Every finding on record at Aspen Hill Rehabiliation & Healthcare Center

Based on observations, record review, policy review and interview, the facility failed to ensure dental services were provided for two Residents (#105 and #20) out of a total sample of 27 Residents. Specifically, the facility failed to:1. For Resident #105, the facility failed to acknowledge and implement the dentist's continued recommendations for the extractions of seven teeth.2. For Resident #20, the facility failed to ensure dental services were provided after being assessed by the contracted dentist on 10/22/2024, with recommendations.Findings include:Review of the facility policy titled Dental Services, dated and revised December 2016, indicated the following: - Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. - Routine and 24-hour emergency dental services are provided to our residents through: a contract agreement with a licensed dentist that comes to the facility monthly, referral to the resident's personal dentist, referral to community dentists, referral to other health care organizations that provide dental services. - Residents have the right to select dentists of their choice when dental care or services are needed. - Selected dentists must be available to provide follow-up care. - Medicare and Medicaid residents will be billed for routine and emergency dental services. - Social services representatives/designee will assist residents with appointments, transportation arrangements and for the reimbursement of dental services under the state plan, if eligible. 1. Resident #105 was admitted to the facility in June 2024 with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, and dementia. Review of Resident #105's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 9 out of 15, indicating moderate cognitive impairment. During an interview on 1/6/26 at 7:45 A.M., Resident #105 was eating his/her breakfast in his/her room. Resident #105 said he/she was waiting for dentures for months, but he/she needs teeth removed first and he/she has been waiting for months. Resident #105 then said his/her mouth hurts all the time and it is hard to chew food and he/she needs to chew food slowly. During a follow-up interview on 1/6/26 at 2:20 P.M., Resident #105 said someone is supposed to take out his/her teeth, but no one has yet. Resident #105 showed the surveyor his/her bottom, middle teeth. The Surveyor observed seven teeth worn down to the gumline with multiple black markings on the teeth. The surrounding gums of the teeth appeared to be reddened and inflamed. Resident #105 then told the surveyor he/she wants to go out to a dentist and get them taken out because they hurt. Review of Resident #105's physician's orders indicated the following: - May go out for appointments – dated 8/7/23 Review of Resident #105's document titled Request for Service, for the facility's contracted dental company, indicated that the Resident's legal guardian requested for the Resident to be seen by dental services while in the facility, signed and dated 8/7/23. Review of Resident #105's oral/dental health problems care plan, dated 10/7/25, indicated the following interventions: - Coordinate arrangements for dental care, transportation as needed/as ordered - Monitor/document/report to physician PRN (as needed) s/sx (signs/symptoms) of oral/dental problems needing attention: pain (gums, toothache, palate), abscess, debris in mouth, teeth missing, loose, broken, eroded, decayed. Review of Resident #105's treatment notes from the facility's contracted Dentist dated 5/7/24, indicated the following: - Patient presents for periodic exam. Patient complains that bottom teeth hurt occasionally, comes and goes for the last two months. Doesn't specifically say which area. No swelling or exudate noted. Patient admits he/she doesn't brush his/her teeth often. Patient is now requesting dentures to be able to eat better. Recommend ext. (extraction) non-restorable teeth prior to fabrication of dentures: #23, 24, 25, 26, 31. Patient states he/she is afraid of needles and would like extractions done under sedation. Refer to Oral Surgery (OS) for extraction of teeth. Recommend follow up after referral to OS. Recommend FMX (full mouth x-rays) for insurance approval of partial denture - will ask for x-rays to be sent from OS. Discussed healing time prior to fabrication of dentures. Reviewed denture fabrication steps with patient. Discussed treatment plan and referral with his/her nurse. - Action Required by Nursing Home Staff: Refer to oral surgeon to extract #23, 24, 25, 26, 31. Please obtain x-rays from OS and email to [dentist's email address]. Review of Resident #105's treatment notes from the facility's contracted Dentist dated 4/17/25, indicated the following: - Reviewed Med (medical) Hx (history). Patient presents for annual exam. Remaining teeth are now all broken at gum level. Root tip #31 exfoliated. Patient aware this happened. Gingiva is generally severely inflamed. Patient complains it is uncomfortable. Stressed to patient that he/she still needs to brush his/her teeth even though they are all going to be extracted. Patient requests OS (oral surgery) to be sedated during extraction. Facility working on appt. (appointment). Discussed with Registered Nurse. Recommend annual exam. Recommend fabrication of complete set of dentures to improve chewing ability and quality of life. Reviewed denture fabrication steps with patient. Discussed healing time prior to fabrication of dentures. Recommend follow up after referral to OS. - Action Required by Nursing Home Staff: Recommend refer to OS for extraction of remaining teeth (7) Review of Resident #105's treatment notes from the facility's contracted Dentist dated 5/21/25, indicated the following: - Reviewed Med Hx.; Patient presents for follow up after referral to OS and limited exam. Patient was referred to OS to extract remaining teeth and has not gone. The gingiva around the remaining root tips are slightly less inflamed than last visit. Patient states he/she is willing to try extractions here. Discussed with the new unit manager. Patient would still like to make an appointment with an OS because he/she would prefer to be sedated. But if appointment is too far out, then he/she is willing to attempt extractions at facility. NV: ext. remaining teeth (if approved) - Action Required by Nursing Home Staff: Refer to MD/OS for extraction of all remaining teeth, obtain signature for Consent for Extractions form Review of Resident #105's treatment notes from the facility's contracted Dentist dated 9/5/25, indicated the following: Reviewed Med Hx.; Patient presents for denture step 1 for fabrication of complete set of dentures. Patient's nurse, had stated patient had remaining teeth extracted and was ready for dentures. Performed follow up exam. Upon presentation, patient stated that he/she did not have any teeth removed. Clinical exam confirms that no root tips on the mandible were removed. The tissue surrounding the root tips is severely inflamed. Patient complains of severe soreness in this area. Discussed extracting teeth in facility, as patient agreed previously. However, today he/she declines extracting teeth anywhere but under sedation at OS. Showed Nurse patient's remaining teeth and inflamed tissue. NV: follow up after OS Review of Resident #105's treatment notes from the facility's contracted Dentist dated 10/6/25, indicated the following: Reviewed Med Hx.; Patient presents for follow up exam for referral to OS for extraction of remainder of teeth. Teeth have not been extracted. Again, recommend extractions performed at facility. Patient agrees to do here but also wants to make appt. at OS - whichever is sooner. HCP invoked. Discussed with Unit Manager. Patient is asymptomatic at this time. No clinical sign of acute infection. Recommend extraction #22, 23, 24, 25, 26, 27, 28 due to root tips, pre-prosthetic. Refer to OS but also will submit PA (prior authorization) to perform at facility. Recommend follow up after referral to OS. NV: ext. remaining teeth or follow up - Action Required by Nursing Home Staff: Obtain Signature for Consent for Extractions Form Review of Resident #105's medical record indicated there was a Consent for Extraction – Removal of a Tooth or Teeth, which was signed by the Resident's legal guardian with a date of 8/28/25. Review of the Resident #105's Oral Exam assessment completed by the facility dated 10/7/25, indicated the following: - Teeth Appearance: Fractured/missing teeth, Generalized breakdown, soft plaque build-up - Oral Exam Comments: Seen by dentist 10-6-25. She is referring to outside oral surgeon for possible bottom teeth extractions. He/she denies having any pain. He/she is edentulous on top and had step 1 denture fitting. During an interview on 1/7/26 at 11:21 A.M., Unit Manager #1 said Medical Records is in charge of making dental appointments and if a Resident needs an appointment then she would reach out to Medical Records. During a telephone interview on 1/7/26 at 1:03 P.M., the Nurse Practitioner (NP) said she was unaware that Resident #105 needed multiple teeth extracted for an extended amount of time. The NP said she would expect the facility to let her know if he/she was experiencing any dental pain. The NP further said the facility should arrange transportation for any dental appointment needed and she would expect the facility to set up oral surgery consultations as recommended by the dentist. During a telephone interview on 1/7/26 at 1:19 P.M., the Medical Director (MD) said he would expect any recommendations made by the dentist to be followed and typically whatever a specialty doctor recommends he is okay with doing. During an interview on 1/7/26 at 1:33 P.M., Nurse #1 said Resident #105 typically does not refuse care and is alert and oriented towards him/herself. During an interview on 1/7/26 at 1:42 P.M., the Medical Records staff said right now she is in charge of making outside appointments. She further said the nurses will let her know if a resident needs an appointment and she will arrange it which includes going to a specialty dentist such as an oral surgeon. The Medical Records staff then said she was not aware of Resident #105 needing any dental appointments. During an interview on 1/7/26 at 1:59 P.M. with the Director of Nursing (DON) and Unit Manager #1, the DON said the facility will obtain consents from residents to be seen by the consulting dentist on admission to the facility. The DON said when the dentist sees a resident, they will email a visit summary to herself and the Unit Managers and she will print it and send it to the Unit Managers who are responsible for following up. The DON said we will usually implement any recommendations that the dentist makes. The DON then said if we need permission from the Resident's Guardian we will reach out and she would expect staff to document any attempt made to speak with a Guardian. The DON continued to say she has not heard or seen any nursing documentation about dental follow-ups for Resident #105. The surveyor then discussed each treatment recommendation made by the dentist for Resident #105 and the DON said none of it is familiar sounding. The DON said at the time there was a different Unit Manager who no longer works here who should have been responsible for setting up Resident #105's appointments. The DON then said no one has come to the facility to attempt to extract Resident #105's teeth and the facility reached out to an outside dentist, but they were unable to see the Resident due to financial reasons. The DON said Resident #105 has an appointment in two days because they became aware of his/her dental needs and she said it should have been done sooner especially if there was documentation since April 2024 and documentation of Resident #105 being in severe discomfort. Review of the Resident #105's medical record on 1/7/26 indicated that the Administrator uploaded a consent for dental extractions on 1/7/26. During an interview on 1/7/26 at 2:34 P.M., the Administrator said the DON made her aware that extractions were needed for Resident #105, so she reached out to his/her guardian and heard back within the day. The Administrator said she was not aware of a signed, existing consent for dental extractions from 8/28/25. During a telephone interview on 1/8/26 at 8:30 A.M., the Consulting Dental Company's Customer Care Representative said there was no record of the facility sending over a signed consent form for extractions in August 2025. The Customer Care Representative then said she attempted to obtain Prior Authorization from the facility's Medical Records Associate 16 times from 6/5/25 – 1/6/26 but never heard back, which is extremely unusual. The Customer Care Representative said the dental company requests Prior Authorization approval from the facility which would allow Resident #105 to receive his/her extractions. During a follow up interview on 1/8/26 at 9:13 A.M., the Medical Records staff said the facility has had a lot of Unit Managers over the past couple of months and it has been hard to keep track of things. She said she has not seen any Prior Authorization requests from the consulting dental company. During a follow up interview on 1/8/26 at 9:13 A.M., the DON said she was not aware that the consulting dental company requested Prior Authorization 16 times. 2. Resident #20 was admitted to the facility in July 2024 and has diagnoses that include but are not limited to mild cognitive impairment, hypertension, schizophrenia, and anemia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #20 as having obvious or likely cavity or broken natural teeth. Review of the most recent MDS assessment dated [DATE] indicated Resident #20 scored 12 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having moderately impaired cognition and requires supervision or touching assistance for oral care. During an observation and interview on 1/6/26 at approximately 10:47 A.M., and 1/7/26 at 2:22 P.M., Resident #20 was sitting on his/her bed, while he/she was talking, his/her mouth was observed to have missing, and broken teeth on the top and bottom. Review of Resident #20's medical record indicated the following: - A consent signed to have dental services by the dental services provider dated 7/24/24. -An IDT (interdisciplinary team) care plan meeting review document dated 12/24/25, problems needs identified: dental cracked teeth, inflamed gums. -An oral assessment document dated 6/25/25 indicated oral exam, teeth appearance fractured/missing teeth, generalized breakdown, teeth are loose, soft plaque build-up. Recommendations, comments; Followed by (Named) contracted dental services company. -A care plan date initiated 7/25/24, I have oral/dental health problems r/t (related to) missing natural teeth, cracked teeth inflamed gums, interventions included but not limited to *Coordinate arrangements for dental care, transportation as needed/as ordered, dated 7/30/24 Review of the document titled Contracted Dental Group, dated 10/22/24, indicated the reason for visit, initial exam. Treatment notes: Clinical exam reveals generalized severe periodontitis, discussed with unit manager and recommend extracting the severely mobile teeth #2 and #23 to prevent choking or aspiration of teeth. Recommended treatment annual exam, prophy (professional care such as cleaning designed to prevent oral health issues) q (every) 6 months, extractions tooth #2;23, prior approval completed. During an interview on 1/6/25 at 2:01 P.M., Social Worker #1 said Resident #20 has been seen by the contracted dental services. The surveyor requested all contracted dental service documentation for Resident #20 and was provided with the initial exam dated 10/22/24, revealing Resident #20 had no further treatment from the contracted dental services provider. During an interview on 1/7/26 at 3:34 P.M., Unit manager #2 said she did not realize Resident #20 was not seen again since the initial exam with recommendations. Unit Manager #2 said she just got an email yesterday from the dental provider with a list of residents who have not been seen due to insurance coverage. Unit Manager #2 said if a resident has needs, they will be seen and they will work with the business office to work out the ins and outs of coverage. Unit Manager #2 said the dental provider sends a list of residents who will be treated and that she did not realize Resident #20 was not seen again and should have been. During an interview on 1/8/26 at 9:21 A.M., Unit Manager #2 said they cleared up the insurance issues. Unit Manger #2 said when the dentist has recommendations, they usually are seen on follow up visits. Unit Manager #2 said she had no idea they (the dentist) did not see Resident #20 because of an insurance issue. Resident #20 had several recommendations made by the dentist over 14 months ago that were not addressed. During an interview on 1/8/26 at 11:21 A.M., the Director of Nursing said it appears that the dental provider put the Resident on a do not treat list due to insurance verification. The DON said if it was brought to her or the Administrator's attention they would have assisted with making arrangement to have Resident #20 seen for services needed. During an interview on 1/8/26 at 2:05 P.M., the Administrator said Resident #20 was on a do not treat list from the dental provider and there was a communication issue. The Administrator said the Resident does have standard insurance and the facility should have identified that the Resident was not seen for the recommended dental services and the issue with insurance could have been solved sooner.

Based on record review and interview, the facility failed to obtain the necessary psychotropic consent for one Resident (#44) out of a total sample of 27 residents. Findings include: Review of the facility policy titled Psychotropic Medication Use, revised February 2025, indicated the following: Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal The resident's/representative's right to accept or decline treatment. Resident #44 was admitted in June 2023 with diagnoses including dementia, anxiety, and depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating a severe cognitive impairment. Review of the physician's orders for Resident #44 indicated he/she was prescribed the following medications: Mirtazapine 7.5 milligrams (a medication used to treat depression), initiated 5/31/25. Lorazepam 0.5 milligrams (a medication used to treat anxiety), initiated 11/6/25.Duloxetine Hydrochloride 60 milligrams (a medication used to treat depression), initiated 6/8/23.Review of the medical record failed to indicate that any psychotropic consents were obtained. During an interview on 1/7/26 at 2:18 P.M., the Director of Nursing said that the facility could not locate the consents for psychotropics and that the facility sent new consents to the Resident's guardian for a signature.

Based on record review and interviews, the facility failed to ensure an advanced directive was current and not expired for one Resident (#20) out of a total sample of 27 residents. Specifically, for Resident #20 the facility failed to ensure the [NAME] Guardianship and Probate Court Treatment Plan (a guardian appointed by a judge in probate court who is responsible for making decisions for an individual after a judge has decided they are not competent to make their own informed choices, including treatment with antipsychotic medication) was reviewed prior to the court appointed [NAME] Treatment Plan expired.Findings include: Review of the facility's policy titled, Advance Directives, undated, indicated Advanced Directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation included but not limited to, 6. Prior to admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 18. The interdisciplinary team will review annually with the resident his or advance directive to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS Minimum Data Set). Resident #20 was admitted to the facility in [DATE] with diagnoses including but not limited to mild cognitive impairment, hypertension, Schizophrenia, and anemia. Review of the most recent MDS assessment, dated [DATE], indicated Resident #20 scored 12 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. Review of the MDS also indicated Resident #20 received antipsychotic medication on a routine basis.Review of Resident #20's medical record indicated the following:-A care plan, initiated [DATE] with a target date of [DATE] - I use antipsychotic medication.-A care plan initiated [DATE] with a target date of [DATE], for Advanced Directives - Resident has Court Appointed Guardian with [NAME] Order (expiration [DATE]). Review of Resident #20's medical record indicated a Decree and Order of Appointment of Gaudian for An Incapacitated Person dated as filed [DATE]. The powers and duties of the Guardian shall further include:After making a substituted judgment determination, the Court authorizes treatment of the Incapacitated Person: with antipsychotic medication in accordance with a treatment plan dated [DATE] which shall be reviewed on or before [DATE]. Review of the Treatment Plan indicated; This plan shall be reviewed one year from today's date on [DATE] and if not sooner extended, shall expire at 4 P.M. on that date, signed by a judicial designee.Further review of the Resident #20's medical record failed to have a current, not expired,Treatment Plan to administer antipsychotic medication. During an interview with Social Worker (SW) #1 and SW #2 on [DATE] at 1:36 P.M., SW#1 said Resident #20's [NAME] Treatment Plan expired in [DATE]. SW #1 said it came to her attention in [DATE] that Resident #20 had a [NAME] Treatment Plan and that it was expired. SW #1 said Resident #20 is administered antipsychotic medication. SW #1 said she called the Guardian to see if the Guardian filed for review of the [NAME] Treatment Plan. SW #1 said the Guardian did not petition for the Treatment Plan to be reviewed by the court and said she does not do that. SW #1 said then she contacted the facility's legal counsel to start the process to petition the court for review of Resident #20's [NAME] Treatment Plan.During an interview on [DATE] at 4:10 P.M., the Administrator said she became aware that Resident #20 had an expired [NAME] Treatment Plan sometime in [DATE]. The Administrator said the goal would be for the facility staff to start the process for the review of the [NAME] Treatment Plan prior to the expiration date.The failure to petition the court prior to the expired date of [DATE] resulted in Resident #20 having a court appointed expired [NAME] Treatment plan for nearly over 7 months.

Based on observations, record review and interview, the facility failed to ensure that activities of daily living were provided for one Resident (#79) out of a total sample of 27 Residents. Specifically, for Resident #79, the facility failed to ensure that the Resident received 1:1 (one to one) supervision while eating breakfast and that the plan of care was followed while Resident #79 was eating breakfast.Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated and revised April 2025, indicated the following:- Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.- Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: dining (eating, including meals and snacks).Resident #79 was admitted to the facility in April 2015 with diagnoses including cervical disc disorder, dysphagia, and psychotic disorders. Review of Resident #79's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 11 out of 15, indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident requires supervision or touching assistance with eating. Review of Resident #79's ADL Self Care Performance Deficit care plan indicated the following interventions, dated 12/30/24:- 1:1 (one to one) supervision with meals. Use wrist weights for all meals. Pt. (patient) will also sit at sturdy table for all meals not bedside table to prevent table from rolling away and pt. spilling his/her meal.On 1/6/26 at 8:32 A.M., Resident #79 was sitting in a wheelchair in his/her room eating his/her breakfast from a tray placed on his/her bedside table. There were multiple scraps of dropped food all under the Resident's table and some eggs on the Resident's chest. Next to the Resident's tray was a pink wrist weight.On 1/7/26 at 7:38 A.M., two staff members were setting up Resident #79's breakfast tray on a bedside table while he/she was sitting in a wheelchair. The staff members then proceeded to leave the room. From 7:38 A.M. through 7:52 A.M., Resident #79 was eating his/her breakfast in his/her room with no supervision or assistance. The Resident was not wearing his/her wrist weight and there were multiple scraps of food on the ground beneath the Resident's tray.On 1/8/26 at 7:28 A.M., Certified Nursing Assistant (CNA) #1 was setting up Resident #79's breakfast tray on a bedside table while he/she was sitting in a wheelchair. At 7:30 A.M., CNA #1 left the room. At 7:41 A.M., Resident #79 waved down the surveyor and asked the surveyor for help peeling a banana. The surveyor informed CNA #1 who proceeded to help the Resident. CNA #1 then told the surveyor that Resident #79 does fine with eating as long as he/she was wearing his/her wrist weight as he/she has hand tremors, and it helps keep his/her hand steady. The surveyor asked CNA #1 if Resident #79 was wearing the wrist weight, CNA #1 proceeded to check and he/she was not and the wrist weight was located in the Resident's bathroom. CNA #1 then put the wrist weight on Resident #79. CNA #1 said the Resident can eat on his/her own as long as he/she is wearing the wrist weight. During another observation at 7:49 A.M., Resident #79 was still eating his/her breakfast with no supervision or assistance, there were multiple scraps of food beneath the Resident's tray on the ground.Review of Resident #79's discontinued physician's order dated 10/3/24 indicated the following:- 1:1 supervision with meals. Use wrist weights for all meals. Pt. (patient) will also sit at sturdy table for all meals not bedside table to prevent table from rolling away and pt. spilling his/her meal.Review of Resident #79's Kardex (a care card indicating the level of care a Resident needs) indicated the following under the Eating/Nutrition section:- 1:1 supervision with meals. Use wrist weights for all meals. Pt. (patient) will also sit at sturdy table for all meals not bedside table to prevent table from rolling away and pt. spilling his/her meal.Review of Resident #79's Speech Therapy Discharge summary dated from 8/29/24 - 10/31/24 indicated the following:- Skilled Interventions: Pt. was provided with skilled dysphagia services targeting safety with PO (by mouth) intake of mechanical soft solid using safe swallow strategies. It has been determined that the pt. does require close supervision w/ intake due to inability to independently recall and carryover safety strategies. He/she has been deemed safe and an order is written that pt. may have grilled cheese sandwiches in dining room with close supervision.Review of the CNA documentation for December 2025 for eating indicated that 27 of 28 documented occurrences of eating breakfast that Resident #79 received only set-up assistance with the meal and not supervision.Review of the CNA documentation for January 2026 for eating indicated that 6 of 7 documented occurrences of eating breakfast that Resident #79 received only set-up assistance with the meal and not supervision.During an interview on 1/8/26 at 9:38 A.M., Nurse #1 said Resident #79 only needs set-up assistance with meals and he/she uses adaptive equipment because he/she has hand tremors. Nurse #1 said 1:1 supervision means that someone should be always watching a resident while they are eating. Nurse #1 and the surveyor reviewed Resident #79's care plans and she was not aware that that the Resident required 1:1 supervision and should be wearing wrist weights. Nurse #1 said she would expect the care plan to be followed.During an interview on 1/8/26 at 10:02 A.M., Unit Manager #1 said Resident #79 can self-feed and requires weighted wrist bands for his/her hand tremors. Unit Manager #1 said the CNAs are responsible for putting on the Resident's wrist band. The surveyor shared the breakfast observations and care plan with Unit Manager #1 and she was not aware the Resident requires 1:1 supervision and she said he/she should be wearing wrist weights with meals.During an interview on 1/8/26 at 11:05 A.M., the Director of Nursing (DON) said 1:1 supervision means someone should be with a resident while they are eating. The DON said Resident #79's care plans should be followed and his/her wrist weights should have been put on prior to eating and supervision should have been provided while he/she was eating his/her breakfast.

