Every finding on record at Autumn Lake Healthcare at Norwalk

Based on clinical record reviews, resident interviews, review of policy and staff interviews for 2 of 7 residents reviewed for choices (Residents #62 and #80), the facility failed to ensure residents were not restricted from an outdoor common area without an individualized assessment and failed to notify residents of rule changes. The findings included: 1.Resident #62's diagnoses included polyneuropathy (a painful nerve condition that affects several areas of the body at the same time) and insomnia.A physician's order dated 9/17/2025 directed Resident #62's ambulation status as independent using a two-wheeled walker on/off the unit and in the community for Leave of Absence) LOA.A quarterly activity review dated 1/23/2026 identified that some of Resident #62's favorite activities included enjoying the outdoors, walking, and people watching.A quarterly MDS (Minimum Data Set) assessment dated [DATE] identified Resident #62 was cognitively intact and was independent for transfers and walking at least 150 feet in a corridor or similar space.A wandering/elopement risk evaluation dated 2/9/2026 identified Resident #62 was at low risk for elopement.A fall risk evaluation dated 2/9/2026 identified Resident #62 was a low fall risk.A social services care plan progress note dated 2/11/2026 identified Resident #62 preferred to engage in independent activities and noted the therapy orders continued as independent with transfers and ambulation using a walker. Additionally, the note indicated that Resident #62 continued with outpatient physical therapy at a different healthcare facility and independently managed her/his own appointments and transportation.A care plan reviewed on 2/12/2026 identified Resident #62 enjoyed walking. Interventions included encouraging walking following facility guidelines. The care plan also identified that the resident had a self-care performance deficit related to failure to thrive and neuropathy. Interventions included encouraging the resident to discuss feelings about self-care deficit and ambulating independently using a two-wheeled walker on/off the unit and in the community for leave of absence.On 3/10/2026 at 12:00 PM, an interview with Resident #62 identified she/he had been in the facility for a few years and had not had a problem going outside. Resident #62 stated that on 3/10/2026, she/he was first informed that she/he needed a staff member to accompany them outside. Resident #62 indicated she/he enjoyed walking outside and sitting outside watching people, and the requirement for staff accompaniment was new as of that date.A follow-up interview on 3/16/2026 at 3:30 PM, Resident #62 indicated the facility had told residents they could use the back courtyard/garden or the smaller side patio. Resident #62 indicated that the suggested areas were boring because there was nothing there except the back of the building, whereas the front had more activity and people coming and going, and she/he could more easily enjoy people watching.2. Resident #80's diagnoses included brain injury and mild cognitive impairment.A wandering/elopement evaluation dated 1/2/2026 identified Resident #80 was at low risk for elopement.An annual MDS assessment dated [DATE] identified Resident #80 was cognitively intact and did not exhibit behaviors of wandering. The MDS assessment further indicated that Resident #80 identified the ability to go outside for fresh air when the weather was good as very important.A care plan reviewed 1/15/2026 indicated Resident #80 needed continued social interaction to help promote positive well-being. Interventions included providing friendly reminders of resident council meetings.An activity quarterly review dated 3/9/2026 identified Resident #80 enjoyed the outdoors.On 3/11/2026 at 1:05 PM, Resident #80 was observed in the main lobby in her/his wheelchair. Resident #80 was observed self-propelling in her/his wheelchair and stopping to talk to other residents sitting in a sitting area in the main lobby. Resident #80 was overheard by the surveyor saying to other residents that it did not make sense that residents needed to have a staff member to go outside with them. An interview with Resident #80 indicated Resident #80 was upset that she/he needed to have someone accompany them to the outside front patio. Resident #80 indicated the rule requiring staff accompaniment was new, and that prior to 3/9/2026, she/he had always gone outside by her/himself. Resident #80 further stated she/he learned about the new rule on 3/9/2026 when attempting to go outside and did not know why it was implemented.On 3/11/2026 at 1:29 PM, an interview with the Recreation Director identified residents can go outside in the back courtyard/garden or in the smaller side patio since the areas are enclosed. The Recreation Director indicated there was concern with residents independently going to the front patio due to cars and ambulances driving by, and to ensure that residents do not walk in the roadway or sit in the direct sun. The Recreation Director indicated she found out about the change from the administrator at a morning staff meeting but could not recall the date. A tour with the Recreation Director identified that the courtyard/patio was partially enclosed (there was a gap between the end of the fence and the building) and had small branches in the walkways. The side patio was observed to be enclosed, clean, with a small concrete area and a larger grassy area. An observation with the Recreation Director identified that access to both the courtyard/garden and the side patio was locked and required a code. The Recreation Director indicated that residents are not given the code.On 3/11/2026 at 2:56 PM, an interview with Receptionist #1 identified that the rule requiring residents to be accompanied by a staff member or a family member when going to the outside front patio was a new rule, and that he was informed about it on 3/10/2026. Receptionist #1 indicated that, prior to 3/10/2026, residents could access the front patio by signing out on a log. He clarified that the log was different from the LOA log because it only tracked residents who were outside for fresh air.On 3/13/2026 at 10:35 AM, an interview and observation with the Director of Maintenance identified no environmental hazards in the patio, such as excessively uneven surfaces. The Director of Maintenance indicated that the construction cones on the upwards sloping sidewalk leading from the patio to the street were there from a prior construction to fix the drain on the road, but that the work had been completed at the beginning of November 2025 but could not recall the exact date. The Director of Maintenance indicated that he was aware that residents could not be in the patio independently and believed it was related to elopement risks.On 3/13/2026 at 11:45 AM, an interview with Receptionist identified residents were not allowed to independently go to the front patio and needed to have someone with them, such as a staff member or family member. Receptionist #2 indicated the rule started on 3/9/2026, and she was informed by the Administrator. Additionally, Receptionist #2 indicated that she did not think residents were aware because residents were asking her to let them out, and she had to tell residents she could not let them out, and she noticed that residents were confused and upset by the change. On 3/13/2026 at 12:10 PM, the Administrator indicated that shortly after starting employment in October 2025, she implemented a facility-wide rule prohibiting all residents from going to the front of the building without staff or family accompaniment. The Administrator identified the rule applied to all residents, including those considered independent or oriented. According to the Administrator, even though she made the decision earlier, residents only became aware of the change on 3/9/2026 and 3/10/2026, when attempts to go outside coincided with unexpectedly warm weather. She had planned to further address the change at a future Resident Council meeting.Although requested, the facility was unable to provide a written policy that addressed residents' access to the outdoors.

Based on clinical record review, facility documents, review of facility policy and interviews for 1 of 7 residents (Resident # 57) reviewed for choices, the facility failed to ensure that the resident received scheduled showers as per resident preferences. The findings include: Resident #57's diagnoses included muscle weakness and difficulty walking.The annual MDS assessment dated [DATE] identified Resident #57 as cognitively intact and was dependent for shower and bathing and required partial to moderate assistance for tub and shower transfers. The MDS assessment further indicated Resident #57 had not exhibited behaviors of rejection of care.On 3/9/2026 at 10:41 AM, Resident #57 indicated that she/he should be getting a shower twice a week on Mondays and Thursdays but usually missed the Monday shower. Resident #57 indicated she/he prefers to get two showers weekly.A review of the facility shower schedule identified Resident #57 was scheduled for a shower on Mondays and Thursdays during the 7:00 AM to 3:00 PM shift.Review of the nurse aide care card failed to identify the frequency of showers. Or any indication that the resident had refused showers but did indicate that the resident required assistance for bathing.A review of the nurse aide bathing flowsheet from 2/1/2026 through 3/10/2026 identified Resident #57 had missed Monday showers on 2/9, 2/16, 2/23, 3/2, and 3/9, as well as a Thursday shower on 2/26. The bathing flowsheet further indicated Resident #57 received a bath on those days instead of a shower.On 3/10/2025 at 10:30 AM, an interview and tour of the unit shower rooms with NA#1 identified that the bathtub in the unit was not in use.On 3/11/2025 at 2:08 PM, an interview with NA#8 identified Resident #57's scheduled showers were on Mondays and Thursdays, and the resident did not refuse showers. NA#8 also indicated that she provides showers only until around 9:00 AM because she must report to the dining room afterward. NA#8 indicated Resident #57 often preferred to sleep in on Mondays and, at times, requests her/his shower as late as 11:45 A.M., but the nurse aide indicated she could not accommodate that time due to dining room responsibilities and therefore provided a bed bath as an alternative. NA#8 further indicated that although she had spoken to the nurse regarding the resident requesting showers late in the morning, there had not been a conversation about switching the shower days or shift times.On 3/13/2026 at 1:14 PM, an interview with the Unit Manager/Coordinator Licensed Practical Nurse (LPN#2) identified there had been recent adjustments to dining room responsibilities, but she was not aware Resident #57 had been missing her/his Monday showers; otherwise, she would have worked with the resident on finding a time for showers.A review of the facility policy for Activities of Daily Living (ADLs) indicated that the facility will provide services based on the resident's comprehensive assessment and consistent with the resident's needs and choices, including bathing, dressing, showering, grooming, and oral care.

Based on review of facility assessment, review of facility documentation and staff interview, the facility failed to ensure all Nurse Aide Resident Care competencies were completed for 2025. The findings include: The Facility Assessment Tool reviewed on 1/13/2026 indicated staff training/education and competencies( skill checks) are necessary to provide the level and types of support and care needed for the resident population. An interview and facility document review on 3/13/2026 at 11:23 AM with the ADNS, responsible for staff development in the facility identified the Nurse Aide Resident Care competencies (observations made to ensure a person can provide care to meet the needs of the residents) had been completed in 2024. The ADNS further indicated when s/he was given the responsibility late in 2025 she/he was only able to complete the Intravenous (IV) Care competencies for the nurse aides and was currently starting to work toward completion of all competencies.

Based on review of the clinical record review, observations, review of policy and staff interviews for 1 of 1 resident reviewed for Communication ( Resident # 38), the facility failed to ensure normal saline syringes for flushing an Intravenous Therapy ( IV) line were stored appropriately and the facility failed to ensure saline flushes and IV supplies for resident use, stored in the medication rooms were labeled appropriately. The findings included: 1.Resident #38's diagnosis included Sepsis(an infection that had spread to the bloodstream).The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was cognitively intact had an intravenous (IV) device and was receiving intravenous(IV)medication. Resident #38's care plan dated 2/23/2026 indicated Resident #38 was receiving IV medications for an infection with interventions including documenting and reporting to the physician any signs of redness at the IV insertion site. An observation and interview with RN #1 The unit manager and supervisor on 3/10/2026 at 11:10 AM identified a large bag of normal saline IV flushes labeled from the pharmacy for Resident #38 was hanging from the IV pole in Resident #38's room. RN #1 indicated not knowing why the flushes were on the IV pole in the resident's room as they should have been in the medication room. 2. An observation of the 3rd floor medication room (C/D) with LPN #7 on 3/09/2026 at 10:48 AM identified saline solution syringes in a drawer of the medication room.Inspection of 2nd floor medication room (A/B) with LPN #7 at 11:02 AM on 3/9/26, identified saline solution syringes in two drawers. LPN #7 indicated the saline flushes in the drawers were from residents that had been discharged and used now as house stock for other residentsAn observation and interview with RN #1 on 3/10/2026 at 11:20 AM of the first-floor medication room identified a large 3 drawer clear plastic chest of drawers with each drawer filled to the top with IV flushes and on the counter a box containing 2 dark brown plastic bags one with a pharmacy label for Resident #38 which contained multiple IV medications for Resident #38. Another box to the left of the first box has unlabeled IV supplies including IV tubing to administer the medications and tubing caps. RN #1 indicated we place all the residents supplies in one bin and use them. RN #1 indicated the large amount of IV flushes in the chest of drawers were used when needed and further indicated staff use the saline flushes for wound care as well.An interview on 03/10/2026 at 12:15 PM with the administrative staff including the Director of Nursing Services (DNS), the Assistant Director of Nursing Services, the Administrator, the 2 regional RN's # 3 and #4 the regional nurse RN #4 indicated the current IV supply storage would be corrected immediately as the current practice is not how it should be. A request was made for the last 6 months of IV house stock supplies ordered but were not provided.

