fibrillation, and convulsions. The care plan dated 10/25/23 identified Resident #27 was at risk to fall due to a history of frequent falls with injury, decreased mobility, worsening dementia, history of CVA, and noncompliance with calling and waiting for assistance due to decline in cognition and safety awareness. Interventions included assistance with ADL's and transfers, and to offer the resident early bedtimes. The physician's order dated 11/1/23 directed to provide the assistance of 2 with transfers and ambulation with platform rolling walker. The quarterly MDS assessment dated [DATE] identified Resident #27 had severely impaired cognition and required extensive assistance with transfer and toilet use. The reportable event form dated 11/20/23 at 7:00 PM identified Resident #27 was found on the floor in his/her room in front of the recliner bleeding from the top of the head. Review of the fall scene investigation form dated 11/20/23 identified Resident #27 had a history of prior falls, was alert and confused and the fall was unwitnessed. The nurse's note dated 11/20/23 at 7:24 PM identified Resident #27 had an unwitnessed fall and was observed on the floor in the room at 7:00 PM with bleeding from the head. The RN supervisor assessed the resident, notified the APRN and 911 was called. The revised care plan dated 11/20/23 identified Resident #27 was sent to the hospital for evaluation and was to be monitored every 1 hour upon return. The nurse's note dated 11/21/23 at 1:45 AM identified Resident #27 returned from the hospital with a diagnosis of laceration to the head repaired with 4 sutures. The reportable event form dated 11/23/23 at 1:45 PM identified staff responded to Resident #27's yelling for help and the resident was found on the side of the wheelchair and bed. Per the resident roommate, Resident #27 got up and fell . The RN assessment revealed no internal or external rotation and neurological assessment within normal limits. Resident #27 was alert and confused and required assist of 1 with transfers. Resident #27 initially complained of back pain. The physician and the resident's representative were notified with a decision to not send to the hospital for an evaluation. On 11/24/23, Resident #27 complained of left lower extremity pain, the physician was notified and a new order for an x-ray of the left hip was obtained. The x-ray result revealed acute very subtle impacted left femoral neck fracture, visible only on oblique view, CT scan work up advised. Resident #27 was sent to the hospital for further evaluation. The investigative report dated 11/23/23 identified the nurse aide (NA #2) last saw the resident at 12:15 PM when lunch was served, an hour and a half prior to the fall. The summary report dated 11/29/23 at 12:49 PM identified Resident #27 had an acute impacted left femoral neck fracture and underwent a left hip pinning on 11/25/23. Resident #27 returned to the facility on [DATE]. Review of the clinical record during the period of 11/21/23 - 11/23/23 at 1:45 PM failed to identify documentation that the resident was monitored every hour in accordance with the revised care plan. Review of the clinical record and interview with LPN #6 on 6/18/24 at 11:00 AM identified documentation of every 1 hour monitoring checks after the 11/20/23 fall between 11/21/23 - 11/23/23 could not be found and she was not aware the nurse aides were not monitoring the resident every hour. Review of the clinical record and interview with the DNS on 6/18/24 at 11:20 AM indicated she was not aware that the documentation of the 1 hour checks after the 11/20/23 fall between 11/21/23 - 11/23/23 were not completed. The DNS indicated the RN and the LPN on the units are responsible to give report to the nurse aides when the resident is on every 1 hour checks. The DNS indicated it was the responsibility of the nurse aides on the unit to monitor the resident and document his/her whereabouts every 1 hour. Although attempted, an interview with NA #2, (who last saw Resident #27 an hour and a half prior to the fall on 11/23/23 at 1:45 PM) was not obtained. Review of the Close Monitoring of a Resident policy identified to maintain the safety and well-being of all residents who are exhibiting behaviors that pose a high risk for harm or injury to self or others will be assessed by the RN or designee for close monitoring, which may include either 1:1 observation, or incremental checks (every 15 minutes, every 30 minutes, every 1 hour). Incremental checks (every 15 minutes, every 30 minutes, every 1 hour) are observations and documentation of a resident's status at a given point in time. Incremental checks may be used in instances where a resident may benefit from increased monitoring (i.e. at risk for falls). The close monitoring will be documented in the resident's medical record. 2. Resident #41was admitted to the facility on [DATE] with a diagnosis that included in part, dementia. The significant change MDS assessment dated [DATE] identified Resident #41 had severely impaired cognition, was always continent of bowel, frequently incontinent of bladder, required substantial assistance from staff with dressing, bathing, and toileting and partial to moderate assistance with walking once standing. The care plan dated 1/2/24 identified Resident #41 had a history of multiple falls. Interventions included completing every 15-minute checks and to analyze previous falls to determine whether a pattern/trend could be addressed. Review of the clinical record and reportable event forms identified Resident #41 had 13 falls between 1/24/24 and 5/30/24: a. Unwitnessed fall on 1/24/24 at 4:00 PM in his/her room. Care plan intervention included to sit in common areas when not doing activities for extra safety monitoring. The care card (generated from the care plan and utilized by staff to administer care), included 1 hour checks when the resident was in their room. b. Unwitnessed fall on 2/25/24 at 10:15 AM while in his/her room. c. Unwitnessed fall on 3/2/24 at 3:15 PM while in his/her room. Care plan intervention included the resident should sit in the lobby area during shift change. The care card, included every 1 hour monitoring checks. d. Unwitnessed fall 3/3/24 at 11:45 AM in his/her room. Review of the clinical record failed to identify 1 hour monitoring checks had been completed from 1/24/24 - 3/3/24. e. Unwitnessed fall 3/15/24 at 6:15 PM in the unit's dining room. Care plan intervention included Resident #41 was not to be left unattended in the dining room. f. Unwitnessed fall on 3/15/24 at 7:15 PM in his/her room. Care plan intervention included a pharmacy medication review was conducted with no new recommendations. g. Witnessed fall on 3/16/24 at 3:00 PM by LPN #3 in the unit lobby with subsequent bleeding from the head. Care plan intervention directed that staff perform purposeful staff rounding at shift change to identify Resident #41's location. The clinical record identified Resident #41 was sent to the hospital for evaluation on 3/17/24 at 3:25 PM and returned to the facility with 2 sutures on 3/17/24 at 2:00 AM. h. Unwitnessed fall on 3/20/24 at 1:45 PM in the unit lobby. The investigation form identified Resident #41 was placed on every 15-minute monitoring checks following this fall. The care plan and care card identified Resident #41 had been placed on every 15-minute monitoring checks. i. Unwitnessed fall on 4/1/24 at 10:00 PM the resident was found lying on the floor against a storage door on the unit. Care plan intervention included monitoring for mental status changes. j. Unwitnessed fall on 4/11/24 at 7:00 PM on the floor of the bathroom. Care plan intervention included every 15-minute checks. Review of Resident #41's care card identified Resident #41 was on every 15 minutes checks but needed 1:1 monitoring. Review of the clinical record failed to identify documentation that monitoring checks were conducted during the period of 3/20/24 - 4/11/24. k. Unwitnessed fall on 4/29/24 at 3:15 PM in the unit's shower room. Review of the clinical record failed to identify documentation that the resident was in the lobby during shift change in accordance with the 3/2/24 care plan and that the resident was monitored every 15-minutes during the period of 4/11/24 - 4/29/24. l. Unwitnessed fall on 5/12/24 at 12:00 PM in his/her room. Care plan intervention included the continuation of 15-minute monitoring checks. Review of the clinical record failed to identify documentation that Resident #41 was monitored every 15 minutes during the period of 4/29/24 - 5/12/24. m. Fall on 5/30/24 at 3:00 PM witnessed by the resident's roommate in his/her room. Review of the clinical record failed to identify documentation that Resident #41 was monitored every 15 minutes during the period of 5/12/24 - 5/30/24. Review of Resident #41's care card, provided to this surveyor on 6/18/24, identified that Resident #41 was on every 15-minute checks beginning 5/30/24 and was not to be left unattended. Review of reportable events and the facilities investigations during the period of 1/24/24 - 5/30/24 and interview with the DNS on 6/18/24 at 10:13 AM identified she thought Resident #41 was being monitored every 15 minutes based on the fall history, and this was a nursing measure with no definitive timeframe on how long the monitoring would be completed. The DNS identified that Resident #41 had multiple falls since admission, and she was unable to identify the rationale as to why the resident was not monitored. The DNS indicated that the resident should have been monitored according to the care plan and care card. The facility policy on falls directed that residents would not be left unattended until deemed safe by a supervisor. The policy further directed that the resident's care card would include fall risk and prevention strategies. The policy also directed that each time a resident experienced a fall, a reportable event form would be completed along with an interdisciplinary fall assessment to identify the potential causes of the fall. The facility policy on close monitoring of a resident directed the purpose of the policy was to maintain the safety and wellbeing of all residents in a dignified manner. The policy further directed that residents who were exhibiting behaviors that posed a high risk of harm or injury to self would be assessed by an RN or designee for close monitoring, which would include 1:1 monitoring or incremental checks (i.e every 15 or 30 minutes, or every hour). The policy further directed that the resident's care plan would be updated to reflect the close monitoring status and that the close monitoring would be documented in the resident's medical record. 46040

Based on review of facility documentation, facility policy, and interviews, the facility failed to place resident council funds in an interest-bearing account and hold, safeguard, manage, and account for the funds. The findings include: The Resident Council Funds bank account statements dated 4/1/21 to 4/30/24 identified that the account was closed on 4/14/21 and there was $1808.64 withdrawn at that time. Review of the resident council meeting minutes from 1/1/23 to 3/24/24 failed to reflect any discussion of resident council funds. Interview with Residents #13, 17, 23, 33, 35, and 61 on 6/16/24 at 2:00 PM indicated that there was a council president and secretary but not a treasurer. Resident Council residents were in agreement they were not aware of any money or any account that had money for them to use as part of the resident council. Interview with the Director of Recreation on 6/16/24 at 2:45 PM indicated that there was not a treasurer for the resident council. The Director of Recreation indicated that were no monthly or quarterly bank statements for the residents since April 2012. The Director of Recreation indicated that the prior Director of Recreation had a resident council funds account at a local bank and the residents did receive the monthly statements for the monthly resident council meetings but when the prior Director of Recreation left, someone closed the account in April 2021. The Director of Recreation indicated that she was the Assistant Director of Recreation prior to being the Director of Recreation now. The Director of Recreation indicated that the prior Administrator, Administrator #2, informed her that the money, $1806.64, was being held in the business office. The Director of Recreation indicated that when she asked the new Business Office Manager about the money, she was informed it was not in the business office. The Director of Recreation indicated that she had asked Administrator #2 how to open a resident council bank account and was not given any guidance. The Director of Recreation indicated that the facility just had a resident council car show and raised $2400 that is being held in the business office. Interview with the Business Office Manager on 6/16/24 at 2:55 PM indicated that she had only worked at the facility since January 2024 and when she had started, she had heard about the resident council's $1806, but it was not in the business office. The Business Office Manager indicated that there was no ledger or accounting documentation for the resident council funds of $1806. The Business Office Manager indicated that the Recreation Director had asked her regarding the money but indicated she did not have it in the business office. The Business Office Manager indicated she had the $2400 from the car show to give to the Director of Recreation once she opens a bank account. The Business Office Manager pulled a white garbage bag from a file cabinet and inside was a small metal lock box. The Business Office Manager opened the locked box and indicated that was the $2400 from the car show and that she did not have the $1800, did not know where it was and she never saw that money. Interview with Administrator #1 on 6/18/24 at 11:34 AM indicated he had heard about the resident council having an account with $1806 that was closed but he did not know what happened to the money. Administrator #1 indicated subsequent to surveyor inquiry on 6/16/24 facility staff was looking into what happened to the money. Administrator #1 indicated that he thinks yesterday the accountant figured it out, but he could not explain it and recommended to ask the VP of Operations. Interview with the Business Office Manager on 6/18/24 at 12:00 PM indicated that the accountant does not know what happened to the $1806 and indicated that they could not find it. Interview with the VP of Operations on 6/18/24 at 12:10 PM indicated that he believes the last account was closed. The VP of Operations indicated there is a corporate account that contains resident council funds, but is not interest bearing, and he cannot account for the $1800 moving from the closed account in 2021 into this corporate account. After reviewing the corporate account dated from 4/1/2021 until 6/18/24, the VP of Operations indicated that he was not able to show a transfer or a deposit of the $1806 and identified that at the next resident council they will discuss opening a back account for the resident council funds. Interview with the Business Office Manager on 6/18/24 at 12:15 PM indicated that prior to today, she was not aware that there was a corporate account that contained resident council funds and after reviewing the corporate account dated 4/1/2021 until 6/18/24, the Business Office Manager indicated that there was no transfer or a deposit of $1806. Although attempted, an interview with Administrator #2 multiple times was not obtained. Review of the facility Resident Council Funds Policy identified the facility will maintain the resident council funds. The facility will encourage and assist in the establishment of a resident council through periodic communications with residents and families and/or such other means as the facility feels appropriate. Designating the Recreation Director to be approved by the resident council to assist the group and respond to grievances and recommendations of the resident council. Review of the Resident Rights Policy identified the residents have the right to manage their personal financial affairs and cannot be required to your personal funds with the facility. The residents have the right to have the facility to manage your personal funds if you authorize this in writing. The residents have the right to a quarterly accounting of their funds. A separate statement about how the facility manages residents' funds is provided.