Based on observation record review and interview, the facility failed to ensure staff maintained an accurate medical record for one Resident (#16) out of a total sample of 27 residents. Specifically, the facility failed to accurately document and transcribe Resident #16's supplemental oxygen flow rate.Findings include: Review of the facility policy titled Oxygen Administration dated and revised October 2010, indicated the following:- Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration.Resident #16 was admitted to the facility in May 2023 with diagnoses including asthma, morbid obesity and acute and chronic respiratory failure, chronic pulmonary edema, chronic diastolic heart failure.Review of Resident #16's most recent Minimum Data Set assessment dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident receives oxygen therapy. The surveyor made the following observations:- On 1/6/26 at 8:13 A.M., Resident #16 was awake lying in bed receiving supplemental oxygen via nasal canula. The oxygen concentrator was set to 4.5 liters of supplemental oxygen.- On 1/7/26 at 7:34 A.M., Resident #16 was awake lying in bed receiving supplemental oxygen via nasal canula. The oxygen concentrator was set to 4.5 liters of supplemental oxygen.- On 1/7/26 at 12:30 P.M., Resident #16 was sleeping in bed receiving supplemental oxygen via nasal canula. The oxygen concentrator was set between 4 and 4.5 liters of supplemental oxygen.- On 1/8/26 at 7:26 A.M. Resident #16 was awake lying in bed receiving supplemental oxygen via nasal canula. The oxygen concentrator was set between 4 and 4.5 liters of supplemental oxygen. Resident #16 said he/she was having a hard time breathing this morning.Review of Resident #16's care plans indicated the following:- I am O2 (oxygen) dependent, SOB (shortness of breath) while lying flat r/t (related to) chronic respiratory failure, Asthma. On 4lpm (liters per minute) cont (continuous)Review of Resident #16's discontinued orders indicated the following:-Oxygen at 4L/minute via nasal cannula - discontinued 11/24/25From 11/24/25 through 11/28/25, Resident #16 was on a medical leave of absence in the hospital.Review of Resident #16's physician's order dated 11/28/25 indicated the following: Oxygen at 2L/Minute via Nasal Canula.Review of Resident #16's Medication Administration Record for January 2026 indicated that staff documented that Resident #16 received supplemental oxygen at 2 liters per minute despite his/her oxygen concentrator being set between 4-4.5 liters per minute.Review of a nursing progress note dated 11/28/25 indicated the following:- Resident returned to facility to the facility at 1:45 P.M. via ambulance on a stretcher. O2 sats (saturation) 93% on O2 (oxygen) at 2L (2 liter) nasal canula. Orders verified and call to on call regarding resident return.Review of a nursing progress note dated 12/10/25 indicated the following:- This writer went into resident's room to check oxygen at 1700. Resident was SATing at 72%. NC (nasal canula) was on and at 2L. TW (this writer) increased O2 to 4L and resident came up to 90%. On call stated to increase O2 to 4L for overnight.During an interview on 1/8/26 at 9:50 A.M., Nurse #1 said Resident #16 received supplemental oxygen at 4 liters. Nurse #1 and the surveyor reviewed Resident #16's physician's orders and she said the order for 2 liters is incorrect as Resident #16 should have his/her supplemental oxygen at 4 liters.During an interview on 1/8/26 at 10:36 A.M., the Respiratory Therapist said Resident #16 has been receiving supplemental oxygen at 4 liters for a while. The Respiratory Therapist said she believes that written order is a typo because if Resident #16 was receiving supplemental oxygen at 2 liters he/she would constantly be desatting (oxygen levels dropping).During an interview on 1/8/26 at 11:05 A.M., the Director of Nursing (DON) said Resident #16's oxygen order for 2 liters was put in incorrectly and it should have been put it for 4 liters. The DON said the Resident receives his/her oxygen at 4 liters and she is not sure why staff members were signing off that Resident #16 was receiving his/her oxygen at 2 liters and did not question the order being incorrect.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), whose comprehensive plan of care and Care Kardex (a summary of the resident's care needs, utilized by Certified Nurse Aides) indicated he/she required staff assistance with ambulation, the Facility failed to ensure staff consistently implemented and followed interventions related to ambulation, per his/her plan of care. On 02/11/25, Certified Nurse Aide (CNA) #2 saw Resident #3 ambulating by him/herself, and although she thought he/she required staff supervision with ambulation, CNA #2 did not provide him/her with supervision or assistance (per the plan of care) with ambulation. Resident #3 ambulated unassisted to his/her room, fell , was found a short time afterward on the floor, and was bleeding from a cut on his/her left eyebrow. Resident #3 was transferred to the Hospital Emergency Department (ED) and required three sutures to close the wound. Findings include: The Facility Policy, titled Comprehensive Person-Centered Care Plans, dated as revised 03/2022, indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs would be developed and implemented for each resident. The Facility Policy, titled Managing Falls and Fall Risk, dated as revised 03/2018, indicated that based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling, and the staff would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk. Resident #3 was admitted to the Facility in February 2023, diagnoses included chronic kidney disease, anemia, depression, anxiety, and insomnia. Review of Resident #3's Annual Minimum Data Set (MDS) Assessment, dated 01/16/25, indicated he/she required partial to moderate assistance from staff with ambulation. Review of Resident #3's Activities of Daily Living Care Plan, reviewed and renewed with his/her January 2025 MDS, indicated interventions included Resident #3 required assistance of one staff member for ambulation. Review of Resident #3's CNA Kardex Report, dated 02/11/25, indicated he/she required one staff member assistance with ambulation. Review of Resident #3's Nurse Progress Note, dated 02/11/25, indicated that at 02:45 P.M., Resident #3 was found by a physician on the floor in his/her room, he/she was complaining of neck pain, and was bleeding from a cut on the left side of his/her forehead. The Progress Note indicated Resident #3 was transferred to the Hospital ED for evaluation. Review of Resident #3's Hospital ED Discharge Summary, dated 02/11/25, indicated Resident #3 was diagnosed with a left eyebrow laceration as a result of a fall at the Facility, and required three sutures to close the wound. During an interview on 03/10/25 at 02:37 P.M., Certified Nurse Aide (CNA) #2 said she was familiar with Resident #3 and had been his/her assigned CNA many times. CNA #2 said the CNAs accessed the residents' Kardex's via the computer, and said she had been trained to do so prior to caring for her assigned residents. CNA #2 said she had never reviewed Resident #3's Kardex. CNA #2 said she thought Resident #3's ambulation status was that he/she was independent with just staff supervision. CNA #2 said she had seen Resident #3 ambulating without assistance in the past, so she had not checked his/her ambulation status on the Kardex. CNA #2 said that on 02/11/25 at 02:40 P.M., she was monitoring the residents in the unit dining room while the Activities Aide was off the unit, when Resident #3 got up and left the dining room. CNA #2 said she asked Resident #3 to wait because she could not leave the other residents unsupervised, but Resident #3 said he/she wanted to go to his/her room, and left. CNA #2 said she called out to a nurse (exact name unknown) who was down the hall working at a medication cart that Resident #3 was ambulating, but the nurse did not respond. CNA #2 said five minutes later she was relieved from monitoring the Dining Room by the Activities Aide, so she went to check on Resident #3, but he/she had already fallen and nursing staff were attending to him/her. During an interview on 03/10/25 at 01:20 P.M., The Unit Manager said that on 02/11/25 at the time Resident #3 fell , she was in her office. During an interview on 03/11/25 at 08:15 A.M., Nurse #1 said she was normally Resident #3's nurse and that on 02/11/25 she was his/her nurse. Nurse #1 said she was not sure what Resident #3's Care Plan indicated his/her ambulation status was, and said he/she usually ambulated by his/herself. Nurse #1 said at the time Resident #3 fell , she was off the unit on her break. During an interview on 03/10/25 at 02:12 P.M., Nurse #5 said that on 02/11/25 between 02:30 P.M., and 02:40 P.M., she was preparing and administering medications to residents on the unit, said she did not see Resident #3 at that time and did not hear CNA #2 say anything about Resident #3 ambulating by him/herself. Nurse #5 said she was not familiar with Resident #3's ambulation status at all, and said she only knew him/her in passing as she had never been his/her assigned nurse. During an interview on 03/10/25 at 03:41 P.M., the Director of Nurses (DON) said Resident #3's Plan of Care and Kardex, indicated he/she required assistance from one staff member for ambulation, and it was expected that staff would follow the Plan of Care, but that on 2/11/25, staff had not done so.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), who was assessed by nursing as being at risk for falls, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to prevent an incident resulting in an injury. On 02/11/25, Certified Nurse Aide #2, who was familiar with and had provided care to Resident #3, observed him/her ambulating alone, but did not provide or get another staff member to assist or supervise him/her. Resident #3 was found a short time later on the floor in his/her room, was bleeding from a cut on his/her left eyebrow, was transferred to the Hospital Emergency Department (ED) and required three sutures to close the head wound. Findings include: The Facility Policy, titled Managing Falls and Fall Risk, dated as revised 03/2018, indicated that based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling, and the staff would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk. Resident #3 was admitted to the Facility in February 2023, diagnoses included chronic kidney disease, anemia, depression, anxiety, and insomnia. Review of Resident #3's Fall Risk Evaluation, dated 10/11/24, indicated he/she was at risk for falls due to deconditioning and weakness. Review of Resident #3's Annual Minimum Data Set Assessment, dated 01/16/25, indicated he/she required partial to moderate assistance from staff with ambulation. Review of Resident #3's Activities of Daily Living Care Plan, reviewed and renewed with the January 2025 MDS, indicated interventions included Resident #3 required assistance of one staff member for ambulation. Review of Resident #3's Kardex Report (a summary of the resident's care needs, utilized by Certified Nurse Aides), dated 02/11/25, indicated he/she required one staff member assistance with ambulation. Review of Resident #3's Nurse Progress Note, dated 02/11/25, indicated that at 02:45 P.M., Resident #3 was found by a physician on the floor in his/her room, he/she was complaining of neck pain, and was bleeding from a cut on the left side of his/her forehead. The Progress Note indicated Resident #3 was transferred to the Hospital ED for evaluation. Review of Resident #3's Hospital ED Discharge Summary, dated 02/11/25, indicated Resident #3 was diagnosed with a left eyebrow laceration as a result of a fall at the Facility, and required three sutures to close the wound. During an interview on 03/10/25 at 02:37 P.M., Certified Nurse Aide (CNA) #2 said she was familiar with Resident #3 and had been his/her assigned CNA many times. CNA #2 said she thought Resident #3's ambulation status was for staff to supervise him/her. CNA #2 said she had seen him/her ambulating without assistance in the past. CNA #2 said that on 02/11/25 at 02:40 P.M., she was monitoring the residents in the unit dining room while the Activities Aide was off the unit, when Resident #3 got up and left the dining room. CNA #2 said she asked Resident #3 to wait because she could not leave the other residents unsupervised, but Resident #3 said he/she wanted to go to his/her room, and left. CNA #2 said she called out to a nurse (exact name unknown) who was down the hall working at a medication cart that Resident #3 was ambulating, but the nurse did not respond. CNA #2 said five minutes later she was relieved from monitoring the Dining Room by the Activities Aide, so she went to check on Resident #3, but he/she had already fallen and nursing staff were attending to him/her. During an interview on 03/10/25 at 01:20 P.M., The Unit Manager said that on 02/11/25 at the time Resident #3 fell , she was in her office. During an interview on 03/11/25 at 08:15 A.M., Nurse #1 said she was normally Resident #3's nurse and that on 02/11/25 she was his/her nurse. Nurse #1 said at the time Resident #3 fell , she was off the unit on her break. During an interview on 03/10/25 at 02:12 P.M., Nurse #5 said that on 02/11/25 between 02:30 P.M., and 02:40 P.M., she was preparing and administering medications to residents on the unit, and said she did not see Resident #3 at that time and did not hear CNA #2 say anything about Resident #3 ambulating by him/herself. During an interview on 03/10/25 at 03:41 P.M., the Director of Nurses (DON) said Resident #3 required assistance from one staff member for ambulation, and it was expected that staff would provide the necessary level of care and assistance to each resident.

Based on record review and interview, the facility failed to keep one Resident (#1) free from abuse out of a total sample of 28 residents. Specifically, an allegation of abuse was made by Resident #95 and filed as a grievance, subsequently allowing the accused certified nursing aide to continue working, which led to the physical abuse of Resident #1. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation and Missapropriation Prevention Program, undated, indicated the following: - Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misapporopriation of resident property. - Investigate and report any allegations within timeframes required by federal requirements. - Establish and implement a QAPI review and analysis of reports, allegations or findings of abuse, neglect mistreatment or misappropriation of property. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised September 2022, indicates the following: -All reports of resident abuse (including injuries of uknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -All allegations are thoroughly investigated. The administrator initiates investigations. -The administrator is responsible for keeping the resident and his/her representative informed of the progress of the investigation. -Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. -The individual conducting the investigation as a minimum: * interviews the person(s) reporting the incident * interviews any witnesses to the incident * interviews the resident * interviews the resident's attending physician as needed to determine the resident's condition * interviews the reisdent's roommate * interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident * review all events leading up to the alleged incident * documents the investigation completely and thoroughly -The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. 1. Resident #95 was admitted in November 2023 with diagnoses including hypertension and osteoporosis. Review of the Minimum Data Set (MDS) assessment, dated 10/31/24, indicated Resident #95 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated Resident #95 requires partial to moderate assistance with all activities of daily living. During review of a grievance filed on 11/27/24, written by the Administrator, it indicates Resident #95 reported to the Unit Manager that a C.N.A. (Certified Nursing Assistant #5) did not follow his/her preferences for transferring. The grievance also indicated Resident had reported that a CNA (CNA #5) pulled his/her arm too hard during a transfer. Resident said he/she felt safe and had no concerns and wants the Unit Manager to train her (CNA #5) on his/her (the Resident) preferences for transfer. During an interview on 1/15/25 at 11:48 A.M., Resident #95 told the surveyor that he/she clearly remembers the incident and told a staff member that CNA #5 was rough with him/her. Resident #95 said that CNA #5 was rough when transferring him/her to the toilet and Resident #95 said he/she requires an extra large brief, but CNA #5 only brought in a small one. Resident #95 said he/she told CNA #5 that he/she needs an extra large brief and CNA #5 said she was going to leave and started counting down 5, 4, 3, 2, 1 . to get Resident #95 to put on the small brief. Resident #95 said he/she forced the small brief on because he/she thought CNA #5 would leave him/her in the bathroom if he/she didn't put the brief on. Resident #95 said he/she felt like CNA #5 was purposeful in her actions. Resident #95 said he/she had never seen CNA #5 before and has not seen CNA #5 since the incident. Resident #95 said he/she does not remember if anyone came to check on him/her to see if he/she felt safe or follow up with him/her. During an interview on 1/15/25 at 12:28 P.M., the Administrator said that Resident #95 reported to the Unit Manager that CNA #5 was kind of rushed and the Resident was upset with the transfer because the CNA was not taking her time. The Administrator said that from what she remembers, the CNA was very fast and quick and she does not remember the Resident mentioning anything about the briefs. The Administrator said that she asks residents verbatim if they feel like they have been abused. The Administrator said that from her recollection, she believes it was a customer service issue and that is why she filed it as a grievance. The Administrator said the Resident initially reported to her that it was rough handling, but she honed down the interview and the Resident wanted the CNA to go slower with his/her care. During an interview on 1/15/25 at 12:57 P.M., the Director of Nursing said she asked the Resident if he/she felt it was malicious and the Resident said no. Review of the medical record failed to indicate any information regarding the incident. Shortly after the interview, the facility Administrator provided two written statements and a skin check, dated 11/27/24. The written statements were from the Director of Nursing and the Unit Manager. The facility could not provide a written statement for the CNA involved. There was no action taken to prevent CNA #5 from working on the unit or at the facility. 2. Resident #1 was admitted in September 2020 with diagnoses including depression and arthritis. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #1 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated Resident #1 requires substantial/maximal assistance with upper body dressing, is dependent on staff for lower body dressing and toileting. During an interview on 1/14/25 at 7:46 A.M., Resident #1 told the surveyor that on 12/9/24, a female CNA hurt his/her arm during an interaction. Resident #1 said that his/her arm still hurts from the incident. Review of a facility reported incident, dated 12/10/24, indicated Resident #1 reported to facility staff that CNA #5 was rough with him/her during care. Resident #1 told staff that, on 12/9/24, CNA #5 forcefully pulled the laptop case handle from my arm, causing him/her left upper arm pain, 8 out of 10 pain and that CNA #5 forcefully pulled a brief off of Resident #1. Resident #1 reported that he/she asked for a diet cola and CNA #5 brought the soda, but would not pour it for Resident #1 and told Resident #1 to open the bottle him/herself or he/she won't get any. Resident #1 also told staff that CNA #5 asked Resident #1 if he/she was full of urine or feces because she didn't have time to change Resident #1. Review of the Resident/Witness Statement, dated 12/10/24, indicated Resident #1 told the Social Worker that Resident #1 was not moving fast enough so CNA #5 grabbed the bag and pulled it off my arm fast and it hurt. The Social Worker documented Resident #1 reports his/her arm is still sore. There are no marks on the arm, but Resident #1 winced when it was lightly touched . He/she states that he/she feels safe with the other staff, but did not feel safe with CNA #5. Review of the medical record indicated that an x-ray was obtained on 12/10/24 in the facility of Resident #1's arm and showed a fracture of the left ulna (the long bone of the forearm) with indeterminate age (time of fracture could not be determined). Review of the Employee Performance Improvement Notification, dated 12/16/24, indicated CNA #5 was suspended from the facility, 6 days after the alleged incident occurred. Review of the Employee Performance Improvement Notification, dated 12/27/24, indicated CNA #5 was terminated due to performance. During an interview on 1/15/24 at 8:37 A.M., the Director of Nursing said Resident #1 reported the event the day after it occurred to the Unit Manager. The Director of Nursing said that Resident #1 felt like CNA #5 pulled his/her bag abruptly off when CNA #5 was changing him/her and felt the CNA was rude. The Director of Nursing said CNA #5 was suspended and then let go. See F609, F610, and F867.

Based on record review and interview, the facility failed to 1a. investigate an allegation of potential abuse for one Resident (#95), which 1b. failed to keep Resident (#1) free from abuse, out of a total sample of 28 residents. Specifically, Resident #95 reported to staff having been rough handled by a certified nursing aide. The report was not thoroughly investigated, which allowed the accused certified nursing aide to continue working, and eventually abuse Resident #1. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised September 2022, indicates the following: -All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -All allegations are thoroughly investigated. The administrator initiates investigations. -The administrator is responsible for keeping the resident and his/her representative informed of the progress of the investigation. -Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. -The individual conducting the investigation as a minimum: * interviews the person(s) reporting the incident * interviews any witnesses to the incident * interviews the resident * interviews the resident's attending physician as needed to determine the resident's condition * interviews the resident's roommate * documents the investigation completely and thoroughly -The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. 1a. Resident #95 was admitted in November 2023 with diagnoses including hypertension and osteoporosis. Review of the Minimum Data Set (MDS) assessment, dated 10/31/24, indicated Resident #95 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the MDS indicated Resident #95 requires partial to moderate assistance with all activities of daily living. Review of a grievance filed on 11/27/24, written by the Administrator, indicates Resident #95 reported to the Unit Manager that a C.N.A. (certified nursing aide #5) did not follow his/her preferences for transferring. The grievance also indicated Resident had reported that a CNA pulled his/her arm too hard during a transfer. Resident said he/she felt safe and had no concerns and wants the Unit Manager to train her (staff member) on his/her (the Resident) preferences for transfer. Review of the medical record failed to indicate any information regarding the incident. During an interview on 1/15/25 at 11:48 A.M., Resident #95 said that he/she clearly remembers the incident and told a staff member that a CNA (CNA #5) was rough with him/her. Resident #95 said that CNA #5 was rough when transferring him/her to the toilet and Resident #95 said he/she requires and extra large brief, but CNA #5 only brought in a small one. Resident #95 said he/she told the CNA that he/she needs an extra large brief and CNA #5 said she was going to leave and started counting down 5, 4, 3, 2, 1 . to get Resident #95 to put on the small brief. Resident #95 said he/she forced the small brief on because he/she thought CNA #5 would leave him/her in the bathroom if he/she didn't put the brief on. Resident #95 said she felt like CNA #5 was purposeful in her actions. Resident #95 said he/she had never seen CNA #5 before and has not seen CNA #5 since the incident. Resident #95 said he/she does not remember if anyone came to check on him/her to see if he/she felt safe or follow up with him/her. During an interview on 1/15/25 at 12:28 P.M., the Administrator said that Resident #95 reported to the Unit Manager that a CNA was kind of rushed and the Resident was upset with the transfer and that the CNA was not taking her time. The Administrator said that from what she remembers, the CNA was very fast and quick and she does not remember the Resident mentioning anything about the briefs. The Administrator said that she asks residents verbatim if they feel like they have been abused. The Administrator said that from her recollection, she believes it was a customer service issue and that is why she filed it as a grievance. The Administrator said the Resident initially reported to her that it was rough handling, but she honed down the interview and the Resident wanted the CNA to go slower with his/her care. During an interview on 1/15/25 at 12:57 P.M., the Director of Nursing said she asked the Resident if he/she felt it was malicious and the Resident said no. Shortly after the interview, the facility Administrator provided two written statements and a skin check, dated 11/27/24. The written statements were from the Director of Nursing and the Unit Manager. The facility could not provide a written statement from the CNA involved nor could she provide any written statements from other staff working on the unit that day. 1b. Resident #1 was admitted in September 2020 with diagnoses including depression and arthritis. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #1 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated Resident #1 requires substantial/maximal assistance with upper body dressing, is dependent on staff for lower body dressing and toileting. On 12/10/24, an abuse incident report was filed through the healthcare facility reporting system detailing an incident that occurred with CNA #5 and Resident #1, who alleged that CNA #5 pulled a bag off of his/her shoulder roughly and hurt Resident #1's arm. Review of a facility reported incident, dated 12/10/24, indicated Resident #1 reported to facility staff that CNA #5 was rough with him/her during care. Resident #1 told staff that, on 12/9/24, CNA #5 forcefully pulled the laptop case handle from my arm, causing him/her left upper arm pain, 8 out of 10 pain and that CNA #5 forcefully pulled a brief off of Resident #1. Resident #1 reported that he/she asked for a diet cola and CNA #5 brought the soda, but would not pour it for Resident #1 and told Resident #1 to open the bottle him/herself or he/she won't get any. Resident #1 also told staff that CNA #5 asked Resident #1 if he/she was full of urine or feces because she didn't have time to change Resident #1. Review of the Resident/Witness Statement, dated 12/10/24, indicated Resident #1 told the Social Worker that Resident #1 was not moving fast enough so CNA #5 grabbed the bag and pulled it off my arm fast and it hurt. The Social Worker documented Resident #1 reports his/her arm is still sore. There are no marks on the arm, but Resident #1 winced when it was lightly touched . He/she states that he/she feels safe with the other staff, but did not feel safe with CNA #5. Review of the medical record indicated that an x-ray was obtained on 12/10/24 in the facility of Resident #1's arm and showed a fracture of the left ulner (the long bone of the forearm) with indeterminate age (time of fracture could not be determined). Review of the Employee Performance Improvement Notification, dated 12/16/24, 6 days after the alleged incident, indicated CNA #5 was suspended from the facility pending investigation of the incident that occurred with Resident #1. Review of the Employee Performance Improvement Notification, dated 12/27/24, indicated CNA #5 was terminated.