Based on observation, facility policy and staff interviews for 1 of 18 residents on Enhanced barrier precautions ( Resident #69),the facility did not ensure proper Personal Protective Equipment (PPE) was readily available and for 5 of the 18 residents (Residents #5, #88, #121,#132 and #160) on enhanced Barrier precautions, the facility did not ensure trash receptacles were available to dispose of the used PPE prior to exiting the resident's rooms.The findings included: 1. Resident #69 's diagnoses included diverticulitis with perforation and ileostomy.During observations conducted on 3/9/26 from 10:00 AM to 1:00 PM, 3/10/26 from 8:30 AM to 12:30 PM, and 3/11/26 from 6:00 AM to 8:00 AM, surveyors observed multiple residents designated as requiring Enhanced Barrier Precautions (EBP).For Resident #69 identified a sign indicating EBP was present outside the resident's room; however, required PPE, including gowns and gloves, was not readily accessible at or immediately outside the point of care. Surveyors observed that staff would need to leave the immediate resident care area and retrieve PPE from a hallway storage location more than three rooms away before providing care.2.During the same observation periods, surveyors observed that designated PPE disposal receptacles were not present in the resident rooms of Residents #5, # 88, 121, 132, and #160. Instead, disposal bins were in the hallway outside of the resident rooms. This required staff to exit resident rooms while wearing contaminated PPE to dispose of used equipment.Residents requiring EBP had the following conditions: Residents #5, #132, and #160 had wounds; Resident #88 had a history of vancomycin-resistant enterococci (VRE); and Resident #121 had a wound and an ostomyDuring an interview with the Infection Prevention (IP) Nurse on 3/11/26 at 11:17 AM, the IP Nurse stated PPE should be consistently stocked outside or immediately accessible to rooms with residents on Enhanced Barrier Precautions.The IP Nurse acknowledged that while staff may retrieve PPE from other locations, it should not be located at a substantial distance from the point of care.The IP Nurse further stated PPE disposal bins should be located inside resident rooms and that staff are expected to remove PPE and perform hand hygiene before exiting the room.The IP Nurse further indicated during a review of facility policy and the infection prevention program on 3/11/26 at 11:17 AM staff receive ongoing education regarding PPE use and Enhanced Barrier Precautions, including training at hire, annually, and during infection control updates. The IP Nurse stated that she conducts routine rounds and provides real-time education when breaches are identified.Review of the facility's infection prevention and control policy (reviewed February 2026) indicated that PPE must be readily accessible at the point of use, and that contaminated PPE must be removed and discarded prior to leaving the resident room. After surveyor inquiry, the IP Nurse reported that during facility rounds on 3/11/26 she/he identified that disposal bins had been removed from some resident rooms by family members due to bin size. The facility responded by providing smaller disposal bins and re-educating staff and family members on maintaining disposal receptacles within resident rooms and proper PPE disposal practices. This information was shared with the survey team on 3/13/26 at 10:11 AM. These corrective actions occurred after the identified deficient practice.The facility failed to ensure that PPE was readily accessible at the point of care and failed to ensure appropriate disposal of contaminated PPE within resident rooms, which is inconsistent with infection prevention and control standards.

Based on record review, resident interview, and staff interviews, for 1 of 7 residents reviewed for choices (Resident #9), the facility failed to provide written notice before a resident's room was changed. The findings include: Resident #9 was admitted with diagnoses that included severe morbid obesity, Post-Traumatic Stress Disorder (PTSD), and panic disorder.A quarterly MDS assessment dated [DATE] identified Resident #15 was cognitively intact, utilized a walker, and was independently able to ambulate at least 50 feet and make two turns.A social services note dated 1/22/2026 indicated that social services had met with Resident #9 to follow up on concerns related to facility policies and procedures for maintaining a tidy room and the risks of excessive belongings.A social services note dated 1/23/2026 indicated Resident #9's room was changed related to infection control needs, and the resident's family member agreed.A further review of the electronic medical record and the paper chart on the unit failed to identify evidence of a written notice given to Resident #9 prior to the room change.On 3/9/2026 at 1:00 PM, an interview with Resident #9 indicated that she/he was changed from a private room to a double room on 1/23/2026. Resident #9 indicated the facility moved her/his room without prior notice. The resident was under the impression she/he was moved because she/he had too many personal belongings or were giving advice to other residents.On 3/17/2026 at 10:45 AM, an interview with Social Worker #1 and Social Worker #2 identified Resident #9 was moved from her/his private room on 1/23/2026 so the facility could accommodate a resident who required a private room for infection control isolation. Social Worker #1 indicated that the facility learned of the need for a private isolation room a couple of days in advance and notified the resident verbally at that time. Social Worker #1 further indicated Resident #9 preferred moving on 1/23/2026 because that's when the resident was able to receive help from family to move their belongings. Social Worker #1 indicated residents are given the opportunity to refuse a room change and that neither Resident #9 nor their family members had refused. However, Social Worker #1 and #2 indicated the facility did not provide written notice for room changes.A review of the facility policy for Change of Room or Roommate given during the survey indicated that the notice of a change in room or roommate would be provided in writing and would include the reason why the move or change was required.

Based on review of the clinical record, review of policy and staff interviews for 1 of 1 resident reviewed for communication (Resident #38) , the facility failed to comprehensively assess a resident with hearing loss in the comprehensive Minimum Data Set assessment. The findings include: Resident #38 diagnosis includes Metabolic Encephalopathy. The Care Plan Conference Summary dated 2/24/2026 indicated the 72-hour care plan meeting was held with a family member and caregiver present via phone with the RN supervisor, social worker, and physical and occupational therapy representatives present. The summary indicated Resident #38 presented as alert oriented, hard of hearing and able to make needs known. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was cognitively intact, had adequate hearing. A provider encounter note dated 2/27/2026 at 00:00 indicated Resident #38 had a cognitive deficit and hearing impairment. A provider encounter note dated 3/08/2026 at 00:00 indicated Resident #38 was using a communication device. An observation in Resident #38's room on 3/9/2026 at 12:12 PM identified a sign posted on the wall on the right side of the bed indicating Resident #38 could not hear, and to use the communication device with writing supplies. An interview and record review with the MDS nurse (LPN #5) indicated the MDS assessment that was completed was most likely done by the nursing staff and indicated Resident #38 had adequate hearing although provider note and signage in Resident #38's room and communication device noted different. LPN#5 indicated she/he did not know how the hearing loss was missed on the assessment. LPN #5 also indicated the assessment did not accurately reflect the resident's status. She/he further indicated as a charge nurse in the facility prior to the MDS role she/he believed nursing received training in the past on how to complete the assessments for the MDS. An interview on 3/16/2026 at 9:58 AM with the Speech Language Pathologist (SLP #1) indicated Resident #38 was on service for dysphagia and s/he could not hear. SPL #1 also indicated that the resident can communicate effectively by using the communication device. Resident #38 would then verbalize the answers or any questions s/he had. On 3/16/2026 at 10:10 AM an interview with RN # 7 indicated s/he was the regular charge nurse for Resident #38. S/he indicated the sign posted in Resident #38's room that indicated Cannot Hear, use communication device was brought in by the resident's caregiver in the home setting and further indicated the communication device for the resident and staff to ensure resident understands questions being asked. LPN #5 indicated everyone knows Resident #38 cannot hear and they need to use the communication device but did not know if it was on the NA care card or in the care plan. An interview and record review on 03/16/2026 at 12:10 PM with the Regional MDS Nurse RN #6 indicated it was up to the MDS nurse to put in a care plan or correct an assessment entry if the clinical record shows information to the contrary that requires care planning. It is also up to any of the departments to add a care plan if needed. RN #6 indicated a modification of the admission MDS would need to be made and proceed with care planning for Resident #38's hearing loss with interventions indicating how to meet his/her needs The facility policy labeled Comprehensive Care Plans indicated the care planning process would include an assessment of the resident's strengths and needs and would be individualized and person centered.

Based on clinical record review, observation, review of policy and staff interviews for 1 of 1 resident (Resident # 38) reviewed for communication, the facility failed to add hearing loss and interventions to the baseline care plan to meet the immediate needs within 48 hours of admission. The findings include: Resident #38 diagnosis includes metabolic encephalopathy. The Care Plan Conference Summary dated 2/24/2026 indicated the 72-hour care plan meeting was held with a family member and caregiver present via phone with the RN supervisor, social worker, and physical and occupational therapy representatives present. The summary indicated Resident #38 presented as alert oriented, hard of hearing and able to make needs known. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was cognitively intact, had adequate hearing. A provider encounter note dated 2/27/2026 at 00:00 indicated Resident #38 had a cognitive deficit and hearing impairment. A provider encounter note dated 3/8/2026 at 00:00 indicated Resident #38 was using a communication device. An observation in Resident #38's private room on 3/9/2026 at 12:12 PM had a sign posted on the wall on the right side of the bed indicating Resident #38 could not hear, and to use a communication device with writing supplies. An interview and record review with the MDS nurse LPN #5 at the time of observation indicated Resident #38's care plan initiated 2/23/2026 through present did not indicate the resident could not hear. An interview on 3/16/2026 at 9:58 AM with the Speech Language Pathologist (SLP #1) indicated Resident #38 was on service for dysphagia and s/he could not hear. SPL #1 also indicated the resident can communicate effectively by using the communication device. Resident #38 would then verbalize the answers or any questions s/he had. On 3/16/2026 at 10:10 AM an interview with RN # 7 indicated s/he was the regular charge nurse for Resident #38. S/he indicated the sign posted in Resident #38's room that indicated Could Not Hear, communication device was brought in by the resident's caregiver in the home setting. She/he also indicated she/he could not explain why a baseline care plan had not been developed with intervention for Resident # 38's hearing loss within 48 hours of admission.

Based on review of the clinical record, facility policy for 1 of 1 resident (Resident # 38) reviewed for communication, the facility failed to develop a comprehensive care plan with goals, timetable and interventions to meet the needs of a resident with hearing loss and for 1 of 2 residents reviewed (Resident # 2) reviewed for dementia, the facility failed to ensure staff identified cognitive deficits and developed plan of care for a resident with cognitive loss and a diagnosis of dementia. The findings included: Resident #38 diagnosis includes metabolic encephalopathy. The Care Plan Conference Summary dated 2/24/2026 indicated the 72-hour care plan meeting was held with a family member and caregiver present via phone with the RN supervisor, social worker, and physical and occupational therapy representatives present. The summary indicated Resident #38 presented as alert oriented, hard of hearing and able to make needs known. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was cognitively intact, had adequate hearing. A provider encounter note dated 2/27/2026 at 00:00 indicated Resident #38 had a cognitive deficit and hearing impairment. A provider encounter note dated 3/8/2026 at 00:00 indicated Resident #38 was using a communication device. An observation in Resident #38's private room on 3/9/2026 at 12:12 PM had a sign posted on the wall on the right side of the bed indicating Resident #38 could not hear, and to use a communication device with writing supplies. An interview and record review on 3/16/2026 at 12:10 PM with the Regional MDS nurse (RN #6) indicated it was up to the MDS nurse and the nursing department to ensure the resident had a care plan and the information was placed on Nurse Aide Assignment Card . The facility policy labeled Comprehensive Care Plans indicated the care planning process would include an assessment of the resident's strengths and needs and would be individualized and person centered and developed within 7 days after the completion of the comprehensive MDS assessment. Resident #2's diagnosis includes dementia. The Nursing admission assessment dated [DATE] indicated Resident #2 was rarely or never understood and indicated s/he had severe cognitive impairment. The admission Minimum Data Set ( MDS) assessment dated [DATE] indicated Resident #2 had moderate cognitive loss and indicated the facility was to proceed with care planning for dementia. On 3/16/2026 at 11:24 AM the MDS Nurse (LPN #3) indicated she/he could not find a dementia care plan though the MDS indicated a care plan with interventions to meet Resident #2's cognitive needs. On 3/16/2026 at 11:40 AM an interview and clinical record review with RN #6 (Regional MDS Nurse) indicated the social worker was responsible for the cognitive assessment and adding the care plan and facility MDS nurse who completed the admission assessment should have added the care plan if it had not already been added by the social worker.