Based on observations, review of facility documentation, review of job descriptions, and interviews for 4 of 4 units, the facility failed to ensure the environment was clean, sanitary, maintained in good repair and homelike. The findings included: Review of the infection control surveillance & safety rounds form dated 4/24/24 identified rounds were completed by RN #1 and the Maintenance Supervisor. The infection control surveillance & safety rounds form failed to reflect documentation regarding resident room conditions. Observations on 6/16/24 at 2:08 PM through 2:35 PM, on 6/17/24 at 9:22 AM through 9:50 AM, and on 6/18/24 at 8:46 AM with the Maintenance Supervisor, Housekeeping/Laundry Supervisor, Administrator, and RN #1 identified the following: a. Damaged, missing and/or broken floor tiles in the bedroom on [NAME] unit in room [ROOM NUMBER], and on Cortland unit in room [ROOM NUMBER], and 213. b. Damaged, missing and/or broken floor tiles in the bathroom on [NAME] unit in rooms [ROOM NUMBER], c. Damaged, stains, chipped and/or marred bedroom walls, bathroom walls, on [NAME] unit in rooms 30, 31, 32, 33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, and 45. On Crestbrook unit in rooms 50, 51, 52, 53, 54, 57, 58, 59, 60, 61, 62, 63, 64, and 65. And on Taft unit in rooms 220, 221, 223, 227, 229, and hallway. d. Damaged, broken, bent and/or rusty bathroom radiator covers, on [NAME] unit in rooms 32, and 44. On Crestbrook unit in room [ROOM NUMBER], and on Taft unit in rooms [ROOM NUMBER]. e. Damaged, broken, stains, chipped and/or marred bedroom radiators on [NAME] unit in rooms 30, 32, 33, 35, 40, 45, and on Taft unit in room [ROOM NUMBER]. f. Damaged, dirty and/or missing cove base in bedroom and bathroom on [NAME] unit in rooms 31, 33, 36, 39, 40, and 44. On Taft unit in room [ROOM NUMBER]. g. Stains, dirt, debris, discoloration and/or wax build up on the floor bedrooms on [NAME] unit in rooms 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, and 45. On Crestbrook unit in rooms [ROOM NUMBER]. On Cortland in rooms 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 215, shower room, and lounge. On Taft unit in rooms 214, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, 226, 227, and 229. h. Stains, dirt, debris, discoloration and/or wax build up on the floor in the bathroom on [NAME] unit in rooms 30, 31, 32, 33, 34, 35, 37, 38, 39, 40, 41, 42, 43, 44, and 45. i. Damaged, peeling, chipped and/or broken nightstand on [NAME] unit in room [ROOM NUMBER]. j. Damaged, peeling, and/or brown stains on bedroom and bathroom ceiling, on [NAME] unit in rooms 31, 35, 37, 41, and hallway. On Crestbrook unit in rooms [ROOM NUMBER]. Cortland unit hallway, and lounge. k. Damaged and/or broken towel rack on [NAME] unit in room [ROOM NUMBER]. l. Damaged, rusty, and/or stain commode in the bathroom on [NAME] unit in rooms [ROOM NUMBER]. Cortland unit tub room. m. Damaged, and/or rusty overbed table legs on [NAME] unit in rooms 31. n. Rusty and/or stains bedframe in bedroom on [NAME] unit in room [ROOM NUMBER] and 45. o. Damaged, broken, and/or missing nightstand drawer knob in bedroom on [NAME] unit in rooms 32 (2nd and 3rd drawer knob missing). p. Damaged, broken, peeling, and/or missing dresser drawer knob in bedroom on [NAME] unit in rooms 35 (2nd and 3rd drawer knob missing), 39, 43, 44, and 45 (3rd drawer knob missing). Cortland unit in rooms 203, 205 (4th drawer knob missing), 206 (4th dresser knob missing), 215 (3rd drawer knob missing). Taft unit in rooms 218 (3rd drawer knob missing), 224 (1st drawer knob missing). q. Damaged, and/or stains privacy curtain in bedroom on [NAME] unit in rooms 33, and 35. r. Damaged and/or stains window curtain in bedroom on Crestbrook unit in room [ROOM NUMBER]. s. Damaged, peeling and/or staining toilet seat in the bathroom on Crestbrook unit in room [ROOM NUMBER]. t. Damaged and/or broken wall protector in hallway on Taft unit. Interview with the Housekeeper/Laundry Supervisor on 6/18/24 at 9:05 AM identified she has been employed with the facility for approximately 8 months. The Housekeeper/Laundry Supervisor identified she was not aware of the resident bedroom floors with stains, dirt, debris, discoloration and/or wax build up on the floors, and the privacy and window curtains dirty with brown stains. Interview with the Maintenance Supervisor on 6/18/24 at 9:10 AM identified he has been employed by the facility in the supervisor position since October 2023. The Maintenance Supervisor indicated he was aware of some of the issues. The Maintenance Supervisor indicated he and the Maintenance Assistant are trying to repair some of the damaged walls in the bedrooms and bathrooms. Interview with RN #1 on 6/18/24 at 9:10 AM identified she has been employed by the facility for approximately 3 years. RN #1 indicated she was aware of some of the issues that were identified during the tour. RN #1 indicated the Maintenance Supervisor, and she does environmental rounds quarterly. Interview with the Administrator on 6/18/24 at 10:20 AM identified he has been employed by the facility for approximately 4 months. The Administrator indicated he was aware of some of the issues identified. The Administrator indicated going forward there will be a meeting with the Maintenance Supervisor, the Housekeeper/Laundry Supervisor, DNS, and RN #1 regarding the expectation of a home like environment. The Administrator indicated that maintaining the facility in a safe comfortable manner is always an ongoing priority. Interview with the DNS on 6/18/24 at 10:30 AM identified she was aware of some of the issues. The DNS indicated that going forward there will be a meeting with the Maintenance Supervisor, the Housekeeper/Laundry Supervisor, and RN #1 regarding the expectation of a home like environment. Review of the infection control surveillance and safety rounds identified to observe facility compliance with infection control policies and procedures. Surveillance rounds are to be conducted on a regular basis by the Infection Control Nurse or his/her designee. The ICN will coordinate times to conduct surveillance rounds. Review of the maintenance supervisor job description identified plans, organizes, and directs the maintenance and repairs of the physical plant, equipment and all essential building systems. Ensures the facility is safe and secure while fostering TQM and striving to attain the facility's mission statement. Review of the maintenance technician identified under direct supervision provides quality maintenance services. Assists in the maintenance and repair of the physical plant and grounds, equipment, and various buildings systems. Provides a clean, orderly, and safe environment for all facility residents and staff. Review of the housekeeping supervisor identified plans, organizes, and directs the provision of housekeeping services. Ensures the facility is safe and secure while fostering quality and striving to attain the facility's mission statement. Within budget guidelines, plans for needed supplies and equipment to maintain quality cleanliness standards. Review of the housekeeping assistant identified under direct supervision provides quality housekeeping services, and a clean, orderly and safe environment for all facility residents and staff.

Based on review of facility documentation, facility policy, and interviews the facility failed to ensure the residents private information was kept confidential. The findings include: Observation on 6/17/24 at 8:10 AM of medication administration identified LPN #7 moved the medication cart to the room of Resident #23. LPN #7 opened the medication cart and prepared the medications for Resident #23. At 8:15 AM, LPN #7 entered Resident #23's room, without the benefit of closing the computer screen, and gave Resident #23 his/her medications. LPN #7 then exited the room noting that the computer screen had been open with 16 residents' personnel demographics such as names, photo, and room number visible. LPN #7 prepared Resident #37's medications and without the benefit of closing the computer screen, proceeded into Resident #37's room and gave the medications to resident #37. Again, 16 residents' private information was visible on the computer screen. LPN #7 exited the residents' room. LPN #7 pushed the medication cart to the nurse's station and entered the medication room and left the computer screen open with the same 16 residents' information open on the computer screen. LPN #7 exited the medication room. LPN #7 proceeded to enter Resident #37's room and verbally stated she was going to give a tablet of Senna 8.6 mgs to Resident #37 and again, the computer screen was left open to the 16 residents' information. Interview with LPN #7 on 6/17/24 at 8:45 AM indicated that she was not aware that she could not leave the computer screen open with all the resident demographics including photos, room numbers, names, for the 16 residents that were on her unit. LPN #7 that she thought she only had to close the computer screen when the list of a resident's medications were visible. Interview with the DNS on 6/17/24 at 9:40 AM indicated LPN #7 was not supposed to leave the computer screen open with the any resident information unless the nurse was in front of the computer screen. The DNS indicated after she prepares the medication and is leaving the medication cart, the nurse either can close the computer screen or hit a button that makes the screen go to the screen saver so the screen will look blank. The DNS indicated that resident information including the names, room numbers and photos cannot be left on the computer screens when the nurse is not at the computer due to residents right to confidentiality. Review of the facility Medication Administration Policy identified that the nurse was to observe each residents' rights in accordance with applicable law such as blocking unnecessary access to the MAR. Review of the Resident Rights Policy identified residents have the right to privacy and confidentiality regarding all personal and health information kept by the facility pertaining to the resident.

Based on review of facility documentation, facility policy, and interviews, the facility failed to place resident council funds in an interest-bearing account and hold, safeguard, manage, and account for the funds. The findings include: The Resident Council Funds bank account statements dated 4/1/21 to 4/30/24 identified that the account was closed on 4/14/21 and there was $1808.64 withdrawn at that time. Review of the resident council meeting minutes from 1/1/23 to 3/24/24 failed to reflect any discussion of resident council funds. Interview with Residents #13, 17, 23, 33, 35, and 61 on 6/16/24 at 2:00 PM indicated that there was a council president and secretary but not a treasurer. Resident Council residents were in agreement they were not aware of any money or any account that had money for them to use as part of the resident council. Interview with the Director of Recreation on 6/16/24 at 2:45 PM indicated that there was not a treasurer for the resident council. The Director of Recreation indicated that were no monthly or quarterly bank statements for the residents since April 2012. The Director of Recreation indicated that the prior Director of Recreation had a resident council funds account at a local bank and the residents did receive the monthly statements for the monthly resident council meetings but when the prior Director of Recreation left, someone closed the account in April 2021. The Director of Recreation indicated that she was the Assistant Director of Recreation prior to being the Director of Recreation now. The Director of Recreation indicated that the prior Administrator, Administrator #2, informed her that the money, $1806.64, was being held in the business office. The Director of Recreation indicated that when she asked the new Business Office Manager about the money, she was informed it was not in the business office. The Director of Recreation indicated that she had asked Administrator #2 how to open a resident council bank account and was not given any guidance. The Director of Recreation indicated that the facility just had a resident council car show and raised $2400 that is being held in the business office. Interview with the Business Office Manager on 6/16/24 at 2:55 PM indicated that she had only worked at the facility since January 2024 and when she had started, she had heard about the resident council's $1806, but it was not in the business office. The Business Office Manager indicated that there was no ledger or accounting documentation for the resident council funds of $1806. The Business Office Manager indicated that the Recreation Director had asked her regarding the money but indicated she did not have it in the business office. The Business Office Manager indicated she had the $2400 from the car show to give to the Director of Recreation once she opens a bank account. The Business Office Manager pulled a white garbage bag from a file cabinet and inside was a small metal lock box. The Business Office Manager opened the locked box and indicated that was the $2400 from the car show and that she did not have the $1800, did not know where it was and she never saw that money. Interview with Administrator #1 on 6/18/24 at 11:34 AM indicated he had heard about the resident council having an account with $1806 that was closed but he did not know what happened to the money. Administrator #1 indicated subsequent to surveyor inquiry on 6/16/24 facility staff was looking into what happened to the money. Administrator #1 indicated that he thinks yesterday the accountant figured it out, but he could not explain it and recommended to ask the VP of Operations. Interview with the Business Office Manager on 6/18/24 at 12:00 PM indicated that the accountant does not know what happened to the $1806 and indicated that they could not find it. Interview with the VP of Operations on 6/18/24 at 12:10 PM indicated that he believes the last account was closed. The VP of Operations indicated there is a corporate account that contains resident council funds, but is not interest bearing, and he cannot account for the $1800 moving from the closed account in 2021 into this corporate account. After reviewing the corporate account dated from 4/1/2021 until 6/18/24, the VP of Operations indicated that he was not able to show a transfer or a deposit of the $1806 and identified that at the next resident council they will discuss opening a back account for the resident council funds. Interview with the Business Office Manager on 6/18/24 at 12:15 PM indicated that prior to today, she was not aware that there was a corporate account that contained resident council funds and after reviewing the corporate account dated 4/1/2021 until 6/18/24, the Business Office Manager indicated that there was no transfer or a deposit of $1806. Although attempted, an interview with Administrator #2 multiple times was not obtained. Review of the facility Resident Council Funds Policy identified the facility will maintain the resident council funds. The facility will encourage and assist in the establishment of a resident council through periodic communications with residents and families and/or such other means as the facility feels appropriate. Designating the Recreation Director to be approved by the resident council to assist the group and respond to grievances and recommendations of the resident council. Review of the Resident Rights Policy identified the residents have the right to manage their personal financial affairs and cannot be required to your personal funds with the facility. The residents have the right to have the facility to manage your personal funds if you authorize this in writing. The residents have the right to a quarterly accounting of their funds. A separate statement about how the facility manages residents' funds is provided.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure the refrigerator and freezers temperatures were recorded, prepared food items were labeled, dated and discarded timely, the kitchen fan was dust free, dietary staff wore a beard guard while preparing food, employee personal items were not stored in kitchen area, the nourishment refrigerator food items were labeled, dated, and discarded when expired, food temperatures were recorded prior to serving. The findings include: Tour of the kitchen with the Director of Dietary (DOD) #1 on [DATE] at 7:00 AM identified: 1a. Observation on [DATE] at 7:03 AM identified that the temperature log for the walk-in refrigerator and the walk-in freezer were not completed. The log indicated that the temperatures were not recorded between [DATE] - [DATE] in the mornings. Interview with the DOD #1 on [DATE] at 7:05 AM indicated that the cook was responsible for checking and recording the temperatures of the walk-in refrigerator and walk in freezer every morning. DOD #1 indicated that he did not know why it was not done from [DATE] - [DATE] but he had not done it today because he got called at the last minute due to the cook not showing up and had not had any time. b. Observation of the milk refrigerator and ice cream reach in freezer temperature logs on [DATE] at 7:06 AM for [DATE] identified they were not completed. The Temperature Log dated [DATE] identified that staff was to record the temperature of the refrigerator twice a day next to the correct date, all temperatures must be in the following range Freezer 0 degrees or colder, refrigerator 41 degrees of colder, and any temperature that was out of range contact your supervisor immediately. The log identified that the milk refrigerator temperatures were not recorded 4 out of 15 mornings, and 8 times out of 15 times in the evening. The ice cream reach in freezer temperature log identified 6 out of 15 times in the evening the temperatures were not recorded. Interview with DOD #1 on [DATE] at 7:06 AM indicated that the dietary aides were responsible to record the temperature twice a day for the milk refrigerator and the ice cream freezer. 