Based on observations, record review and interviews, the facility failed to meet professional standards of practice for four Residents (#111, #106, #71, and #112) out of a total of sample of 28 residents. Specifically; 1. For Resident #111, the facility failed to ensure nursing implemented compression stockings as ordered by the physician. 2. For Resident #106 the facility failed to ensure nursing clarified a physician's order for g-tube flushes (two different flush orders) and failed to ensure Resident #106's feeding tube pump was set to the correct flush settings. 3. For Resident #71 the facility failed to ensure Resident #71's diet was least restrictive. 4. For Resident #112 the facility failed to obtain weights as ordered by the physician. Findings include: 1.) Review of the facility policy titled Apply Anti- Emboli Stockings (TED Hose), dated as revised October 2010, indicated the purpose of this procedure is to improve venous return to the heart, to improve arterial circulation to the feet, to minimize edema to the legs and feet, and to prevent complications associated with deep vein thrombosis and pulmonary embolism. - Preparation 1. Verify that there is a physician's order for anti-emboli stockings. If there is no order for anti-emboli stockings, contact the Attending Physician to obtain orders. (Note: Document the receipt of telephone orders in the resident's medical record.) General Guidelines 1. If possible, anti-emboli stockings should be applied in the morning, prior to the resident getting out of bed. Resident #111 was admitted to the facility in December 2024 with diagnoses including pneumonia, chronic diastolic heart failure, atrial fibrillation, and generalized edema. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/23/24, indicated that Resident #111 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 11 out of a possible 15. This MDS further indicated Resident #111 received a diuretic (a medication that increases urine production and help lower blood pressure and fluid retention), did not reject care, and was dependent on staff with putting on/taking off footwear which included the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility. Review of Resident #111's physician's order, dated 12/27/24, indicated: -Compression Stockings applied to bilateral lower extremity (BLE) in the morning for lower extremity (LE) edema. Apply compression stockings in the morning (scheduled daily at 8:00 A.M.) and at bedtime for LE edema Remove Compression stockings (scheduled daily at 9:00 P.M.). On 1/14/24 at 7:47 A.M., 8:07 A.M., 12:20 P.M., 3:42 P.M., 4:24 P.M., and on 1/15/25 at 7:42 A.M.,11:09 A.M., and 1:25 P.M., the surveyor observed Resident #111 dressed and out of bed and sitting. Resident #111's legs were swollen, and he/she was not wearing compression stockings. Review of the January 2025 Treatement Administration Record (TAR) on 1/15/24 at 3:15 P.M., indicated nursing had documented that they had applied Resident #111's compression stockings. The surveyor and Unit Manager #3 went into Resident #111's room. Resident #111 was not wearing his/her compression stockings. The compression stocking were in his/her dresser drawer. The TAR further indicated nursing applied Resident #111's compression stockings on 1/14/25 and 1/15/25. However, based on the surveyor's observations on 1/14/25 and 1/15/25, the compression stockings were not applied. During an interview on 1/15/25 at 3:22 P.M., Nurse #9 said she did not apply Resident #111's compression stockings on 1/15/25, but she signed off the order that they were applied. During an interview on 1/15/25 at 3:18 P.M., Unit Manager #3 said that nursing should apply compression stockings as ordered by the physician. During an interview on 1/15/25 at 3:38 P.M., the Director of Nursing said nursing should apply Resident #111's compression stockings as ordered by the physician. 2.) Review of the facility policy titled Enteral Nutrition, dated November 2018, indicated that adequate nutritional support through enteral nutrition is provided to residents as ordered. 3. The dietitian, with input from the provider and nurse: d. calculates fluids to be provided (beyond free fluids in formula). Resident #106 was admitted to the facility in November 2024 with diagnoses including metabolic encephalopathy, anxiety and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/29/24, indicated that Resident #106 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 11 out of a possible 15. The MDS further indicated Resident #106 required assistance with activities of daily living and required a feeding tube for nutrition. On 1/14/25 at 7:32 A.M., the surveyor observed Resident #106 receiving tube feeding. The tube feeding machine was set for water flushes at 100 milliliters every 8 hours. The water flush bag was dated 1/13/25 and had approximately 800 mL in the bag. On 1/15/25 at 7:27 A.M., the survey observed Resident #106 receiving tube feeding. The tube feeding machine was set for water flushes at 100 milliliters every 8 hours. The water flush bag was dated 1/13/25 and had approximately 600 mL in the bag. Review of Resident #106's plan of care related to enteral nutrition support, dated 1/7/25, indicated: - Registered Dietitian to evaluate nutritional status and make recommendations as applicable PRN (as needed). Review of Resident #106's Nutritional Risk Assessment - V 8, dated 1/3/25, indicated: -Recommend increasing free water flushes to 150 milliliters every six hours to meet daily fluid goal. Review of Resident #106's physician's order, dated 1/7/25, indicated: -Free water flushes of 150 ml every 6 hours, every 6 hours for patency and hydration. Scheduled every 6 hours at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. Review of Resident #106's physician's order, dated 1/9/25, indicated: -Five times a day free water flush: 150 ml every 4 hours (total volume 750 ml). The order was scheduled five times daily at 4:00 A.M., 7:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Further review of this physician's order revealed the order was unclear to the reader (every 4 hours would indicate that nursing should administer the flushes six times daily), the order was not scheduled every four hours and the times that flushes were scheduled were not consistently spaced four hours apart. During an interview on 1/15/25 at 7:56 A.M., Nurse #5 said that Resident #106's flush orders are based on the physician's order. Nurse #5 said that the flushes on the pump are set to 100 ml every 8 hours. Nurse #5 said he verifies the physician's order and provides flushes according to the orders. During an interview on 1/15/25 at 8:22 A.M., the Registered Dietitian (RD) said she most recently estimated Resident #106's fluid needs and she reviewed Resident #106's labs on 1/9/25. The RD said that she calculated Resident #106's fluids need to be 150 ml every four hours during the 20-hour tube feeding run period. The RD said that providing too much water to Resident #106 could cause him/her hyponatremia. On 1/15/25 at 8:30 A.M., the surveyor and the RD observed Resident #106's flush bag dated 1/13/25 and the pump was set to 100 ml water flushes every 8 hours. During an interview on 1/15/25 at 8:50 A.M., Unit Manager #3 reviewed the physician's orders for Resident #106's water flushes. Unit Manager #3 said the flush orders are not scheduled every 4 hours and there are two different orders for flushes. Unit Manager #3 said that nursing should have clarified the flush orders. During an interview on 1/15/25 at 3:51 P.M., the Director of Nursing said nursing should set the pump to the correct settings and that nursing should read the flush orders correctly. 36797 3. Review of the facility policy titled Therapeutic Diets, dated 2001, indicated that the dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of prescribed therapeutic diets. Resident #71 was admitted to the facility in May 2024 with diagnoses including Parkinson's, malnutrition and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/31/24, indicated Resident #71 scored a 11 out of a possible 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. During an interview on 1/13/25, at approximately 8:00 A.M., Resident #71 said he/she wants a regular diet and explained I am on mechanical diet for the past six months. I want to eat regular food, a burger would be nice. I'm not sure why I need this diet. Review of the hospital discharge summary, dated 5/15/24, indicated Resident #71 was on a regular diet consistency. Review of the physician's order, dated 5/20/24, indicated an order for a Regular diet, Regular texture, Thin consistency. Review of the dietitian note titled Nutritional Risk Assessment - V 8, dated 5/22/24, indicated the following recommendation: -Continue Regular unrestricted, regular texture, thin liquid diet a/o. Review of the hospital discharge summary dated 8/12/24, indicated to continue an L 6 SBS (soft bite size) diet. Review of the physician's order, dated 8/19/24, indicated an order for a Regular diet, Mechanical Soft texture, Thin consistency. Review of the physician's order, dated 8/13/24, indicated an order for Consult Speech Therapy for evaluation and treatment as needed. Review of the dietician note, dated 11/1/24, indicated: -Recommendations & Plan: Continue Regular, Mechanical Soft texture, Thin liquid diet, w/ 2x portions; ? SLP (speech language pathology) re-eval (evaluation). Review of the physician's orders indicated an order, dated 1/15/25, for SLP Clarification Order: Oropharyngeal swallow grossly WFL (within functional limits) at bedside. Poor po (by mouth) intake suspected d/t on-going GI deficits (sic)/colostomy. Resident appropriate for upgrade but defer to provider re: upgrade in setting of GI deficits w/ hx (with history) of perforation and colostomy status. No acute ST (speech therapy) needs indicated. Please reconsult (sic) as needed. During an interview on 1/15/25 at 10:00 A.M., the Director of Rehabilitation said that Resident #71 had not been evaluated by speech therapy for a recommended diet consistency. The Director of Rehabilitation said that when the dietitian makes a recommendation for speech therapy, nursing generates a communication form in the electronic health record that triggers the therapy department to screen a resident for evaluation and treatment, but that in this case nursing did not generate a form to notify therapy of the recommendation. She added that the therapy department reviews admission records including any diet changes and Resident #71's hospital discharge records should have triggered the speech therapist to screen the Resident. 49880 4. Resident #112 was admitted to the facility in December 2024 with diagnoses that include anemia, muscle wasting and atrophy and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) Assessment, dated 12/29/24, indicated a Brief Interview for Mental Status exam score of 15 out of a possible15 indicating that Resident #112 is cognitively intact. The MDS further indicated that Resident #112 has coughing or choking during meals and complaints of difficulty or pain when swallowing. Further, the MDS indicates that the Resident has a feeding tube and did not indicate any behaviors for refusal of care. Review of Resident #112's active nutrition care plan, initiated on 1/12/25, indicated the following: -I have a nutritional problem or potential nutritional problem r/t (related to) reported weight loss, PMHx (past medical history) significant for malignant CA (cancer), malnutrition, dysphagia w/ PEG (percutaneous endoscopic gastrostomy), a feeding tube that goes directly into the stomach), anemia, depression, HLD (hyperlipidemia), GERD (Gastroesophageal reflux disease), and anxiety. -Interventions in Resident #112's care plan include to obtain weights at ordered intervals. Review of Resident #112's Nutritional Risk Assessment, dated 12/31/24, indicated the following: -Recommendations and Plan: Weekly weights x4 from admission. Review of Resident #112's physician's orders indicated the following: -Weight on admission then weekly every Friday, dated initially 12/30/24, then updated on 1/10/25. Review of Resident #112's documented weights in the Electronic Medical Record (EMR) indicated the following: -12/28/24: 149.2 pounds (lbs.) -12/30/24: 146.0 lbs. -1/15/25: 141.5 lbs. Review of the medical record failed to indicate that Resident #112 was weighed as ordered between 12/30/24 and 1/15/25. Further review of the medical record failed to indicate that Resident #112 refused to be weighed. During an interview on 1/15/25 at 12:02 P.M., Unit Manager #3 said that weights should be obtained on admission and weekly for four weeks, unless otherwise specified by a physician's order. She said that Resident #112 should have been weighed weekly and monitored per physician's orders. Unit Manager #3 said that given Resident #112's recent history he/she is at risk for weight loss and malnutrition. She said that someone should have noticed that the Resident was not weighed since 12/20/24 but they did not. During an interview on 1/15/25 at 2:01 P.M., the Director of Nurses said that it is the facility policy to weigh residents on admission and weekly for four weeks. She further said that she would expect that nurses are obtaining resident weights per physician orders. During an interview on 1/16/25 at 7:57 A.M., the Dietitian said that she would expect staff to obtain weights as ordered for appropriate weight management.

Based on record review and interview the facility failed to ensure sufficient staffing to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well being. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal report submitted to The Centers of Medicare and Medicaid (CMS) for FY (Fiscal Year) Quarter 4, 2024. Findings include: Review of the PBJ Staffing Data Report CASPER Report 1705D FY Quarter 4 2024 (July 1 - September 30) indicated the following: -This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey). -Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low Review of the facility's 'Facility Assessment Tool, not dated, indicated at the staffing plan the following: Total Number Needed or Average or Range of Staff: -Licensed nurses providing direct care = 15. -Nurse Aides = 30. -Hours Per Patient Day (HPPD) = 3.20 total direct care staff. Review of the facility staffing records indicated that only one out of 12 weeks, during the FY Quarter 4 2024, did the facility meet the 3.20 HPPD required to adequately care for the residents in the facility. During an interview on 1/16/25, at approximately 9:00 A.M., the Administrator said that the facility had difficulty recruiting last year, but has since been able to staff appropriately using on call nursing management when needed.

Based on observations, and interviews, the facility failed to ensure 1.) medications were labeled, and dated once opened, according to manufacturer's guidelines in two out of three medication carts sampled, and 2.) ensure medications were stored in locked compartments on one nursing unit. Findings include: Review of facility policy titled Medication Labeling Storage undated, indicated the following: -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biological's are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. -If the facility has discounted, outdated or deteriorated medications or biological's, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. -Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. -Multi-dose vials that have been opened or accessed (e.g., needle punctured are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. -If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. 1. The facility failed to ensure medications were labeled, and dated once opened, according to manufacturer's guidelines. During an observation on 1/14/25 at 12:22 P.M., the following medications were observed of the B-Unit medication Cart 1: - One bottle of saline nasal spray, opened and undated, therefore unable to determine an expiration date. Manufacturer instruction indicates to discard the bottle after 30 days of opening. -One bottle of Risperidone Oral Solution, USP. Open and undated, therefore unable to determine an expiration date. Manufacture instructions to discard after 90 days of opening. -Two Fluticasone-salmeterol (an inhaled medication to treat breathing conditions) 250mcg/ 50 mcg (micrograms), open and undated. Manufacturer's instructions to discard 30 days after the foil pouch is opened. -One bottle of fluticasone nasal spray (nasal spray contains steroid used to treat allergies) 50 mcg (micrograms) open and undated, therefore unable to determine the expiration date. Manufacture instructions to discard after using 120 sprays. During an interview on 1/14/25 at 12:22 P.M., Nurse #6 said medications must be dated when opened and discarded according to the manufacturer's directions. During an interview on 1/14/25 at 12:25 P.M., Unit Manager #3 said medications should not be stored undated or expired and must be removed from the medication cart. During an interview on 1/15/25 at 12:30 P.M., the Director of Nursing (DON) said medications must be dated and labeled appropriately when opened according to the manufacturer's instructions and said expired medications must be removed. During an observation on 1/14/25 at 12:51 P.M., the following medications were observed on the A-Unit medication Cart 2: -One 887mL (milliliter) Bottle of Liquid Protein opened and undated, therefore unable to determine an expiration date. Manufacturer instruction indicates to discard the bottle after 90 days of opening. -One bottle of fluticasone nasal spray (nasal spray contain steroid used to treat allergies) 50 mcg (micrograms) open and undated, therefore unable to determine the expiration date. Manufacture instructions to discard after using 120 sprays. -4 packages of ipratropium Bromide and albuterol sulfate (an inhaled medication to treat breathing conditions) 0.5 mg/ 3mg ml (milligrams/milliliter) open and undated, therefore unable to determine an expiration date. Manufacturer instructions indicate once removed from foil pouch individual vials should be used within one week. -One Bottle Tuberculin Purified Protein Derivative (Mantoux) Tubersol. Multi-dose vial (50 Tests) 5 Tuberculin units per test. Open and dated 12/19/24, unrefrigerated. Manufacturer instructions indicate to store refrigerated after opening. During an interview on 1/14/25 at 1:05 P.M., Nurse # 5 said medications should have been dated when opened and said the Tuberculin solution needs to be refrigerated after opening. During an interview on 1/14/25 at 1:07 P.M., Unit Manager #3 said medications should not be stored undated or expired and must be removed from the medication cart. Unit Manager #3 said Tuberculin solution should be dated when opened and stored in the medication room in the refrigerator. During an interview on 1/15/25 at 12:35 P.M., the Director of Nursing (DON) said medications must be dated and labeled appropriately when opened according to the manufacturer's instructions and said expired medications must be removed. The DON said she would expect staff to know that Tuberculin must be stored in the refrigerator. 41105 2. On 1/15/25 at 8:14 A.M., the surveyor observed a medication cart unlocked on the Dementia Unit and was able to open and access it. There were no staff present. On 1/15/25 at 8:17 A.M., Nurse #1 walked down the hallway and returned to the medication cart. Nurse #1 said that the cart was supposed to be locked when unattended.

Based on record review and interviews, the facility failed to ensure that recommended specialist appointments were scheduled for three Residents (#32, #28, and #93), who had recommendations for an evaluation for cataract surgery from the consulting eye doctor, out of a total sample of 28 residents. Findings include: Review of facility policy titled Consultants, dated as revised December 2009, indicated the following: -Our facility may use as needed outside resources to furnish specific services to residents and to the facility. During the Resident Group meeting on 1/15/25 at 11:06 A.M., three residents indicated that they were recommended to have follow up appointments for the evaluation of cataracts, but no appointments have been communicated with them. 1a. Resident #32 was admitted to the facility in December 2021 with diagnoses that include vertigo and hyperlipidemia. Review of Resident #32's most recent Minimum Data Set (MDS) Assessment, dated 10/17/24, indicated a Brief Interview for Mental Status exam score of 8 out of a possible 15, indicating moderate cognitive impairment. The MDS further indicated the use of corrective lenses for vision. Review of Resident #32's medical record failed to indicate a plan of care for vision impairment. Review of Resident #32's eye doctor consult, dated 4/23/24, indicated the following: -Plan: cataract surgery recommended. -Referral: cataract ophthalmology; note to nurses please call [outpatient eye doctor's office] and schedule initial cataract evaluation and removal to improve vision. Review of the medical record failed to indicate that facility staff scheduled the recommended follow up for evaluation for cataract surgery. During an interview on 1/16/25 at 7:39 A.M., Resident #32 said that he/she is not aware of any follow ups scheduled for cataract evaluation. Resident #32 said that he/she would like to pursue options because he/she has trouble seeing the television and is unable to read anymore due to worsening vision which is very frustrating. Resident #32 said that no one from the facility has followed up about an appointment. During a phone interview on 1/16/25 at 8:11 A.M., an employee at the outpatient eye doctor's office [which was specifically recommended from the consulting eye doctor in the facility] said that the office has not received any referrals or inquiries to schedule evaluations for cataract surgery for Resident #32. During a phone interview on 1/16/25 at 8:20 A.M., Resident #32's activated Health Care Proxy (HCP) said that he/she was not aware of the need for a consult regarding cataract surgery. The HCP said that Resident #32 does express frustration about his/her vision but that the facility had not indicated that there were follow up recommendations that needed to be scheduled. He/she said they are open to exploring Resident #32's options regarding improvement of vision. During an interview on 1/16/25 at 9:11 A.M., the Director of Nurses said that her expectation is that recommendations from consulting providers are followed up on within a week, and the recommendations for Resident #32 were not. 1b. Resident #28 was admitted to the facility in February 2023 with diagnoses that include chronic obstructive pulmonary disease, depression and anxiety. Review of the most recent Minimum Data Set (MDS) Assessment, dated 11/23/24, indicated a Brief Interview for Mental Status exam score of 15 out of a possible 15, indicating that the Resident is cognitively intact. Review of Resident #28's medical record failed to indicate a plan of care for vision impairment. Review of Resident #28's eye doctor consult, dated 12/5/24, indicated the following: -Cataract surgery recommended; ophthalmology consult -Note to nurses: Please call [outpatient eye doctor's office] and schedule initial cataract evaluation ASAP (as soon as possible) and schedule initial cataract evaluation and removal. Review of the medical record failed to indicate that facility staff scheduled the recommended follow up for evaluation for cataract surgery. Review of Resident #28's medical record failed to indicate that the Resident has an activated health care proxy. The record indicates that Resident #28 makes his/her own healthcare decisions. During an interview on 1/16/25 at 7:44 A.M., Resident #28 said that the eye doctor told him/her that a follow up is needed at an outpatient setting regarding cataracts and his/her vision. Resident #28 said he/she gets frustrated because he/she loves watching television but is also hard of hearing so uses closed captioning to read the words. He/she said this has become increasingly difficult to do as he/she cannot always see the closed captioning. Resident #28 also said that he/she loves to read and has not been able to read because he/she cannot read the pages anymore. Resident #28 said that he/she would like to pursue their options regarding cataract surgery but that no one at the facility has followed up with him/her regarding the recommendations from the eye doctor over a month ago. During a phone interview on 1/16/25 at 8:11 A.M., an employee at the outpatient eye doctor's office [which was specifically recommended from the consulting eye doctor in the facility] said that the office has not received any referrals or inquiries to schedule evaluations for cataract surgery for Resident #28. During an interview on 1/16/25 at 9:11 A.M., the Director of Nurses said that her expectation is that recommendations from consulting providers are followed up on within a week, and the recommendations for Resident #28 were not. 1c. Resident #93 was admitted to the facility in June 2024 with diagnoses that include chronic obstructive pulmonary disease, hypertension and depression. Review of Resident #93's most recent Minimum Data Set (MDS) Assessment, dated 12/5/24, indicated a Brief Interview for Mental Status exam score of 9 out of a possible 15, indicating moderate cognitive impairment. The MDS further indicated that Resident #93 has no vision impairment and utilizes corrective lenses. Review of Resident #93's active care plan failed to indicate a plan of care for vision impairment. Review of Resident #93's eye doctor consult dated 12/5/24 indicated the following: -plan: Cataract surgery recommended -Referral: cataract ophthalmology; note to nurses please call [outpatient eye doctor's office] and schedule initial cataract evaluation and removal. Review of the medical record failed to indicate that facility staff scheduled the recommended follow up for evaluation for cataract surgery. During an interview on 1/16/25 at 7:47 A.M., Unit Manager #2 said that when consultant recommendations are made, it is reviewed with the resident's health care proxy and the attending provider and then orders are put into place. She said a hard copy of the consult is provided to the Unit Managers to review with providers. During a phone interview on 1/16/25 at 8:11 A.M., an employee at the outpatient eye doctor's office [which was specifically recommended from the consulting eye doctor in the facility] said that the office has not received any referrals or inquiries to schedule evaluations for cataract surgery for Resident #93. During a follow up interview on 1/16/25 at 8:26 A.M., Unit Manager #2 said she was not aware of the recommendations for evaluation for cataract surgery needed for Residents #32, #28 or #93. She reviewed the eye doctor consults and said referrals should have been made. During an interview on 1/16/25 at 9:11 A.M., the Director of Nurses said that her expectation is that recommendations from consulting providers are followed up on within a week, and the recommendations for Resident #93 were not.