Based on review of the clinical record reviews, observations, facility policy and staff interviews for 1 of 7 residents ( Resident #1 ) reviewed for choices, the facility failed to ensure that a physician's order regarding leave of absence (LOA) was followed, and for 2 of 4 residents reviewed for accidents (Residents #17 and #130), the facility failed to ensure a nursing assessments were completed following a near-fall event and a change of condition and for 1 of 1 resident (Resident # 38)reviewed for communication, the facility failed to ensure staff appropriately identified a venous access site, obtain the correct physician orders for its use. The findings included: Resident #17's diagnoses included orthopedic conditions, phantom limb syndrome with pain, cervical disc (discs that provide space between the bones of the neck) degeneration, chronic pain syndrome, cervical radiculopathy (neck compression that causes pain to radiate to the arms or changes feeling in the arms), heart failure, asthma, bipolar disorder, depression, anxiety, and schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms, such as hallucinations, delusions, disorganized speech, and mood disorders, such as mania or depression). A Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was cognitively intact. The resident used no assistive device for mobility, had a reduced range of motion on one side of the upper extremities, required set-up assistance for eating and showering, moderate assistance for toilet hygiene and repositioning, and was independent with oral hygiene, dressing, and transfers. The assessment also identified that the resident was prescribed multiple psychoactive (medications that alter brain function and can change perception, mood, behavior, and consciousness) medications, opioids (strong pain medications), and an antipsychotic medication. On 11/12/25, Resident #17 experienced a witnessed fall, with subsequent identification of non-displaced fractures of several toes on the left foot. Nursing assessments were completed on 11/12/25, along with a change-in-condition nursing note describing the incident and assessment findings. A follow-up evaluation was conducted on 11/13/25 by an advanced practice registered nurse (APRN) who ordered a left foot x-ray to rule out fracture due to focal (specific spot or area) pain in the foot. A Resident Care Plan (RCP) update, dated 11/12/25, included interventions such as orthostatic blood pressure monitoring (checking blood pressure with changes in position) each shift for three days, a medical work-up, and monitoring for signs and symptoms of latent (present but not yet showing signs or symptoms) injury or pain. A change-in-condition note dated 11/14/25 at 4:52 PM indicated the resident was evaluated by orthopedics, and a repeat x-ray confirmed fractures of the third, fourth, and fifth toes of the left foot. The resident was placed in a surgical boot for ambulation with instructions for follow-up in three weeks. A physician's order dated 11/15/25 directed Resident #17 could ambulate in and out of the unit with a cane or without an assistive device. A Resident Care Plan update, dated 11/17/25, reflected the physician's order. On 12/8/25, Resident #17 experienced a slip when exiting an elevator but did not descend to the ground. Facility staff did not classify the event as a fall. This event was not reported to the nursing supervisor on the evening of the incident, and no nursing assessment or documentation was completed that day. The clinical record did not contain evidence that a nursing assessment was completed following the 12/8/25 slip event. On the morning of 12/9/25, Resident #17 informed the Assistant Director of Nursing Services (ADNS) about the incident while they were riding the elevator together. A change-in-condition note, dated 12/9/25 at 8:34 AM, written by the ADNS, indicated the resident reported slipping in the elevator the prior evening and pain in the same foot, previously injured and currently in an orthopedic boot. A physiatry provider note, dated 12/9/25 at 4:57 PM, indicated the resident was evaluated for pain management follow-up. The provider documented the reported slip and observed the resident ambulating in the hallway wearing socks, with no motor weakness noted. The provider continued the planned dose reduction of pain medication while maintaining pain control. A quarterly MDS assessment dated [DATE] indicated Resident #17 was cognitively intact. He/she used no devices for mobility and was independent with all activities of daily living, hygiene, and transfers. He/she was reported as having had one fall with major injury, including broken bones. Taking multiple psychoactive medications, opioids, and an antipsychotic. Surveyor observations of Resident #17's room on 3/9/26 at 11:10 AM and 3/11/26 at 6:25 AM identified clutter and various items obstructing or narrowing the resident's walking path within the room, creating potential trip hazards. Additionally, during observations on: 3/9/26 between 11:10 AM and 1:00 PM; 3/10/26 between 8:30 AM and 11:30 AM; 3/13/26 between 8:30 AM and 10:00 AM, Resident #17 was observed ambulating in his/her room and hallways wearing gripper socks rather than shoes. During an interview with the ADNS on 3/13/26 at 1:00 PM, the ADNS stated Resident #17 reported the 12/8/25 elevator slip to her the following morning while they were on the elevator together. The ADNS stated she asked the resident twice whether a fall had occurred, and the resident reported he/she had slipped but did not fall. The ADNS stated that she encouraged the resident to obtain a new X-ray to assess the healing status of the injured foot. The ADNS stated she later asked staff why an Accident and Incident (A&I) report had not been completed. Staff informed her they did not complete an A&I report because the resident described the event as a slip rather than a fall. The ADNS further stated that the Director of Nursing Services at the time, who was no longer employed at the facility, advised that an A&I report was not necessary because no fall had occurred. The ADNS stated that, given the circumstances, she would complete an A&I report for such an event in the future, but at the time, she followed the Director of Nursing Services direction. The MDS definition of a fall includes any episode in which a resident loses balance and would have fallen if not for catching themselves. During an interview with Registered Nurse (RN) 1 on 3/16/26 at 11:07 AM, RN #1 stated she was the nursing supervisor on 12/8/25 when the slip occurred. RN #1stated the incident was not reported to her by staff or the resident, and therefore, no nursing assessment was completed on that date. RN #1 stated that if she had been notified, she would have completed a nursing assessment, documented a change-in-condition note, and notified the APRN to determine whether additional evaluation or new physician's orders were needed, consistent with facility policy and practice. All facility policies were reviewed by the administrative team and Medical Director in January 2026. These policies included Charting and Documentation. This policy directed that any changes in the resident's condition and any events, incidents, or accidents involving the resident must be documented in the medical record. The policy, Falls Clinical Protocol, directed staff to evaluate and document falls that occur while the individual is in the facility, including the time and location of the event and any observations. Additionally, the Accidents and Incidents policy, directs that an accident or incident must be reported to the department director, and the Accident/Incident Report Form must be completed on the shift that the accident or incident occurred; the charge nurse must be informed, and that the charge nurse or designee shall examine the victim, notify the physician, notify the resident's family or legal representative, and if necessary transfer the injured person to the hospital. The facility failed to follow its policies regarding documentation, fall evaluation, and reporting of accidents or injuries, resulting in unidentified injuries and missed opportunities to prevent future falls. Resident #130's diagnosis included dementia and cerebral infarction. The 6/13/2025 quarterly Minimum Data Set (MDS) assessment indicated Resident #130 had a moderate cognitive decline. The care plan dated 6/18/2025 indicated Resident #130 had altered cardiovascular status. Interventions included: to assess chest pain, shortness of breath and cyanosis (when oxygen moves away from the lips and nail beds, leaving the skin/nailbeds a blue/gray color versus pink), and to report changes to the physician. A progress note labeled Change in Condition dated 8/15/2025 at 5:06 PM indicated Resident #130 was sitting in a wheelchair and noted to be pale and unresponsive at which time the physician was notified and an order was obtained to send to the emergency room. 911 was called while awaiting their arrival Resident #130 had become alert and at his/her baseline. The resident was sent to the emergency room for an evaluation. An assessment labeled Change in Condition/Concurrent Review completed by LPN # 3 indicated Resident #130's blood pressure was 142/65, pulse 52 and regular rhythm, and temperature was 97.0 degrees F. and the physician and responsible party were notified of Resident #130s transfer to the hospital for evaluation. An interview and clinical record review with the current Director of Nursing Services (DNS) on 3/11/2026 at 1:21 PM indicated there was no documented Registered Nurse (RN) assessment of Resident #130 prior to the transfer to the emergency room and s/he would have expected an RN assessment of Resident #130 written in the progress notes if the LPN documented the assessment the RN would then sign the assessment the LPN had documented. The DNS further indicated not finding evidence of assessment that included the following: the exact time of the incident, when the Emergency Medical Services (EMS) arrived and left the facility with the resident, the state of alertness at the time of the transfer, sending a copy of the resident face sheet including all diagnosis medications and other pertinent data with the resident to the hospital and calling the hospital emergency room with expectation of the resident arriving to them along with the reason for the transfer and resident condition. The DNS further indicated not finding any documentation in Resident #130's clinical record. On 3/12/2026 at 2:45 PM an interview with LPN #4 working the 3-11PM shift on 8/15/2025 indicated s/he arrived late to his/her shift and while counting medication at the medication cart with LPN #3 a nurse aide rolled Resident #130 in her wheelchair to the nurses as s/he was not responding. LPN#4 indicated having immediately checked the blood sugar level of Resident #130, but she/he was unable to remember the exact reading but recall it was within normal range (70-110) and having minimally responded to a sternal rub (a painful stimulus technique used by professionals to check for responsiveness in unconscious patients, involving firm, grinding knuckle pressure on the breastbone LPN #4 and the nurse aide brought Resident #130 to her/his room and transferred him/her to the bed and Resident #130 had started to come around further indicating the 3-11PM nursing supervisor, RN #5 was at the nurses station making the calls and preparing the transfer paperwork and had not been in the room. An interview on 3/12/2026 at 2:40 PM with RN #5 indicated she had seen Resident #130 in the wheelchair and started to come to but was unable to remember any details. The facility policy labeled Acute Condition Changes/RN Assessment Protocol indicated as part of the initial assessment RN would help identify the resident having acute changes of condition, document and consult with the physician. Resident #38's diagnosis included sepsis (an infection that had spread to the bloodstream). The physician's orders dated 2/21/2026 directed to observe the central catheter every two hours during continuous therapy every shift with intermittent therapy or when not in use, before and after administration of intermittent medications, during dressing changes documenting in notes at least every shift considering prescribed therapy and resident condition. A second physician's order is directed to change the central catheter dressing and securement devise every week and as needed with using transparent dressing. The third physician's order directed to flush the unused ports of the catheter every 12 hours with 5 milliliters(ML)of normal saline( flushed the Intravenous Therapy (IV) line of the prior solution in the line) followed by 5ml's of Heparin 10 units/ml(which prevents blood from clotting in the line). A fourth physician's order directed to flush a central line called a PICC line( Peripherally inserted Central catheter every 12 hours with normal saline. Another physician's order directed to change the needleless access device every 24 hours with Total Parenteral Nutrition(a specialized IV treatment that provides nutrition intravenously) another physician's order directs to change the IV administration set (tubing)every 96 hours. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was cognitively intact had an intravenous (IV) device and was receiving intravenous(IV)medication. Resident #38's care plan dated 2/23/2026 indicated Resident #38 was receiving IV medications for an infection with interventions including documenting and to report to the physician any signs of redness at the IV insertion site. On 3/10/2026 at 10:40 AM an interview and record review with charge nurse LPN #1 identified Resident #38 had orders for a central line catheter for administration of antibiotic medication intravenously ( a central line is the longest IV catheter that reaches large veins near the heart, designed for long-term use, high-volume fluid resuscitation, and administration of caustic medications). While reviewing the paper clinical record with LPN #1, a loose paper document labeled PICC/Midline Nursing Documentation from an outside IV company, placement company dated 3/03/2026 indicated Resident #38 had a midline catheter(an intermediate-length venous access line inserted into an upper arm vein with its tip stopping near the axilla, used for 1–4 weeks of intravenous therapies such as antibiotics) placed in the hospital but the line was pulled out by the Resident # 38 and the IV Nurse was there to replace the midline catheter. A 12 centimeter (cm) long midline catheter (one valve) was placed in a vein in the middle of the inside of the left arm with notes indicating to provide midline catheter care per protocol and post procedure instructions were provided to a facility nurse(not named). LPN # 1 reviewed the hospital discharge summary and the Intra-Agency Report upon surveyor request, and it indicated Resident #38 was discharged to the facility with a midline catheter (not a central line). LPN #1 indicated not knowing why the admitting nurse obtained physician orders for a Central Line Catheter. LPN #1 was unable to locate any physician's orders in the clinical record for dressing changes to the IV site and called for the nursing supervisor. On 3/10/26 at 10:42 AM a clinical record review, interview and observation with the nurse manager/Supervisor RN #1 indicated Resident #38 physician's orders were for a central line and the resident did not receive anything s/he should not have. Review of the physician's orders indicated not only flush the catheter with normal saline but Heparin as well. RN #1 indicated the facility does not use Heparin in any IVs as the practice ended years ago. She/he further indicated that when the physician's orders are electronically by the nurse the prepopulated orders for heparin need to be removed. RN #1 pulled up the standing physician's orders for a midline catheter and the same normal saline flush as the central line was what would have been ordered. An observation of the resident room found a labeled bag of saline syringes for IV-line flushing, and the observations of the medication rooms by surveyors identified only normal saline syringes containing 10ml of solution for IV flushing, no heparin syringes were found. Further review of the orders identified no documentation for a dressing change was completed since admission; no documentation of the IV line being flushed, or consistent documentation every shift as there were no orders on the Medication/Treatment Administration records( MAR/TAR) indicating how to take care of the IV devise and document that care was completed per the physician's orders and facility protocol. Review of the admission orders for the central line catheter identified the scheduling of the dressing changes and flushes were not completed. An observation at 11:10 AM with RN #1 in the resident's room identified Resident #38 had a clear dressing over the insertion site of the midline catheter in the inner left elbow dated 3/9/2026 and the catheter had a manufactural label that stated MIDLINE. RN #1 indicated s/he would inform the APRN and obtain new physician's orders. On 3/10/2026 ( no time indicated) subject to surveyor inquiry, physician orders were obtained for a Midline catheter(long peripheral catheter, not a central catheter) directed to flush the catheter with 10ml of normal saline solution, to change the catheter dressing 24 hours after insertion; on admission, and weekly using a transparent dressing , to observe the IV site every 2 hours during continuous therapy, every shift during intermittent therapy or when not in use. The facility policy labeled( Midline/Extended Dwell Catheter Flushing given onsite indicated a physician's order is required for vascular access devices with orders specific to the flushing solution and documentation of the procedures in the resident's clinical record will include date and time, site assessment flushing agent and volume amount used, any difficulty flushing and intervention, the resident's response to the procedure and any resident/caregiver education provided. The facility policy labeled Midline/Extended Dwell Catheter Dressing Change given onsite indicated the physician IV therapy order for care and maintenance is required, a transparent dressing is preferred referring to the IV order form for the frequency of the change utilizing sterile technique once the soiled dressing is removed. Assessment of the vascular access device included checking the site at least every 2 hours during a continuous infusion, before during and after medication administration, during dressing changes at a minimum of once per shift when not in use and at prescribed intervals if complications are observed. Resident #1's diagnoses included type 2 diabetes mellitus, depressive episodes, schizophrenia, anxiety disorder, chronic kidney disease, end-stage renal disease (ESRD) requiring hemodialysis, weakness, chronic pulmonary edema, mild cognitive impairment of unknown etiology, and dementia with psychotic disturbance. A physician's order dated 11/15/25 directed Resident #1 may leave the facility on leave of absence (LOA) with a responsible party and medications. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact with a Brief Inventory of Mental Status (BIMS) Summary Score of 15. The resident used a walker and wheelchair for mobility, required varying levels of assistance with activities of daily living, and was receiving specialized treatment for ESRD. A psychiatric advanced practice registered nurse (APRN #1) evaluation dated 12/8/25 indicated the resident was psychiatrically stable with no acute concerns and no risk to self or others. A nursing note dated 12/11/25 indicated Resident #1 informed staff he/she was going to the lobby but subsequently left the facility via a ride-share without notifying staff or formally signing out on LOA, which was inconsistent with the physician's order requiring a responsible party accompaniment. Facility staff identified that the resident had left when he/she was no longer present in the lobby and initiated efforts to determine the resident's whereabouts. Staff contacted the resident by phone, and the resident reported that he/she had gone to a local hospital to see his/her nephrologist. Resident #1's conservator and co-conservator were notified, and upon the resident's return, an alert bracelet was placed on the resident's ankle as a reminder to notify staff prior to leaving the facility. Education was provided to the resident and conservators regarding the importance of notifying staff for safety and medication management. All parties expressed understanding. An elopement assessment dated [DATE] identified the resident as low risk for elopement. On 12/11/25, Resident #1 left the facility independently, which was not consistent with the active physician's order requiring the resident to be accompanied by a party responsible for leave of absence. A physician's order dated 12/12/25 was subsequently updated to allow Resident #1 to leave the facility independently on LOA. The Resident Care Plan (RCP) was updated on 12/12/25 to include an alert bracelet as an intervention. A follow-up elopement assessment dated [DATE] continued to identify the resident as having low risk. A psychiatric APRN evaluation dated 1/15/26 indicated the resident had mild situational anxiety but remained stable with no change in care plan. During a resident interview on 3/10/26 at 9:45 AM, Resident #1 expressed frustration with wearing the bracelet but acknowledged understanding of the facility's safety concerns. This was reconfirmed on 3/11/26 at 6:46 AM, with no additional concerns identified. During an interview with the Facility Administrator on 3/16/26 at 11:00 AM, the Administrator stated that the alert bracelet was used as a reminder tool for Resident #1 to notify staff prior to leaving, rather than for traditional elopement monitoring. During an interview with APRN #1 on 3/18/26 at 9:38 AM, APRN #1 stated the resident was psychiatrically stable for independent community access and exhibited improved mood when outside the facility. During an interview with APRN #2 on 3/18/26 at 9:54 AM, APRN #2 stated the resident was medically stable for independent LOA, and that the prior physician's order requiring a responsible party likely reflected an earlier condition and had not been subsequently updated.