2. Observation on [DATE] at 7:09 AM of the walk-in freezer identified very thick frost all around the freezer door, inside the freezer door, and on the fan inside the freezer. Interview with the DOD #1 on [DATE] at 7:10 AM indicated that the freezer frosting up like that started last year and the facility had a new door installed a few months ago. The DOD #1 indicated that after the door was changed the same problem had continued to occur. The DOD #1 indicated that the company that had installed the door was in the facility for something else and he had mentioned it to the company, but the Director of Maintenance was notified at that time and was responsible to set up the appointment for the company to return and fix the door. DOD #1 indicated he was not aware of the date when the company would return to fix the freezer door. Interview with the Director of Maintenance on [DATE] at 7:35 AM indicated that he had been aware of the buildup of frost on the inside and the outside of the walk-in freezer door for about a month. The Director of Maintenance indicated that he had attempted to call the company prior but did not reach anyone and he did not recall any dates that he had attempted to call for service. The Director of Maintenance indicated that he was aware that it is still a problem with the frost build up in the freezer. After surveyor inquiry interview with the Director of Maintenance on [DATE] at 8:20 AM indicated that he had called the company, and they will be at the facility tomorrow morning to look at the freezer door to repair it. Interview with Person #1 on [DATE] at 8:30 AM indicated that he had not received a call from the Director of Maintenance for the freezer door but about 2 months ago the Director of Dietary #1 had informed him that there was buildup of frost on the freezer door and that maintenance would reach out. Person #1 indicated that after surveyor inquiry the Maintenance Director reached out to him about coming to the facility tomorrow, Monday morning, to look at the frost build up. Person #1 indicated that the facility had ordered a new freezer door in July of 2023, but it was not installed until [DATE] awaiting payment. Person #1 indicated normally it would take 5 weeks from the time the order for the door goes in through installation. Person #1 indicated after his people had installed the door that he had noted there was wood above the inside of the freezer door and that moisture would accumulate due to air not being able to move around. Person #1 indicated that he would have to apply metal and calking to fix it. Person #1 indicated that the facility was aware of the issue a couple of months ago, but he was waiting to hear from them to come out and fix it. 3. Observation on [DATE] at 7:12 AM of the prepared food items in the walk-in refrigerator identified hotdogs cooked dated [DATE], pork cooked dated [DATE], macaroni was not labeled or dated, a metal container of brown liquid dated [DATE] not labeled, pink large insulated mug with brown substance not covered, labeled, or dated, banana cream pie, 6 individual slices not covered, labeled, or dated, 1 employee personal water bottle not labeled or dated. Interview with the Director of Dietary #1 on [DATE] at 7:15 AM indicated that he or the cooks were responsible to discard any item after 3 days and to make sure everything was labeled and dated when being placed in the refrigerator. The Director of Dietary #1 indicated that he did not know why it was not being done. 4. Observation on [DATE] at 7:19 AM identified employee personal jackets and pocketbooks were being stored in the kitchen dry storage room for residents. Interview with DOD #1 on [DATE] at 10:02 AM indicated that employees were not to store personal belongings in the kitchen dry storage room. DOD #1 indicated that staff have an area outside of the kitchen to store their personnel items. DOD #1 told staff to immediately remove items. 5. Observation on [DATE] at 7:20 AM Director of Dietary #1 was making hot cereal over the stove adding the cereal mix into the pot of hot water stirring it without the benefit of a beard guard to cover his facial hair. Interview with the Director of Dietary #1 on [DATE] at 7:22 AM indicated that the scheduled cook had called out, so he came in to cover and forgot to put on the beard guard. The Director of Dietary #1 indicated that he was to wear a beard guard while in the kitchen preparing food. 6. Observation on [DATE] at 9:30 AM of 1 out of 2 resident nourishment rooms identified in the first-floor nourishment refrigerator was fruit with an expiration date of [DATE], a yogurt that expired on [DATE], 2 yogurt that expired on [DATE], 2 yogurt that expired on [DATE], 2 yogurt that expired on [DATE], and a go-go squeeze apple sauce expired on [DATE]. Additionally, there was a lunch box not labeled or dated. Additionally, the bottom right-side drawer was covered in a light brown dried liquid. Interview with the Director of Dietary #1 on [DATE] at 9:31 AM indicates that all the unopened prepackaged foods were to be discarded by the expiration dates on the packages. DOD #1 indicated that the lunch box was an employee lunch box and did not belong in the resident's refrigerator. DOD #1 indicated that it was the dietary departments responsibility to discard food items not labeled, dated, or expired and to clean out the refrigerators each day once in the morning and once in the evening when delivering the nourishments. DOD #1 indicated that he does not know why it has not been getting done. 7. Tour of the kitchen with DOD on [DATE] at 10:00 AM noted the wall fan in the kitchen was covered in thick dust. Interview with the DOD #1 on [DATE] at 10:01 AM indicated that he was responsible to make sure the fans were cleaned, and he tries to take it down and clean it once a month. DOD #1 indicated that he did not recall the date of when it was last cleaned. DOD #1 immediately removed the fan from the kitchen. 8. Review of the Meal Serving Temperature Chart form dated [DATE] to [DATE] identified that the temperatures were not completed for all food items for breakfast, and none were recorded for supper. Review of the Cooked Foods Temperature Chart form dated [DATE] to [DATE] identified that on [DATE] breakfast, lunch and supper were not recorded and on [DATE] breakfast was not recorded. Review of the Meal Serving Temperature Chart form dated [DATE] to [DATE] identified that the [DATE] supper was not reordered and that [DATE] breakfast was not recorded. Interview with [NAME] #1 on [DATE] at 10:45 AM indicated that he did not take the temperatures of the food at breakfast once prepared and when being to serve because the kitchen was short staffed today and he did not have time. Interview with Dietary Manager #2 on [DATE] at 10:50 AM indicated that the expectation was the cook takes the temperature of the food once they are prepared before going into the steam table and document on the cooked foods temperature chart for all foods prepared and cold items and then take the temperature again once the foods are on the steam table and document on the meal serving temperature chart. Review of the documents, DOD #2 indicated that from [DATE] - [DATE] only the hot cereal and milk was temped daily, and the cook did not take the temperature of the eggs or main meal at breakfast, and hot beverages were not temped daily, and nothing for supper was documented all week for the meal serving temperatures. Review of the forms dated [DATE] - [DATE], DOD #2 identified the temperatures were not taken on [DATE] all day and so far for breakfast on [DATE] today was missed. DOD #2 indicated that it was the responsibility of the cook to take the temperatures of all the hot and cold foods being served each meal twice and document at the time the temperatures are being taken. Review of the facility Procedure for Taking Serving Temperatures Policy identified to ensure that all foods are served at the correct temperatures. Minimum and maximum temperatures are outlined on the Serving Food Temperature Chart. Food items that do not meet these temperatures will not be served, until reheated to the proper temperatures. Using a calibrated bimetal thermometer measure the internal temperature of food items and record the temperatures on the Serving Food Temperature Chart. Serving temperatures should be taken when food is placed in the steam table, no longer than 15 minutes before serving time. Review of the facility Dress Code Policy identified to establish dress code for dietary employees. It is the responsibility of the Director of Dietary to make sure all employees meet the minimal requirements. [NAME] guard need to be worn as appropriate. Review of the facility Refrigerator and Freezer Temperature Logs Policy identified to assure that the proper temperature ranges are maintained in all refrigerators and freezers. A temperature log should be maintained on the piece of equipment. This includes refrigerators in the nourishment areas. Temperatures should be checked and recorded on the logs. Refrigerators range from ,d+[DATE] degrees and freezers at zero degrees. Review of the facility Snack Dating Policy identified to assure storage and rotation of snacks in resident areas. All items brought to the refrigerators will be dated with the current date. Discard dates once the product is opened. Unopened containers of yogurt discard date stamped on container.

Based on review of facility documentation, facility policy, and interviews the facility failed to ensure the nurse completed hand hygiene during the medication administration according to facility policy. The findings include: Inservice Education dated 1/12/24 identified LPN #7 was educated on hand washing. Licensed Nurse Competency for LPN #7 dated 3/26/24 identified infection control demonstrated hand washing and LPN #7 met the competency. Observation of medication administration on 6/17/24 at 8:10 AM identified LPN #7 moved the medication cart to the room of Resident #23, opened the medication cart and prepared Resident #23's 9:00 AM medications and administered Resident #23's medications without the benefit of hand hygiene prior. Further, while Resident #23 was taking the medications, LPN #7 went over to the resident's roommate and touched him/her on the hair and shoulder, exited the room and did not hand sanitize or wash her hands. LPN #7 moved the medication cart to Resident #37's room and prepared the residents medications and proceeded into Resident #37's room and gave Resident #37 his/her medications. LPN #7 was observed to touch the resident's chest and remove food from the resident's face. LPN #7 did not use hand sanitizer or wash her hands after administering medications and went to the medication room to prepare a medication for Resident #37. LPN #7 went to the nurse's station pushing her medication cart to the medication storage room, entered the medication room touching the door handle and went into the cabinets looking for a medication. LPN #7 exited the room after touching the door handle and administered the medication to Resident #37 without the benefit of hand hygiene. Interview with LPN #7 on 6/17/24 at 8:44 AM indicated that she knew she should conduct hand hygiene before and after providing a resident medication, but she does not know why she did not do it. LPN #7 indicated that after going to the medication room and returning to prepare the medication she should have hand sanitized. LPN #7 indicated that she had been educated on sanitizing her hands during a medication pass but did not know why she did not wash her hands all those times that she should have. Interview with the DNS on 6/17/24 at 9:20 AM indicated that the nurses must hand sanitize prior to preparing a resident's medications, after giving the resident the medications as they go back to the medication cart, and if they have direct contact with a resident. The DNS indicated the nurse must hand sanitize between residents during the medication pass. Interview with RN #1 (Infection Control Nurse) on 6/17/24 at 9:50 AM indicated that the nurse was to use hand sanitizer while doing a medication pass prior to preparing the medication and when exiting a room. RN #1 indicated that the nurses were educated many times on hand washing and the use of hand sanitizer during a medication pass. RN #1 indicated that nurses must hand sanitize between residents and if they touch anything. Review of the facility Medication Administration Policy identified that the nurse was to use appropriate hand hygiene. Prior to preparing or administrating medications, authorized and competent facility staff should follow the facility's infection control policy. Appropriate hand hygiene should be performed before and after direct resident contact.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #8) reviewed for accidents, the facility failed to ensure that a resident's meal choices were honored. The findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses that included multiple (MS) sclerosis, spasmodic torticollis, and dementia. The care plan dated 4/8/24 identified Resident #8 required assistance with ADLs due to history of MS. Interventions included providing total assistance with ADLs, transfers, and incontinent care. The annual MDS dated [DATE] identified Resident #8 had severely impaired cognition, was always incontinent of bowel, utilized a nephrostomy tube, was dependent on staff for dressing, bathing and toileting and required set up only with meals. The reportable event form dated 5/6/24 identified Resident #8 called for staff assistance between 5:30 PM - 6:00 PM and reported he/she had spilt soup on his/her chest and gown. Further, Resident #8 was identified with a 3 cm x 2 cm reddened area with small, scattered blisters on the left upper quadrant of his/her abdomen/chest area. Interventions included to provide Resident #8 a clothing protecter with meals. The reportable event form failed to identify any additional information related to the soup and resulting burn, including if the soup was part of Resident #8's meal on 5/6/24 or from an outside source. A nurse's note dated 5/6/24 at 10:23 PM identified that Resident #8 had a burn from soup on his/her upper left abdomen and chest area. Further review of the clinical record failed to identify any further documentation related to this incident. An APRN note dated 5/7/24 identified Resident #8 had a second degree burn with blistering noted on his/her chest wall. Treatment included cleansing with normal saline, applying Silvadene and an ABD pad twice daily, and monitor the area for infection. Interview with Resident #8 on 6/16/24 at 8:53 AM identified he/she had spilled soup on his/herself causing a burn. Resident #8 identified that he/she waited 2 minutes, but it was still too hot. Resident #8 was unable to identify when he/she was burnt by the soup or if the soup was part of his/her meal or from an outside source. Interview with Person #2 on 6/16/24 at 10:00 AM identified that Resident #8 had a burn following the facility staff reheating soup on 5/6/24 that Person #2 had brought into the facility for Resident #8. Person #2 identified that Resident #8 had a favorite Italian wedding soup that was made by a local grocer for several years. Person #2 identified he/she would purchase several containers of the soup at a time, freeze them, and then bring 1 - 2 containers every couple of weeks to the facility for Resident #8. Person #2 identified Resident #8 would ask the facility staff to reheat the soup for him/her, and until 5/6/24 there had never been any issues regarding this. Person #2 identified that from the report he/she received from the DNS and Resident #8 on 5/6/24, Resident #8 requested a portion of the soup to be reheated, but instead of the full cup of soup, he/she only requested a half a cup of soup instead. Person #2 identified that Resident #8 then requested the soup be reheated for 2 1/2 minutes, as this is the amount of time the soup was usually reheated. Person #2 identified that Resident #8 was given the soup, which he/she assumed would have been much hotter due to the portion being smaller, and then at some point Resident #8 was left with the soup in his/her room and found later to have spilt the soup on his/herself, resulting in a burn. Person #2 identified that that he/she was notified of the burn on 5/6/24 and told that going forward Resident #8 would have the soup reheated by the facility but only by dietary staff or a nurse, and that the soup had previously been reheated by nurse aides. Person #2 further identified that while this information was provided to him/her on 5/6/24, Resident #8 identified to Person #2 that the facility had told Resident #8 that if he/she wanted to have any food provided from the outside going forward, that outside food would not be reheated by any staff of the facility under any circumstances, and only visitors coming to see Resident #8 could reheat any food for him/her, including soup. Person #2 identified that while he/she had not been notified by the facility of this, he/she hoped this was not true as Resident #8 looked forward to the soup and he/she would not be able to come to facility on a regular basis just to reheat the soup for Resident #8 to be able to enjoy. Interview with NA #1 on 6/17/24 at 10:25 AM identified that the facility staff had been instructed that any outside food brought in by visitors for residents of the facility could not be reheated by any facility staff following the burn sustained by Resident #8 on 5/6/24. NA #1 identified this had been the practice since she began working at the facility in 6/2023 until Resident #8 was burned on 5/6/24. Interview with the DNS on 6/18/24 at 10:13 AM identified that facility staff had been reheating food for residents prior to this incident, but that the policy of the facility was that no outside food was to be reheated by the facility and any outside food would have to be reheated by the resident, if able, or by a visitor to bring to the resident. The DNS identified that the reheating policy had been in place for several years, and that staff were not provided with or in serviced on reheating temperatures since this was not a policy of the facility. The DNS also identified since the policy dictated that staff were not to reheat food for residents, no thermometers were available on any of the resident units to check food temperatures. The DNS was unable to identify how the facility would be able to allow residents to have access to food from the outside, including reheating the food, if they were not physically able to do so themselves, or if visitors were not able to come and visit a resident to allow for reheating of food, and that the facility would have to look into this. The facility policy on food brought into the facility from home directed that dietary personnel would not be responsible for holding or reheating any food [NAME] in from an outside source, and that any food items would be stored in airtight containers with labels including the resident's name, date and contents, to be discarded after 3 days. The policy further directed cold foods should be kept at 41 degrees Fahrenheit or colder, and hot foods to at least 135 degrees Fahrenheit. The facility policy on Resident Rights directed that residents of the facility had the right to make choices about aspects of their lives significant to them, and to be treated with consideration, respect and full recognition of their dignity and individuality.