Based on record review and interview the facility failed to ensure accurate documentation in the medical record for four Residents (#88, #47, #418, #89) out of a total sample of 28 residents. Specifically: 1. For Resident #88 nursing documented in the Treatment Administration Record (TAR) that a. oxygen (O2) was running at the correct setting, when it was not, b. that the O2 tubing was changed as ordered and c. that foam ear protectors were in place as ordered. 2. For Resident #47 the facility failed to ensure his/her risperidone (antipsychotic medication) order included an associated diagnosis as part of the physician's order. 3. For Resident #418 the facility failed to document accurately in the Medication Administration Record (MAR) when the nurse documented adminstraion of Insulin was given when it was not. 4. For Resident #89 the facility failed to document the appropriate vitals location for blood pressure. Findings include: 1. The facility policy titled Oxygen Administration, dated as revised October 2010, indicated the following: -Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). -Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Resident #88 was admitted to the facility in September 2024 and has diagnoses that include Acute Respiratory Failure with Hypoxia and shortness of breath. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/7/24, indicated that on the Brief Interview for Mental Status exam Resident #88 scored a 7 out of a possible 15, indicating severely impaired cognition. The MDS further indicated that Resident #88 was dependent on staff for upper and lower body care. Review of the current physician's orders indicated the following orders: a. Oxygen at 2L (2 liters)/ Minute via Nasal Cannula to O2 sat greater than 90%, start date 12/2/24; b. Change Oxygen Tubing, Humidifier, and clean filter weekly on Sunday 11 to 7 and as needed for soiling or damage, start date 12/2/24; and c. Apply foam ear protectors to oxygen nasal cannula tubing. check for placement every shift, start date 12/2/24. Review of Resident #88's current care plans indicating the following: 1. FOCUS: I have altered respiratory status r/t (related to) Hypoxia, Shortness of Breath, Hypoxemia, initiated 12/19/24. Interventions include: -Administer oxygen as ordered. 2. FOCUS: I require supplemental oxygen r/t decrease O2 sats (saturations), initiated 12/2/24. Interventions include: -Change tubing as per facility protocol. -Monitor skin on ears and nose for breakdown from oxygen tubing. Pad tubing as needed. 3. FOCUS: I have an ADL Self Care Performance Deficit r/t Dementia, weakness, dated as revised 9/12/24. Interventions include: -Turn & Position Dependent The care plan failed to indicate Resident #88 has any behaviors of removing the foam ear protectors or of changing his/her O2 level. Review of the January 2025 Treatment Administration Record (TAR) indicated the following was documented by nursing, contrary to observations: a. On 1/14/25 the O2 was running at 2L all three shifts; b. The O2 tubing was changed by nursing on 1/5/25 and 1/12/25; and c. The foam ear protectors were in place all three shifts on 1/14/25. On 1/14/25 at 7:45 A.M., Resident #88 was observed in bed asleep wearing O2 that was running at 3L. The O2 tubing was dated 12/31/24 and there were no foam ear protectors in place. On 1/14/25 at 11:39 A.M., Resident #88 was observed in bed asleep wearing O2 that was running at 3L. The O2 tubing was now dated 1/10/25 and there were no foam ear protectors in place. On 1/15/25 at 7:15 AM Resident #88 was observed in bed asleep wearing O2 that was running at 3L. The O2 tubing was dated 1/10/25 and there were no foam ear protectors in place. During an observation and interview on 1/15/25 at 7:25 A.M., Certified Nursing Assistant (CNA) #1 said that Resident #88 requires max assist with bed mobility and has no known behavior of changing the O2 setting. The surveyor and CNA #1 observed Resident #88 in bed with the O2 running at 3L and no foam ear protectors in place. CNA #1 said that nursing is responsible to set the O2 to the accurate setting and that the foam ear protectors come with each tubing kit and should be in place. During an interview on 1/15/25 at 7:29 A.M., with Unit Manager #1, she said that when nurses are signing off on the TAR it should be accurate. Unit Manager #1 said that on 1/10/24 Resident #88 was at rehabilitation using his/her portable oxygen and the 12/31/24 tubing. She said that she left the 1/10/24 tubing in the room but never circled back when the resident returned from rehabilitation to remove the 12/31/24 tubing and connect the resident to the new tubing. She could not explain why it was documented in the TAR that the tubing was changed on 1/4/25 and 1/12/24, when the tubing was still dated 12/31/24. During an interview on 1/15/25 at 8:46 A.M., with the Director of Nursing (DON) she said that she would expect that the documentation in the TAR be accurate. 44095 2. Review of the facility policy, Psychotropic Medication Use, dated July 2022, indicated that residents will not receive medications that are not clinically indicated to treat a specific condition. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics. 3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: a. indications for use. Resident #47 was admitted to the facility in May 2024 with diagnoses including chronic obstructive pulmonary disease, tracheostomy status, paranoid schizophrenia, anxiety, and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/17/24, indicated that Resident #47 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. The MDS was coded as the following: -Antipsychotic coded as yes, indication coded as yes. Review of Resident #47's physician's order, dated 5/4/24, indicated: -Risperidone oral tablet 4 milligrams (mg) (Risperidone), give 1 tablet via PEG-Tube at bedtime for antipsychotic (class of medication and not a diagnosis). Further review of the physician's order failed to include a medical diagnosis related to the administration of risperidone. During an interview on 1/14/25 at 3:01 P.M., Unit Manager #3 said that Resident #47's Risperidone order should have an associated medical diagnosis as part of the physician's order. During an interview on 1/15/25 at 3:35 P.M., the Director of Nursing said that Resident #47's Risperidone order should have an associated diagnosis as part of the physician's order. 48671 3. Review of the facility policy titled Administering Medications, Dated as revised April 2019, indicated the following: -Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 4.Medications are administered in accordance with prescriber orders, including any required time frame. 5.Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication. b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. 7. Medications are administered withing one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR (medication administration record) space provided for that drug and dose. Resident #418 was admitted to the facility in January 2025 with diagnoses including type two diabetes mellitus and acute kidney failure. Review of Resident #418's most recent Minimum Data Set Assessment (MDS) assessment, dated 1/8/25, indicated the Resident had a Brief Interview for Mental Status exam score of 11 out of a possible 15, indicating he/she has moderate cognitive impairment. Further review of the MDS indicated that Resident #418 had received insulin injections seven days leading up to the assessment. Review of Resident #418's active physician orders dated 10/15/24 indicated: -Insulin Aspart Prot & Aspart Subcutaneous Suspension (70-30) 100 UNIT/ML (units per milliliter) (Insulin Aspart Protamine & Aspart (Human) (Rapid acting insulin used to treat diabetes). Inject 25 units subcutaneously two times a day for DM (diabetes mellitus). Start Date: 1/02/25. Review of Resident #418's Medication Administration Record indicated that Nurse #3 administered 25 units of Insulin Aspart Protamine & Aspart Subcutaneous Suspension on 1/25/25 at 7:52 A.M. On 1/15/25 at 7:56 A.M., the surveyor observed Nurse #3 prepare and administer oral medications to Resident #418. Resident #418 said You didn't give me my insulin yet. Nurse #3 told Resident #418 she was working on it and would be back to administer the morning insulin. Nurse #3 told the surveyor she checked Resident #418's blood sugar earlier in the morning and said she would be back to administer the insulin. The surveyor continued to observed Nurse #3 as she completed her medication pass with Resident #418 and exited the room. Nurse #3 did not administer insulin during the medication pass observation. On 1/15/25 at 8:06 A.M., the surveyor observed a staff member deliver a breakfast tray to Resident #418. The surveyor observed Resident #418 eating breakfast in bed at 8:09 A.M. The surveyor continued to make observations of Nurse #3 in the hall and she did not re-enter Resident #418's room throughout the observation period. During an interview on 1/15/25 at 8:13 A.M., the surveyor asked Resident #418 if he/she had received the morning insulin yet and the Resident sad no I am supposed to have it before breakfast, but she didn't give it to me. During an interview on 1/15/25 at 8:18 A.M., Nurse #3 said she has not administered the insulin to Resident #418 and said she is working on getting it together now. The surveyor observed Nurse #3 continue with her medication pass with other Residents and did not return to Resident #418's room. During an interview on 1/15/25 at 9:28 A.M., the surveyor asked Resident #418 if he/she received the insulin and Resident #418 said, Yes, I got it late, it was after breakfast and usually its before, but I didn't get it until now. During an interview on 1/15/25 at 8:45 A.M., Unit Manager #3 said blood sugar checks are done early in the morning and said Residents requiring morning insulin must be administered as ordered and before meals. During an interview with Nurse #3 on 1/15/25 at 9:54 A.M., Nurse #3 said she should not have documented the insulin as given when she did not administer it and said she is new and thought she gave i,t but did not. Nurse #3 said she administered the insulin after breakfast around 9:30 A.M. During an interview on 1/15/25 at 12:38 P.M., the Director of Nursing (DON) said Nurse #3 should not have documented the insulin as given when it was not administered to the Resident and said insulin must be given when ordered and before breakfast. The DON said the Nurse should have notified the doctor if the insulin was given late and said the Nurse corrected the administration time in the medical record. Review of Resident #418's Medication Administration Record on 1/15/25 indicated that Nurse #3 documented the insulin was administered at 8:26 A.M., despite previous documentation of administration at 7:20 A.M., and actually administering the medication to Resident #418 at 9:30 A.M. 41019 4. The facility failed to document the appropriate vitals location for blood pressure for 1 Resident (#89) out of a total sample of 28 residents. Specifically, documentation shows the nurse obtained a blood pressure on the Resident's right arm when blood pressure vitals are to be obtained on the left arm per physician orders. Resident #89 was admitted in July 2024 with diagnoses including end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 12/19/24, indicated Resident #89 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated Resident #89 attends dialysis. Review of the medical record for Resident #89 indicated that he/she should not have blood pressure vitals, intravenous fluids, or blood drawn from his/her right arm due to having a dialysis shunt (an access point for when a patient receives dialysis). Review of the blood pressure vitals measurements for the month of December 2024 indicated the nurse obtained a blood pressure measurement from Resident #89's right arm on 5 occasions. During an interview on 1/16/25 at 8:09 A.M., the Director of Nursing said that she is willing to bet that the nurse who obtained the blood pressure reading is documenting the wrong arm in the computer because Resident #89 is cognitively intact and would advocate for him/herself. The Director of Nursing said that she would expect nurses to document the appropriate arm that the vitals were taken from.

Based on record review and interview, the facility failed to implement their abuse policy by failing to investigate an allegation of abuse from one Resident (#95), which led to the abuse of another resident by the same certified nursing aide, out of a total sample of 28 residents. Specifically, Resident #95 alleged a certified nursing aide handled him/her roughly and refused to put the correct sized brief on Resident #95, which was filed as a grievance by the facility, ultimately leading to the same certified nursing aide physically abuse Resident #1. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised September 2022, indicates the following: -All reports of resident abuse (including injuries of uknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -All allegations are thoroughly investigated. The administrator initiates investigations. -The administrator is responsible for keeping the resident and his/her representative informed of the progress of the investigation. -Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. -The individual conducting the investigation as a minimum: * interviews the person(s) reporting the incident * interviews any witnesses to the incident * interviews the resident * interviews the resident's attending physician as needed to determine the resident's condition * interviews the reisdent's roommate * documents the investigation completely and thoroughly -The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised September 2022, indicates the following: - All reports of resident abuse (including injuries of uknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. - If resident abuse, neglect, exploitation, misappropriation of resident property or injury of uknown source is suspected, the suspicion must be immediately reported to the administrator and to other officials according to the state law. - The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: * The state licensing/certification agency responsible for surveying/licensing the facility - Immediately is defiened as: * Within two hours of an allegation involving abuse or result in serious bodily injury - Notices include, as appropriate: * The date and time the alleged incident occurred * The names of all persons involved in the alleged incident * What immediate action was taken by the facility Resident #95 was admitted in November 2023 with diagnoses including hypertension and osteoporosis. Review of the Minimum Data Set (MDS) assessment, dated 10/31/24, indicated Resident #95 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the MDS indicated Resident #95 requires partial to moderate assistance with all activities of daily living. During review of the a grievance filed on 11/27/24, written by the Administrator, indicates Resident #95 reported to the Unit Manager that a C.N.A. (certified nursing aide) did not follow her preferences for transferring. The grievance also indicated Resident had reported that a CNA pulled his/her arm too hard during a transfer. Resident said he/she felt safe and had no concerns and wants the Unit Manager to train her (staff member) on his/her (the Resident) preferences for transfer. During an interview on 1/15/25 at 11:48 A.M., Resident #95 said that he/she clearly remembers the incident and told a staff member that a CNA was rough with him/her. Resident #95 said that the CNA was rough when transferring him/her to the toilet and Resident #95 said he/she requires and extra large brief, but the CNA only brought in a small one. Resident #95 said he/she told the CNA that he/she needs an extra large brief and the CNA said she was going to leave and started counting down 5, 4, 3, 2, 1 . to get Resident #95 to put on the small brief. Resident #95 said he/she forced the small brief on because he/she thought the CNA would leave him/her in the bathroom if he/she didn't put the brief on. Resident #95 said she felt like the CNA was purposeful in her actions. Resident #95 said he/she had never seen that CNA before and has not seen the CNA since the incident. Resident #95 said he/she does not remember if anyone came to check on him/her to see if he/she felt safe or follow up with him/her. During an interview on 1/15/25 at 12:28 P.M., the Administrator said that Resident #95 reported to the Unit Manager that a CNA was kind of rushed and the Resident was upset with the transfer and that the CNA was not taking her time. The Administrator said that from what she remembers, the CNA was very fast and quick and she does not remember the Resident mentioning anything about the briefs. The Administrator said that she asks residents verbatim if they feel like they have been abused. The Administrator said that from her recollection, she believes it was a customer service issue and that is why she filed it as a grievance. The Administrator said the Resident initially reported to her that it was rough handling, but she honed down the interview and the Resident wanted the CNA to go slower with his/her care. During an interview on 1/15/25 at 12:57 P.M., the Director of Nursing said she asked the Resident if he/she felt it was malicious and the Resident said no. Review of the medical record failed to indicate any information regarding the incident. Shortly after the interview, the facility Administrator provided two written statements and a skin check, dated 11/27/24. The written statements were from the Director of Nursing and the Unit Manager. The facility could not provide a written statement for the CNA involved. Review of the Healthcare Facility Reporting System failed to indicate the facility reported the incident to the state agency. Review of a facility reported incident, dated 12/10/24, indicated Resident #1 reported to facility staff that CNA #5 was rough with him/her during care. Resident #1 told staff that, on 12/9/24, CNA #5 forcefully pulled the laptop case handle from my arm, causing him/her left upper arm pain, 8 out of 10 pain and that CNA #5 forcefully pulled a brief off of Resident #1. Resident #1 reported that he/she asked for a diet cola and CNA #5 brought the soda, but would not pour it for Resident #1 and told Resident #1 to open the bottle him/herself or he/she won't get any. Resident #1 also told staff that CNA #5 asked Resident #1 if he/she was full of urine or feces because she didn't have time to change Resident #1. Review of the Resident/Witness Statement, dated 12/10/24, indicated Resident #1 told the Social Worker that Resident #1 was not moving fast enough so CNA #5 grabbed the bag and pulled it off my arm fast and it hurt. The Social Worker documented Resident #1 reports his/her arm is still sore. There are no marks on the arm, but Resident #1 winced when it was lightly touched . He/she states that he/she feels safe with the other staff, but did not feel safe with CNA #5. Review of the medical record indicated that an x-ray was obtained on 12/10/24 in the facility of Resident #1's arm and showed a fracture of the left ulner (the long bone of the forearm) with indeterminate age (time of fracture could not be determined). Review of the Employee Performance Improvement Notification, dated 12/16/24, indicated CNA #5 was suspended from the facility pending investigation of the incident that occurred with Resident #1. Review of the Employee Performance Improvement Notification, dated 12/27/24, indicated CNA #5 was terminated due to performance. During an interview on 1/15/25 at 11:36 A.M., the Administrator was asked why CNA #5 was terminated and what performance indicated. The Administrator said she terminated CNA #5 for customer service and insubordination because CNA #5 was mouthy with her. The Administrator cannot recall the exact phrases CNA #5 said to her, but remembers it was her body language and attitude. The Administrator did not specify if CNA #5 was terminated due to the investigated allegations.

Based on record review and interview, the facility failed to report an allegation of potential abuse for one Resident (#95) out of a total sample of 28 residents. Specifically, Resident #95 reported rough handling of a certified nursing aide to another staff member and the incident was not reported and filed as a grievance. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised September 2022, indicates the following: - All reports of resident abuse (including injuries of uknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. - If resident abuse, neglect, exploitation, misappropriation of resident property or injury of uknown source is suspected, the suspicion must be immediately reported to the administrator and to other officials according to the state law. - The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: * The state licensing/certification agency responsible for surveying/licensing the facility - Immediately is defiened as: * Within two hours of an allegation involving abuse or result in serious bodily injury - Notices include, as appropriate: * The date and time the alleged incident occurred * The names of all persons involved in the alleged incident * What immediate action was taken by the facility Resident #95 was admitted in November 2023 with diagnoses including hypertension and osteoporosis. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #95 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated Resident #95 requires partial to moderate assistance with all activities of daily living. During review of the a grievance filed on 11/27/24, written by the Administrator, indicates Resident #95 reported to the Unit Manager that a C.N.A. (certified nursing aide) did not follow her preferences for transferring. The grievance also indicated Resident had reported that a CNA pulled his/her arm too hard during a transfer. Resident said he/she felt safe and had no concerns and wants the Unit Manager to train her (staff member) on his/her (the Resident) preferences for transfer. During an interview on 1/15/25 at 11:48 A.M., Resident #95 said that he/she remembers the incident and told a staff member that a CNA was rough with him/her. Resident #95 said that the CNA was rough when transferring him/her to the toilet and Resident #95 said he/she requires and extra large brief, but the CNA only brought in a small. Resident #95 said he/she told the CNA that he/she needs an extra large brief and the CNA said she was going to leave and started counting down 5, 4, 3, 2, 1 . to get Resident #95 to put on the small brief. Resident #95 said he/she forced the small brief on because he/she thoguht the CNA would leave him/her in the bathroom if he/she didn't put the brief on. Resident #95 said she felt like the CNA was purposeful in her actions. Resident #95 said he/she had never seen that CNA before and has not seen the CNA since the incident. Resident #95 said he/she does not remember if anyone came to check on him/her to see if he/she felt safe or follow up with him/her. During an interview on 1/15/25 at 12:28 P.M., the Administrator said that Resident #95 reported to the Unit Manager that a CNA was kind of rushed and the Resident was upset with the transfer and that the CNA was not taking her time. The Administrator said that from what she remembers, the CNA was very fast and quick and she does not remember the Resident mentioning anything about the briefs. The Administrator said that she asks residents verbatim if they feel like they have been abused. The Administrator said that from her recollection, she believes it was a customer service issue and that is why she filed it as a grievance. The Administrator said the Resident initially reported it was rough handling, but she honed down the interview and the Resident wanted the CNA to go slower with his/her care. During an interview on 1/15/25 at 12:57 P.M., the Director of Nursing said she asked the Resident if he/she felt it was malicious and the Resident said no. Review of the medical record failed to indicate any information regarding the incident. Review of the Healthcare Facility Reporting System failed to indicate the incident was reported on or around 11/27/24.