Based on clinical record review, observation, review of facility documentation and staff interviews for 1 of 4 (Residents #17) reviewed for accidents, the facility failed to ensure that a resident's environment was free of potential hazards and failed to provide adequate interventions to mitigate fall risk, including ensuring safe footwear and a clear ambulatory path during a period of increased risk related to a recent lower extremity injury and the facility failed to ensure that the main entrance non-smoking area was free of cigarette butts to prevent a potential hazard. The findings included: Resident #17's diagnoses included orthopedic conditions, phantom limb syndrome with pain, cervical disc degeneration, chronic pain syndrome, cervical radiculopathy, heart failure, asthma, bipolar disorder, depression, anxiety, and schizoaffective disorder. A Resident Care Plan (RCP) initiated 7/14/24 and last updated 9/9/25, indicated the resident preferred to wear gripper socks and declined shoes. Interventions included encouraging the resident to wear shoes as tolerated and providing gripper socks as needed. A Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, used no assistive device for mobility, required varying levels of assistance with activities of daily living, and was prescribed multiple psychoactive medications (medications that alter brain function and can change perception, mood, behavior, and consciousness), opioids, and an antipsychotic medication, all of which may increase fall risk. An additional RCP intervention dated 11/27/24 directed staff to encourage and remind the resident to wear proper footwear. On 11/12/25, Resident #17 was assessed as a moderate fall risk and experienced a witnessed fall, resulting in non-displaced fractures of several toes on the left foot. The resident was placed in a walking orthopedic shoe; however, a physician's order dated 11/15/25 indicated the resident could ambulate with or without an assistive device. A care plan update dated 11/17/25 reflected this order. On 12/8/25, Resident #17 experienced a slip while exiting an elevator without descending to the ground. The facility did not classify the event as a fall, and the clinical record lacked evidence of nursing assessment, change-in-condition documentation, or provider notification following the event. The clinical record also lacked evidence of updates to the resident's care plan interventions to address environmental or safety risks. A physiatry provider note dated 12/9/25 at 4:57 PM documented the reported slip and observed the resident ambulating in the hallway wearing socks, with no motor weakness identified. On 12/11/25, during orthopedic follow-up, the resident reported slipping on an unmarked wet floor, resulting in an ankle injury. The resident was fitted with a short orthopedic boot to stabilize the injury and support healing of prior fractures. A quarterly MDS assessment dated [DATE] indicated the resident remained cognitively intact, independent with activities of daily living, and had experienced one fall with major injury (fractures). The resident continued to receive psychoactive medications, opioids, and antipsychotic medication. Observations on 3/9/26 at 11:10 AM and 3/11/26 at 6:25 AM identified clutter and multiple items obstructing or narrowing the Resident #17's walking path, creating potential trip hazards within the resident's room. Additional observations on 3/9/26 (11:10 AM–1:00 PM); 3/10/26 (8:30 AM–11:30 AM); 3/13/26 (8:30 AM–10:00 AM) showed Resident #17 ambulating in his/her room and hallways wearing gripper socks instead of appropriate footwear. The prior fall with a fracture and subsequent slip indicated an ongoing pattern of accident risk that required more effective environmental and safety interventions to reduce it. Given the resident's recent fractures, use of an orthopedic boot, chronic pain condition, and prescribed psychoactive and opioid medications, the resident had an increased risk for falls. Facility policies reviewed by the facility administrative team and Medical Director in January 2026, including the Falls Clinical Protocol, directed that when a resident continues to experience falls or fall-related events, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. The facility failed to ensure a safe environment and to implement effective fall-prevention interventions, including maintaining a clear ambulatory path and addressing unsafe footwear practices, despite the resident's known and ongoing fall risk. The facility also failed to reassess and revise interventions following repeated fall-related events. On 3/16/2026 at 11:22 AM, a tour of the front outdoor common area/patio identified multiple cigarette butts on the concrete area of the patio, including one on a support column of the patio cover. There were also at least 33 cigarette butts counted on the grass next to the far end of the patio near a brick wall. On 3/16/2026 at 2:00 PM, an interview with the Director of Maintenance indicated he usually cleans the area, but it had been covered in snow until recently, when the snow had melted. The Director of Maintenance indicated that he thought the cigarette butts may have been from visitors or people crossing through the property. On 3/16/2026 at 2:40 PM, an interview with the Administrator identified that the building was a non-smoking building and staff and visitors were not allowed to smoke in the building or the common areas.

Based on clinical record, review of facility policy and staff interviews for 1of 1 resident (Resident # 5) reviewed for specialized treatment, the facility failed to ensure physician orders were obtained for a specialized type of venous access site, its location, assessment and care for the access site and failed to avoid medications prohibited as outlined in the facility policy. The findings include:Resident #5's diagnosis includes End Stage Renal(kidney) Failure. The physician's orders dated 2/7/2026 directed to have Resident #5 attend appointments at a specialized service facility for treatment of the End Stage Renal Failure 3 times per week.A physician's order dated 2/7/2026 included to provide Milk of Magnesia 30 milliliters (ml) by mouth as needed for constipation and a Fleet enema (brand name rectal solution used for constipation for quick results) on day 3 if there is no bowel movement after day 2. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact and received a specialized service for treatment of Renal Failure. The care plan dated 2/27/2026 indicated Resident #5 received a specialized service outside the facility 3 times per week with interventions including encouraging the resident to attend the appointments for service and to observe laboratory results. An interview and observation with charge nurse LPN #6 identified when Resident #5 went to the specialized service location 3 times weekly, the residents port referring to a vascular access site in the upper chest was used to provide specialized treatment). The access site would be checked to ensure the dressing was dry and intact. When asked how nurses would know what specific care needs Resident #5 required LPN #5 reviewed the physician's orders. However, LPN # 6 could not find any orders referring to the access site type or its location or any physician's orders for the assessment and care of the access site. (The access site could be a catheter in the chest, or an atrioventricular shunt placed in an arm or a resident could have both, each requiring different assessment and safety equipment). LPN #6 indicated a resident would have a red bracelet on the wrist to indicate not to take blood pressure in the upper arm( if there was an access shunt located there). However, observation of Resident #5'wrists identified no red bracelet and LPN #6 indicated she/he would obtain the bracelet and apply it. At 9:45 AM LPN #6 indicted consulting with the nursing supervisor who clarified to her/him the red bracelets came from the hospital already on the resident, so it is ok to do laboratory work or blood pressure on the lower portion of either arm. An interview, record review and facility policy review on 3/13/2026 at 10:35 AM with nursing supervisor, RN#1 indicated the facility did not apply red bracelets to residents if a blood pressure or laboratory work should not be utilized on a particular arm. RN #1 indicated nurses would know not to take blood pressure on an arm with specialized venous access by looking at the physician's orders. RN #1 could not locate any physician orders but indicated it was standard knowledge for nurses to know. While reviewing the facility policy labeled Dialysis given onsite indicated in for any type of access route the physician's order should be carried to the treatment kardex (where the nurse would look for care needs to be provided and sign off its completion). This would include the type and location of the catheter or graft(shunt), and the days and times for the appointments at the specialized service location. The policy further indicated the care of the Atrioventricular(AV) access site(a Fistula or Graft in an upper arm) notes not to utilize the arm with an access site for blood pressure or laboratory work, after specialized treatment the bandage should be removed the next day, any scabs being left intact. An assessment of the bruit and thrill of the access site in the arm( palpation of a pulsation and auscultation over the access site with a stethoscope to hear the blood flow) would be completed and the physician notified if either or both were absent. Uncontrolled or large amounts of bleeding from the access site would require applying direct pressure to the site and transfer to the emergency room, notifying the physician and family. RN #1 indicated s/he would obtain the appropriate physician orders that should have been in place. Further review of the physician orders, the Medication Administration Record (MAR) and the facility policy with RN#1 noted physician's orders for Milk of Magnesia and Fleets enema as needed. The MAR from admission through to present identified the fleets enema had not been utilized but the Milk of magnesia was administered on 2/16/2026 at 8:23 AM and on 2/23/2026 at 5:10 PM. The facility Specialized Treatment policy indicated Milk of Magnesia and Fleets enema were medications to be avoided. RN #1 identified she/he did not know why Resident #5 had the orders. On 3/13/2026 at 10:48 AM an interview, record review and policy review with APRN #3 indicated the physician's orders for Milk of Magnesia and Fleets enema were signed by the physician( Medical Doctor (MD #1) and indicated she/he would have discontinued the orders upon review if s/he felt they should not be given. When asked if complications could occur from their use, APRN #3 indicated with continued use blood levels of magnesium could build up, the risk is very low. On 3/13/2026 at 5:15 PM an interview and facility policy review with MD #1 indicated being involved in reviewing the facility policies and procedures. MD #1 further indicated specialized treatment patients should not receive Milk of Magnesia, and she/he would review the resident's physician's orders and the facility policy for administration.