43032 Based on review of facility documentation, facility policies, and interviews for 5 of 16 residents reviewed for elopement (Resident #24, 40, 41, 43 and 79) the facility failed to effectively manage roam alert bracelets resulting in residents wearing expired roam alert bracelets, bracelet serial numbers improperly documented in the physician order and a resident wearing an elopement bracelet without a physician's order, and for 2 of 5 residents (Resident #41 and 51) reviewed for falls, the facility failed to ensure that neurological assessments and post fall assessments were completed following falls, and for 2 of 4 residents (Resident #46 and 53) reviewed for nutrition, the facility failed to ensure that the physician's orders were followed related to weight monitoring. The findings include: 1. Resident #24 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnosis that included Alzheimer's disease, dementia, and a history of falling. The quarterly MDS dated [DATE] identified Resident #24 had severely impaired cognition, had the ability to walk 150 feet in a corridor or similar space with moderate assistance, had the ability to propel in wheelchair 150 feet in a corridor or similar space independently, and used a wander/elopement alarm daily. Resident #7 seeks out areas of exit, is cognitively impaired and leaves unit without staff knowledge. The corresponding care plan identified a concern with elopement with interventions that included roam alert on the right ankle, check expiration date, monitor function every shift. A physician's order dated [DATE] directed to monitor psychotropic behaviors including elopement, and roam alert to left ankle, check placement every shift, check function every night shift, expiration date ,d+[DATE] Serial Number: F03BC4 every shift check placement every shift. 2. Resident #40 was admitted to the facility [DATE] with a readmission of [DATE] with diagnoses that included dementia, history of falling, and anxiety disorder. The quarterly MDS dated [DATE] identified severe cognitive impairment, utilized a manual wheelchair for mobility and used a wander/elopement alarm daily. The care plan dated [DATE] identified a concern with elopement with interventions that included to monitor function of roam alert and monitor placement. A physician's order dated [DATE] directed roam alert to right side of wheelchair, check placement every shift, check function every night shift, expiration date ,d+[DATE] serial number F04B83. 3. Resident #41 was admitted to the facility on [DATE] with a readmission [DATE] with diagnoses that included dementia, anxiety disorder, and emphysema. Resident #41's Nursing Admission assessment dated [DATE] identified that Resident #41 was an elopement risk and was identified with a cognitive impairment and leaves the unit without staff knowledge. The quarterly MDS dated [DATE] identified severely impaired cognition, ability to walk 150 feet with moderate assistance, and used a wander/elopement alarm daily. The care plan dated [DATE] identified a concern with elopement, and previous attempt to elope with interventions that included to apply roam alert, check the placement each shift, check functioning of roam alert every day as per facility policy, check functioning of roam alert each shift, discuss with my family risks of wandering and elopement. Resident #41 was seen by psychiatry monthly with the most recent evaluation dated [DATE] identifying restlessness with symptoms of wandering, will provide medications and interventions and continue to monitor mood, sleep, and behaviors, continue with current meds, and evaluate for gradual dose reduction (GDR) in the future. A physician's order dated [DATE] directed to monitor psychotropic behaviors including elopement every shift. 4. Resident #43 was admitted to the facility [DATE] and readmitted [DATE] with diagnosis that included dementia, disturbance psychotic, mood disturbance and anxiety. The quarterly MDS dated [DATE] identified severely impaired cognition, utilized a walker and a wheelchair for mobility, and used a wander/elopement alarm daily. The care plan dated [DATE] identified a focus for wandering with interventions that included to apply roam alert, check the placement each shift, and to check functioning every day per facility policy. A physician's order directed to check placement of roam alert Serial number F06FFB expiration date ,d+[DATE] to left ankle every shift and check function every night, and a second order to check roam alert placement every shift and to check function every night for serial #F06FFB expiration ,d+[DATE]. 5. Resident #79 was admitted to the facility [DATE] and readmitted [DATE] with diagnoses that included dementia, hypokalemia (low potassium levels), hypertension. The quarterly MDS dated [DATE] identified Resident #79 had severely impaired cognition, did not utilize a wander/elopement alarm daily, and was able to walk 50 feet with 2 turns with moderate assistance. Resident #79's care plan failed to provide a focus on wandering or elopement. Resident #79 had several Elopement Risk evaluations after hospitalization s. The Elopement Risk evaluation identifies risk factors after determining the resident's mobility. One yes indicator out of 7 results in an elopement risk indicates the resident is at risk for elopement. The form identifies to institute the use of an elopement device (Wander guard/secure care) and follow the guidelines of the AHC Elopement Risk Policy or if it is determined (by) the interdisciplinary team that a resident's behavior does not constitute a risk for elopement, a care plan will be written to reflect appropriate interventions. Resident #79's Elopement Risk evaluations identified the following. [DATE]: 0 of 7 indicators were identified as yes however and Resident #79 was not identified as an elopement risk. [DATE]: 7 of 7 indicators were identified as yes however and Resident #79 was identified as an elopement risk. [DATE]: 3 of 7 indicators were identified as yes however the elopement risk was not addressed. [DATE]: 1 of 7 indicators were identified as yes however, the resident was identified as not an elopement risk. Observation and testing of the roam alerts on [DATE] at 2:20 PM with the ADNS following a reported malfunction identified the following. Using the facility's Roam Alert sheet, which consists of a photograph of the resident who is at risk for elopement and is kept at the main entrances of the facility and every nurse's station. The testing device tests the roam alert for functionality and identifies the serial number of the device worn by the resident at that time. The Roam Alert sheet identified 18 residents on roam alerts with 2 on hospice and currently immobile, one which was discontinued [DATE], 2 expired devices one ,d+[DATE] and the second ,d+[DATE], and 2 residents who had a device without orders. The ADNS could not provide an explanation regarding the use of expired roam alerts, serial numbers that did not match the clinical record for roam alerts and how roam alerts were checked when there was no physician's order. During the testing, the following discrepancies were identified. Resident #24; roam alert serial # F03BC4 had expired ,d+[DATE]. Resident #40; the MAR identified the roam alert serial #F04B83 with an expiration date of ,d+[DATE], and currently had roam alert serial #F0D277. The clinical record had an incorrect serial number, and the corresponding expiration date was unknown. Resident #41 did not have an active order for a roam alert, had a history of wandering, was assessed as an elopement risk, and found to be wearing roam alert serial #F079F2, expiration date unknown. Resident #43 roam alert serial #F06FFB had expired ,d+[DATE]. Resident #79 did not have an active order for a roam alert, had a history of wandering, was assessed as an elopement risk, and found to be wearing roam alert serial #F00260, expiration date unknown. An interview with the ADNS on [DATE] at 10:10AM identified the night supervisor has the responsibility to check the roam alerts nightly. She identified, although it is the night supervisor's job to test each roam alert nightly as the ADNS she is responsible for overseeing the process. On [DATE] at 9:50 AM the ADNS provided an updated facility Roam Alert sheet which consisted of 15 residents. Interview and clinical record review with DNS on [DATE] at 11:30 AM identified she had been made aware of the facility's roam alert discrepancies and indicated the facility is in the process of auditing each alert device and updating the clinical record to support resident monitoring for the device. She indicated all expired devices will be replaced. The facility policy for elopement risk identified an activated elopement bracelet (Wander guard) will be placed on the resident and documented in the medical record if deemed appropriate. Each shift placement of the elopement bracelet will be verified and documented in the medical record. The functioning of the elopement bracelet will be tested on ce a day by utilizing a tester unit and documented in the medical record. 46040 6. Resident #41 was admitted to the facility on [DATE] with diagnoses that included dementia, heart failure, and hypertension. The significant change MDS dated [DATE] identified Resident #41 had severely impaired cognition, was always continent of bowel, frequently incontinent of bladder, and required substantial assistance from staff with dressing, bathing, and toileting. The care plan dated [DATE] identified Resident #41 had a history of multiple falls. Interventions included every 15-minute checks and to analyze previous falls to determine whether a pattern/trend could be addressed. Review of the clinical record and facility reportable event form identified Resident #41 had an unwitnessed fall on [DATE] at 4:00 PM. The neurological checks documented for the 72 hours following the fall were incomplete related to vital signs, pupil reaction, and extremity strength. Review of the clinical record also failed to identify a fall assessment was completed or documented related to the fall on [DATE]. Review of the clinical record and facility reportable event form identified Resident #41 had an unwitnessed fall on [DATE] at 10:15 AM. The neurological checks following the fall failed to identify any documentation after 2:15 PM on [DATE]. Review of the clinical record and facility reportable event form identified Resident #41 had an unwitnessed fall on [DATE] at 3:15 PM. The neurological checks documented following the fall failed to identify any documentation related to vital signs after 8:15 PM on [DATE] and failed to identify any documentation related to neurological assessments on [DATE] after 4:15 AM. The neurological sheet also identified the following see attached, had another fall annotated at [DATE] at 8:15 AM. Further review of the clinical record and facility reportable event form identified Resident #41 had an unwitnessed fall [DATE] at 11:45 AM with corresponding neurological checks and post falls assessments beginning [DATE] at 11:45 AM. Review of the clinical record and facility reportable event form identified Resident #41 had an unwitnessed fall on [DATE] at 6:15 PM. The neurological checks documented related to this fall identified neurological checks began [DATE] at 6:00 PM, 15 minutes prior to the incident, and further review of the neurological checks failed to identify any documentation related to this fall after 11:15 AM on [DATE]. Further review of the facility reportable event form identified a form Fall Scene Investigation which failed to identify any resident's name, date, time of fall, or any legible information related to facility staff completing the form. In addition, a neurological check also attached to this form failed to identify any resident name or date of incident. Review of the reportable event investigation form, which identified an investigation was completed related to this fall, was identified as signed by the DNS on [DATE]. Review of the clinical record and facility reportable event form identified Resident #41 had second unwitnessed fall on [DATE] at 7:15 PM. The neurological checks related to this fall failed to identify vital signs or neurological checks were reinitiated at every 15-minute intervals per the facility neurological check flowsheet directions. The documentation related to neurological checks for this fall identified they were initiated at 6:00 PM on [DATE], a neurological check was completed at the time of this fall at 7:15 PM, with the next check done at 8:15 PM on [DATE]. Further review of the neurological checks failed to identify any neurological check documentation completed after [DATE] at 3:15 PM. Review of the clinical record and facility reportable event form identified Resident #41 had a witnessed fall on [DATE] at 3 PM and observed by LPN #3 to fall and on the floor in the unit lobby and had bleeding from the head. The clinical record identified Resident #41 was sent to the hospital for evaluation at 3:25 PM and returned to the facility with 2 sutures on [DATE] at 2:00 AM. Review of the clinical documentation failed to identify any post-accident assessments completed for this fall on Resident #41. Review of the clinical record and facility reportable event form identified Resident #41 had an unwitnessed fall on [DATE] at 1:45 PM. Further review of the facility reportable event form identified the form Interdisciplinary Fall assessment which failed to identify any documentation related to a resident name or date the form was completed, and the form Fall Scene Investigation which failed to identify any resident's name, date, or time of fall. In addition, a neurological check also attached to this form failed to identify any resident name or date of incident. Review of the reportable event investigation form, which identified an investigation was completed related to this fall, was identified as signed by the DNS on [DATE] and identified that Resident #41 was placed on every 15-minute checks following this fall. Review of the clinical record failed to identify any documentation related to neurological checks were initiated or completed, or that 15 minutes checks were implemented. Review of the clinical record and facility reportable event form identified Resident #41 had an unwitnessed fall on [DATE] at 10:00 PM. Review of the neurological checks failed to identify any documentation related to an incident date and failed to identify any documentation of dates and times that neurological checks documented on the flowsheet were completed. Further review of the clinical record and facility reportable event form failed to identify any documentation related to dates and times that the post incident assessments following this fall were completed. Review of the clinical record and facility reportable event form identified Resident #41 had an unwitnessed fall on [DATE] at 7:00 PM. Review of the clinical record identified a resident locator for every 15-minute checks or 1:1 monitoring dated [DATE] with locations documented beginning at 3:00 PM, 4 hours prior to Resident #41's documented fall on [DATE]. The form failed to identify any staff member signatures or identifying information, including any issues, to verify who completed the form. The form failed to identify any documentation after 10:45 PM on [DATE]. Review of the clinical record and facility reportable event form identified Resident #41 had an unwitnessed fall on [DATE] at 3:15 PM. Further review of the facility reportable event form identified the form Interdisciplinary Fall assessment failed to identify any documentation related to a resident name or date the form was completed. Review of the reportable event investigation form, which identified an investigation was completed related to this fall, was identified as signed by the DNS on [DATE]. Further review of the clinical documentation also failed to identify any documentation that post A&I assessments were completed on [DATE]. Review of the clinical