Based on observation, record review, and interview, the facility failed to ensure that an individualized, comprehensive care plan was implemented for one Resident (#106), out of a total sample of 28 residents. Specifically for Resident #106, the facility failed to implement fall mats. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Center, dated as revised March 2022, indicated: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. Resident #106 was admitted to the facility in November 2024 with diagnoses including metabolic encephalopathy, falls, anxiety, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 11/29/24, indicated that Resident #106 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 11 out of a possible 15. This MDS further indicated Resident #106 required assistance with activities of daily living. Review of Resident #106's plan of care related to falls, dated 11/27/24, indicated: - Fall mat(s) to both side(s) of the bed at all times when the resident is in bed. Review of Resident #106's incident accident reports indicated Resident #106 had fallen on the following dates and times: - On 11/9/24 at 12:45 P.M., Resident #106 fell in his/her room while ambulating. There were not witnesses and the Resident was found on floor. - On 11/10/24 at 11:04 P.M., Resident #106 fell in his/her room and was found on the floor. - On 11/27/24 at 8:45 P.M., Resident #106 fell in his/her room and was sitting and yelling for pain medications. Injuries included three skin tears. An intervention to include fall mats to the plan of care. - On 12/1/24 at 1:45 A.M., Resident #106 had a fall in his/her room on the floor. - On 12/10/24 at 12:15 A.M., Resident #106 had a fall in his/her room on the floor. - On 12/16/24 at 3:57 P.M., Resident #106 had a fall in his/her room on the floor. - On 12/17/24 at 5:30 A.M., Resident #106 had a fall in his/her room on the floor. Review of Resident #106's health status note, dated 1/12/25 at 2:33 A.M., indicated: -Note Text: At 1:00 A.M., the CNA (Certified Nursing Assistant) found the resident on the floor in a praying position. This writer responded immediately to the resident's room. Assessment performed; Resident was safely removed from the floor. On 1/14/25 at 8:03 A.M., 1:54 P.M., 3:13 P.M., and at 4:24 P.M., and on 1/15/25 at 6:48 A.M., and 7:27 A.M., the surveyor observed Resident #106 in his/her bed without bilateral fall mats on both sides of bed. During an interview on 1/15/25 at 7:30 A.M., CNA #3 said that Resident #106 does not utilize fall mats. CNA #3 and the surveyor searched the Resident's room and CNA #3 was unable to locate any fall mats. During an interview on 1/15/25 at 7:55 A.M., Nurse #5 said that Resident #106 had a fall on 1/12/25, and Nurse #5 is not aware of Resident #106 requiring fall mats. Nurse #5 said that Resident #106 is a high risk for falls. During an interview on 1/15/25 at 9:01 A.M., Unit Manager #3 said that Resident #106 is a high risk for falls. Unit Manager #3 reviewed Resident #106's care plan and Unit Manager #3 said that the intervention for fall mats should be implemented if it is on the plan of care. During an interview on 1/15/25 at 3:44 P.M., the Director of Nursing (DON) said Resident #106 has altered mental status and he/she is cognitively impaired. The DON said that Resident #106 has had multiple falls, and nursing should implement the care plan for bilateral fall mats.

Based on record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#111), out of a total sample of 28 residents. Specifically, the facility failed to follow physician orders to obtain daily weights for a resident with a diagnosis of congestive heart failure (condition when the heart muscle doesn't pump blood as well as it should causing a potential for fluid buildup/ weight gain), nursing did not obtain daily weights for 3 consecutive days and then Resident #111 was found to have a 5.2-pound weight gain. Findings Include: Review of the facility policy titled Heart Failure - Clinical Protocol, dated as revised November 2018, indicated: 1. The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights) to monitor, when to report findings to the physician, etc. Resident #111 was admitted to the facility in December 2024 with diagnoses including pneumonia, chronic diastolic heart failure (CHF), atrial fibrillation, and generalized edema. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/23/24, indicated that Resident #111 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15. This MDS further indicated Resident #111 received a diuretic (medicines that increase urine production and help lower blood pressure and fluid retention), did not reject care, and was dependent on staff with putting on/taking off footwear, which included the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility. Review of Resident #111's plan of care related to fluid deficit, dated 1/9/25, indicated: -Obtain weights at ordered intervals. Notify physician and registered dietitian of significant changes. Review of Resident #111's physician's order, dated 12/18/24, indicated: - Weights Daily at 6:00 A.M., in the morning Notify physician if weight is greater than or equal to 3 pound increase. Review of Resident #111's Medication Administration Record (MAR), dated January 2025, indicated nursing did not obtain the daily weights on 1/10/25, 1/11/25, 1/12/25, and 1/13/25. Review of Resident #111's eMar - Medication Administration note, dated 1/12/25 and 1/13/25, indicated: -Weights Daily at 6:00 A.M., in the morning Notify physician if weight is greater than or equal to 3 pound increase. Scale Broken Review of Resident #111's weights and vital signs summary, dated 12/19/24 to 1/14/24 indicated the following weights: -1/8/25 179.7 pounds (lbs), -1/9/25 181.4 lbs, -1/13/25 186.6 lbs, a weight gain on 5.2 lbs in 3 days. (there were no weights obtained or documented in the clinical record on 1/10/25, 1/11/25, or 1/12/25) Review of Resident #111's nursing progress note, dated 1/13/25, indicated: -Resident up 5.2 lbs since 1/9. Review of Resident #111's physician's order, dated 1/14/25, indicated: 2 view chest x-ray (CXR) and a kidneys ureters and bladder (KUB) - diagnosis: lower extremity edema and abdominal distention. Review of Resident #111's nursing progress note, dated 1/15/24, indicated: -Resident with weight fluctuations, trending up since 1/9/25 in setting of CHF. During an interview on 1/16/25 at 8:34 A.M., Nurse #10 said that Resident #111 has congestive heart failure and requires daily weights. Nurse #10 said she couldn't remember why she documented the weight as refused on Friday 1/10/25 on the MAR, but the daily weight should have been obtained. During an interview on 1/16/25 at 8:39 A.M., Nurse #11 said that Resident #111 has congestive heart failure and required daily weights for monitoring. Nurse #11 said the scale was broken and she was unable to obtain Resident #111's weight on Saturday 1/11/25. During an interview on 1/15/25 at 1:28 P.M., Nurse #7 said he worked the overnight shift over the weekend and he said the scale was not consistently working over the weekend. Nurse #7 said the scale had last been serviced in 2023. Nurse #7 said he was unable to obtain Resident #111's weight for 2 days (1/12/25 and 1/13/25) and Nurse #7 said he was not sure if there was another scale in the facility to use. During an interview on 1/15/25 at 3:22 P.M., Nurse #8 said the scale on the unit was not working correctly and there have been issues with the scale over the last few months. Nurse #8 said that a few residents, including Resident # 111, have congestive heart failure and their weights needs to be monitored closely. During an interview on 1/15/25 at 12:08 P.M., Unit Manager #3 said she was not aware nursing was not obtaining Resident #111's weights because the scale was broken. Unit Manager #3 said that Resident #111 has congestive heart failure and is receiving a diuretic. Unit Manager #3 said that staff should have used a scale from a different unit to obtain Resident #111's weight. During an interview on 1/15/25 at 3:39 P.M., the Director of Nursing (DON) said she was not aware the scale was broken until she read the nursing progress notes. The DON said Resident #111 has congestive heart failure and has orders for daily weights and should have obtained the weights using a different scale.

Based on observations, interviews and record review, the facility failed to provide care, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one Resident (#473) out of a total sample of 28 residents. Specifically for Resident #473, the facility failed to obtain a physician's order with appropriate settings for an air mattress that was in use. Findings include: Resident #473 was admitted to the facility in December 2024 with diagnoses that include heart failure and hypotension Review of Resident #473's most recent Minimum Data Set (MDS) Assessment, dated 1/2/25, indicated a Brief Interview for Mental Status exam score of 12 out of 15, indicating moderate cognitive impairment. On 1/14/25 at 7:57 A.M. and 1:36 P.M., the surveyor observed Resident #473 in bed on an air mattress. The air mattress was set at 175 pounds (lbs.). On 1/15/25 at 7:34 A.M., 8:08 A.M., and 9:31 A.M., the surveyor observed Resident #473 laying in bed on an air mattress. The air mattress was set at 175 lbs. Review of Resident #473's active physician's orders failed to indicate an order for an air mattress with settings. Review of progress notes indicated a note, dated 1/14/25 that indicated, Rt (Resident) has DTI (Deep Tissue Injury) to coccyx, and DTI to right heel. Review of Resident #473's active skin breakdown care plan, initiated 1/1/25, indicated that the Resident has a pressure ulcer, or has potential for pressure ulcer development, related to immobility. DTI to right heel and coccyx present on admission. Review of the care plan indicated the use of a low air loss mattress, but failed to indicate appropriate settings. Review of Resident #473's most recently documented weight in the Electronic Medical Record (EMR) indicated Resident #473 weighed 148.7 lbs. on 1/14/25. During an interview on 1/15/25 at 9:34 A.M., Nurse #5 said that air mattresses are set according to the Resident's weight. He said there should be a physician's order indicating the settings so that nursing can assess the settings and ensure they are correct. Nurse #5 said that if the settings are too high or too low, according to the Resident's weight, then the air mattress does not serve it's purpose for preventing skin breakdown. He further said that when air mattresses are applied, maintenance applies them, and asks the nurse for the resident's weight so that the settings are set appropriately. During an interview on 1/15/25 at 11:50 A.M., Unit Manager #3 said that Resident #473 has two unstageable DTI pressure wounds, one to the heel and one to the coccyx. She said that air mattresses can be set to weight or comfort, but when being used by a resident with skin breakdown, it should be set by weight. Unit Manager #3 said there should be a physician's order with the settings in it so staff can monitor and ensure the correct settings every shift, but that Resident #473 does not have one. During an interview on 1/15/25 at 2:02 P.M., the Director of Nurses (DON) said that the general rule with air mattresses is to be set by weight or comfort, but that their should be a physician's order with settings and nurses should be following that order and checking the settings on the air mattress.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#106), out of a total sample of 28 residents. Specifically, for Resident #106, the facility failed to change the PICC line dressing as ordered by the physician and the facility failed to obtain weekly measurements for the external length of Resident #106's PICC line to ensure the PICC line had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm). Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Edition, dated 2021, included the following for documentation related to PICC line migration and dressing changes: Use a sterile measuring tape or incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated. Review of the facility policy titled Central Venous Catheter Care and Dressing Changes, dated as revised March 2022, indicated that the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). 2. Maintain sterile dressing (transparent semi-permeable membrane (TSM] dressing or sterile gauze) for all central vascular access devices. The type of dressing is based on the condition of the resident and his or her preference. 3. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for TSM dressing. 6. Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. 8. For PICCs, measure arm circumference and compare to baseline when clinically indicated to assess for edema and possible deep-vein thrombosis. Documentation 1. The following information should be recorded in the resident's medical record: a. Date and time dressing was changed. b. Location and objective description of insertion site. c. Any complications, interventions that were done. f. Signature and title of the person recording the data. Resident #106 was admitted to the facility in November 2024 with diagnoses including metabolic encephalopathy, falls, pain, benign prostatic hyperplasia, anxiety and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/29/24, indicated that Resident #106 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 11 out of a possible 15. The MDS further indicated Resident #106 required assistance with activities of daily living. On 1/14/25 at 8:03 A.M., the surveyor observed Resident #106's PICC line dressing dated 1/2/25. Review of Resident #106's plan of care related to intravenous (IV) therapy, dated 1/3/25, indicated: - Monitor dressing at IV insertion site daily and change as ordered and as needed. Review of Resident #106's physician's order, dated 1/3/25, indicated: -Daptomycin Intravenous Solution Reconstituted 500 milligrams (mg) (Daptomycin), Use 400 mg intravenously one time a day for bacteremia (infection in the flood) until 1/18/25. Review of Resident #106's physician's order, dated 1/3/25, indicated: - IV:(Midlines and PICCs) Document baseline mid-upper arm circumference, check arm circumference as needed, one time only for admission process until 1/3/2025. - IV: (Midlines and PICCs) Document baseline external length of IV catheter, check external length with each dressing change and as needed one time a day every 7 day(s) document external length and as needed. - IV: (Midline, PICC, CVAD) Change Transparent Dressing on Admission and then every 7 days; Caps to be changed during dressing change. one time only for best practices on Admission and one time a day every 7 day(s) for best practices. Review of Resident #106's January 2025 Medication Administration Record (MAR) indicated on 1/10/25, Nurse #3 changed the transparent dressing as ordered by the physician. However, based on the surveyor's observation on 1/14/25 at 8:03 A.M., the dressing was last changed on 1/2/25. During an interview on 1/15/25 at 8:15 A.M., Nurse #3 said that she has never changed a PICC line dressing, and she does not know how to change them. Nurse #3 said she thinks only Registered Nurses can change PICC line dressings and she is a Licensed Practical Nurse. Nurse #3 said that when orders are signed off on the Treatment Administration Record (TAR) they should be completed. During an interview on 1/15/25 at 8:55 A.M., Unit Manager #3 said she observed the PICC line on 1/14/25 and the PICC line was dated 1/2/25. The Unit Manager #3 said that the dressing should have been changed every 7 days, and measurements should have been obtained but they were not. During an interview on 1/15/25 at 3:47 P.M., the Director of Nursing said PICC lines dressings need to be changed every 7 days, and she said the nurse's completing the dressing changes should obtain PICC line measurements.

Based on observation, record review, policy review and interview, the facility failed to provide adequate supervision and ensure an environment free from accidents and hazards, for two Residents (#99 and #92) out of a total sample of 34 Residents. Specifically: 1.) For Resident #99, who was assessed by nursing to be a high risk for falls, the facility failed to ensure he/she received adequate supervision to prevent accidents when he/she experienced 13 falls over a span of 51 days, with two of those falls resulting in injuries which required 6 staples (12/16/23) and 12 sutures (12/29/23). 2.) For Resident #92, the facility failed to implement preventative interventions for accidents in a timely manner resulting in the Resident burning his/her feet on the heater, subsequently causing hospitalization . Findings include: Review of the facility policy titled Accidents and Incidents - Investigating and Reporting, dated and revised July 2017 indicated the following: All accidents or incidents involving residents occurring on the facility's premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable shall be included in the report of the incident/accident: a. The date and time the accident or incident took place b. The nature of the injury c. The circumstances surrounding the accident or incident d. Where the accident or incident took place f. The injured person's account of the accident or incident g. The time the injured person's attending physician was notified i. The condition of the injured person, including his/her vital signs j. The disposition of the injured k. Any corrective action taken 5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. 6. The director of nursing service shall ensure that the administrator received a copy of the Report of Incident/Accident for each occurrence. Review of the facility policy titled, Assessing Falls and Their Causes, dated as revised March 2018, indicated: 1. Review the resident's care plan to assess for any special needs of the resident. 1.) For Resident #99 who was assessed to be a high risk for falls the facility failed to ensure he/she received adequate supervision to prevent accidents when he/she experienced 13 falls over a span of 51 days, with two of those falls resulting in injuries which required 6 staples (12/16/23) and 12 sutures (12/29/23). Resident #99 was admitted to the facility in November 2023 with diagnoses including dementia, hemiplegia, dysphagia and cerebral infraction. Review of the Minimum Data Set (MDS) assessment, dated 12/30/23, indicated Resident #99 had a memory problem and indicated he/she had a history of falls. Review of the nursing note, dated 11/2/23, indicated: - Resident was found in the bathroom alone. Review of the nursing note, dated 11/6/23, indicated: - Pt (patient) kept getting off wheel chair without assistance. Poor safety awareness redirected with minimal effects. 1. Review of the incident report, dated 11/8/23 at 12:00 A.M., indicated Resident #99 had a fall in his/her room while ambulating, unwitnessed. He/she sustained an abrasion to his/her left knee. I wanted a cup of juice, then I lost my balance. 2. Review of the incident report, dated 11/8/23 4:58 P.M., indicated Resident #99 had a fall in his/her room while sitting, witnessed by his/her roommate. He/she sustained a bruise to mid center back and right rear thigh. Review of the nursing note dated 11/8/23, indicated: -At 4:58 P.M. Certified Nurse Assistant (CNA) reported to writer that the pt was on the floor. Writer observed him/her on his knees trying to get himself back up. Roommate reported that he/she had an unwitnessed fall. By the time writer entered the room pt was transferring himself/herself to wheelchair. Writer didn't get an opportunity to do a full assessment on the floor because of this. Writer did an assessment with him/her in chair and observes two bruises mid back. Pt brought to the nursing station for close monitoring. Review of the nursing note, dated 11/12/23 at 10:00 P.M., indicated: -Patient has poor safety awareness, he/she keeps getting up from wheelchair. Pt was moved closer to nursing station for close monitoring. Patient was redirected when he/she stood up without help. 3. Review of the incident report, dated 11/13/23 at 12:00 A.M., indicated Resident #99 had a fall in his/her room while transferring, unwitnessed. I just fell , that's it. Review of the health status note, dated 11/13/23, indicated: -At 00:00, writer and CNA heard someone yelling out. CNA responded to Resident #99 room first and observed him/her on the floor. CNA then alerted writer Resident #99 was on the floor. Writer entered the room to find Resident #99 laying supine on the floor, parallel next to his/her bed, with his/her brief removed, and his/her arms crossed behind his/her head. A new brief was applied, and he/she was put into his/her wheelchair and brought to the nurses station. Writer then asked Resident #99 what happened, I fell . Writer asked the question a few different ways and pt would not or could not elaborate further. Resident #99 was unable to say if he/she was doing anything, how the fall happened or any information about the fall. Writer believes he/she was trying to change himself/herself. His/her brief had a very small spot of stool on it, and it seems like Resident #99 took the brief off and lost his/her balance. Writer had yet to do rounds yet, and writer had not seen him/her yet this shift, prior to the fall. However, the previous shift 3-11 nurse did report to writer that Resident #99 was asked to not sit on the very edge of the bed, to either lay down or get in his/her wheelchair, but he/she denied their request and continued on with his/her behavior. Resident #99 sat with writer or CNA at the nurse's station up until 03:30. Resident #99 is still not tired. Writer keeps asking periodically if he/she is tired and wants to go to bed, however, he/she is still not ready yet. Care is ongoing. 4. Review of the incident report, dated 11/24/23 at 4:15 P.M., indicated Resident #99 had a fall in a common area, unwitnessed. Complaint of right rib pain Review of the health status note, dated 11/24/23, indicated: - S/P fall with complaints of right rib pain 9/10 and a noted abrasion, new order obtained to send to the ER for further evaluation and treatment by NP. Resident #99 is on Eliquis with a history of a stroke and right sided hemi-paresis. Resident was transferred out to Holy Family Hospital by EMS-assisted off of the floor with 2 assist by EMS. BP noted to be Hypotensive on initial Vital sign check, unable to obtain further vital signs secondary to Resident moving his/her arm with increased pain. Review of the health status note, dated 11/24/23, indicated: - Resident admitted to pneumothorax (collapsed lung). Review of the health status note, dated 12/1/23, indicated: - Resident readmitted . 5. Review of the health status note, dated 12/3/23, indicated: - Patient with unwitnessed fall @12:40 P. M. in day room. Staff heard loud noise coming from dayroom, this writer at med cart by room [ROOM NUMBER] at the time, also heard loud noise, and ran to day room at the time. Patient found by sink lying on floor on L side. Denied hitting head, stated I walked over to get some soda. Stated my chest hurts while guarding R side of body. On call provider notified of findings, new order to send to ED for evaluation. 6. Review of the incident report, dated 12/6/23 at 8:20 A.M., indicated Resident #99 had a fall in a common area, unwitnessed. I was just moving in my seat, and I slipped Review of the health status note, dated 12/6/23, indicated: - Patient with unwitnessed fall this AM @8:20 A, found sitting on floor in front of wheelchair, with slipper socks on, liner clean, no fluids noted on floor. Patient stated he/she slid to the floor on my ass. Patient attempting to reposition himself/herself per conversation, intervention; [NAME] [sic] (dycem a non-slip, rubber-like plastic material used to stabilize surfaces) to wheelchair cushion. Review of the health status note, dated 12/8/23, indicated: - falls reviewed at risk. Patient intervention for fall was to monitor in common areas while awake and [NAME] to wheelchair in place 7. Review of the incident report, dated 12/9/23 at 1:45 P.M., indicated Resident #99 had a fall in a common area, witnessed by a staff member. Review of the health status note dated 12/9/23, indicated: - At around 1:45 pm Resident was sitting next to nurse station; he/she was trying to stand up lost balance and fell to the floor. 8. Review of the incident report, dated 12/16/23 at 4:03 P.M., indicated Resident #99 had a fall in a common area, unwitnessed. Resident #99 had head trauma to the back of the head. Review of the health status note, dated 12/16/23, indicated: -Nurse heard loud noise near nurses' station, noted patient was on the floor, bleeding from his/her head. Pt unable to verbalize what he/she was trying to do and why he/she got up unattended. 911 called and transferred to hospital. Review of the health status noted, dated 12/17/23, indicated: - returning from hospital, 6 staples to head laceration. 9. Review of the incident report, dated 12/18/23 at 7:30 P.M., indicated Resident #99 had a fall in the dining room, unwitnessed. Review of the health status note, dated 12/18/23, indicated: -Patient having a fall in the dining room next to dining room table. Review of the physician's order, dated 11/30/23, indicated: - Supervision at meals with meals 10. Review of the incident report, dated 12/19/23 at 4:45 P.M., indicated Resident #99 has a fall in the common area, unwitnessed. Resident #99 sustained a skin a skin tear on the left elbow. Review of the health status note, dated 12/19/23, indicated: - Resident was noted on the floor in the dining Room at 4:45 pm. Left elbow old skin tear is reopened. 11. Review of the incident report, dated 12/20/23 at 5:20 P.M., indicated Resident #99 had a fall in the dining room, unwitnessed. Resident #99 sustained a skin tear on the lower center back. Review of the health status note, dated 12/20/23, indicated: - Patient fell today at 5:20 pm. He/she was attempting to get up from his wheelchair in the day room and lost his/her balance. He/she rated his/her pain a 6/10. I put him/her in bed to do a skin check and found a small superficial scrape on the center of his/her lower back. 12. Review of the incident report, dated 12/24/23 at 3:30 P.M., indicated Resident #99 had a fall in the common area, unwitnessed. Resident #99 sustained a skin tear on left elbow and an abrasion to the right elbow. Review of the health status note, dated 12/24/23, indicated: - Patient fell today in the common room at 1730. Patient fell facing forward and used his/her elbows to brace his/her fall. He/she got a scrape on each one of his/her elbows. Review of the health status note, dated 12/26/23, indicated: - Patient awake and attempting out of bed at 2 am. Patient remains out of bed near nurses station for safety. Review of the health status note, dated 12/27/23, indicated: - Patient was up all night. 13. Review of the incident report, dated 12/29/23 at 10:49 P.M., indicated Resident #99 had a fall in his/her room, unwitnessed. Resident #99 sustained a laceration to his/her left upper arm. Review of the health status note, dated 12/29/23, indicated: - Heard loud bang and patient yell out. Patient found on floor bleeding profusely from left arm. awake and alert. EMS called. pressure applied to site with ice. ambulance arrived and transferred patient to hospital. Review of the hospital paperwork, dated 12/30/23, indicated: - There is a 15-centimeter flap laceration that is deep into the subcutaneous tissue. Review of the incident report, dated 1/5/24, indicated: - Resident #99 had 12 sutures. Review of the MQS: Fall Risk Evaluation - V 2 assessment indicated the following: 11/13/23 Fall Risk score of 23, indicating he/she is a high fall risk. 11/21/23 Fall Risk score of 23, indicating he/she is a high fall risk. 11/24/23 Fall Risk score of 32, indicating he/she is a high fall risk. 12/18/23 Fall Risk score of 24, indicating he/she is a high fall risk. Review of the plan of care related to falls indicated the following interventions: - 11/2/23 Keep personal items and frequently used items within reach. Create a safe environment; floors clear of clutter, clean up spills, adequate lighting. Be sure the call light is within reach and provide reminders to use call for assistance as needed. Assist and/or remind me to change position and get up from sitting or lying slowly due to orthostatic blood pressure problems. - 11/9/23 Urinal at bedside - 11/13/23 Low bed in lowest position, except during care. Assist with incontinent care at the beginning of the 11-7 shift. Encourage resident, involved family members, and caregivers about safety reminders, fall prevention, and what to do if a fall occurs. - 11/24/23 Send to ER for evaluation, Medication Review of Cardiac Medications, Antibiotic for urinary tract infection. Resident has poor impaired vision. Make sure that the room has adequate lighting. Consult optometry as needed. Resident receives sedatives/ hypnotics at night for sleep. Monitor safety throughout the night. - 12/6/23 Non-skid socks at all times. - 12/9/23 Offer Toileting every 2 hours. - 12/16/23 Dycem to seat of chairs when out of bed, monitor scalp laceration. - 12/18/23 Toilet Resident first rounds 3-11, Staple removal. - 1/3/24 Mats on floor next to bed and anti-rollbacks (prevents a wheelchair from rolling backward and helps prevent falls. As the wheelchair resident begins to stand, the device grabs the tires to prevent the chair from rolling backward. When the resident is seated, the device is in standby mode and the chair can be easily moved in all directions) on wheel chair. On 1/23/24 at 12:09 P.M., Resident #99 was in his/her wheelchair in a common area unsupervised by staff, the antiroll backs were not engaged (the brake arms were not positioned over the tires and the lift lever was not in the functioning position) and Resident #99 was not seated on dycem. On 1/23/24 at 5:25 P.M., Resident #99 was in his/her wheelchair in a common area, the antiroll backs were not engaged and Resident #99 was not seated on dycem. On 1/24/24 at 12:12 P.M., Resident #99 was in his/her wheelchair in a common area, the antiroll backs were not engaged, and Resident #99 was not seated on dycem. On 1/24/24 at 2:46 P.M., the surveyor observed Resident #99 transfer to bed with Certified Nurse Assistant (CNA) #6. When CNA #6 stood Resident #99 up and out of his/her wheelchair the chair began to roll back. CNA #6 said the antiroll backs were broken. There was no dycem under Resident #99. On 1/25/24 at 10:09 A.M., CNA #6 transferred Resident #99 from the bed to the wheelchair, there was no dycem on the chair and when Resident #99 sat in the wheelchair the anti-rollbacks did not engage. CNA #6 said the antiroll backs were still broken. On 1/25/24 at 11:08 A.M., CNA #6 and CNA #8 transferred Resident #99 into the bathroom. When CNA #6 and CNA #8 stood Resident #99 up the wheelchair slid back and the anti-rollbacks were not engaged. There was no dycem on the wheelchair. On 1/25/24 at 11:16 A.M., CNA #6 and CNA #8 transferred Resident back into the wheelchair. There was no dycem in the chair and CNA #6 and CNA #8 said they were not aware that Resident #99 required dycem. CNA #6 and CNA #8 tried to adjust the anti-rollback and said that they were broken and not working. During an interview on 1/24/24 at 1:50 P.M., CNA #7 said that Resident #99 has a history of falls. CNA #7 said Resident #99 uses a standard cushion and is not aware he/she needs dycem. During an interview on 1/24/24 at 2:24 P.M., CNA #6 said Resident #99 has a history of falls. CNA #6 said that Resident #99 uses the bathroom and does not use a urinal. During an interview on 1/25/24 at 8:22 A.M., Nurse #6 said Resident #99 has a history of falls. Resident #99 uses antiroll backs to his/her wheelchair. During an interview on 1/25/24 at 12:21 P.M., the Director of Nursing (DON) said she was aware that Resident #99 did not have dycem on his/her wheelchair. The DON said that Resident #99 has a fall history and nursing should implement the interventions to prevent falls. 45984 2.) Resident #92 was admitted to the facility in May 2023 with diagnoses including type 2 diabetes mellitus, atherosclerosis, and legal blindness. Review of Resident #92's most recent Minimum Data Set Assessment (MDS) indicated the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicating that the Resident is cognitively intact. The MDS further indicated Resident #92 required assistance with all activities of daily living. On 1/24/24 at 11:45 A.M., the surveyor observed Resident #92 lying in his/her bed with his/her feet exposed. Resident #92's feet were observed to have large, fluid filled blisters on them. Review of Resident #92's nursing progress notes indicated the following: *Dated 12/16/23 at 3:15 P.M. written by Nurse #1: [Resident #92] was sitting in his/her w/c (wheelchair) with his/her feet resting on the room heater wrapped in blankets. He/she was then assisted back to bed. *Dated 12/18/23 at 12:19 P.M.: It was brought to this UM's (Unit Manager) attention that (Resident #92) has burns on his/her feet from sleeping with his/her feet on the heater. When asking the Resident why he/she sleeps with his/her feet on the heater he/she states that he/she is very cold. He/she also stated that he/she doesn't feel the burns so he/she will continue to do this. We have offered resident more blankets and he/she said that might help. Resident seen by wound MD (medical doctor) and NP (nurse practitioner). Notified DON (director of Nursing) and administrator. *Dated 1/2/24: At 10:20 A.M. resident noted to have increased lethargy. Resident noted to have left sides weakness. NP made aware and new order to send resident to hospital for Evaluation. Review of Resident #92's care plan for resistive care (refusing care, treatment) related to ineffective coping skills, dated 11/22/23 indicated the following interventions: *Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Review of Resident #92's skin breakdown care plan dated 5/20/23 was updated after the Resident received burns on his/her feet from putting his/her feet on the heater despite staff being aware of the Resident's behaviors. Review of Resident #92's nursing progress notes from 12/16/23 through 12/18/23 failed to indicate any education or refusal of care was documented regarding the Resident putting his/her feet on the heater. Review of Resident #92's medical record indicated safety interventions to prevent injury were only put into place after the Resident burned his/her feet despite staff knowing of Resident #92's behaviors prior to being burned. Review of a wound evaluation and management summary from the wound doctor written on 12/18/23 indicated Resident #92 had a burn on his/her left, lateral foot; a burn on his/her right, medial foot; a burn of the right lateral foot. Review of Resident #92's hospital discharge summary dated 1/2/2024 indicated the following: *Hospitalist course: Sepsis from cellulitis. LE (lower extremity) wounds seem likely entry point, continue wound care. *Wound care: Bilateral feet and left heel burns Review of a General Medicine Progress Note from the Hospital dated 1/2/2024 indicated the following: *Cellulitis of lower extremities *Sepsis from cellulitis During an interview on 1/24/24 at 12:41 P.M., Nurse #2 said Resident #92 had burns on his/her feet from putting them on the heater. She continued to say that the Resident is diabetic and has neuropathy (numbness from nerve damage) in his/her feet so he/she did not feel them burning. She said the Resident would often turn the heat so he/she could feel warmer. She then said since his/her injury we switched his/her room so he/she would not be on the side where the heater is. During an interview on 1/24/24 at 12:53 P.M., Resident #92 said he/she would put his/her feet on the heater all the time but he/she did not feel his/her feet burning. When asked if staff members have ever seen the Resident put his/her feet on the heater, the Resident responded with I am sure staff have seen me with my feet up there before. During an interview on 1/24/24 at 1:54 P.M., Nurse #1 said she does not normally work on the B unit (where Resident #92 resides), it was her first time on that unit. She said she saw Resident #92's feet wrapped in blankets and on the heater and she told the resident to take his/her feet off the heater so he/she would not burn his/her feet. Nurse #1 then said she was told by nurses who normally work on that unit that Resident #92 has been putting his/her feet on the heater. During an interview on 1/24/24 at 2:18 P.M., Certified Nursing Assistant (CNA) #1 said Resident #92 likes to be warm so he/she would put his/her feet on the heater. He continued to say the Resident has little to no feeling in his/her feet so he/she did not know they were burning. During an interview on 1/24/24 at 2:19 P.M., Unit Manager #1 said she did not know Resident #92 had a pattern of putting his/her feet on the heater. She thought he/she only did it once on 12/18/23. She was not aware of the nursing progress note written two days before the Resident burned his/her feet mentioning this behavior. She said the progress note written two days before the incident was written by the 11-7 shift and they never told her that the Resident was putting his/her feet on the heater, she said she would have expected someone to tell her. She continued to say if she knew about Resident #92's behavior of putting his/her feet on the heater she would have moved his/her room right away to prevent an accident from happening. Unit Manager #1 then said Resident #92 ended up going to the hospital with sepsis resulting from the burns on his/her feet. During an interview on 1/24/24 at 2:31 P.M., the Director of Nursing (DON) said if a resident sustains a burn in the facility, it should be reported and investigated right away. When asked about Resident #92's feet, the DON initially said she was not aware he/she burned his/her feet. The surveyor and the DON looked though Resident #92's incident/accident reports for December 2023 and did not see a report mentioning the burns on his/her feet. She said she would have the wound doctor assess Resident #92's feet and she would do it herself as well, she said she did not assess his/her feet. She continued to say if she knew that Resident #92 was putting his/her feet on the heater she would have expected that preventative interventions to be put in place right away.