Based on clinical record review, review of facility documentation, observation and staff interviews for 1 of 5 residents (Resident # 130) reviewed for unnecessary medications, the facility failed to ensure the physician acted upon a pharmacy recommendation timely. The finding included. Resident # 130's diagnoses included adjustment disorder, atherosclerotic heart disease, cerebral infarction, hypertension, anemia, cystic disease of the liver, cystic of the kidney, polyneuropathy, bradycardia and osteoarthritis.A Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was cognitively intact. The resident used no assistive device for mobility, had a reduced range of motion on one side of the upper extremities, required set-up assistance for eating and showering, moderate assistance for toilet hygiene and repositioning, and was independent with oral hygiene, dressing, and transfers .A review of the Pharmacy Recommendation report dated 11/9/25 for Resident # 130 noted a recommendation for behavior monitoring for the following psychoactive medication is required for Trazodone when necessary.The Resident Care Plan dated 3/10/26 for Resident has impaired cognitive function/or impaired thought process. Interventions included: administering medications as ordered, follow up with psychiatry when needed, keep resident routine consistently and try to have consistent care givers as much as possible to decrease confusion, monitor and report to Medical Doctor ( MD), any changes in decision making ability, memory, recall, general awareness, difficulty understanding others and level of consciousness.However, reviewing the electronic medical record from 11/10/25 through 3/17/26 failed to reflect the physician's response to the pharmacy recommendation on 11/9/2025.Observations on 3/17/26 at 11:15 AM identified Resident # 130 in a recreational activity groomed appropriately and noted with agitation. Resident # 130 was easily re-directed by recreational staff.A review of the electronic medical record and interview with the DNS on 3/17/26 at 11:48 AM identified no behavioral monitoring conducted from 11/9/2025 through 3/17/2026 and no physician's response to the pharmacy recommendation on 11/9/25. The DNS indicated it is nursing responsibility to follow up on pharmacy recommendations with the physician and indicated she could explain why this was done.

Based on review of the clinical records, review of facility policy and staff interview for 1 of 4 residents (Resident # 130) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate. The findings include: Resident #130's diagnosis included dementia and cerebral infarction.The 06/13/2025 quarterly Minimum Data Set (MDS) Assessment indicate Resident #130 had moderate cognitive decline.The care plan dated 06/18/2025 indicated Resident #130 had altered cardiovascular status with interventions to assess for chest pain, shortness of breath and cyanosis(when oxygen moves away from the lips and nail beds, leaving the skin/nailbeds a blue/gray color versus pink), and to report changes to the physician.A progress note labeled Change in Condition dated 08/15/2025 at 05:06 PM indicated resident #130 was sitting in a wheelchair and noted to be pale and unresponsive the physician was notified and an order obtained to be sent to the emergency room. 911 was called while awaiting their arrival Resident #130 had become alert and was at his/her baseline and was sent to the emergency room.An assessment labeled Change in Condition/Concurrent Review completed by LPN # 3 indicated Resident #130's blood pressure was 142/65, pulse 52 and regular rhythm, and temperature was 97.0 degrees F. and the physician and responsible party were notified of Resident #130s transfer to the hospital for evaluation.An interview and clinical record review with the current Director of Nursing Services (DNS) on 03/11/2026 at 01:21 PM indicated there was no documented Registered Nurse (RN) assessment of Resident #130 prior to the transfer to the emergency room and s/he would have expected an RN assessment of Resident #130 written in the progress notes if the LPN documented the assessment the RN would then sign the assessment the LPN had documented. The DNS further indicated not finding Documentation of the exact time of the incident, when The Emergency Medical Services (EMS) arrived and left the facility with the resident, the state of alertness at the time of the transfer, sending a copy of the resident face sheet including all diagnosis medications and other pertinent data with the resident to the hospital and calling the hospital emergency room with expectation of the resident arriving to them along with the reason for the transfer and resident condition. The DNS further indicated not finding any documentation in Resident #130's clinical record.On 03/12/2026 at 2:45 PM an interview with LPN #4 working the 3-11 shift on 08/15/2025 indicated s/he arrived late to his/her shift and while counting medication at the medication cart with LPN #3 a nurse aide rolled Resident #130 in her w/c to the nurses as s/he was not responding. LPN#4 indicated having immediately checked the blood sugar level of Resident #130, unable to remember the exact reading but within normal range (70-110) and having minimally responded to a sternal rub (a painful stimulus technique used by professionals to check for responsiveness in unconscious patients, involving firm, grinding knuckle pressure on the breastbone LPN #4 and the nurse aide brought Resident #130 to her room ad transferred him/her to the bed and Resident #130 had started to come around further indicating the 3-11 nursing supervisor, RN #5 was at the nurses station making the calls and preparing the transfer paperwork and had not been in the room. No documentation of the medical evaluation and care provided by LPN #4 as described within his/her interview we found within the clinical record.An interview on 03/12/2026 at 02:40 PM with RN #5 indicated she had seen Resident #130 in the wheelchair and started to come to but was unable to remember any details.The facility policy labeled Charting and Documentation indicated documentation should include medications administered, treatments or services performed, changes in the resident's condition, events, incidents or accidents involving the resident.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for advanced directives, the facility failed to ensure the code status was obtained from the legal representative, and failed to ensure the medical record included the accurate advance directives. The findings include: Resident #1 had a diagnosis of dementia, hypertension (high blood pressure), and cirrhosis of the liver. Record review identified Resident #1 had a court appointed Conservator of Person (COP), with an effective date of [DATE]. The COP was listed as Emergency Contact #1 in the record. Advanced Directives Level of Treatment Options dated [DATE] identified the form directed DNR (Do Not resuscitate) - No CPR will be performed, CMO (Comfort Measures Only/DNR/DNI (Do Not Intubate) - no CPR will be performed. The form was signed by Emergency Contact #2. Additional review identified the line for the COP to sign was blank, and the line for the physician to sign was blank. Physician admission order dated [DATE] directed full code (administer CPR). The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 7 indicating severely impaired cognition. Resident Care Plan (RCP) dated [DATE] identified a full code status with interventions that directed to administer Cardiopulmonary Resuscitation (CPR) as needed. Physician order dated [DATE] directed full code. The nursing note dated [DATE] at 9:23 AM identified staff notified the supervisor at approximately 8:15 or 8:20 AM that Resident #1 was observed unresponsive. The note identified the resident's chart was reviewed with a signed advanced directive located that directed Do Not Resuscitate (DNR, no CPR) and a physician order that directed full code (perform CPR). The conservator was called and confirmed Resident #1 was a full code. At 8:20 AM a code blue (medical emergency) was paged overhead, all licensed staff responded, and CPR was initiated. At 8:25 AM the crash cart and Automated External Defibrillator (AED, advises when to deliver an electric shock to restore a normal heart rhythm) was on site. Emergency Medical Services (EMS) arrived and continued to deliver CPR until 8:45 AM. EMS then called the local hospital's provider who advised to stop CPR at 8:45 AM and was then pronounced deceased by EMS. EMS run sheet dated [DATE] identified upon arrival of EMS, the Fire Department was performing CPR, and no shock was advised. The run sheet indicated the staff provided EMS with a DNR that was incomplete and dated [DATE]. Additional paperwork indicated full code in the Advanced Directive section. The staff could not obtain updated paperwork or reach the family. CPR was continued and pause identified asystole (no heartbeat) with no palpable pulse, and Resident #1 was pronounced. Interview with the local Assistant Fire Chief #1 on [DATE] at 4:08 PM identified staff were performing CPR upon the Fire Department's arrival at the facility. Record review identified Resident #1 had a DNR advanced directive in the paper medical record that was signed by Emergency Contact #2 who was not the court appointed Conservator of Person. Further, there was a physician order in the electronic health record that directed full code status. Interview with LPN #2 on [DATE] at 12:37 PM identified she found Resident #1 unresponsive between 8:15 and 8:30 AM on [DATE] and she immediately paged the supervisor (RN #1). Interview and record review with RN #1/day shift unit manager on [DATE] at 12:32 PM identified the residents' code status in the hard/paper chart was a DNR and in the electronic medical record it was listed as a full code. RN #1 stated she called the COP who verified Resident #1 was a full code and CPR was initiated. RN #1 further stated she did not know why the code status in the electronic medical record and in the paper chart did not match, and stated they should have matched. RN #1 identified she and RN #2 (night supervisor) performed chest compressions and rescue breaths (artificial respirations) - alternating chest compressions while the other would provide respirations with an Ambu bag (device that delivers air to residents who are not breathing). Interview with RN #2 on [DATE] at 8:50 AM identified she was the night supervisor during the 11 PM to 7 AM shift ending on [DATE], and she responded the code blue page. RN #2 stated she checked the chart for code status which identified DNR, but the nurse stated the resident was a full code and CPR was administered by RN #1 and RN #2. The COP was contacted to verify code status, and the COP verified a full code. RN #2 stated she did not know why the medical record had conflicting code status directions, and stated the paper and electronic records should have matched. Interview with the DNS and Administrator on [DATE] at 3:07 PM identified Emergency Contact #2 was not a POA, and the advanced directive form should have been signed by the court appointed COP. Interview failed to identify why the advanced directive form was signed by Emergency Contact #2. The DNS and Administrator stated they did not know why the code status in the paper medical record and the electronic medical record did not match. They stated the records should direct the same and the court appointed conservator should have signed the advanced directive. Review of the Advanced Directive policy dated 9/2017 directed the facility will approach the health care proxy to formulate an Advance Directive. The decision making will be documented in the resident's medical record and communicated to the interdisciplinary team. The attached form directed to be signed by the resident/responsible party/COP and physician.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure the medical record was complete and accurate to include the responsible party was notified of a change in condition. The findings include: Resident #1 had a diagnosis of dementia, hypertension (high blood pressure), and cirrhosis of the liver. Record review identified Resident #1 had a court appointed Conservator of Person (COP), effective [DATE]. The COP was listed as Emergency Contact #1 in the record. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 7 indicating severely impaired cognition. Resident Care Plan (RCP) dated [DATE] identified a full code status with interventions that directed to administer Cardiopulmonary Resuscitation (CPR) as needed. The nursing note dated [DATE] at 9:23 AM identified staff notified the supervisor at approximately 8:15 or 8:20 AM that Resident #1 was observed unresponsive. At 8:20 AM a code blue (medical emergency) was paged overhead, all licensed staff responded, and CPR was initiated. Emergency Medical Services (EMS) arrived and continued to deliver CPR until 8:45 AM. EMS then called the local hospital's provider who advised to stop CPR at 8:45 AM and Resident #1 was pronounced deceased by EMS. EMS run sheet dated [DATE] identified EMS arrived at 8:39 AM and identified upon arrival, the Fire Department was performing CPR. The Fire Department reported no shock was advised. CPR was continued and pause identified asystole with no palpable pulse, pupils were dilated, with absent lung sounds. At 8:47 AM no pulse, no blood pressure, no respirations, no eye movement, no vocal or motor response, and Resident #1 was pronounced at 8:47 AM. The nursing note dated [DATE] at 11:58 AM identified the facility provider was notified and Resident #1's body was picked up at 9:20 AM by the designated funeral home. Although record review identified the COP was contacted to confirm advance directives when Resident #1 was found unresponsive, record review failed to identify the COP was notified after Resident #1 was pronounced deceased . Interview and record review with RN #1 on [DATE] at 1:50 PM identified after EMS pronounced Resident #1 deceased , she notified the COP (via telephone) of the death. RN #1 stated although she notified the COP, she did not write a nursing note because she thought RN #2 was writing the note. Interview with RN #2 on [DATE] at 8:50 AM identified she contacted the COP after the resident was pronounced deceased , but she forgot to write a nursing note. RN #2 stated she should have written a note. Interview with the DNS and Administrator on [DATE] at 3:07 PM identified the [NAME] was notified, but the nurse failed to document the notification in the medical record. Interview identified the notification should have been documented and they did not know why it was not done. Review of the Charting and Documentation policy (No date) directed to document the notification of family, physician, or other staff if indicated.