record and facility reportable event form identified Resident #41 had an unwitnessed fall on [DATE] at 12:00 PM. Review of the reportable event investigation form, which identified an investigation was completed related to this fall, was identified as signed by the DNS on [DATE], and identified corrective measures included every 15-minute checks would be conducted on Resident #41. Review of the clinical record failed to identify any documentation related to every 15-minute checks being performed prior to or after Resident #41's unwitnessed fall on [DATE]. Review of the clinical record and facility reportable event form identified Resident #41 had a witnessed fall on [DATE] at 3:00 PM. Review of the reportable event investigation form, which identified an investigation was completed related to this fall, was identified as signed by the DNS on [DATE], and identified corrective measures included education to the nurse aide that was assigned to Resident #41 to ensure that the resident was not left unattended. Included in the facility reportable event form was an in-service document completed by the ADNS with one nurse aide signature on [DATE] that the nurse aide review Resident #41's care card every shift, prior to beginning care and be a consistent care giver. Further review of the facility reportable event form identified the nurse aide who was in serviced by the ADNS on [DATE] was not assigned to, and did not provide any care for, Resident #41 at the time of the fall on [DATE]. Review of facility documentation within the facility reportable event form from [DATE] - [DATE] and interview with the DNS on [DATE] at 10:13 AM identified that it was the policy of the facility to complete neurological checks for 72 hours following an unwitnessed fall and if a resident had impaired cognition, and also to complete post-accident and incident assessments for 3 days following any accident or incident that occurred with a resident. The DNS identified that the staff had not completed the neurological checks or post A&I assessments and the facility would need to approach educating the staff differently to ensure that the checks and assessments were completed. Review of the post A&I assessment flowsheet directed that the assessment was to be completed each shift for 72 hours following an accident or incident and to notify the physician if the assessment revealed new or worsened symptoms, and included assessment areas for skin bruising, range of motion, pain, blood pressure, pulse and respirations. The facility policy on falls identified each time resident experienced a fall, post A&I assessments would be completed and documented on for 72 hours after the fall, and that neurological checks would also be completed for 72 hours after a fall for any resident that experienced an unwitnessed fall and was unable to accurately verbalize a head strike due to cognitive status or experienced any type of head injury. The facility policy on neurological assessments directed that neurological checks were used to assess a resident's neurological status following a head injury or any other situation that might alter the resident neurological status, including a fall when a resident was unable to cognitively verbalize a head injury. The policy further directed that the neurological flow sheet would be instituted by the nurse and would be completed every 15 minutes for the first hour, every hour for 4 hours, every 4 hours for the next 24 hours, and every shift for 48 hours after that. The policy directed that the flowsheet documentation should include the date and time of the assessment, the level of consciousness, the pupillary response, the strength and sensation of the extremities, and vital signs. 7. Resident #51 was admitted to the facility on [DATE] with diagnoses that included dementia, adjustment disorder with disturbance of conduct, history of falling, and left sided maxillary, orbital floor, radius, and ulna fractures. The admission MDS dated [DATE] identified Resident #51 had moderately impaired cognition, required a maximal assist with chair/bed-to-chair transfers, sustained a fracture related to a fall within the last 6 months prior to admission, and sustained 1 fall with no injury since admission. The care plan dated [DATE] identified Resident #51 was at risk for falls due to decreased mobility, history of a fall at home, Parkinson's disease, confusion, seizure disorder, and antipsychotic medication use. Interventions included keeping the call bell in reach, maintaining frequent checks on the resident, and the provision of a well-lit and clutter free environment. The nurse's note dated [DATE] at 11:38 PM identified that around 5:00 PM, Resident #51 was found on the floor by the dietary aide, sitting on his/her bottom to the right side of the bed, facing the bed. Water was on the floor secondary to Resident #51 throwing cups of water on the floor throughout the shift. No injuries were noted, Resident #51 denied pain, vital signs were stable, and the nursing supervisor was in to assess. Resident #51 was assisted back into wheelchair by the nurse and nurse aide. Around 6:15 PM, Resident #51 was sitting in front of the nurse's station and complained of increased pain to his/her right lower extremity. A message was left for the resident representative and the on-call APRN was updated and a new order for an x-ray to the right lower extremity was obtained. Resident #51 was assisted into bed around 7:00 PM and had been resting well, with the call light in reach. The nurse's notes dated [DATE] through [DATE] failed to identify neurological checks, including vital signs, and post fall assessments were completed, per the facility policy, following Resident #51's fall on [DATE] at 5:00 PM. The weights and vitals documentation dated [DATE] through [DATE] identified vital signs were obtained at the following times, prior to Resident #51's transfer to the hospital: [DATE] at 11:54 PM. [DATE] at 3:29 AM. [DATE] at 11:19 AM. The Reportable Event Summary dated [DATE] identified that Resident #51 spilled water onto the floor then when he/she attempted to get up sustained a fall. Resident #51 was sent to the hospital and was diagnosed with an acute displaced right femoral neck fracture and a small mildly hyper dense subdural hematoma, with no mass or midline shift. Interview and clinical record review with LPN #4 on [DATE] at 9:49 AM failed to identify neurological monitoring and post-fall assessments were completed following Resident # 51's fall, on [DATE]. LPN #4 indicated that she was the nurse caring for Resident #51, at the time of the fall. LPN #4 further indicated that Resident #51 had been living at the facility for less than 1 month, was agitated, and had been throwing cups of water on the floor during the shift. LPN #4 identified that the staff had gone into Resident #51's room to clean the water throughout the shift, and Resident #51 had refused to go into the dining room, for closer supervision. LPN #4 indicated that Resident #51 was found sitting on the floor around 5:00 PM, by the dietary aide, and that Resident #51 reported that he/she slipped on the water. LPN #4 identified that initially Resident #51 denied pain; the nursing staff put him/her into the wheelchair, and Resident #51 was brought out to sit by the nurse's station for closer monitoring. LPN #4 further identified that she notified the nursing supervisor and began neurological checks and post-fall assessments, immediately and throughout the remainder of her shift. Interview and clinical record review with LPN #5 on [DATE] at 9:49 AM failed to identify neurological monitoring and post-fall assessment documentation was completed following Resident #51's fall on [DATE]. LPN #5 identified that she was the nurse caring for Resident #51 from 11:00 PM until the time of the hospital transfer and that he/she did not complain of pain over night or during the first round of care in the morning; it wasn't until later the next morning that he/she began to complain of pain. LPN #5 further identified that all of Resident #51's neurological checks and post-fall assessments were completed during her shift and were all within normal limits. Interview and clinical record review with the DNS on [DATE] at 2:44 PM identified that they were unable to locate the accurate documentation for Resident #51's neurological checks and post-fall assessments, but that she would continue to look for the documentation, as it could have been misfiled. Interview and clinical record review with the DNS on [DATE] at 12:25 PM identified that she would expect neurological checks and post-fall assessments to be completed, per the facility policy. The facility's Falls: Minimizing Risk of Injury policy directs each time a resident experience a fall, an Accident and Incident (A&I) report will be completed and an interdisciplinary fall assessment in order to identify the potential causes of the fall. Statements will be obtained from staff members at the time of the fall. A status post A&I assessment and neurological checks will be completed and any resident that experiences an un-witnessed fall and is unable to accurately verbalize if he/she hit head due to cognitive status or experienced any type of head injury. The post A&I assessment and neurological monitoring will be documented for 72 hours. 8. Resident #46 was admitted to the facility on [DATE] with diagnoses that included dysphagia, hypertension, and diabetes. A physician's order dated [DATE] directed to check Resident 46's weight every Monday, Wednesday, and Friday on day shift for CHF protocol. The quarterly MDS dated [DATE] identified Resident #46 had severely impaired cognition, was frequently incontinent of bowel, utilized a suprapubic catheter, and required substantial assistance with bathing, dressing, and set up for meals. The care plan dated [DATE] identified Resident #46 was at nutritional risk of weight loss. Interventions included obtaining weights as ordered. Review of the clinical record identified the following weights documented for Resident #46 from [DATE] - [DATE]. [DATE]: 209.7 lbs. [DATE]: 213.6 lbs. [DATE]: 211.0 lbs. [DATE]: 211.0 lbs. [DATE]: 214.0 lbs. [DATE]: 210.0 lbs. [DATE]: 210.9 lbs. [DATE]: 213.8 lbs. [DATE]: 211.9 lbs. [DATE]: 222.0 lbs. [DATE]: 211.9 lbs. [DATE]: 212.0 lbs. [DATE]: 204.0 lbs. Further review of the clinical record failed to identify any additional weights documented for Resident #46. 9. Resident #53 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, atrial fibrillation, and COPD. Review of the clinical record identified Resident #53 was hospitalized from [DATE] - [DATE] due to acute kidney injury. Review of the clinical recorded identified Resident #53 weighed 338.5 lbs. upon readmission the facility on [DATE]. The physician's orders dated [DATE] directed Torsemide (a diuretic medication used for hypertension and fluid retention) 100 mg one daily and to obtain Resident #53's weight weekly for 4 weeks. Further review of the clinical record identified Resident #53 had previous physician's orders to obtain weights daily from [DATE] - [DATE]. The quarterly MDS dated [DATE] identified Resident # 53 had intact cognition, was continent of bowel and occasionally incontinent bladder, and required substantial assistance with bathing, dressing, and set up for meals. The care plan dated [DATE] identified Resident #53 was at risk for cardiac issues related to CHF and required use of a diuretic. Interventions included to monitor weights as ordered. Interview on [DATE] at 8:45 AM with Resident #53 identified he/she had been being weighed weekly due to his/her history of CHF for weight gain. Resident #53 identified that he/she had been weighed at least 2 - 3 times weekly prior to his/her hospitalization , however following readmission to the facility on [DATE], he/she had only been weighed once or twice. Resident #53 identified he/she had brought up the issue with a staff member on one prior occasion but could not remember the staff member's name or the date. Resident #53 identified he/she was concerned that his/her weights were not being checked as frequently due to his/her cardiac history and ongoing respiratory issues. Review of the clinical record identified Resident #53 weighed 315.5 lbs. on [DATE], a 23 lb. or 6.79% weight loss from [DATE], 13 days prior. The clinical record also identified Resident #53 weighed 306.0 lbs. on [DATE], 9.5 lb. weight loss from [DATE], 40 days prior, and a 32.5 lb. or 9.3% weight loss from [DATE], approximately 7 weeks prior. Further review of the clinical record failed to identify any additional weights documented for Resident #53. Interview with APRN #1 on [DATE] at 8:00 AM identified that Resident #53 did have a previous order for daily weights, but that they were no longer needed due to Resident #53 having a history of stable weights prior to hospitalization on [DATE]. APRN #1 further identified that Resident #53 had not been receiving diuretics in the hospital, and that they were restarted following readmission to the facility, which accounted for his/her weight loss from [DATE]. APRN #1 identified that while Resident #53 did not need daily weights, he/she should have had an order placed for at least weekly weights due to his/her history of CHF and fluid retention while hospitalized . APRN #1 identified that she was responsible for placing the weight orders, and this was an oversight on her part. APRN #1 identified she would place a new order for weekly weights for Resident #53. Interview with the DNS on [DATE] at 10:13 AM identified that it was the policy of the facility to follow the physician's orders related to weight monitoring, that Resident #46 should have had weights obtained and documented 3 times weekly, and Resident #53 should have had weekly weight monitoring for 4 weeks following readmission to the facility on [DATE]. The DNS identified that she would reeducate her staff on the importance of following the physician's orders. The facility policy on heart failure directed that the physician would make recommendations for a resident that included monitoring weight, and that the physician would also monitor for adverse side effects of medications, including diuretics, including fluid imbalance. The facility policy on weight monitoring directed that residents would be weighed upon admission and readmission to the facility every week for 4 weeks and then at least monthly unless otherwise indicated by the physician's order. 47457

Based on review of facility documentation, facility policy and interview for 1 resident (Resident #91) who had orders to monitor oxygen saturation, the facility failed to monitor oxygenation saturation as ordered by the physician. The findings include: Resident #91 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, malignant neoplasm of breast, and supraventricular tachycardia. The care plan dated 2/20/24 identified a focus on cardiovascular disease with interventions that included oxygen therapy, oxygen saturations as ordered, and vital signs as ordered per policy. The quarterly MDS dated [DATE] identified Resident #91 had moderately impaired cognition, required moderate assistance with toileting, showering, upper and lower body dressing, and personal hygiene. Resident #91 was dependent with putting on and taking off footwear and was on oxygen therapy. A physician's order dated 6/1/24 directed to monitor oxygen saturation with pulse oximeter every 8 hours, titrate oxygen levels to maintain oxygen saturation above 90 % on room air. The oxygen saturation report dated 6/1/24 - 6/17/24 identified the following: Of 51 opportunities, oxygen saturations were only done 16 times. Interview and clinical record review with the DNS on 6/18/24 at 11:30AM identified it is her expectation that the physician's orders are followed, and oxygen saturations should have been measured and documented every shift for titration. The policy for oxygen administration indicates that a physician's order is necessary for the administration of oxygen.