Based on interviews, record review and facility policy review the facility failed to maintain acceptable parameters of nutritional status, by providing adequate interventions to maintain body weight and prevent weight loss for 1 Resident (#60) out of a total sample of 21. Specifically, for Resident (#60) the facility failed to follow a physician's order to obtain weekly weights resulting in the failure to identify an unplanned, significant weight loss of 18.8 pounds (11.9%) over 6 weeks. Findings include: Review of the facility policy titled Weight Monitoring Standard, with a revision date of March 2017, indicated the following: *Policy-Each resident will be weighed and measured within 24 hours of admission. *Each resident will be weighed within 24 hours of re-admission. *Each resident will be weighed weekly for 4 weeks following admission or readmission. *Residents identified with or at risk for compromised nutrition status will continue to be weighed weekly and referred to the weight and nutrition committee. *All residents who are stable and not deemed at risk for compromised nutrition status will be weighed monthly, unless there is a provider order to discontinue weighing the resident. *Weights may be obtained more frequently, depending upon a resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *Weight variance parameters- 1. Unintentional gain or loss of 2% or more in 1 week. 2. Unintentional gain or loss of 5% or more in 1 month. 3. Unintentional gain or loss of 7.5% or more in 3 months. 4. Unintentional gain or loss of 10% or more in 6 months. Resident #60 was admitted in May 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #60 scored a 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating a severe cognitive deficit. Further review of the MDS indicated that Resident #60 required supervision with eating. Review of Resident #60's Nutritional status care plan last edited on 3/30/21 indicated the following goal: *Will have stable weight without significant change. Review of Resident #60's April 2021 physician's orders indicated the following: *Order start date 11/6/20- Weekly weight on Mondays 7-3 shift. Review of the electronic medical record vital sign-weights indicated the following weights: *2/8/21- 156 pounds *2/17/21- 157.2 pounds *4/11/21- 139.2 pounds *4/14/21- 141 pounds (a total loss of 9.61% of his/her body weight since 2/8/21) On 4/15/21, the surveyor reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -February MAR *weekly Monday weights were not documented. -March MAR *3/1/21-158 pounds. 3/8/21,3/15/21,3/22/21 and 3/29/21 weights were not documented. -April MAR 4/5/21 weight was not documented. 4/12/21-139 pounds (a total loss of 11.9% his/her body weight since 3/1/21) A review of all documented weights for Resident #60 failed to indicate that any weights were obtained from the weight documented on 3/1/21 to the weight documented on 4/11/21, despite a physician's order for weekly weights. During an interview on 4/15/21, at 12:56 P.M., Nurse #1 said that the Nurses are responsible for telling the Certified Nurse's Aides (CNA) when weights are due. Nurse #1 said that she did not know why the weights were blank on the MAR for the entire month of February, 4 Mondays in March and one Monday in April. Nurse #1 said maybe they were in the computer or the CNA's documented them somewhere else. Nurse #1 could not find any additional documented weights to show the surveyor. Review of the March 2021 through April 14, 2021 Physician's progress notes indicated that Resident #60 was to be weighed weekly on Mondays. Further review indicated that the Physician was not aware of a significant weight loss until 4/14/21. Review of Resident #60's March 2021 through April 13, 2021 Physician's orders failed to indicate that Resident #60 was receiving any type nutritional supplement until 4/14/21 when the Physician wrote the following orders: *Glucerna (a diabetic nutritional supplement) three times daily -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *Registered Dietitian Consult-diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Dietitian's progress notes indicated the following notes for Resident #60: *3/29/21- Resident reviewed for annual nutrition assessment weight 157.2 pounds 2/17/21 indicating weight stable for 6 months, updated March weight needed to fully assess weight status. Most recent body mass index 27.84, within normal limits for older adult, goal is weight maintenance, weekly weights ordered. No acute nutrition concerns this quarter, recommend continue current interventions, will continue to monitor intakes, weights, medications, labs and status. *4/19/21-Registered Dietitian aware of significant weight loss. Weight 139 pounds 4/11 indicating 12% loss, compared to 158 pounds 3/1/21. Resident reweighed at 141 pounds on 4/14/21 and 143.6 pounds 4/19/21 with a slight uptrend x 1 week but overall still a significant loss. Resident with previous weight loss November 2020, Glucerna was ordered with good effect and discontinued in December 2020 following a period of weight gain and improved intakes. Glucerna supplement ordered 4/14, was not well received by resident, order updated to magic cup at all meals. During an interview on 4/20/21, at 10:05 A.M., Dietitian #2 said that he did not provide a consult for Resident #60 when he was in on 4/14/21, he further said that he requested a reweigh of Resident #60 on 4/14/21, however did not complete a consult. During an interview on 4/20/21, at 10:27 A.M., Dietitian #1 said that she was in on 4/12/21 and she ran the weight report, she said that she worked her way about half way down the list of residents to see and then left the remainder of the list for Dietitian #2 to complete when he came in on 4/14/21. Dietitian #1 said that she did not provide a consult for Resident #60 on 4/12/21. Dietitian #1 further said that she provided a consult on 4/19/21, 8 days after the significant weight loss was identified. During an interview on 4/20/21, at 11:35 A.M., The Director of Nursing (DON) said that once Resident #60's weight became stable at the end of December he/she stopped being discussed at the weekly weight risk meeting. The DON said that Resident #60 was supposed to be a weekly weight and she did not know why the weights were not obtained. The DON further said that she would have expected the dietitian to provide a consult on 4/14/21.

Based on interviews and records reviewed, for two of five sampled residents (Resident #2 and Resident #5), the Facility failed to provide an environment free from abuse, when Resident #1, who was known to be sexually abusive to others, was not appropriately monitored and sexually abused Residents #2 and #5. -On 12/31/18, Resident #1 was found by staff in Resident #5's room holding him/her up on the side of his/her bed with his/her face approximately an inch from Resident #1's exposed genitalia. -On 3/17/19, Resident #1 entered Resident #2's room while Resident #2 was sleeping and reached under Resident #2's blankets and touched his/her genitalia. Findings include: The Facility Policy titled Resident Abuse, dated 4/2017, indicated residents had the right to be free from abuse, and sexual abuse was defined as including, but not limited to sexual harassment, sexual coercion, sexual assault, or any non-consensual sexual contact of any type with the resident. The Facility Policy titled Resident to Resident Altercation, dated 7/2017, indicated the Facility would provide supervision of residents to prevent resident to resident altercations and ensure safety of residents. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Care Plan, dated 6/29/18 and updated on 10/2/18, indicated Resident #1 was known to wander intrusively into other residents' rooms, and was known to physically and verbally attack staff. Interventions included when out of room, Resident #1 would remain in a supervised area, and an alarm on his/her bedroom door to alert staff when he/she exited his/her room. The Care Plan updated on 1/4/19 to include one on one monitoring by staff. The Care Plan was also updated on 2/8/19 to include an alarmed floor mat inside Resident #1's room with the alarm box placed outside the room to alert staff when Resident #1 was exiting the room, and decrease one on one supervision on the 11:00 P.M. to 7:00 A.M. shifts to every 15 minute checks, with attention to alarms. Resident #2 was admitted to the Facility in (MONTH) 2019, [DIAGNOSES REDACTED]. Resident #5 was admitted to the Facility (MONTH) 2014, [DIAGNOSES REDACTED]. The Care Plan, dated 5/16/14, and updated 12/6/18, indicated Resident #5 was nonverbal due to cognitive loss, and had a history of [REDACTED]. The Care Plan, dated 6/29/18, updated 1/22/19, indicated Resident #1 was to be seated away from females, and one on one supervision at all times. The Nurse's Note, dated 9/4/18 and signed by Unit Manager #1, indicated Resident #1 was observed guiding another resident (later identified as Resident #5) into another room and closing the door. The Note indicated when staff opened the door and asked Resident #1 what he/she was doing, Resident #1 said nothing and left the room. The Note indicated Resident #1 was placed on 15 minute checks due to his/her history of sexually inappropriate behavior. The Surveyor interviewed Unit Manager #1 at 10:04 A.M. on 3/26/18. Unit Manager #1 said Resident #1 was known to be sexually inappropriate and had known behaviors towards staff and residents. Unit Manager #1 said Resident #1 was intermittently on one on one supervision and 15 minute checks during his/her admission on the Dementia Unit. Unit Manager #1 said there was an alarm placed at Resident #1's bedroom door to alert staff when he/she exited his/her room, however Resident #1 eventually learned how to disable the alarm and at times the unit was busy and staff didn't always hear the alarm sound. Unit Manager #1 said the Dementia Unit had a vulnerable population, and said Resident #1 was known to seek out certain residents (including Resident #5) and appeared to be stalking them. Unit Manager #1 said that on 9/4/18, some time in the morning, she witnessed Resident #1 ushering something into another resident's room and close the door. Unit Manager #1 said she went to the room and found Resident #5 was across the room near the window and Resident #1 was still near the door. Unit Manager #1 said when she asked Resident #1 what he/she was doing, Resident #1 said words to the effect of nothing, and left the room. Unit Manager #1 said Resident #5 was nonverbal and unable to answer any questions related to the incident. The Facility's Investigation Report, dated 12/31/18, indicated Resident #1 was observed by staff entering Resident #5's room at approximately 8:30 P.M. on 12/31/18. The Report indicated Resident #1 was found holding Resident #5 up by his/her shoulders on the side of the bed and Resident #1's penis was out of his/her pajamas. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 4:28 P.M. on 3/25/19. CNA #1 said that on 12/31/18 at approximately 8:30 P.M. another staff member said she saw Resident #1 enter another resident's room (later identified as Resident #5's room). CNA #1 said she went to Resident #5's room and saw Resident #5's bed was in the low position, and his/her legs were off the side of the bed, and Resident #1 had his/her hands on Resident #5's shoulders, pulling Resident #5's face towards his/her groin area, and Resident #1's pajama pants were open and his/her penis was exposed. CNA #1 said Resident #1 was facing her. CNA #1 said Resident #5's face was almost touching Resident #1's genitalia. CNA #1 said she told Resident #1 to stop, and Resident #1 let go of Resident #5. CNA #1 said she could not recall if she heard Resident #1's door alarm sounding at that time. The Surveyor interviewed Nurse #1 at 2:52 P.M. on 3/25/19. Nurse #1 said Resident #1 was known to be sexually inappropriate and said staff were aware of his/her behaviors. Nurse #1 said there was an alarm placed at the door of Resident #1's room to alert staff when he/she exited his/her room, and said Resident #1 was known to turn off the alarm at times. Nurse #1 said that at approximately 8:30 P.M. on 12/31/18, another staff member said that Resident #1 had entered another resident's room (later identified as Resident #5's room). Nurse #1 said she entered Resident #5's room behind CNA #1, and saw Resident #1 standing next to Resident #5's bed, holding Resident #5 in a seated position with his/her hands on Resident #5's shoulders. Nurse #1 said Resident #5's face was almost touching Resident #1's groin area, and Resident #1 let go of Resident #5's shoulders as soon as she and CNA #1 entered the room. Nurse #1 said Resident #1 was transferred to the Hospital emergency room for psychiatric evaluation on 3/25/19, after this incident. The Telephone Order, dated 1/4/19, indicated Resident #1 was readmitted to the Facility, and orders included one on one supervision. The Physician's Note, dated 2/28/19, indicated Resident #1 had a history of [REDACTED]. The Neuropsychologist's Note, dated 2/28/19, indicated Resident #1 had a history of [REDACTED]. The Note indicated Resident #1 was assessed as a threat to him/herself and others, and this was a chronic disorder. The Surveyor interviewed Unit Manager #2 at 11:58 A.M. on 3/26/19. Unit Manager #2 said Resident #1 was moved to her unit after a short hospital stay following the incident on 12/31/18 involving Resident #5. Unit Manager #2 said Resident #1 was on one on one supervision upon readmission to the Facility. Unit Manager #2 said that at some point, the one on one was discontinued on the 11:00 P.M. to 7:00 A.M. shifts, and a door alarm and 15 minute checks were initiated to monitor Resident #1. Unit Manager #2 said she voiced concerns to the Director of Nurses regarding the safety of other residents when removing one on one for Resident #1, and said removing one on one was mostly due to staffing concerns. Unit Manager #2 said she did not realize there was a Nurse Practitioner's order for one on one supervision for Resident #1, and said she thought it was a nursing measure. The Facility's Investigation Report, dated 3/20/19, indicated that at approximately 4:30 A.M. on 3/17/19, Resident #1 wandered into Resident #2's room while Resident #2 was asleep. The Report indicated that on 3/20/19, Resident #2 alleged that on 3/17/19, Resident #1 reached under his/her blankets and touched his/her genitalia. The Surveyor interviewed CNA #2 at 6:50 A.M. on 3/26/19. CNA #2 said that Resident #1 was known to be sexually inappropriate and known to wander into other residents' rooms. CNA #2 said Resident #1 was assigned a staff member for one on one supervision from 7:00 A.M. to 11:00 P.M., but on the 11:00 P.M. to 7:00 A.M. shift he/she was on every 15 minute checks and had an alarm at his/her bedroom door to alert staff if he/she left his/her room. CNA #2 said that at approximately 4:30 A.M. on 3/17/19, he heard Resident #1's door alarm sounding. CNA #2 said he could not immediately respond to the alarm because he was providing care for another resident in another room. CNA #2 said when he came out of the other room, he observed Resident #1 moving quickly into another resident's room on the opposite side of the hall as his/her own room, and said he redirected Resident #1 back to his/her own room at that time. CNA #2 said Resident #2's call bell was on, and when he answered the light, Resident #2 said someone was just in his/her room. Resident #2's room was located on the same side right next to Resident #1's room. CNA #2 said Resident #2 did not say that Resident #1 had touched him/her at that time. The Surveyor interviewed Resident #2 at 8:37 A.M. on 3/26/19. Resident #2 said that on 3/17/19 in the early morning, he/she was asleep in his/her bed, and woke up when he/she heard someone in his/her room. Resident #2 said he/she looked and saw a person in the room (later identified as Resident #1), and thought it was a staff member, so he/she rolled over facing away from the person and closed his/her eyes. Resident #2 said moments later, he/she felt someone reach under the blankets and felt a hand touch his/her genitalia. Resident #2 said he/she grabbed Resident #1's arm and said get out or words to that effect, and recognized the person as Resident #1 when he/she saw Resident #1 leaving the room. Resident #2 said he/she told CNA #2 that Resident #1 was in his/her room, but did not tell staff that Resident #1 had touched him/her until 3/20/19. The Surveyor interviewed the Director of Nurses at 8:02 A.M. and throughout the dates of this survey. The Director of Nurses said that Resident #1 was known for sexually inappropriate behavior and sexually assaulting Resident #5. The Director of Nurses said that following the incident on 12/31/18 when Resident #1 sexually assaulted Resident #5, Resident #1 was moved to another unit, where he/she was initially placed on one on one supervision at all times, and the Facility eventually decreased the one on one supervision to 15 minute checks on the 11:00 P.M. to 7:00 A.M. shifts. The Director of Nurses said the Facility was actively seeking alternate placement for Resident #1 throughout that time.