Based on clinical record review and staff interview for one of three residents (Resident #1) reviewed for discharge the facility failed to notify the discharging facility timely that they would not readmit the resident following hospitalization. The findings include: Resident #2's diagnoses included anxiety, depressive episodes, and substance abuse. A quarterly MDS dated [DATE] identified Resident #2 was alert and oriented, and was independent with ADLs and transfers. The RCP dated 10/4/2023 identified Resident #2 had intermittent agitation, inappropriate behaviors toward staff in a sexual nature, and non-complaint with care. Interventions directed to explain why behavior is inappropriate. APRN note dated 10/30/2023 at 10:12 AM identified Resident #2 was seen for angry and defensive behaviors, making verbal threats to staff and visitors. Directed to transfer to the hospital for evaluation due to threats of bodily harm to staff. Police were notified and with resident pending transfer. Record review identified Resident #2 was discharged to the hospital on [DATE]. admission documentation dated 11/22/2023 identified Resident #2 was ready for hospital discharge and readmission to the facility on [DATE]. Interview with the Director of Admissions and the Former Director of Admissions on 8/13/2024 at 11:27 AM identified Resident #2 was denied readmission to the facility by the DNS and Administrator but did not state a reason why. Interview failed to identify the denial of readmission was communicated to the discharging facility. Interview with the DNS and Administrator on 8/13/24 at 11:55 AM identified they originally agreed to readmit Resident #2 on 11/27/2023 until they were notified Resident #2 had recently hit a hospital staff member with his/her cane and attempted to elope from the hospital. The DNS and Administrator further stated an ambulance arrived with Resident #2 on 11/27/2023 and they notified the ambulance staff that they could not meet the needs of the resident and directed the ambulance to take Resident #2 back to the hospital. Interview failed to identify the denial of readmission was communicated to the discharging facility prior to Resident #2's arrival at the facility. No facility policy was provided for surveyor review.

Based on clinical record review and staff interview for one of three residents (Resident #1) reviewed for discharge, the facility failed to ensure a complete and accurate record to include documentation regarding a readmission or refusal to readmit a resident. The findings include: Resident #2's diagnoses included anxiety, depressive episodes, and substance abuse. A quarterly MDS dated [DATE] identified Resident #2 was alert and oriented, and was independent with ADLs and transfers. The RCP dated 10/4/2023 identified Resident #2 had intermittent agitation, inappropriate behaviors toward staff in a sexual nature, and non-complaint with care. Interventions directed to explain why behavior is inappropriate. APRN note dated 10/30/2023 at 10:12 AM identified Resident #2 was seen for angry and defensive behaviors, making verbal threats to staff and visitors. Directed to transfer to the hospital for evaluation due to threats of bodily harm to staff. Police were notified and with resident pending transfer. Record review identified Resident #2 was discharged to the hospital on [DATE]. admission documentation dated 11/22/2023 identified Resident #2 was ready for hospital discharge and readmission to the facility on [DATE]. Interview with the Director of Admissions and the Former Director of Admissions on 8/13/2024 at 11:27 AM identified Resident #2 was denied readmission to the facility by the DNS and Administrator but did not state a reason why. Interview identified the facility does not deny admissions or readmissions unless told by the DNS or Administrator. Interview with the DNS and Administrator on 8/13/24 at 11:55 AM identified they originally agreed to readmit Resident #2 on 11/27/2023 until they were notified Resident #2 had recently hit a hospital staff member with his/her cane and attempted to elope from the hospital. The DNS and Administrator further stated an ambulance arrived with Resident #2 on 11/27/2023 and they notified the ambulance staff that they could not meet the needs of the resident and directed the ambulance to take Resident #2 back to the hospital. Interview and record review with the DNS and Administrator on 8/13/24 at 2:15 PM identified the facility was unable to provide documentation of any communication with the hospital regarding accepting or refusing to readmit Resident #2. Further, the DNS and Administrator were unable to provide documentation in the clinical record identifying the hospital was notified timely of the refusal to readmit. Review of facility policy for Documentation in the Medical Record identified each residents medical record shall contain an accurate representation of the actual experiences of the resident. Review of facility policy for Transfer and discharge date d 4/2024 identified the facility must document the reasons for the transfer or discharge in the residents medical record, and in the case of necessity for the residents welfare and the residents needs cannot be met in the facility, document the specific resident needs that cannot be met.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #93) reviewed for personal property, the facility failed to ensure the resident's personal property was kept safe from loss and based on tour of the environment, the facility failed to maintain a safe, clean, comfortable, and homelike environment. The findings include: 1. Resident #93 was admitted to the facility on [DATE] with diagnoses that included hypertension, chronic kidney disease, and depression. Review of the social services notes and grievance log dated 4/25/24 through 7/22/24, three months, failed to identify that Resident #93 had reported personal items were missing. The admission MDS dated [DATE] identified Resident #93 was cognitively intact, had no active neurological diagnoses (including dementia), required set-up assistance for upper body dressing, and required a partial assist for lower body dressing. The care plan dated 5/13/24 failed to identify that Resident #93 had accusatory behaviors. Interview with Resident #93 on 7/14/24 at 10:05 AM identified that he/she had sent 2 Hawaiian shirts, 2 khaki cargo shorts, 1 black pair of shorts, 1 grey pair of capri shorts, a leather jacket, and a tee-shirt with a carnival cruise logo to the laundry, and the items were not returned. Resident #93 further identified that he/she reported the items missing and made inquiries to anyone at the facility that would listen, including calling down to the laundry room, but could not specifically recall which staff members he/she had reported to. Resident #93 indicated that some of the missing items were replaced by the facility with items that had been donated by other residents. Resident #93 further indicated that he/she appreciated the replacement items, but now there were only a few clothing items remaining that originally belonged to him/her. Resident #93 identified that 4 of the missing items had sentimental value: a. A leather winter jacket, that was labeled with his/her name and room number was reported to the facility as missing about 4 - 5 weeks ago; a (non-specified) manager had offered him/her another jacket as a replacement. b. 2 Hawaiian shirts that were labeled with his/her name were reported missing to the facility staff, about 3 - 4 weeks ago. c. A tee shirt with a [NAME] cruise logo, was reported missing to the facility over 2 weeks ago. Resident #93 identified that the missing clothing was an on-going issue, and despite complaining nothing had been done except to receive other people's donated clothes. On 7/15/24 Resident #93's Hawaiian shirts were returned. Interview with the Director of Laundry on 7/22/24 at 10:22 AM identified that he was unaware that Resident #93 was missing clothing items, and that the facility would not be able to clean a leather jacket, it would have to be sent out for dry cleaning. Interview with Laundry Aide #1 on 7/22/24 at 10:30 AM identified that Resident #93 called down to the laundry room inquiring about missing Hawaiian shirts; she could not recall the date of the call but estimated it was the week prior. Laundry Aide #1 indicated that the Hawaiian shirts were returned to Resident #93, but she had not seen a leather jacket. Laundry Aide #1 further indicated that she was unaware of the missing [NAME] Cruise tee shirt, but she would search lost and found for it. Follow-up interview with Resident #93 on 7/22/24 at 10:53 AM identified that he/she was happy that the 2 Hawaiian shirts were returned, but the leather jacket and tee-shirt with a [NAME] Cruise logo had not been returned. Resident #93 further identified that he/she began to make inquires with the facility staff greater than 2 weeks ago when the items were not returned with all the other items that they were sent down with to the laundry. Resident #93 indicated that a report was also filed with the social worker once he/she realized the items were not coming back. Interview with SW #1 on 7/22/24 at 11:03 AM identified that she had been working at the facility for 3 months and that Resident #93 had not reported any missing items to her. Interview with the DNS on 7/23/24 at 9:02 AM identified that she was unaware that Resident #93 had reported any missing items. The DNS indicated that reports of missing items were discussed during the facility staff's morning meetings, and then an investigation of the missing item would be initiated. The DNS further indicated that if the facility is unable to locate missing items, then the resident would be reimbursed for the item. Although requested a personal property policy was not provided The facility's Quality of Life-Homelike Environment policy directs that residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. 2. Observation on 7/22/24 at 1:15 PM with the Administrator and Director of Maintenance included the following. The grand lobby had a couch with soiled upholstered fabric on the seat cushion, arm rests, and head rest area. One sofa had a towel on the seat which the Director of Maintenance and the Administrator identified belonged to a specific resident who was not currently seated in the lobby area, however the towel remained. Under the spigot water dispenser was a poorly folded, soiled blanket. The elevator room's foyer sofa had cushioning material extending below the upholstered fabric. The elevator flooring had multiple tiles buckled and corners or tips missing, the elevator entrance flooring was missing tile pieces creating an uneven section of flooring, the grates on the lower elevator wall were not fully adhered to elevator wall. Multiple bathrooms in resident rooms on each floor had the following. The area separating the toilet base from the floor was soiled resulting in a darkened rim at the base flooring of the toilet. The sink faucet spout and handles contained either a cloudy milky residue or rusty discoloration at the base where the chrome met the sink. Multiple toilet seat risers identified with peeling paint and appeared rusted. Grey tiled floors were significantly marred with white scratches of varying degrees, the beige linoleum floors were identified with varying degrees of orange to brownish discoloration around the toilet, the area between the toilet and the wall was heavily soiled with varying degrees of brownish orange discoloration. room [ROOM NUMBER] electrical outlet poorly caulked, porcelain seating area in front of toilet marred and grey in the center area between left and right side of the toilet seat. room [ROOM NUMBER] grey flooring with spots. room [ROOM NUMBER] windowsill peeling paint. room [ROOM NUMBER] stained bathroom floor. room [ROOM NUMBER] broken electrical socket cover, 1/3 of cover missing. room [ROOM NUMBER] bathroom flooring soiled. On the 2nd floor lounge chairs in community areas at end of each hallway were torn at seams, soiled, and one sofa was identified with one of its leg 2 inches off the floor while the diagonal portion of the sofa base was against an intersecting corner of the wall. Every fabric chair observed in the dining room was heavily stained, and the wood accents on the chairs were faded and discolored. Many bureaus and nightstands were trimmed in duct tape or electrical tape. Duct tape was also used on the floors in various rooms including the dining room which had tattered and worn duct tape. The radiators and community areas at end of hall had peeling paint, area underneath radiators appeared rusted. The corridor had several areas of missing paint on drywall. The dining room sink was unclean, and the wooden microwave stand had graffiti and fading varnish. Rooms on the 2nd floor identified the following. room [ROOM NUMBER] paint peeling, curtains not hung on rod properly. room [ROOM NUMBER] diminished varnish above and below the door handles, writing on door door will not work and do not operate, and a rusted toilet seat riser. room [ROOM NUMBER] faucet with continuous running water, soiled drapes. room [ROOM NUMBER] door handle missing. room [ROOM NUMBER] duct tape on bedside table perimeter, worn duct tape on floor separating resident's room and bathroom. Rooms on the 3rd floor identified the following. Walls, bathroom flooring, dressers and nightstands in disrepair, many with duct tape around edges as well as furniture in alcove of corridors in disrepair. Housekeeping door spackled not painted, furniture in alcove has multiple cracks in vinyl seating. Multiple doors with peeling veneer or worn coloring, peeling paint on windowsills, and cracked paint above air conditioning unit. Multiple bathrooms with linoleum flooring with various degrees of orange coloring near toilet, faucet with running water, peeling tops of nightstands and bureaus trimmed in either electrical tape or duct tape, unclean air conditioning units (heavy dust), toilet seats in disrepair. Shower room had debris on the floor; worn glove, bottle of hygiene product, soiled wall tiles, sink containing dirty towels, hole in tile near upper door-opposite of door closer hardware, room [ROOM NUMBER] soiled flooring near toilet, varying degrees of orange stains on floor. room [ROOM NUMBER] veneer split on door unsmooth edges of veneer exposed. room [ROOM NUMBER] faucet has constant drip per maintenance requires change of faucet. room [ROOM NUMBER] red toilet seat has discoloration. room [ROOM NUMBER] dripping faucet. room [ROOM NUMBER] dripping faucet. room [ROOM NUMBER] frayed duct tape on flooring separating room from bathroom. room [ROOM NUMBER] drapes not hung properly on curtain rod. room [ROOM NUMBER] drapes with brown speckled discoloration. room [ROOM NUMBER] brown stained ceiling tiles. room [ROOM NUMBER] door veneer split unsmooth edges exposed. room [ROOM NUMBER] bathroom floor visibly soiled, toilet paper roll empty. room [ROOM NUMBER] bathroom floor with varying degrees of orange discoloration near toilet. room [ROOM NUMBER] dripping faucet, marred walls behind beds. room [ROOM NUMBER] curtains visibly soiled. Interview with the Administrator and the Maintenance Director on 7/22/23 at 1:10 PM identified the facility is under a major renovation and all matters identified are a part of the renovation. The Maintenance Director indicated concerns regarding cleanliness would be addressed and as a recent new hire was not aware of many of the items identified during the walk through. On 7/23/24 at 12:30 PM a copy of the letter of intent for repairs was provided. The letter was dated 7/5/24 and signed by the contractor on 7/8/24. The letter addressed replacing the bathroom flooring, bathroom tile, toilet tank and toilet seat, ramp up and repair entrance as well as wall hung cabinets. The letter of intent was signed by the contractor only, the owner's name, signature and date were absent from the document, and a signed agreement by both parties was not provided. A copy of the environmental rounds was requested, however not provided. Interview with the DNS and RN #3 (Corporate Clinical Director) on 7/23/24 at 12:50 PM identified that the nursing staff is aware of the protocols to report concerns to maintenance, and the expectation is that the rooms are clean and maintained, and further identified corporate was addressing the concerns. The policy for Quality of Life-Homelike Environment states that residents are provided with a safe, clean, comfortable and homelike environment and facility staff should reflect a homelike setting with characteristics that include cleanliness and order. 47457