Based on review of the clinical record, tour of Resident #1's unit and staff interview for one of one resident (Resident #1) reviewed for accidents, the facility failed to provide supervision to prevent Resident #1 from accessing an unsecured stairwell, where he/she fell down the stairwell while self propelling in the wheelchair and sustained a right distal femur fracture. The findings include: Resident #1's diagnoses included dementia with behavioral disturbance, Alzheimer's disease and Diabetes Mellitus. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required extensive assistance from 2 staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS further indicated Resident #1 required supervision of two staff for locomotion off the unit and supervision of one for locomotion on the unit (although interview with the DNS on 7/25/22 at 1:30 PM identified Resident #1 self propelled on and off the unit). Physician orders dated 6/2/22 directed Resident #1 was a full mechanical lift for out of bed transfers. A Resident Care Plan dated 10/13/21 and updated quarterly through 7/8/22 identified Resident #1 frequently wandered, could be confused/forgetful and was at risk for elopement from the facility. Interventions included to apply a roam alert and check placement each shift, check functioning of the roam alert, discuss with Resident #1's family the risks of wandering and elopement and if Resident #1 was seen heading towards an exit door, offer to escort his/her to another area of the building. Nurse's notes dated 7/7/22 at 9:21 PM and written by LPN #1 identified while answering the front doorbell at 7:15 PM, she heard a resident calling out. The nurse's note further indicated that she found Resident #1 on the floor at the foot of 4 stairs with the wheelchair on top of Resident #1. LPN #1 immediately called the Nursing Supervisor to assess Resident #1, and the resident was not moved until the ambulance arrived and moved him/her onto the stretcher. Resident #1 was awake, at baseline upon leaving the facility and all parties were notified by the RN. A facility Reportable Event Report dated 7/7/22 at 7:15 PM identified Resident #1 self propelled through the inside stairway door and fell down a couple stairs, no immediate injury, sent to Emergency Department for evaluation. MD and family updated. Nurse's notes dated 7/7/22 at 10:08 PM and written by RN #1 identified she was alerted by the Charge Nurse (LPN #1) that Resident #1 was found lying on the floor, upon assessment, Resident #1 was observed lying on the floor on his/her left side at the bottom of the stairs, the wheel chair was on top of him/her and his/her head was lying on the left arm. Resident #1 was alert and verbal at the time of the fall, confused at baseline, denied pain, no neurological deficit noted, skin intact, no bruise, no bleeding noted, no visible injury. 911 was called in and assisted Resident #1 off the floor to the stretcher by 4 attendants. RN #1's nurse's note further indicated Resident #1 wondered off the unit, opened the door and wheeled off the stairs. Hospital discharge summary dated 7/11/22 identified Resident #1 was being transferred back to the Long Term Care facility with diagnoses of a urinary tract infection and a right distal femur fracture. The hospital discharge summary further indicated Resident #1 underwent a right femur closed reduction in the Operating Room on 7/9/22 and was provided a hinged knee brace locked in extension to the right lower extremity at all times. On 7/25/22 at 10:00 AM, tour of the unit and interview with the DNS identified on 7/7/22 (DNS was unsure of the time) Resident #1 was near the nurses' station and self propelled in his/her wheel chair down the corridor past the Receptionist (whose shift had already ended). On 7/25/22 at 3:00 PM the Director of Maintenance estimated the length from the nurses station to the Receptionist to be approximately 60 feet. Resident #1 then self propelled to the right of the Receptionist's desk through double doors that remained open on magnetic holders, opened an unlocked/unalarmed stairwell located across from the elevator (estimated to be 25 feet from the opened magnetic doors) and Resident #1 fell down 4 stairs in the wheelchair, landing with the wheelchair on top of him/her at the bottom of the stairs. Additionally, the DNS identified that immediately Maintenance was contacted to secure the door to deter another resident from opening until an alarm/key pad could be installed and a staff member was placed at the door to prevent any resident attempting to open the door. On 7/25/22 at 10:47 AM, interview with NA #2 identified on 7/7/22 she observed Resident #1 sitting near the nurses' station a shortly before 7:00 PM and Resident #1 was in the wheelchair talking to another resident. Additionally, NA #2 identified on 7/11/22 Resident #1 had previously attempted to go into the storage room where incontinent briefs, body lotions and soaps are stored, but stated that Resident #1 was always trying to touch things, staff would re-direct him/her and provide crayons and coloring pages which Resident #1 would respond to. On 7/25/22 at 3:46 PM, interview with LPN #1 identified that on 7/7/22 she worked the 3:00 PM to 11:00 PM shift, and while answering the front door (approximately around 7:15 PM), she heard yelling, and that's when she saw Resident #1 at the bottom of the stairwell steps (4 steps down), partially lying on his/her side with the wheelchair on top of the resident. LPN #1 further stated that she had observed Resident #1 at the nurses' station approximately 10 minutes prior to the fall and was his/her usual self. On 7/25/22 at 3:47 PM, interview with RN #1 identified that she was the Nursing Supervisor on the 3:00 PM to 11:00 PM shift on 7/7/22. RN #1 further identified Resident #1 was at the nurses' station because that was an intervention for being at risk for falls when Resident #1 wandered off the unit. RN #1 further identified that LPN #1 went to let a visitor into the facility and heard someone yelling which was Resident #1. RN #1 further identified that LPN #1 requested she assess Resident #1 who was at the bottom of the stairwell at which time RN #1 kept Resident #1 on the ground and completed an assessment until Emergency Medical Services (EMS) arrived. When EMS began to pick Resident #1 up from the floor, Resident #1 complained of left knee pain. The facility alleges past non-compliance as evidenced by developing an immediate plan of correction on 7/7/22 which consisted of educating all staff that the door to the interior stairs would have an alarm on it and all staff must respond to that alarm, a keyed manual Emergency entrance device was applied to the door and remained in the on alarmed position until the Corporate Electrician could install a keypad/alarm on the interior stair door and staff were inserviced to keep the device on the on position. Additionally, the Maintenance Director conducted audits to all exterior doors, all elopement resident assessments were reviewed and updated, all elopement risk sheets were reviewed and updated, the Receptionist and Kitchen staff were educated to close the doors to the Kitchen access area and the lobby, and new recreational activities for Resident #1 were developed to include a busy blanket, Catholic mass on TV and DVD player for his/her room to play music and memory videos.

Based on clinical record reviews, review of facility documentation and interviews for one sampled resident (Resident #1) who was reviewed for allegation of abuse, the facility failed to ensure resident was free from misappropriation of resident funds. The findings include: Resident #1 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had intact cognition, not depressed, no behavior concerns, and an assist of 1 with bed mobility, transfers, and personal hygiene. Ambulates with assist of one with a walker and able to self-propel in wheelchair. The assessment also noted the utilization of anti-psychotic, anti-anxiety, and anti-depressant within the last 7 days. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident care plan dated 10/12/21 identified mood/behaviors with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions directed harvest healthcare care consultation as needed for psychiatric evaluation, AIMS (Abnormal Involuntary Movement Scale) screen every six months due to [MEDICATION(S)] (anti-psychotic) use, observe for any sign and symptoms of hallucination, delusion, excessive happiness/[CONDITION(S)] or signs and symptoms of depression and report to physician. Additionally, directed to offer support and reassurance if appears anxious. A Reportable Event form dated 10/25/21 at 9:30 AM identified Resident #1 stated she had given an employee close to $500.00 dollars in the last few months which included $200 for clothes for him/herself and never received them and the other money for the employee to pay his bills. Description of event identified Resident #1 was visually upset, and the nursing assistants went to talk to him/her, and he/she stated she gave money to a staff member over the last couple of months. A written statement dated 10/25/21 from Nurse Aide (NA #1) identified while feeding Resident #1's roommate on 10/25/21 she noticed Resident #1 was upset, and he/she became hysterical and verbalized he/she was being used by Recreational Assistant #1 for his/her money and that Recreational Assistant #1 was going to leave him/her with nothing. Resident #1 stated that Recreational Assistant #1 had taken close to if not more than $500.00 and Recreational Assistant #1 needed $280.00 by the morning for his electric bill. Resident #1 stated Recreational Assistant #1 came into the facility on the morning of 10/25/21 to apologize and told him/her how much he loves him/her and cared for him/her. NA#1 further identifiedt on 10/25/21 at 9:15 AM, Resident #1 told NA #1 that Recreational Assistant #1 called him/her to state that he would never use him/her and wanted to make sure all was good. NA#1 identified after the phone call, Resident #1 began to cry again and stated he/she felt used and that all the clothes Recreational Assistant #1 promised to give him/her that he/she gave him money for he/she never got. A written statement taken by Social Worker (SW) at the time of the facility investigation identifiedResident #1 stated Recreational Assistant #1 asked him/her for money 4 times, it started near his/her birthday in August 2021 and that he/she knew about Recreational Assistant #1 car problems and electric bill because Recreational Assistant #1 visited him/her on 10/25/21 and that Recreational Assistant #1 was not upset but he looked angry. Recreational Assistant #1 used the money for his personal use and not for Resident #1 personal items. A written statement dated 10/25/21 from NA #2 identified that she was walking towards Resident #1 room on 10/25/21 and overheard Recreational Assistant #1 assuring Resident #1 that he loved him/her, and he promised he would pay him/her back for whatever he/she would lend him, and that Resident #1 seemed upset when Recreational Assistant #1 left stating friends don't use friends. A written statement dated 10/25/21 from Licensed Practical Nurse (LPN #1) identified she was notified by the NA #1 and NA #2 that Resident #1 was upset and crying. LPN #1 identified that Resident #1 told her that he/she was upset because Recreational Assistant #1 keeps asking him/her for money and that Recreational Assistant #1 still has not paid back the money he/she gave him and that he/she told him right to his face that he/she could not give him the money and that Recreational Assistant # 1 called him/her after he left stating that he was sorry and that he was going to give Resident #1 the money back when he got his check. LPN #1 instructed NA #1 and NA #2 to notify the SW of the incident. A written statement dated 10/25/21 from SW identified that she was approached by NA #1 and NA #2 that Resident #1 was crying and upset stating that he/she feels used by Recreational Assistant #1. SW identified that she was going to visit Resident #1 and overheard Recreational Assistant #1 stated that he promised to pay Resident #1 back. SW then entered the room and saw Resident #1 crying. Recreational Assistant #1 stated to SW that Resident #1 was fine. Resident #1 responded to SW and stated he/she thought Recreational Assistant #1 was taking advantage of him/her. Recreational Assistant #1 responded that he talked to Resident #1, and everything was good now. SW asked Recreational Assistant #1 why he was visiting Resident #1 and Recreational Assistant #1 stated he was there to visit human resources but that human resources was not available. SW further identified that Recreational Assistant #1 left the residents room and Resident #1 then stated to SW that Recreational Assistant # 1 had called him/her last night for $280.00 for his electrical bill and that he/she had given him money in the past, close to $500.00, $250.00 for clothes that he/she had never received. A physician's telephone order dated 10/25/21 directed to administer [MEDICATION(S)] 0.25 MG every 12 hours as needed for anxiety for 5 days. An email correspondence to Person #3 dated 10/26/21 from Recreational Assistant #1 identified that Recreational Assistant #1 did get money from Resident #1 for items and that he has not gotten the items and that he had the money and indicated Resident #1 told him to hold onto it until he gets to the store. Recreational Assistant #1 stated he has bought her/him tissues, body wash and cough drops and that he would never take from the residents and indicated that he felt bad, and he had the money if someone want to go pick up the $300. 