Based on record review and interview, the facility failed for 1 of 8 residents (Resident #1), to ensure during an undetermined period of time prior to [DATE] and on unknown dates, that Nurse #1 did not repeatedly in a loud or yelling tone of voice say shut up to Resident #1 and to other residents (identities unknown) on the dementia care unit when displaying socially inappropriate behavior in the living room. Findings include: The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:35 P.M. on [DATE]. CNA #1 said on an unknown date during the week of [DATE], she witnessed an incident while standing between 5 to 10 feet away from Nurse #1. CNA #1 said Resident #1 was speaking loudly in the living room, and then Nurse #1 and Resident #1 bickered with each other for approximately 5 minutes. CNA #1 said as Nurse #1 began to walk away from Resident #1, she turned to face Resident #1 and loudly said shut up to him/her. CNA #1 said Resident #1 replied by saying words to the effect of you shut up to Nurse #1. CNA #1 said she told Nurse #1 that she should speak nicely to Resident #1, and Nurse #1 in response rolled her eyes. CNA #1 said she did not immediately report the incident until information was requested by Administration. The Surveyor interviewed CNA #2 at 3:45 P.M. on [DATE]. CNA #2 said approximately 3 days a week (dates unknown), over a 2 month period of time, Nurse #1 yelled shut up to Resident #1 and to another resident (whose identity was unknown to CNA #2 and who was now deceased ) in the living room while Nurse #1 stood by the entrance at the medication cart. CNA #2 said Nurse #1 yelled at Resident #1 and the other residents to shut up in response to them displaying yelling out behavior. CNA #2 said Nurse #1 stated Resident #1's first name after saying shut up to him/her. CNA #2 said CNA #2 said she did not report the incidents to the Administrator, the Director of Nurses or to a Supervisor. The Surveyor interviewed Family Member #1 at 3:30 P.M. on [DATE]. Family Member #1 said approximately 4 days a week while visiting the unit over a 6 month period of time (dates unknown), Nurse #1 yelled shut up to Resident #1 and other residents (identities unknown) in the living room. Family Member #1 said Nurse #1 yelled shut up to Resident #1 followed by his/her first name in response to Resident #1 making repetitive verbalizations, such as asking the time. Family Member #1 said on one occasions Resident #1 responded by saying words to the effect of that's not very nice deary after Nurse #1 told him/her to shut up. Family Member #1 said Nurse #1 yelled shut up at the other residents when they displayed yelling out behavior.

Based on record review and interview, the facility failed for 1 of 8 residents (Resident #1), to ensure employees immediately reported an allegation of abuse to the Administrator that Nurse #1 was heard in a loud or yelling tone of voice saying shut up to Resident #1 and to other residents (identities unknown) residing the dementia care unit's living room when displaying socially inappropriate behavior. The failure to report the allegation of abuse to Administration resulted in the failure to prevent reoccurrences of Nurse #1 telling Resident #1 and other residents to shut up and resulted in the allegation of abuse not being reported within 5 working days of the incident to the Department of Public Health. Findings include: The Surveyor reviewed of the Facility's Resident Abuse Policy and Procedure (revised on [DATE]). The Resident Abuse Policy and Procedure indicated that when abuse is observed or suspected by any employee, staff immediately notifies the Administrator, Director of Nursing, or the Nursing Supervisor on duty who would then remove the accused employee from all resident contact, and suspend the employee (pending the outcome of the facility investigation). The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:35 P.M. on [DATE]. CNA #1 said on an unknown date during the week of [DATE], she witnessed an incident while standing between 5 to 10 feet away from Nurse #1. CNA #1 said Resident #1 was speaking loudly in the living room, and then Nurse #1 and Resident #1 bickered with each other for approximately 5 minutes. CNA #1 said as Nurse #1 began to walk away from Resident #1, she turned to face Resident #1 and loudly said shut up to him/her. CNA #1 said Resident #1 replied by saying words to the effect of you shut up to Nurse #1. CNA #1 said she told Nurse #1 that she should speak nicely to Resident #1, and Nurse #1 in response rolled her eyes. CNA #1 said she did not immediately report the incident until information was requested by Administration. The Surveyor interviewed CNA #2 at 3:45 P.M. on [DATE]. CNA #2 said approximately 3 days a week (dates unknown), over a 2 month period of time, Nurse #1 yelled shut up to Resident #1 and to another resident (whose identity was unknown to CNA #2 and who was now deceased ) in the living room while Nurse #1 stood by the entrance at the medication cart. CNA #2 said Nurse #1 yelled at Resident #1 and the other residents to shut up in response to them displaying yelling out behavior. CNA #2 said Nurse #1 stated Resident #1's first name after saying shut up to him/her. CNA #2 said CNA #2 said she did not report the incidents to the Administrator, the Director of Nurses or to a Supervisor. The Surveyor interviewed the Administrator at 3:15 P.M. on [DATE]. The Administrator said none of the facility employees reported the allegation that Nurse #1 told Resident #1 and other residents to shut up to herself, the Director of Nurses or to a Supervisor. The Administrator said immediately after Family Member #1 reported the allegation on [DATE] to her, Nurse #1's employment was suspended and an investigation was conducted. The Administrator said during the course of the investigation, CNA #1 reported having heard Nurse #1 tell Resident #1 to shut up. The Administrator said CNA #2 did not report that she heard Nurse #1 tell Resident #1 and other residents to shut up. Review of the Department of Public Health's Incident Report Form indicated that on [DATE] the Facility reported an allegation of abuse against Nurse #1 following a report by Family Member #1 that Nurse #1 was heard to scream shut up at Resident #1 approximately every week.

Based on record review and interview, the facility failed for 1 of 8 residents (Resident #1), to ensure employees immediately reported that Nurse #1 was heard in a loud or yelling tone of voice saying shut up to Resident #1 and to other residents (identities unknown) residing the dementia care unit's living room when displaying socially inappropriate behavior. Findings include: The Surveyor reviewed of the Facility's Resident Abuse Policy and Procedure (revised on [DATE]). The Resident Abuse Policy and Procedure indicated that when abuse is observed or suspected by any employee, staff immediately notifies the Administrator, Director of Nursing, or the Nursing Supervisor on duty who would then remove the accused employee from all resident contact, and suspend the employee (pending the outcome of the facility investigation). The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:35 P.M. on [DATE]. CNA #1 said on an unknown date during the week of [DATE], she witnessed an incident while standing between 5 to 10 feet away from Nurse #1. CNA #1 said Resident #1 was speaking loudly in the living room, and then Nurse #1 and Resident #1 bickered with each other for approximately 5 minutes. CNA #1 said as Nurse #1 began to walk away from Resident #1, she turned to face Resident #1 and loudly said shut up to him/her. CNA #1 said Resident #1 replied by saying words to the effect of you shut up to Nurse #1. CNA #1 said she told Nurse #1 that she should speak nicely to Resident #1, and Nurse #1 in response rolled her eyes. CNA #1 said she did not immediately report the incident until information was requested by Administration. The Surveyor interviewed CNA #2 at 3:45 P.M. on [DATE]. CNA #2 said approximately 3 days a week (dates unknown), over a 2 month period of time, Nurse #1 yelled shut up to Resident #1 and to another resident (whose identity was unknown to CNA #2 and who was now deceased ) in the living room while Nurse #1 stood by the entrance at the medication cart. CNA #2 said Nurse #1 yelled at Resident #1 and the other residents to shut up in response to them displaying yelling out behavior. CNA #2 said Nurse #1 stated Resident #1's first name after saying shut up to him/her. CNA #2 said CNA #2 said she did not report the incidents to the Administrator, the Director of Nurses or to a Supervisor. The Surveyor interviewed the Administrator at 3:15 P.M. on [DATE]. The Administrator said none of the facility employees reported the allegation that Nurse #1 told Resident #1 and other residents to shut up to herself, the Director of Nurses or to a Supervisor. The Administrator said immediately after Family Member #1 reported the allegation on [DATE] to her, Nurse #1's employment was suspended and an investigation was conducted. The Administrator said during the course of the investigation, CNA #1 reported having heard Nurse #1 tell Resident #1 to shut up.

2. For Resident #12, the facility failed to provide hand strengthening exercises resulting in a decreased ability to use eating utensils with his/her right hand. Resident #12 was admitted to the nursing facility with [DIAGNOSES REDACTED]. Review of the medical record revealed that Resident #12 had been seen by Occupational Therapy from 4/4/12 through 4/30/12 for Activities of Daily Living, transfers, mobility and hand strengthening exercises. An Occupational Therapy daily note, dated 4/17/12, indicated that Resident #12 was encouraged to brush his/her hair; "patient states I cannot because of the broken bones in this hand (right hand), I cannot even eat my supper. Patient has even been observed feeding self with left hand with no deficits." A 4/18/12 note documents that hand therapy with Theraball was started and that the patient demonstrated some limited range of motion to the right shoulder. On 4/19/12, an Occupational Therapist documented that CNA (certified nursing assistant) staff would be in-serviced regarding a hand therapy program. Review of the care plans and CNA care card for Resident #12 indicated that there were no interventions or documentation regarding the hand therapy program. Resident #12 was observed during the noon meal on 8/21/12 and 8/22/12. Resident #12 was observed on 8/21/12 to pick up vegetables on her plate with a spoon in his/her left hand and to push the vegetables onto the spoon with the fingers of his/her right hand. On 8/22/12, Resident #12 was observed to pick up and eat a sandwich with his/her left hand. Resident #12 was interviewed on 8/22/12 at 2:30 P.M. Resident #12 stated that the hand therapy had not been done for a few months. Resident #12 stated that the Theraball was not in his/her room. Resident #12 further stated that his/her ability to use the right hand was limited (the resident stated he/she was right handed). "I have a hard time using my right hand, especially with soup at the evening meal. I have to use my left hand and I spill a lot of the soup." The Director of Rehab was interviewed on 8/22/12 at 2:40 P.M. regarding the hand therapy program for Resident #12. The Director of Physical Therapy stated that CNA staff had been inserviced to provide hand therapy. An Inservice Education sheet, dated 4/19/12, was provided which indicated that CNA staff had been inserviced to provide hand strengthening exercises twice daily (after breakfast and lunch) and that the Theraball and cue card for the exercises were located in the Resident's top drawer of the nightstand. Unit Manager #2 was interviewed on 8/22/12 at 2:55 P.M. Unit Manager #2 stated that she was unaware of the hand therapy program, and that the CNAs were supposed to be doing the hand therapy with Resident #12. Unit Manager #2 stated that the Theraball and cue care for exercises were not in the Resident's nightstand. 3. For Resident #15, the facility failed to provide appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Resident #15 was admitted to the facility on [DATE] with a history of [MEDICAL CONDITION]. According to an Initial MDS dated [DATE], the resident needed extensive assistance with bed mobility, transfers, ambulation, dressing and bathing. The resident was receiving occupational therapy (OT) for upper body active range of motion. A document in the resident's record indicated that an in-service was conducted by OT staff on 7/11/12 to provide nursing staff with education on performing arm exercises with the resident. The documentation indicated the objective was for the resident to be in a sitting or supine position as needed. The railings were to be lowered and the resident would call to raise the railings once the exercises were complete. The exercises are on a sheet on the bulletin board. Staff are to remove for use and return once the exercises are completed. The exercises included shoulder shrugs, clapping hands over head, crossing arms across the chest and arm circles. The resident was discharged from skilled OT on 7/12/12 and nursing staff were to ensure the exercises were done. Resident #15's room was observed on 8/23/12 at 9:30 A.M.. The bulletin board was located on the wall on the right side of the resident's bed. The sheet with the exercises was on the bulletin board, but pinned on the far end of the board and out of the resident's view. At this time, the surveyor took the exercise sheet from the bulletin board and asked the resident if he/she performs these exercises. The resident stated "I do them once in a while when I'm bored, but nobody helps me. I can't see the sheet where they put it very good anyway". On 8/22/12 at 4:00 P.M., the Rehabilitation Director stated staff were in-serviced regarding the exercises and was able to produce a copy of the in-service sheet. Based on observations, record review and staff interviews, the facility failed for 3 sampled residents (#2, #12, #15) with range of motion limitations, in a total sample of 24, to ensure the residents received appropriate treatment and services to prevent further decline. Findings include: 1. For Resident #2, the facility failed to ensure that the staff provided a maintenance hand strengthening exercise program resulting in the Resident's decline. Resident #2 was admitted to the facility on [DATE], and readmitted after a hospitalization on [DATE] with [DIAGNOSES REDACTED]. An Occupational Therapy (OT) note, dated 12/29/11, documented that the Resident required skilled OT 5 x per week, and was focused on self feeding; adaptive equipment training; range of motion and massage on both hands; and a new trial of a hand roll was conducted to provide comfort. Record review indicated a hand strengthening exercise sheet (not dated), which indicated that the Resident would perform the checked exercises in repetitions of 5; 2-3 x per day; 7 days a week. An in-service document in the Resident's record indicated that on 1/27/12, an in-service was conducted by the Occupational Therapist to provide nursing staff with the education on performing hand strengthening exercises with the Resident. The documentation indicated the objective was to place the sheet with the exercises, along with a yellow foam block within the Resident's reach, and for staff to begin cueing the Resident to begin exercises. However, the staff who were trained, were no longer providing care to the Resident. Record review indicated an OT Discharge note, dated 1/30/12, which indicated a hand strengthening program was to be initiated by the Resident's caregivers. The Resident was to independently, with verbal cueing, begin hand exercises on both hands. The Resident was discharged from skilled OT on 1/30/12, and the nursing staff were to ensure that the exercises were done. Record review indicated that there was no documentation from 1/30/12 through 8/23/12 indicating that assisting the Resident with the functional maintenance hand exercises was performed 2-3 times a day as per the discharge instructions from OT. An annual Minimum Data Set (MDS), dated [DATE], identified the Resident as requiring total care for all activities of daily living, however, required only supervision with one person assist when eating. On 8/3/12, the Occupational Therapist documented that the Resident had reduced range of motion in his/her right hand, and that the Health Care Proxy (HCP) was concerned about the Resident's decline. A nursing note, dated 8/6/12, indicated that the Resident was to be treated by OT 3 x per week for 30 days to increase the range of motion of his/her right hand. A document in the Resident's record indicated that on 8/8/12, a weekly OT progress note indicated skilled intervention for the Resident was focused on range of motion and the strengthening of both hands. A quarterly MDS, dated [DATE], identified the Resident as requiring total care for all activities of daily living, and now needed to be fed by staff. During interview with the B Unit Manager on 8/21/12 at 10:30 A.M., she said that she was not aware that the Resident was to have functional maintenance exercises done by staff to prevent further decline on both hands. The B Unit Manager also said that there was no documentation on the CNA care card and/or a care plan in the Resident's record indicating that these exercises were to be initiated by the caregivers. During interview on 8/23/12 at 11:30 A.M., the lead Certified Nursing Assistant (CNA) for the day shift said that the CNAs provide cream and massage to both the Resident's hands. However, the staff were not aware that the Resident had a device (foam sponge) along with exercises that needed to be done 2-3 x daily; 7 days a week. On 8/23/12 at 11:45 A.M., per request of the Surveyor, the COTA (Certified Occupational Therapy Assistant) visited the Resident to discuss his/her hand strengthening exercises. The Resident said that she was not given any exercises for his/her hands in a long while, and the COTA found the foam sponge in the Resident's bedside table. However, the directions for the hand exercises were not in the bedside table. During interview, on 8/23/12 at 11:50 A.M., the COTA said that the Resident did not receive the hand strengthening exercises since January 2012, and that the Resident has the potential to feed self again.