Based on observation, review of facility policy and interviews, the facility failed to ensure food was prepared under sanitary conditions within professional standards. The findings included: Observation on 7/16/24 at 9:36 AM during BFSI tour of the kitchen with the Maintenance Assistance identified [NAME] #1 at the three compartment sinks thawing frozen chicken in a deep pot under running cold water in the third sink. The first sink was full of dirty pots and bowls soaking in a sink full of water with suds. The second sink was identified with a moderate amount of soap suds and food debris. The third sink was identified with a deep pot with chicken under running cold water with [NAME] #1 preparing the chicken without the benefit of gloves. Interview with the Dining Services Director (DSD) on 7/16/24 at 10:40 AM identified he was not aware of the issue. The DSD indicated [NAME] #1 should not have used the three compartment sinks for prepping or thawing out the chicken. The DSD indicated the kitchen has 2 preparation sinks and one of the preparation sinks is used for meat. Interview with Dietitian #2 (Director of Clinical Operations) on 7/16/24 at 10:50 AM identified she was not aware of the issue. Dietitian #2 indicated [NAME] #1 should not have been preparing the chicken in the three compartment sinks with dirty pots and a sink full of water and soap suds in one sink, and suds and food debris in the middle sink. Interview with [NAME] #1 on 7/16/24 at 11:00 AM identified she has been employed by the facility for 3 years. [NAME] #1 indicated she was not supposed to thaw the chicken in the three compartment sinks, especially when it was dirty. [NAME] #1 indicated sink #1 (on the other side of the kitchen) which is used for meat was being occupied and sink #2 (on the other side of the kitchen) is not used for meats it is only use for fruits and vegetables. [NAME] #1 indicated she had to get the chicken ready for supper. Interview with the DNS on 7/16/24 at 11:05 AM identified she was not aware of the issue. The DNS indicated she will meet and discuss with the DSD and [NAME] #1 regarding prepping in the three compartment sinks is not sanitary. Review of the facility food preparation policy identified all foods are prepared in accordance with the Food and Drug Administration (FDA) food code. Dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. The cook(s) thaws frozen items that requires defrosting prior to preparation using one of the following methods: Completely submerging the item under cold water (at temperature of 70 degrees F or below) that is running fast enough to agitate and float off loose ice particles. The FDA Guidelines for three compartment sinks identified: If food products are to be washed or thawed in the three compartment sink each sink must be emptied, washed, and sanitized before and after each use.

Based on observations, clinical record reviews, review of reportable event documentation, review of facility policy, and interviews for two of six sampled residents reviewed for accidents (R #147, R#154), the facility failed to ensure fall prevention measures were implemented and/or the resident was properly assessed for to self-propel in his/her wheelchair, and/or that the resident was properly reassessed following an fall to prevent further falls. The findings include: 1. Resident # 147's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The RCP dated 11/25/16 identified the resident was at risk for falls related to weakness, history of falls and decreased balance. Interventions directed the use of a bed and chair alarm and to ensure the device was in place. An admission MDS assessment dated [DATE] identified the resident had moderately impaired cognition, required extensive assistance with toilet use, personal hygiene and transfers and one person assistance with ambulation. Nurse's notes dated 12/24/16 identified at 1:15 PM, the resident was attempting to toilet him/herself, fell and was found on the floor in another resident's bathroom. The resident complained of upper left thigh pain and an abrasion was noted on the mid back that measured 1.0 cm by 0.5 cm. The physician was notified and directed an x-ray. The x-ray results showed an acute left femur fracture. At 4:42 PM, the resident was transferred to the ED for evaluation and treatment. The Hospital Discharge Summary dated 12/28/16 identified a displaced left femoral fracture and the resident underwent [REDACTED]. Interview and review of a written statement regarding the incident with NA# 4 on 4/26/17 at 1:30 PM identified the NA left the resident by his/her room door. Another resident approached the NA and stated there was a person lying on the floor in his/her bathroom. The NA found the resident on the floor and alerted the nurse. Additionally, NA#4 stated the resident did not have the alarm on at the time of the fall. Interview, review of the clinical record and facility documentation on 4/27/17 at 1:30 PM with RN# 2 and the DNS identified that although an addendum to the original Reportable Event form submitted to DPH identified that the fracture was pathological secondary to osteoporosis, the hospital report indicated that the fall resulted in an acute left hip fracture. Additionally, there was no documentation supporting that the fracture caused the resident to fall. Further review noted that the alarm should have been utilized to alert the staff that the resident was attempting to transfer without assistance. 2. Resident # 154's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident # 154 had severe cognitive impairment and required the assistance of one for bed mobility, transfers, dressing and toileting. The Resident Care Plan (RCP) reviewed on 8/10/16 identified that the resident was at risk for injuries related to falls. Interventions included to keep Resident #154 in a highly visible area for observation, anti-tippers to wheelchair, re-educate resident to call for assistance, and provide a bed alarm. a. The nurse's note dated 10/3/16 at 0800 identified that Resident #154 had fallen and reported that he/she hit his/her head and complained of left wrist pain. A reportable event dated 10/3/16 documented that while being pushed in the wheelchair by NA#1, the resident fell forward out of the wheelchair. A physician order [REDACTED]. Further MD orders on 10/4/16 indicated to splint left wrist until seen by orthopedics for possible hairline fracture to distal radius. An interview with NA #1 on 4/25/17 at 2:45 p.m. indicated that he/she had transferred the resident from the shower chair to his/her wheelchair and was bringing him/her down the hallway to the dining room when Resident #154 put his/her foot down while being pushing down the hallway and he/she fell out of the wheelchair. Further interview indicated that NA#1 could not recall if Resident#154 had the foot rests or a cushion on the wheelchair at the time of the fall on 10/3/16. NA#1 did indicate that he/she was aware that Resident #154 had foot rests available to him/her. Interview with LPN#1 on 4/26/17 at 1:50 PM indicated that Resident #154 did not have foot rests on his/her wheelchair and self-propelled around the unit. b. Nurse's notes on 10/4/2016 at 1636 indicated that the resident was in his/her wheelchair being pushed by a transportation attendant to go out for an orthopedic appointment. The note indicated that the resident leaned forward, fell out of the wheelchair hitting his/her head and sustaining a laceration of left forehead and was being transferred to the hospital for evaluation. A reportable event dated 10/4/16 documented that while being pushed by a transportation attendant from an outside company, the resident fell forward out of his wheelchair, hit his/her left forehead and sustained a laceration. Discharge information from Norwalk Hospital dated 10/4/16 indicated that Resident #154 has a questionable transverse mildly impacted fracture of the distal radius, wrist was splinted and follow-up is recommended with Orthopedics. Interview with NA # 2 on 4/26/17 at 1:50 p.m. indicated that when a resident goes to an appointment with transportation, he/she uses his/her own wheelchair. An interview and clinical record review with the Interim Director of PT and OTR#1 on 4/27/17 at 9:55 a.m. indicated that the last time Resident #154 received treatment for [REDACTED]. OTR#1 indicated that Resident #154 was not being seen at that time for wheelchair mobility. Further interview with OTR#1 on 4/27/17 at 10:25 a.m. indicated that when he/she arrived where the accident occurred, Resident #154 did not have his/her foot rests in place when transporter was taking Resident #154 to his medical appointment. An interview with the Interim Director of the Physical Therapy on 4/25/17 at 1:55 p.m. indicated that when a Resident has Parkinson's disease and/or decreased upper or lower body strength, they should have leg rests on the wheelchair. Further interview indicated that when a resident goes out to an appointment, they should always have foot rests attached to the Resident's specific wheelchairs. The Director indicated that when nursing staff can't find the foot rests they will call Physical Therapy Department.