00. A statement obtained with Recreational Assistant #1 from the Director of Nursing Services (DNS) and Person #3 identified that Resident #1 knew about Recreational Assistant #1 car and bills because he and Resident #1 had normal conversations about life and that he/she offered to pay his bills and that money was also given for Recreational Assistant #1 to get Resident #1 clothes and other items. A psychiatry physicians note dated 10/28/21 identified that Resident #1 was seen via teleconference and that resident had been taken advantage of a staff member and has been observed crying, expressing regret, anger and anxiety since the event and Resident #1 admits to crying more than usual and sleeping poorly. A psychiatry physicians note dated 11/2/21 identified that Resident #1 admits to crying more ever since s/he was swindled out of her/his money and feel like the current dosing of his/her [MEDICATION(S)] 0.5 MG every 12 hours is insufficient to manage her /his sad mood. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The social service note dated 11/5/21 identified social service met with the resident after feeling taken disadvantage of and the resident admitted feeling upset and angry. The Social Worker (SW) provided emotional support and indicated the resident was seen by psychiatry. A summary for the Reportable event dated 11/10/21 identified that Recreational Assistant #1 who was currently on a leave since the end of September 2021 was given money by Resident #1 to purchase the resident personal items. Recreational Assistant #1 confirmed the money was given to him in the end of August 2021and items were never purchased. Recreational Assistant # 1 was in the facility visiting Resident #1 when he was overheard by staff members requesting more money. Resident #1 personal funds account verified withdrawal of $300.00 for personal items Resident #1 never received and $290.00 for Recreational Assistant #1 to pay his electric bill and fix his care. Resident #1 was seen by psychiatric services and social services. A physician's telephone order dated 11/12/21 directed to administer [MEDICATION(S)] tablet 0.5 MG, give 1 tablet by mouth three times a day for anxiety. In an interview with Resident #1 on 12/2/21 at 11:30 AM identified that he/she gave Recreational Assistant #1 money for clothes that he/she never received. Resident #1 stated she gave Recreational Assistant # 1 around $200.00 the first time and then a week later another $200.00. Resident #1 recalled it was about approximately $400.00 August 2021 or near September 2021 of this year. Resident #1 identified that Recreational Assistant #1 approached her/him about the money and said that he could get clothes cheaper, and he would pay the resident back and the last time he had asked for $280.00 to pay his electric bill but the resident did not give Recreational Assistant #1 the money and that was the last time he/she saw him. Resident #1 identified that the police was called and that he/she has never given any other employee money. Observation on 12/2/21 at 11:30 AM, identified that during Resident #1 interview, he/she became visibly upset and started to cry, emotional support was given, and the interview was discontinued by surveyor. Interview with the Administrator on 12/2/21 at 11:45 AM identified that she was informed by the SW on the morning of 10/25/21 when she immediately began her investigation and Recreational Assistant #1 was suspended pending an investigation. The Administrator indicated that her Reportable Event Summary and all the statement obtained substantiated the allegation. Interview with DNS on 12/2/21 at 12:00 PM identified that she was not working on 10/25/21 when Resident #1 reported the incident but that she did visit the resident on 10/26/21. The DNS identified that Resident #1 was still upset because s/he never received her/his clothing and was sad and felt that Recreational Assistant #1 used her/him and that he/she really loved him. Interview with SW on 12/2/21 at 12:26 PM identified that she became aware of the incident with Resident #1 and Recreational Assistant #1 the morning on 10/25/21 at approximately 8:30 AM when NA #1 and NA #2 approached her stating that they overheard a phone conversation Resident #1 was having with Recreational Assistant #1 and Resident #1 stated s/he felt that Recreational Assistant #1 was using him/her, and s/he was crying and upset. SW went to see Resident #1 in the resident's room Person #1 was in his/her room. SW stated she walked into the room and asked him/her why she was crying, and Recreational Assistant #1 answered for the resident and said everything was fine. SW stayed in the room, near the doorway and Resident #1 yelled out that s/he was upset because he/she thought Recreational Assistant # 1 was using him/her and when he/she said this to the SW, Recreational Assistant #1 was still in the room. Recreational Assistant #1 responded no no no and told Resident #1 he loved him/her and would never do that to him/her. SW asked Recreational Assistant #1 why he was in the building because he was out on leave and Recreational Assistant # 1 replied that he wanted to see human resources because he still had not gotten paid. SW reminded Recreational Assistant #1 the location of the human resources office and Recreational Assistant # 1 left the room. SW identified that from Resident #1-bedroom window she could see Recreational Assistant #1 leaving the facility looking into Resident #1-bedroom window, so she closed the curtain and Recreational Assistant #1 left the premises. SW identified that she continued her conversation with Resident #1, and the resident indicated he/she was upset because Recreational Assistant # 1was asking him/her for large amounts of money. Resident #1 stated that on 10/24/21, Recreational Assistant #1 called her/him on the phone and asked her/him for $175.00 for his electric bill and that is what made him/her become upset because then Recreational Assistant #1 called him/her again the morning of 10/25/21 to see if he could come and get the money and he/she was crying and upset with Recreational Assistant #1 and that is when he showed up at the facility. SW indicated that once Resident #1 was more relaxed SW immediately discussed with Administrator about the incident and the investigation. In an interview with Office Manager on 12/2/21 at 1:01 PM identified that Resident #1 would withdraw funds from her account 3-4 times a month for things he/she may need such as tissues, cough drops, or for the hairdresser. Recreational Assistant # 1 did question Resident #1 about why s/he was taking more than the usual amount of money out of his/her account but that s/he did inform Resident #1 that she/he was taking out more than the normal amount of money and his/her funds were depleting. Office Manager stated she had thought Resident #1 was getting clothes from Recreational Assistant #1, but she wasn't aware if the clothes were bought or not bought so she explained to Resident #1 to wait and try not to take out more money until he/she gets his/her clothing. Office Manager #1 indicated that Resident #1 never mentioned that he/she felt that Recreational Assistant #1 was using his/her money on himself and not for his/her clothes. Office Manager identified that since the incident Resident #1 receives assistance with purchasing items he/she may need from the facility and that he/she has not taken money out of his/her funds to purchase personal items. Office Manager further identified that the facility completed an audit to ensure other residents were not affected by personal funds given to any employee. A letter obtained from the Administrator on 12/2/21 identified that Recreational Assistant #1 was on leave of absence from 9/23/21 and never returned from his leave of absence and was terminated due to the incident. A review of Recreational Assistant employee file identified a date of hire on 9/24/20 and a signed acknowledgment that he received the Apple Health care Employee handbook which indicated acceptance of gifts or gratuities from residents is not allowed and receipt of gift, gratuity, or payment without reporting such receipt will result in termination of employment. Additionally, the employee file noted Recreational Assistant #1 received education regarding the facilities code of conduct, residents' rights, and resident abuse. In an interview with Office Manager on 12/3/21 at 12:43 PM identified that she and the SW reviewed the Resident funds statement with Resident #1 to determine the amount of money that he/she withdrew from his/her account but never received her/his personal items/clothing. Office Manager indicated that on 8/31/21, $200.00 was withdrawn, 9/29/21 $150.00 and $140.00 was withdrawn and on 10/14/21 $100.00 was withdrawn. The statement identifies that the Recreational Assistant #1 returned $300.00 to the facility and the facility reimbursed an additional $290.00. Total amount reimbursed to Resident #1 was $590.00. Review of the Abuse/Resident policy directed to ensure each resident is treated with kindness, compassion and in a dignified manner. Abuse or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on clinical record review, facility documentation and interviews for or one of three residents (R #2) reviewed for falls, (Resident #2), the facility failed to ensure the resident was transferred to and positioned in the wheelchair with two staff members in accordance with physician's orders [REDACTED]. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified that the resident was alert, oriented, and required assist of two staff for transfers. The Resident Care Plan (RCP) dated 1/27/18 identified the resident required assist for ADL's with interventions that included, provide assist of two for transfers. A physician's orders [REDACTED]. A Physical Therapy note dated 1/28/18 identified that R #2 transferred bed to wheelchair with maximum assistance, required maximum assist to position in the wheelchair, and utilized a seatbelt while in the MWC. The Occupational Therapy note dated 1/28/18 identified the resident was positioned in a standard hemi-height wheelchair with a roho cushion, and seatbelt for pelvic positioning, resident has poor trunk control. Review of facility documentation dated 1/30/18 at 10:15 AM identified R #2 fell backwards while in his/her wheelchair hitting his/her head. Documentation further described R #2 was an assist of two with transfers, and when NA #3 attempted to elevate R #2's legs on the bed, R #2 had leg spasms, the wheelchair then tipped backward and resident fell on the floor. Review of RN #2's nurse's note dated 1/30/18 at 2:12 PM identified she was called to the room at 10:30 AM and observed R #2 lying on his/her back on the floor. NA #3 reported R #2's wheelchair tipped backwards and resident hit his/her head on the floor. R #2 complained of head pain, ringing in his/her ears, and was crying. Pupils were non-reactive, pulse was 110, and R #2 had a palpable soft raised areas approximately the size of a quarter to the posterior mid skull. The resident was transferred to the hospital for evaluation. Review of the hospital record dated 1/30/18 identified the resident sustained [REDACTED]. The resident was admitted to the intensive care unit for close neurologic monitoring. Interview and clinical record review with the Director of Rehab and PT #1 on 6/15/18 at 1:05 PM stated she (PT#1) responded to the room after the fall on 1/30/18, and found R #2 on the floor, with his/her wheelchair still under him/her and the wheelchair seat belt on. PT #1 stated R #2 could not have tipped the wheelchair over him/herself; R #2 required two staff for transfers, and two staff were required to ensure R #2 was properly positioned in the wheelchair. Interview identified if R #2 was positioned correctly in his/her wheelchair with leg rests on, R #2 does not usually have spasms. PT #1 stated prior to admission, R #2 would elevate his/her legs on a chair or bed to help with dysreflexia symptoms, and on 1/30/18, R #2 could have fallen because the surface was too high when the NA attempted elevate R #2's legs. PT #1 stated when she entered R #2's room after the fall, the bed was in a raised position (wheels off the floor), and she lowered the bed to engage the wheels to move the bed out of the way. Interview, clinical record review, and facility documentation review with RN #2 and the DON on 6/15/18 at 1:45 PM identified NA #3 transferred R #2 into the wheelchair without assistance of a second staff person, and had attempted to elevate R #2's legs per the resident's request. RN #2 stated when NA #3 lifted R #2's legs off the floor, R #2 had spasms and the wheelchair tipped over backwards. The DON stated when R #2 had the spasms and tipped over backwards, R #2 was already positioned in the wheelchair by NA #3. The DON stated NA #3 should have transferred R #2 using two staff. Interview, clinical record review, and facility documentation review with NA #3 on 6/18/18 at 9:24 AM identified she never provided care or assisted with R #2's transfers before 1/30/18. NA #3 stated she was aware R #2 should have had two staff for transfers, and stated she transferred R #2 into the wheelchair without any assistance. NA #3 stated when she lifted R #2's feet up off the floor to elevate them on the bed, R #2 had spasms, and the wheelchair tipped over backwards. NA #3 stated she should have had another staff member assist with the transfer according to facility policy if a resident is a two person transfer. NA #3 further stated when two staff perform a transfer, both staff ensure the resident is correctly positioned in the wheelchair before the second staff member leaves the room. Interview with R #2 on 6/18/18 at 10:10 AM identified he/she had one fall in (MONTH) (YEAR). R #2 stated the occupational therapist came into the room and told NA #3 to call her for assistance when NA #3 was ready to perform the transfer, but stated NA #3 completed the transfer by herself. R #2 stated he/she was not back far enough in the wheelchair when NA #3 lifted her feet off the floor and he/she had spasms, and the wheelchair tipped over backwards. R #2 stated the wheelchair tipped because he/she was not positioned correctly in the wheelchair. Interview with the DON identified there was no facility policy for surveyor review regarding following physician order, however the expectation was that two staff should have performed the transfer. Interview with the ADON identified the expectation was that the NA should follow the care card, and staff should follow the physician's orders [REDACTED].