Based on record review, observation and staff interview, the facility failed to ensure that 2 of 11 Residents (#9 and #10) in a total sample of 24, were provided adequate supervision and effective interventions to prevent accidents. Findings include: 1. For Resident #9, the facility failed to provide proper supervision to a Resident who was identified as being at risk for falls. The Resident later sustained two major injuries within a 10 month period. Findings include: Resident #9 was admitted to the facility in 3/2011. The Resident's current [DIAGNOSES REDACTED]. The Resident also speaks a different language and a communication book is available for staff to communicate with him/her. On 8/20/12, the Unit Manager identified the Resident as being alert and confused and understands some English. A review of the Resident's record was made between 8/20/12 and 8/21/22 and the record indicated the following: A Significant Change Minimum Data Set ((MDS) dated [DATE] identified the Resident as having short-term memory loss, being independent in transfers, ambulation and toileting and being continent of bladder. It also indicated that the Resident did not experience any falls. A Care Plan dated 4/4/11 through 9/29/11 and then updated again through 12/30/11 identified falls as a problem area. It indicated that the Resident was at risk for falls and injury due to decreased mobility, was easily fatigued and exhibited weakness due to a recent illness. In addition, the Resident had poor safety awareness. Approaches included keeping the Resident's walker close to the Resident at all times, encouraging the use of non-skid footwear, keeping the call bell within reach at all times and instructing the Resident on the use of the call bell as needed. A Care Plan dated 4/4/11 through 9/30/11 and then updated again through 12/30/11 identified Activities of Daily Living as an area of decline and included the interventions: Keep rolling walker close to Resident at all times and instruct in the proper use of the walker daily. Review of an Investigation Report dated 10/12/11 identified the Resident as being alert and oriented. It indicated that on 10/10/11 the Resident was attempting to ambulate in his/her room and was found on the floor at 12:15 A.M. The Resident suffered a Nondisplaced Fracture of the right Superior and Inferior Pubic Ramus. The Resident's ambulatory status was noted as: Rolling Walker Independent. The Report further stated that no equipment was used by the Resident at the time of the Resident's Fall. Specifically, no mention was made of the Resident's walker. A Nursing Note dated 10/10/11 11-7 A.M. indicated that the Resident was unable to verbalize what happened. A Quarterly MDS dated [DATE] identified the Resident as requiring extensive assistance of one for transfer, ambulation and toileting. The Resident did not experience any further falls. Review of an Incident Report dated 1/9/12 at 5:30 P.M. identified the Resident as sustaining a fall in the Dining Room while waiting for dinner. It indicated that the Resident unlocked his/her wheelchair and stood up. The wheelchair then rolled backwards and the Resident fell on to the floor. The chair alarm sounded and staff went in to the Dining Room to assist him/her. The Report further indicated that the Resident has Neuropathy, has difficulty walking, has muscle weakness and has a history of a Fracture of the Femur and a Stress Fracture of the Pelvis. It also indicated that the Resident stated he/she was not dizzy at the time of the fall and wanted to get up and walk without assistance. The Resident was sent to the Hospital and returned with a [DIAGNOSES REDACTED]. Review of a 1/10/12 Falls Committee note indicated that the Resident stood from the wheelchair and lost his/her balance in the Dining Room. It further indicated the Resident has periods of confusion, an unsteady gait and weakness. The Resident was to be screened by Physical Therapy for anti-roll backs to his/her wheelchair and staff were to continue to monitor. There was no intervention put in place to address the Resident's desire to get up and walk without assistance. The Quarterly MDS dated [DATE] identified the Resident as having memory loss and requiring extensive assistance of one in transfers, ambulation and toileting. The Resident was also identified as being frequently incontinent. The care plan dated through 9/30/12 identified Activities of Daily Living as an area of decline and included the approaches: Keep rolling walker close to Resident at all times, instruct on proper use of walker daily and staff to assist with all care daily. Record review indicated the Resident did not sustain any further falls until 8/12/12. A nursing note, dated 8/12/12 at 4:10 A.M., indicated that the Resident was self-ambulating three different times. The Resident did not use the call light and was educated to use it. No distress or discomfort were noted. The Resident's gait was noted to be unsteady and the Resident used the restroom 5 times. The Resident had been identified in the record as having memory loss and poor safety awareness since 4/11, yet nursing staff continued to implement the intervention of having the Resident use his/her call light when he/she needed assistance. Nursing staff did not implement any new interventions to address the Resident's periodic attempts to get up and ambulate by himself/herself. A review of an Investigation Report dated 8/17/12 identified the Resident as falling later that same day (8/12/12) at 2:05 P.M. while attempting to get out of bed and fracturing his/her left Superior Pubis Ramus. The report indicated that the Resident was found lying on the floor beside his/her bed. The Resident stated that he/she had to go to the bathroom and fell . The Report also indicated that there was no equipment used by the Resident at the time of the Resident's fall. Further review of the Report indicated a statement made by the Resident's aide that he had put the Resident into bed at around 1:30 P.M. At that time, the Resident asked for a drink of water and the aide gave the Resident a cup of water. The aide then asked the Resident if he/she needed anything else, the Resident said no and the aide then left the room. There was no further information given in regards to the placement of the Resident's walker after he/she was placed in bed. The Resident is presently non-ambulatory and requires the use of a Foley catheter. The Resident was observed on the following dates and times: On 8/20/12 at 4:00 P.M., the Resident was observed asleep in a low bed with two mats on the floor and a bed alarm attached. On 8/21/12 at 8:25 A.M., the Resident was observed sitting up in bed and eating breakfast. Two mats were on the floor and a bed alarm attached. The surveyor asked the Resident if he/she was all right and the Resident nodded that he/she was. Staff were present and assisting Residents. On 8/22/12 at 7:45 A.M., the Resident was observed asleep in bed. A bed alarm was attached and 2 mats were on the floor. On 8/23/12 at 12:30 P.M., the Resident was observed eating lunch in the Day Room. The Resident voiced no complaints. Staff were present and assisting the Resident. On 8/22/12 at 10:30 A.M., an interview was held with Certified Nursing Assistant (CNA) #3. CNA #3 stated that prior to the Resident's fall in 10/11, the Resident did not always use his/her call light as the Resident was forgetful. CNA #3 further stated that the Resident continues to be forgetful. On 8/22/12, an interview was held with the Director of Nurses and the Administrator at 2:30 P.M. and the Resident's falls with significant injuries were reviewed. The facility failed to provide proper supervision to this Resident who sustained major injuries and failed to develop proper interventions to keep the Resident safe from further falls. 2. For Resident #10, the facility failed to provide adequate supervision and effective interventions to prevent falls for this Resident, who was admitted with a hip fracture from a fall. The Resident fell 2 times in a 9 month period sustaining 2 injuries requiring hospitalization s. Resident #10 was admitted to the facility in 8/2011 with dementia and status [REDACTED]. A Falls Risk Assessment was conducted on 8/18/11 with a score of "19" which indicates the Resident is at high risk for falls. The Fall Risk care plan dated 8/18/11 included the following interventions: - Call bell in reach. - Clutter free environment. - Assist with transfers. - Assist with psychological needs. - Bed alarm. - Chair alarm. According to an Initial Minimum Data Set (MDS) completed on 8/31/11, the Resident had severely impaired cognition and needed extensive assistance with bed mobility, transfers, ambulation and toilet use. The Resident also had fallen prior to admission and fractured the right hip. Review of the Resident's medical record indicated that the Resident fell on [DATE]. According to a nurse's note dated 9/4/11, the Resident was found in his/her room lying on the floor at 8:25 A.M. with the alarm sounding. The Resident complained of right hip pain. The physician was notified, and an X-ray of the hips and pelvis was ordered. This X-ray report was negative for fractures. On 9/4/11, the Fall Risk care plan was updated with the following intervention: - Fall 9/4/11 in room, keep in supervised area when out of bed. On 9/5/11, the nurses' notes for the 7:00 A.M.-3:00 P.M. shift and the 3:00 P.M.-11:00 P.M. shift indicated the Resident continued to complain of right hip pain. The Resident was given Vicodin (a pain medication) to help alleviate the pain. On 9/6/11, the physician came to see the Resident and ordered an X-ray of the right femur and the right knee. This X-ray indicated an acute mid right femur fracture (the same side where the Resident had fractured his/her hip approximately 3 weeks earlier). The Resident was admitted to the hospital and had surgery to repair the fractured femur. The Resident returned to the facility on [DATE]. A new care plan for falls was initiated on 9/20/11 with the following problem statement: The Resident is at risk for falls and injury due to decreased mobility, easily fatigues, weakness and use of psychotropic medications. Interventions included: - Bed alarm. - Chair alarm. - Fall mat. - Call bed with in reach at all times. Instruct and reinforce on use of call bell. - Encourage utilization of call bell, staff assist and rolling walker. - Keep bed in lowest position. A Falls Risk Assessment conducted on 1/23/12 with a score of "16" which indicates the Resident is high risk for falls. According to a quarterly MDS completed on 1/30/12, the Resident had moderately impaired cognition, required extensive assistance with bed mobility, transfers and toilet use and limited assistance with ambulation. In addition, the Resident had no falls in the last 90 days. According to the facility incident report dated 4/16/12, the Resident fell on [DATE] at 4:15 A.M. The Resident's bed alarm sounded and the Certified Nursing Assistant (CNA) entered the room and found the Resident lying on the floor on his/her left side near the closet door. The Resident was toileted at 3:45 A.M. At the time of the fall, the Resident stated he/she tripped while walking to the bathroom. The call light was accessible and in reach and the bed alarm was functioning. The resident sustained [REDACTED]. The Resident was sent to the hospital for an evaluation. The hospital notified the facility the resident sustained [REDACTED]. The Resident was observed on 8/21/12 at 8:25 A.M. in bed eating breakfast. The Resident had a mat on each side of the bed. On the same day, 8/21/12, from 10:30 A.M.- 1:30 P.M., the Resident was observed in the dining/activity room seated in a chair. The walker was against the wall. At 1:30 P.M., the Resident was again observed lying in bed with a mat on each side of the bed. The facility failed to provide proper supervision to this Resident who sustained major injuries and failed to develop proper interventions to keep the Resident safe from further falls.

Based on record review and interview the Facility failed to ensure, during routine rounds, that 1 of 6 sampled residents (Resident #1) motion detector alarm was functioning or if his/her bed alarm was present, as required by the plan of care. On 12/23/11 nursing staff discovered Resident #1 on the floor and that none of his/her personal safety alarms sounded. Nurse #1 observed that Resident #1's motion detector alarm malfunctioned and CNA #1 observed that an alarm was not attached to the bed. Resident #1 was diagnosed with [REDACTED]. Findings include: Review of Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's physician orders, dated 12/06/11, indicated that Resident #1 required a a bed alarm and a walker for ambulation. The Fall Risk Assessment, dated 12/9/2011, indicated that Resident #1 was at high risk for falls. Review of Resident #1's admission Minimum Data Set (MDS) assessment , dated 12/12/11, indicated the following conditions: confused, disoriented and forgetful, impulsive, impaired daily decision-making ability, sleep disturbance, and fatigue. Review of Resident #1's plan of care, last reviewed on 12/14/11, indicated that Resident #1 was at risk for falls and injury due to decreased mobility, poor safety awareness, weakness and use of psychotropic medications. The plan of care indicated that Resident #1 required a bed and motion sensor alarm. The plan of care indicated that staff were to check for placement and function every shift and as needed. Review of Resident #1's Certified Nurse Aide (CNA) care card (undated) indicated that Resident #1 was at risk for falls and required a bed alarm. Review of Resident #1's treatment record, dated December, 2011, indicated that Resident #1 required a bed alarm, at all times, and that staff were to check it for placement and functioning, every shift. The treatment record indicated that on the 11:00 P.M. to 7:00 A.M. shift, beginning on 12/23/11, Resident #1's bed alarm was not placed on the bed and/or not functioning. The treatment record indicated that Resident #1 also required a motion sensor alarm, at all times when in bed, and that staff were to check it for placement and functioning, every shift. The treatment record indicated that on the 11:00 P.M. to 7:00 A.M. shift, beginning on 12/23/11, Resident #1's motion sensor alarm was in place and functioning. Review of Resident #1's nurse's note, dated 12/23/11, indicated that at approximately 11:40 P.M. staff discovered Resident #1 on the floor and a nursing assessment determined that Resident #1 complained of left hip pain. The nurse's note indicated that Resident #1 was sent to the Hospital for an evaluation and he/she was diagnosed with [REDACTED]. Nurse #1 was interviewed on 1/20/11 at 3:15 P.M. Nurse #1 said that on 11/23/11, at approximately 11:00 P.M., Nurse #1 asked CNA #1 and CNA #2 to check for placement and functioning of each resident's personal alarm. Nurse #1 said that Nurse #1 did not personally check to determine if Resident #1's bed and motion sensor alarms were in place and functioning. Nurse #1 said that at approximately 11:40 P.M. Nurse #1, CNA #1 and CNA #2 heard Resident #1 calling out and they discovered that Resident #1 had fallen in the hallway at the threshold to his/her bedroom. Nurse #1 said that none of the staff heard an alarm sounding from Resident #1's bedroom. Nurse #1 said that CNA #1 waved her hand in front of the motion detector and that it did not activate. Nurse #1 said that Nurse #1 did not inspect Resident #1's bed alarm and Nurse #1 did not recall if a bed alarm was placed on Resident #1's bed. Review of CNA #1 written statement, dated 12/23/11, indicated that on 12/23/11, beginning at approximately 11:00 P.M., CNA #1 checked residents' personal alarms for placement and functioning. CNA #1 indicated that at approximately 11:15 P.M. CNA #1 entered Resident #1's bedroom to check his/her alarms. CNA #1 indicated that CNA #1 did not see an alarm on Resident #1's bed. CNA #1 indicated that a motion sensor alarm was placed on Resident #1's bureau and that CNA #1 turned the sensor alarm off and then back on and that the alarm emitted a beep. CNA #1 indicated that she did not try to trigger the alarm by tripping the sensor. CNA #1 said that after Resident #1's fall, at approximately 11:40 P.M., his/her motion detector alarm did not sound. CNA #1 said that, following the incident, CNA #1 stood in front of the motion detector alarm and it still did not sound. CNA #1 said that she then picked up the motion detector alarm and that it then sounded. The Director of Nurses (DON) was interviewed on 1/20/11 at 10:15 A.M. The DON said that nursing staff are responsible for ensuring that the personal alarms listed in the treatment records are checked for placement and functioning every shift. The DON said that staff are to trip the sensors to determine if the alarms function properly.

Based on record review, observation and staff interview, the facility failed to provide necessary care and services for 2 sampled residents (#1) for the care of: a) an indwelling urinary catheter to prevent injury; b) a PEG (percutaneous endoscopic gastrostomy) tube to prevent injury; c) the resident's fragile skin and for 1 resident (#16) for the failure to protect this resident's feet from injury and/or observe that this resident's foot had been injured during diabetic foot care in a total sample of 23 residents. Findings include: 1. Resident #1 was readmitted to this facility in December, 2010 with [DIAGNOSES REDACTED]. This resident had an indwelling urinary catheter in place at this time. This resident was readmitted in May, 2011 with [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) of both the sputum and the urine. S/he is currently receiving [MEDICATION NAME] 5,000 units subcutaneously twice a day and aspirin 81 milligrams daily. This resident continues to have an indwelling urinary catheter at this time. Review of the significant change Minimum Data Set (MDS), dated [DATE], and the quarterly MDS, dated April, 2011, identified this resident as having severe impairment of mental status, physically abusive behaviors and periods of refusal of care and requiring total care with all activities of daily living. a. For Resident #1, the facility failed to ensure that a leg strap was in place to prevent pulling on an indwelling urinary catheter. Review of the June, 2011 physician's orders [REDACTED]. *Change leg strap and CD (constant drainage) privacy bag every 2 weeks and as needed. Interview with Nurse #5, on 6/27/11 at noon, confirmed that this resident had been sent out to the emergency room to have the indwelling catheter reinserted. S/he further stated that the indwelling urinary catheter was found to be dislodged with the balloon intact by the CNAs, (Certified Nursing Assistants) who had transferred this resident to bed from the shower chair earlier that morning. In addition, the licensed staff tried to reinsert at the facility but were unsuccessful. There was no mention at this time as to whether the leg strap had been in place at the time of the incident. Observations made on 6/28/11 at noon during the treatment observations were as follows: * CNA #3 was standing on the right side of this resident's bed, which was the same side the the urinary drainage bag, which was attached to the bed frame. Nurse #5 was standing on the left side of this resident's bed. As they prepared to turn this resident onto the left side, they pulled down the top sheet, which was spotted with frank blood, revealing this resident's legs and groin area. There was no leg strap attached to either of this resident's legs; his/her groin was covered with pink-tinged serous fluid; the urinary catheter tubing was pulling toward the right side, where the rest of the tubing was hanging off the bed. CNA #3 and Nurse #5 then attempted to lift the resident up in the bed and turn him/her to the left side, without detaching the constant drainage bag from the bed frame, causing further pulling against the indwelling urinary catheter. This surveyor brought this to their attention; and they still left the constant drainage bag attached to the bed frame but the nurse now held onto the tubing to minimize the pulling. Interview with Nurse #5, subsequent to the treatment observation, confirmed that this resident should have had a leg strap on and that the indwelling catheter had been replaced just the day prior, secondary to it being displaced while staff were providing care for this resident. Interview with Nurse #4, on 6/28/11 at 4:00PM, confirmed that the CNAs had noted that the catheter had been displaced, on 6/27/11 in the morning, subsequent to the staff having provided a shower. It was reported that the catheter was out, with the balloon intact, after this resident was transferred to the bed from the shower chair; and that the leg strap had been on at the time. There was no evidence that the staff had been subsequently inserviced after the incident. Subsequent observations made on 6/28/11, by this surveyor, revealed that the staff continued to put this resident at risk, by not providing a leg strap to minimize pulling on the indwelling catheter, while moving this resident in bed. b. Observations made on 6/28/11, during a treatment observation at noon, revealed that this resident's skin was clearly reddened around the PEG tube site and the PEG tube flange (a round disk attached to the PEG tube) was raised above the resident's abdomen. There was no dressing covering the PEG tube insertion site and there was no anchoring of the tubing to the abdominal skin. Nurse #5 was observed, at this time, to press the raised flange back against the resident's skin with a gloved hand but at no time was the area cleaned, or covered with a 4 x 4 or anchored to the abdomen. Review of Lippincott Manual of Nursing Practice, 8th Edison, page 724 revealed the following standard of practice: Special care of ostomy tube insertion site should include: *Cleaning around tube with prescribed cleaning solution every shift and as needed to prevent [MEDICATION NAME] infection. *Apply sterile 4 x 4 pad and taping in place to collect any drainage. *Apply skin barrier should [MEDICATION NAME] skin become excoriated to prevent breakdown of [MEDICATION NAME] tissue. *Taping of tube to skin with [MEDICATION NAME] tape to anchor tube. Review of the current physician's orders [REDACTED]. Interview with Nurse #5, subsequent to the treatment observation, confirmed that this resident did not have the PEG tube anchored to prevent pulling and irritation of the insertion site or have a dressing covering the insertion site. c. For Resident #1, the facility failed to ensure that geri-sleeves were applied to bilateral arms as ordered, resulting in the development of 2 new skin tears on the right lower arm. Review of the current Treatment Administration Record indicated that geri sleeves should be on both arms at all times. The treatment sheet indicated that the geri sleeves were on both arms, on all days, for all shifts through 6/28/11. Observation of this resident on 6/28/11, at noon, revealed an elderly lethargic resident lying in bed, with quarter and half dollar sized spots of blood scattered around the center and right side of the top sheet. On closer inspection, this resident's right forearm was oozing bright red blood which was freely dripping onto the draw sheet underneath the resident, and in line with where the top sheet would have rested against this resident's arm. There were no geri sleeves on either arm. The left arm and hand contained numerous bruised areas on the forearm and posterior hand but none noted to be open. The right arm also contained numerous bruised areas on the forearm along with the 2 areas that were seeping bright red blood. This resident also had plastic identification bracelets with straight, not rounded, edges against the fragile skin of both wrists. When questioned by this surveyor during the observation, neither Nurse #1 or CNA #1 had any knowledge of the length of time the geri sleeves had not been covering this resident's arms. They were not aware of the open areas on the resident's right arm. The facility failed to ensure that this resident's geri-sleeves were applied at all times, resulting in 2 additional skin tears developing on the right lower arm. 2. For Resident #16, the facility failed to ensure that this resident's feet were protected from injury and failed to observe the injury after it had occurred. Review of the Minimum Data Set, dated dated [DATE], identified this resident as alert and oriented and able to make decisions and needed minimal assist with bathing and dressing. Review of the Treatment Administration Record (TAR) dated June 2011, revealed that skin assessments were performed weekly on Fridays and had been signed off as completed on 6/3/11, 6/10/11, 6/17/11 and 6/24/11; and diabetic foot care was performed daily at bedtime and to apply house moisturizing lotion was signed off as completed every night from 6/1/11 through 6/27/11, except on 6/20/11. Observation was made on 6/27/11 at 2:00PM of this resident in the physical therapy room wearing slipper socks on both feet only. On 6/28/11 at 8:35AM, during medication pass observations, this resident was observed sitting in a wheelchair by the bed, barefoot. It was noted, at this time, by this surveyor, that this resident's left 4th toe was bruised. The tip of the left great toe and left second toe were also slightly discolored; in addition to the lateral aspect of the left foot. When Nurse #6 was asked it s/he was aware, s/he stated no, although s/he had been on duty, on both 6/27/11 and 6/28/11. The resident stated that s/he had run over the foot her/himself but could not recall when that had happened. Observations were made later on 6/28/11 at 1:30PM, and, again, on 6/29/11 at 1:30PM where this resident had on only slipper socks. Review of the nurses' notes and the June, 2011 Treatment Administration Record failed to show any documentation regarding the bruising of the left foot. Interview with Nurse #1, on 6/29/11 at 2:00PM, revealed that there was no information to review regarding the bruising on the left foot; and s/he had not been made aware of any bruising of this resident's left foot.

Based on record review, observations and staff interview, the facility failed to ensure that pressure ulcers did not develop behind the ears of 1 resident (#1) in a total sample of 23 residents. Findings include: Resident #1 was readmitted to this facility in December, 2010 with [DIAGNOSES REDACTED]. This resident was readmitted on [DATE] with [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) of both the sputum and the urine. Review of the significant change Minimum Data Set (MDS), dated [DATE], and the quarterly MDS, dated ,[DATE], identified this resident as having severe impairment of mental status, physically abusive behaviors and periods of refusal of care and requiring total care with all activities of daily living. Review of the Nursing Readmission Assessment, dated 5/11/11, revealed that the anterior aspect of the left ear was circled but without a documented explanation. Further review of the available documentation failed to reveal any explanation as to why this left ear was circled. Review of the Current Pressure Ulcer Status form included an addendum, dated 5/11/11, "(Resident) has a new area on his/her left foot, eschar, that is unable to be staged at this time. Treatment in place, will continue to be followed by (MD)." There was no mention of the left ear in this note or in any other documentation that identified a problem with this resident's left ear. Review of the physician's orders [REDACTED]." However, there was no description of the decubitus areas that developed in the area where the nasal canula tubing was causing constant pressure to the posterior aspects of both ears. Review of the Treatment Administration Record (TAR) and nurses' notes, from 5/11/11 through 5/15/11, revealed that licensed staff had signed off twice a day, every day from 5/15/11 through 6/28/11, as having administered this treatment behind this resident's ears. However, there was no evidence of documentation regarding the size of the decubitus areas that had developed on 5/15/11, which was when the nursing staff had first contacted the physician to obtain a treatment. Observations made on 6/28/11 at 8:00AM and noon included the following: This resident was lying in bed with the oxygen nasal cannula tubing wrapped behind both ears. The cannula tubing was not padded and the resident did not have 2 x 2 pads between his/her ears and the tubing. After Nurse #5 completed the wound treatments to the bilateral buttocks at 12:40PM, s/he prepared to leave the room. When asked about the other treatments needed by this resident, s/he stated that s/he had not planned any others at this time. Nurse #5's understanding was that that this surveyor had only wanted to view the treatments on this resident's buttocks. However, s/he was willing to continue. Then Nurse #5 turned his/her attention to this resident's ears. S/he washed the area behind this resident's left ear, which had a slit that was 1.5 centimeters long at the top posterior edge where the nasal tubing had been lying taunt against the ear and pulled across the resident's chest to the right side of his/her body. Then Nurse #5 applied hydrogel and a 2 x 2 behind this resident's left ear. When preparing to perform the treatment to the right ear, the resident was reluctant to turn his/her head far enough for the posterior of the right ear to be viewed. However, Nurse #5 cleaned the area and applied the hydrogel and 2 x 2 to the area without viewing the skin. Subsequent to the treatment observation, Nurse #5 was interviewed regarding the inability to visualize the back of the right ear which s/he confirmed that s/he was also unable to see at the angle the treatment was performed. Nurse #5 also confirmed that the resident did not have either 2 x 2's behind his/her ears and that the nasal canula tubing was not padded. After leaving this resident's room, Nurse #5 was interviewed regarding the development of the decubitus areas behind Resident #1's ears. S/he was unable to provide any evidence as to the development and monitoring of these decubitus areas behind Resident #1's ears or what, if any, precautions had been put in place prior to the development of the decubitus areas. It was confirmed that the treatment had been ordered on [DATE], a period of 6 + weeks earlier, and had continued until 6/29/11 when it was determined that these decubitus areas behind Resident #1's ears had healed. The facility failed to prevent decubitus areas from developing on both of Resident #1's posterior ears which were in constant contact with the nasal canula tubing.

Based on record review and staff interview, the facility failed to follow the physician's order which was intended to alert staff to a resident who was at risk for falling for one sampled resident (#2) in a total sample of 23. Findings include: For Resident #2, the facility did not follow the physician's order of 3/23/11, to check placement and function of bed alarm while resident was in bed. The resident fell and sustained a fracture on 3/26/11. Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the physician's orders, Treatment Administration Record (TAR) and initial plan of care for March 2011, included an intervention, dated 3/23/11, which stated, "Bed alarm when in bed, check function and placement every shift." On 3/26/11 at 5:00AM, according to the facility's documentation (Event/Incident Report), the resident was heard calling out. When the staff responded, they found the resident on the floor, after getting out of bed without assistance. There was a documented 4 centimeter (cm) bruise noted on the resident's right wrist and forearm. On 3/27/11, the resident complained of pain to the right wrist. Also, edema and painful range of motion was observed by staff. The resident was sent to the hospital for further evaluation which confirmed a right distal radius fracture (wrist). Review of the Treatment Administration Record (TAR) indicated that from 3/23/11 through the end of the month, documentation indicated that the bed alarm was check every shift, as ordered, including 3/26/11 on the 11-7 shift. However, the facility's internal investigation identified that the "bed alarm was not functioning although it was intact." Prior to the resident's fall, the alarm was not checked by nursing staff to ensure that it was functioning properly, for the shift in question (3/26/11 on the 11-7 shift). The resident fell (unwitnessed) and sustained a right wrist fracture. The facility failed to ensure for Resident #2, newly admitted to the facility with a history of falls, that the planned intervention to prevent the resident from falling was implemented.