Based on review of the clinical records, facility policy and procedures, facility documentation and interviews for two of four residents reviewed for accidents (Residents # 48 and #63), the facility failed to provide the necessary assistive device during a transfer and / or failed to monitor the residents trends of falls in accordance to facility policy and procedures to prevent an accident. The findings included: 1. Resident #63's [DIAGNOSES REDACTED]. A MDS 5 day admission assessment dated [DATE] identified the resident without cognitive impairment and requiring extensive assistance of two staff for transfers. The RCP updated on 2/19/14 identified at risk for hospitalization secondary to medical condition. Interventions included assist of two for transfers to wheelchair and an assist of one for moderate to maximum assistance with Activities of Daily Living. The Reportable Event and investigation dated 2/27/14 identified that Resident #63 was noted with moderate amounts of blood on the Left Lower Extremity (LLE) and night gown. Resident #63 indicated "I think I hit my leg on the wheelchair". Upon assessment a 7.0-8.0 CM by 5.0 CM by 0.3 CM open area was noted on the LLE. Resident #63 was transferred to the Emergency Department (ED) for an evaluation and required five sutures to approximate the 9.0 CM irregularly shaped wound. Review of facility in-service education dated 3/19/14 identified Nurse Aide (NA) # 1 received in servicing regarding proper techniques during resident transfers. Interview with Resident #63 on 7/15/14 at 10:15 A.M. indicated one NA performed the transfer from the toilet on the evening of 2/27/14. The resident further indicated that during the transfer, the aide turned him/her the " wrong way " (to the left) causing him/ her to strike the left leg against the wheelchair. Interview and review of the Reportable Event and investigation with NA #1 on 7/15/14 at 5:45 P.M. and 6:15 P.M. indicated that in the process of transferring Resident # 63 from the toilet to the wheelchair, NA #1 linked her/his left hand under the resident ' s left arm. Resident #63 used the "right hand " to grip the grab bar which was mounted to the right of the resident on the wall next to the toilet. When NA #1 stood the resident up to face her, NA #4 moved the resident ' s wheelchair closer to the resident, NA #1 turned and pivoted Resident #63 to the left towards the bathroom sink so the resident could reach back to feel for the right arm of the wheelchair in preparation to sit. NA # 1 verbalized that once Resident # 63 was seated into the wheelchair and was being transported out of the bathroom she/he noticed the wound on the resident's LLE. Interview and review of the Reportable Event and investigation with NA #4 on 7/15/14 at 6:25 P.M. indicated that although she was present in the building at the time of Resident #63 ' s accident on 2/27/14, she did not work on the unit with NA #1 and did not assist NA #1 to transfer Resident #63. NA #4 further noted that if he/she was involved in the transfer he/she would have provided a statement as part of the facility ' s investigation. On 7/16/14 at 10:25 A.M. an interview with identified that when transferring a resident who requires the assistance of two staff it is required that both staff members place their hands on the resident during the transfer. The Rehabilitation Director indicated staff should utilize a gait belt for all transfers in accordance with the facility ' s policy and procedures for transfers. A review of Resident # 63 ' s clinical record, staff interviews, and review of the facility ' s investigation failed to identify that a gait belt was used to transfer Resident #63 in accordance to facility policy and procedures. Additionally, the investigation failed to identify that two staff members were present at the time of the transfer in accordance with the plan of care. Facility policy and procedure for gait belt identified that to ensure the safety of our residents and staff, the use of gait belts is mandatory by all nursing personnel and rehabilitation staff while transferring or ambulating the resident. 2. Resident#48's [DIAGNOSES REDACTED]. MDS dated [DATE] identified the resident with moderately impaired cognition, absence of ambulation, extensive assistance for bed mobility, transfer and personal hygiene and noted a history of falls. A fall risk assessment completed on 10/31/13 further identified the resident a risk for falls. RCP dated 11/7/13 identified falls with interventions that included assist of one for slide board transfers, low bed and care pads to the floor, bed in lowest position when in bed and at highest position, locked when out of bed and to apply a self -release seat belt in wheel chair. The nurse's noted dated 12/27/13 at 6:30 P.M., identified the resident was found on the bedroom floor on top of blankets with no injuries and stated that the resident put him/her self on the floor. Further review of nurse's notes dated 1/2/14 at 6:30 P.M. indicated the resident was found on the floor sitting upright next to the bed. Resident # 48 indicated that he/she was grabbing at the sheets on the bed in an attempt to push self into the back of the chair and then slide out the chair. The resident further indicated that he/she unlocked the seatbelt and was positioned towards the edge of the seat. The resident sustained [REDACTED]. The APRN notes dated 1/6/14 identified the resident was noted with a right lower lobe infiltrate and that antibiotic therapy was initiated for ten days. 1/8/14 the nurse notes indicated that Resident # 48 was found sitting on the floor at 8:10 A.M. next to the bed with no injuries and indicated that he/she could get off the bed and did not realize the bed was high. A bed alarm was initiated and a manual wheelchair was also provided for safety. Further review of nurse's notes indicated that on 2/14/14 at 7:00 P.M., the resident was found sitting upright on the floor next to his/her bed with no injuries. The resident indicated that she / he was moving her/his lower extremities and then began to fall. The nurse notes identified that the resident was seen earlier propelling the wheelchair into the room. On 3/10/14 the nurse notes at 7:30 P.M. identified the resident was heard screaming and then found seated in an upright position on the floor in his/her room. The resident indicated that he/she fell when leaning over in wheelchair. The nurse notes further identified the resident had a right lobe infiltrate and the covering physician directed to start antibiotic therapy for 7 days. On 3/15/14 the nurse notes on the 7-3 P.M. shift indicated the resident was noted with increased agitation trying to leave the building running over other residents and staff members with his/her electric wheelchair. The resident was given Xanax (Anti-anxiety) 0.75 MG at 12:00 P.M. with good effect and was transferred to a manual wheelchair. The APRN was updated and staff was directed to administer Risperdal 0.25 mg (Anti-psychotic) at 4:00 P.M. The nurse notes at 5:00 P.M. identified the resident was very agitated, bumping the wheelchair against furniture, claiming that staff was holding him/her against her/his will and upset that the family could not be reached by phone. At 5:45 P.M. the resident was found on the floor, screaming, crying and indicated that the entire right side hurts and that he/she could not move the right upper and lower extremities. The APRN directed the licensed staff to send the resident to the hospital. Computerized Tomography (CT) scan of the cervical spine identified osteoporosis with no acute fracture. Left knee and left femur x-rays were negative of fracture. 3/17/14 the nurse's notes identified the resident complained of right leg and thigh pain and the APRN directed to obtain an x-ray of the right knee. X-ray indicated osteoarthrities of the right knee and suspected intertrochanteric hip fracture appears present. 3/19/14 nurse's notes indicated that the resident was found on the floor at 5:00 P.M. and that the resident stated she/ he fell out of bed. The nurse notes identified the resident had positive range of motion to all extremities and denied pain. However 3/21/14 the nurse notes identified the physician was notified of intermittent complaints of right hip pain and directed to obtain a CT scan of the right hip. Review of the CT scan revealed a comminuted fracture of the right hip with a treatment of [REDACTED]. Clinical record review and interview with the DNS and Administrator on 7/17/14 at 11:00 A.M. indicated the resident would exhibit anger and then threaten to put self on the floor when he/she perceived that she/he received inadequate family visits, when the electric wheelchair was off for repair and/or when eggs were not served the way he/she wanted them done. Review the clinical record nurse's notes indicated that Resident # 48 had a history of [REDACTED].M. through 7:30 P.M. with or without the identified triggers. Although the clinical record identified interventions were put in place to manage signs and symptoms of infection, at the time of the falls, the clinical record failed to identify additional interventions to manage the behavior when a pattern of attempting to get off the wheelchair between 5:45 P.M. through 7:30 P.M. was evident. The DNS indicated that the resident was discussed during fall rounds to identify strategies. Review of the fall rounds for 3/12/14 and 3/20/14 identified interventions to educate the resident to avoid leaning too far and the importance of the seat belt. During an interview with the DNS on 7/17/14 at 11:00 A.M. indicated that she was unaware of the pattern of Resident # 48 attempting to get off the wheelchair between 5:45 P.M. through 7:30 P.M. could not provide evidence where other options were explored to address the resident's pattern of falls. Despite the direction provided by the facility's policy on falls to complete monthly reviews to identify trends and common causes to guide in identifying interventions. The facility lacked documentation and/ or evidence that the resident's trends were identified in an effort to prevent further falls .

Based on record review and staff interview, for one of four sampled residents requiring supervision with toileting (Resident # 120), the facility failed to ensure services were provided to prevent an injury. The findings include: Resident #120's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident as having a problem with long and short term memory. The MDS further noted the resident required total assistance with transfers, dressing, toilet use and hygiene and the resident was not steady (only able to stabilize with human assistance) with moving on and off the toilet. Care plan dated 7/21/11 identified a potential for falls due to a decline in mobility, dementia with behaviors, and decline in gait status. Interventions include to utilize a bed/chair alarm to remind her/him not to transfer alone and to utilize a standing mechanical lift and assist of two staff members for transfers. Physical therapy evaluation dated 7/16/11 identified fair sitting balance and poor standing balance. Nurses notes dated 11/23/11 at 8:15PM identified the resident was found lying on the bathroom floor on her/his left side complaining of left shoulder pain. The resident was transferred to the emergency room and returned to the facility on [DATE] at 4:50AM with a [DIAGNOSES REDACTED]. On 7/17/12 at 2:50PM interview with NA#3 noted that she transferred the resident by herself using the Sit/Stand (Sara) lift. NA#3 further noted that she left the resident on the toilet with the door open to bring the mechanical lift to the roomate to prepare her/him to transfer. NA#3 further noted that she heard a noise and Resident #120 was on the floor. Further interview with NA#3 noted although she was aware not to transfer the resident by herselft, the other NA on the unit was with another resident and the resident kept stating "bathroom." She further noted that she was aware not to leave the resident unattended in the bathroom, but kept the door open for "only a minute." On 7/17/12 at 1:00PM an interview with the DNS noted that NA's are trained to supervise resident's on the toilet and NA#3 was not to have left Resident #120 unattended on the toilet. On 7/18/12 at 11:14AM an interview with Registered Physical Therapist #1 noted that Resident #120 was not to be left alone in the toilet because she/he was not an independent transfer. Facility policy regarding mechanical stand transfers recommends that two staff members perform the transfer. The facility failed to ensure measures were implemented to prevent an accident and injury.

Based on clinical record review, review of facility documentation and interviews for one sampled resident identified with an injury of unknown origin (R#1), the facility failed to ensure the resident remained free from physical and/or sexual abuse. The findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission assessment dated [DATE] at 4:45 PM identified the resident with no bruises, discolorations or abrasions and continent of bowel and bladder. An admission Minimum Data Set ((MDS) dated [DATE] identified the resident as responsible for self, with short term memory problems and independent with cognitive skills for decision making. The resident was identified as requiring limited assistance with activities of daily living with a one person physical assist. A care plan dated 7/20/10 identified the resident with anxiety and depression. Interventions included [MEDICATION NAME] every 12 hours as needed (prn) and [MEDICATION NAME] every day. Review of facility documentation, and investigation dated 7/18/10 at 2:30 PM and a nurse's note dated 7/18/10 at 3:30 PM identified that the resident complained of bruises to the right inner thigh. An assessment was conducted and identified three (3) bruises on the right inner thigh and vaginal area, one measuring 5.0 centimeter (cm) by 3.0 cm and oval. All bruises were identified as purple in color and scattered. Resident #1 identified that, " It could have happened last night or it could have been a dream, one or two people were in bed with me. I kept trying to push them off me, I could have been raped". The physician, family member and police were notified and the resident was transferred to the emergency room (ER) for evaluation. The resident returned to the facility on [DATE] at 1:30 AM. Review of the Emergency Department Documents dated 7/18/10 at 5:36 PM identified that the resident presented with bruising on his/her inner thigh and buttock and also reported someone being in bed with him/her last night and lying behind him/her. Upon examination, bruising was noted to right inner thigh and buttock. [DIAGNOSES REDACTED]. A sexual assault kit was completed and given to the police for processing. Telephone interview with Detective #1 on 8/23/10 at 9:15 AM identified preliminary results of the rape kit were positive for semen however a copy of the results were not available. Interview with NA#5 on 8/23/10 at 3:20 PM identified she was on duty on 7/17/10 (7 AM-3 PM) and was assigned to care for R #1. NA#5 indicated she got the resident up in the morning and when she washed the resident, did not see any bruising on the thighs, buttocks or anywhere else on the body. Interview with NA# 3 on 8/23/10 at 12:50 PM identified she was on duty on 7/17/10 (11 PM-7 AM). NA#3 identified the resident as an assist of 1 for toileting and that she had toileted the resident between the hours of 2:00 AM and 4:00 AM, did not see any bruising on the inner thigh and did not see the resident after 4:00 AM that night. Interview with NA#8 on 8/31/10 at 12:15 PM identified she was assigned the resident on 7/18/10 on the 7 AM to 3 PM shift and indicated she first noticed the bruising on the resident's right inner thigh at approximately 8:30 AM when she was completing morning care. NA#8 indicated she did not report the bruising because she became side-tracked. Interview with RN #4 on 8/23/10 at 12:35 PM identified she was the charge nurse on duty on 7/17/10 (11 PM-7 AM). RN#4 indicated that NA#3 was assigned to the resident and that NA#3 did not report any bruising on R#1 and/or any unusual occurrences during the shift. RN#3 indicated she did not hear R#1 scream during the night and indicated the resident was toileted twice during the shift. Interview with RN#2 on 8/18/10 at 2:30 PM identified she was the supervisor on duty on 7/18/10 (7 AM-3 PM). RN#2 indicated she was informed by RN#5 that the resident reported bruising and alleged he/she was raped. RN#2 indicated upon assessment she observed bruising to the right inner thigh going up towards the labia. Interview with NA#7 on 8/24/10 at 8:40 AM identified she responded to a call light on 7/18/10 at approximately 2:00 PM. R#1 was sitting in his/her wheelchair with the pants down, pointing and indicating he/she thought he/she may have been raped in the middle of the night. NA#7 indicated she called RN#5 and R#1 repeated the same story.