Based on clinical record reviews, observations, interviews and review of facility policy for three of six residents in the survey sample reviewed for pressure ulcers (Resident # 56, 68, 197), the facility failed to conduct a comprehensive assessment when a pressure sore was noted, and/or failed to conduct weekly skin assessments, and/or failed to identify pressure areas prior to stage 3 or DTI, and/or failed to obtain treatment orders when a wound was discovered, and/or failed to ensure offloading of extremities in residents at risk and/or ensure turning and repositioning assistance were provided and documented. The findings include: 1. Resident # 56's [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. A five day MDS assessment dated [DATE] identified the resident had impaired cognition, required extensive assistance of two staff members for bed mobility, transfers, and toilet use, was always incontinent of bladder, was at risk of developing a pressure ulcer, had no current pressure ulcers, utilized pressure reducing devices on the bed and chair, and was not on a turning and positioning program/schedule. The care plan dated 2/4/16 identified a risk for alteration in skin integrity. Interventions included to encourage resident to maintain good hygiene and educate as to the risk of developing alteration in skin. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Wound care notes dated 2/5/16 identified that the right medial buttock had an unstageable area measuring 1.0 cm x 1.0 cm with surrounding scar tissue, no drainage, positive slough to center, only edges with granulation tissue. Wound care notes dated 2/16/16 noted R #56 complained of right heel pain. The APRN was notified and identified on the right medial heel a flat dry blood blister like area measuring 2.7 cm x 1.5 cm, and on the right lateral heel, mild tenderness with skin intact. Observation of the resident on 3/2/16 at 8:50 am with LPN #6 identified the resident in bed on his/her back eating breakfast with the left leg crossed over the right leg and both heels resting directly on the mattress without the benefit of off loading pressure. No off loading devices were found in the bed but blue foam boots were noted on chair next to the bed and on the floor next to the chair. There were no directions in the care plan or NA ' s assignment that directed use of foam boots. Observation of R #56's heels and interview with MD #1 on 3/3/16 at 12:30 PM identified the resident ' s heels should be off loaded at all times while in bed and not just at bedtime. Although the clinical record identified that off loading of the heels was being done at bedtime, the clinical record and observation on 3/3/16 failed to reflect off loading of the heels was being done when the resident was in bed other than the evening shift. 2. Resident #68's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified the resident without cognitive impairment, displayed no problem behaviors, did not reject care, required extensive assistance with ADL's, was at risk for pressure ulcer development, utilized pressure reducing devices on the bed and chair, had two stage three pressure sores and one that had healed, and was not on a turning and positioning program/schedule. A wound consultant assessment dated [DATE] noted the presence of two abrasions of old scar areas on the posterior right and left thighs. The resident care plan dated 10/6/15 identified the presence of friction rub areas that re-opened to the posterior thighs. Interventions included apply treatment as ordered, assist in turning and repositioning properly in bed, encourage to get out of bed and up, educate on risk verses benefits of not complying with interventions, encourage to ambulate, and assist to avoid shearing to back of thighs. Nurse ' s notes dated 10/12/15 identified a new open area noted on the right medial buttocks. No other information or assessment regarding the open are was noted in the clinical record until 10/14/15. No treatment orders were obtained at that time. The wound care specialist evaluation dated 10/14/15 identified a stage three pressure wound to the right medial buttocks measuring 1 cm x 1 cm x 0.2 cm with 100% granulation tissue, no exudate. Physician orders [REDACTED]. Interview and review of the clinical record with the DNS on 3/2/16 at 1:00 PM identified when the resident was noted with a new open area on 10/12/15, the clinical record should have reflected a thorough assessment of the area including location, size, stage, and presence of any exudate/drainage, and treatment orders should have been obtained and initiated. 3. Resident #197's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #197 had a cognitive impairment and required extensive assistance with bed mobility, transfers, and was non-ambulatory. The care plan dated 1/29/16 identified the resident had a potential for alteration in skin integrity related to decreased mobility and incontinence with a suspected deep tissue injury to the sacrum identified on 2/16/16. Interventions included to administer treatments as ordered, monitor for effectiveness, monitor/document/report to MD as needed, changes in skin status, appearance, color and provide pressure reducing devices as ordered/directed. Review of the pressure wound tracking form identified that a pressure ulcer was identified on 2/16/16 to the sacrum measuring 3.3 cm by 3.3 cm and was staged as a suspected deep tissue injury. Review of the NA care card updated on 2/26/16 directed facility staff to turn and position every 2 hours while in bed, check sacral area every shift for placement of duoderm, and apply barrier cream for incontinence. Review of the physician orders [REDACTED]. Observation, interview and review of facility documentation with LPN #3 on 3/1/15 at 9:30 AM identified that the resident was lying on his/her back, turned slightly to the right and required assistance from staff to turn off the pressure ulcer area. The wound was noted to have a dark brown/maroon center with surrounding peripheral redness that only blanched toward the outer edges. Wound measurements identified that the inner area of the wound was 3 cm x 3.5 cm and that the wound had opened and left a moist, bloody area on the pad (the size of the wound) under the resident. LPN #3 identified that the resident was on a Group 2 mattress, but that this was not appropriate and he/she should have an alternating pressure mattress. LPN #3 identified that he/she had measured the wound but failed to put the measurements in the computer. LPN #3 was unable to explain why he/she did not put an APM mattress on the resident ' s bed. Interview and review of facility documentation with the DNS on 3/2/16 at 8:45 AM identified that the resident is independent in bed mobility and that there was no documentation to show that the resident was turned and positioned until 2/16/16 because he/she was independent, although review of the NA flowsheets and the MDS assessment identified that the resident required extensive assistance to turn and position for bed mobility. physician's orders [REDACTED]. Interview, review of facility documentation and review of facility policy on 3/2/15 at 10:05 AM with the DNS identified that skin checks for the month of February were incomplete, that only two assessments were completed for the month but should have been completed weekly and that the assessment on 2/19/16 failed to identify that the resident had a deep tissue injury pressure ulcer on the sacrum.

Based on reviews of the clinical record, reviews of facility documentation, and interviews for two of six residents reviewed for accidents (R#60, 169), the facility failed to provide the appropriate supervision resulting in a fall and/or failed to ensure that liquid oxygen was placed safely away from the resident's skin resulting in a burn. The findings include: 1. Resident # 60's [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] indicated the resident had severely impaired cognition, required total care with all ADLs, and did not walk. A care plan dated 4/30/14 identified a problem with risk of injury related to the resident not being aware of safety needs. Interventions included anticipate and meet the needs of the resident. Review of a nurse's note dated 5/30/14 indicated R # 60's right upper thigh was noted to be red with multiple fluid filed blisters and 4 small black streaks. The supervisor and MD were notified. A physician's orders [REDACTED]. Apply silvadene and telfa. A wound care specialist note dated 6/10/14 indicated R # 60 had a burn on the left leg caused by oxygen. The burn was 8 cm x 12 cm with 100% black necrotic tissue. The tissue was debrided. The resident continued to be followed by the wound care specialist through 3/11/15. The 3/11/15 note indicated the burn was 0.8 cm x 2.3 cm with only 10% granulation tissue. An observation on 3/19/15 at 11:05 AM noted a reddened area with brown-colored tissue in the center on the resident's right thigh. Review of a facility investigation dated 5/30/14 indicated R # 60 was seen by the podiatrist at 12:30 PM The resident was wheeled back to the nurse's station at 1:00 PM. At 1:15 PM the oxygen tank was noted on the resident's right thigh. The investigation was not able to determine who placed the portable oxygen on the resident's lap. Staff were educated on proper transfers and handling of oxygen tanks to prevent an injury. An interview on 3/18/15 at 8:45 AM with the DNS indicated the resident was found with the liquid oxygen tank lying sideways on his/her right leg/lap with a blanket over his/her lap.. Although the investigation was unable to determine who placed the tank on the resident's lap, the resident was not physically capable of placing the oxygen tank on his/her own lap. An interview on 03/18/2015 at 9:04 AM with NA #1 indicated he/she got R # 60 out of bed between 10:45 am and 11:00 AM on 5/30/14. He/she left the resident near the TV room with the oxygen tank place on the back of the wheelchair. The next time he/she saw the resident, the resident had been moved to a different area and the oxygen tank was lying flat on the resident's leg. The resident's blanket was off to the side. The resident's leg was cold and white. He/she notified the nurse immediately. Nurse aide # 1 indicated at no time did he/she place the oxygen tank on the resident's leg and/or lap. An interview on 3/18/15 at 3:11 PM with podiatrist # 1 indicated as per his/her statement, he/she found the resident in the hallway with his/her portable oxygen placed on the floor. He/she transported the resident and the oxygen to the resident's room. After he/she treated the resident, he/she transported the resident to an area near the nurse's station and placed the oxygen on the floor next to the resident. At no time did he/she place the oxygen tank on the resident's leg and/or leg. 2. Resident #169's [DIAGNOSES REDACTED]. An Admission MDS dated [DATE] identified the resident with moderately impaired cognition, requiring extensive assistance with ADL'S, including transfers and ambulation. Additionally balance during moving on and off toilet, moving from seated to standing, and walking was identified as not steady and only able to stabilize with assistance. physician's orders [REDACTED]. The Resident Care Plan dated 2/5/15 identified the resident was at risk for falls related to the history of falls, deconditioning and gait/balance issues, and a potential for communication problems related to hard of hearing and difficulty with recall. Interventions directed the staff to provide a safe environment. Nurses notes and facility documentation dated 2/16/15 identified the resident was ambulated to the bathroom and instructed to call for assistance when done. One minute later the resident was found sitting on the floor in front of the toilet. The resident sustained [REDACTED]. Nurses notes and facility documentation dated 3/1/15 identified the resident was left on the toilet without supervision while the NA left the bathroom to get the resident's sweater. Subsequently the resident stood up from the toilet without assistance and fell . A skin tear on the resident's left elbow was noted. Interview and review of the clinical record on 3/18/15 at 9:30 AM with the DNS identified that resident's who have balance problems, difficulties with recall and are at risk for falls should not be left unattended while in the bathroom.

Based on observations, clinical record reviews, and staff interviews for two of six residents in the survey sample reviewed for pressure ulcers (R #72, 80), the facility failed to ensure preventative skin assessments were completed weekly resulting in the identification of an unstageable ulcer, and/or that interventions to prevent pressure sores were initiated/documented for residents at risk, and/or failed to review/revise the plan of care to ensure healing of pressure sores or prevent new ones from developing. The findings include: 1. Resident # 80's [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified the resident had severe cognitive deficits, required extensive assistance with bed mobility and transfer, was at risk for pressure ulcers, and had no pressure ulcers. A care plan dated 3/19/13 identified the risk for pressure ulcers related to decreased mobility and incontinence. Interventions included monitor, document, and report changes in skin status. Pressure ulcer assessment documentation dated 5/15/13 indicated that a 0.5 cm x 0.5 cm unstageable pressure ulcer was identified on the resident's left outer ankle (malleolus). The description of the wound was noted to be 100% slough with light serous drainage. Surrounding skin was reddened and macerated. No prior documentation identified redness or other skin conditions on the area. An observation on 6/26/13 at 9:30 AM with RN #3 noted an open area on R #80's left outer ankle. The wound bed was noted to be covered with white slough. At that time RN # 3 measured the open area as .4 cm x. 3 cm. A review of the clinical record and interview on 6/27/13 at 10:00 AM with the ADNS indicated skin body audits are conducted weekly on all residents. She was unable to provide documentation of skin body audits for R#80 from April 2013 through May 15, 2013. The ADNS indicated as a result of the facility's transition to computerized medical records in April 2013, the resident's weekly skin body audits were not completed in April 2013. They were resumed on 5/15/13 when the pressure ulcer was identified. 2. Resident #72's [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified the resident with moderately impaired cognition, no mood or behaviors exhibited, required extensive assist of two for bed mobility, extensive assist with toileting and personal hygiene, frequently incontinent of bladder and bowel, at risk for developing pressure ulcers, and no pressure ulcers identified. A care plan dated 4/26/13 identified a potential for pressure ulcer development. Interventions included monitor nutritional status, monitor/document/report to MD changes in skin status, and to follow facility policies/protocols for the prevention/treatment of [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Nursing notes dated 6/4/13 identified a 2.5 cm x 3 cm wound on the left heel, and the right heel was noted as boggy. Weekly pressure ulcer tracking dated 6/5/13 identified an intact blister located on the right heel. On 6/7/13, the heel wound had declined to an unstageable area measuring 3.0 x 5.0 noted with necrosis, moderate amount of serous drainage, and surrounding [DIAGNOSES REDACTED]. Additionally on 6/7/13, a stage three pressure ulcer was identified on the coccyx measuring 1.5 cm x 1 cm x 0.1 cm with moderate amount of serous drainage. Interview and review of the clinical record with ADNS on 6/26/13 at 1:00 PM failed to provide documentation that pressure relieving interventions had been initiated/carried out to prevent pressure sores from developing. The ADNS identified that residents at risk for skin breakdown are provided with turning and repositioning every two hours, and off loading/elevation of the lower extremities with documentation of these interventions in the treatment kardex. The clinical record failed to reflect that interventions were implemented to prevent the development of a pressure ulcer and/or failed to reflect the care plan was reviewed and/or revised with new interventions when the resident was identified with stage two pressure ulcer on the right heel on 6/5/13, and on 6/7/13 when an unstageable pressure ulcer was identified on the left heel and a stage three pressure ulcer on the coccyx.

Based on clinical record review, review of facility reportable event documentation, and staff/physician interviews for the only sampled resident with a lower extremity fracture (R#130), the facility failed to ensure that appropriate orders to care for the fracture were obtained from the orthopedic surgeon (MD#1), and/or failed to ensure that a soft cast/dressing and immobilizer applied by MD#1 to stabilize the fracture, were not removed without orders resulting in an open fracture and infection, and/or failed to ensure that an immobilizer was in place when the leg/fracture was moved. The deficiency resulted in a finding of immediate jeopardy. The findings include: Resident #130 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated 5/29/12 directed the resident continue with immobilization. No other orders were present on the discharge summary including when the resident should visit MD#1/orthopedic surgeon for follow up. The MDS dated [DATE] identified the resident had severely impaired cognition, required extensive assistance of two staff for bed mobility and transfers and was non ambulatory. Nurse's notes dated 6/13/12 at 8:35 PM identified the resident was in bed, unable to follow instructions, oxygen saturation was 89% on room air and the resident was not readily speaking. After physician notification, the resident was transferred to the hospital for evaluation. Facility reportable event documentation dated 6/14/12 identified that the facility had received a call from the hospital at 3:00 AM stating the right distal femur fracture sustained on 5/24/12 had "deteriorated" to a compound (open) fracture. Interview with RN#6 (who conducted the re-admission assessment on 5/29/12) on 7/30/12 at 11:30 AM identified the resident was readmitted with an immobilizer on the right leg from the hip to the ankle. When the immobilizer was opened, there was cotton padding wrapped around the resident's leg from the hip to the mid ankle. RN#6 stated she removed the wrapping and assessed the resident's leg without written orders to do so or permission from MD#1 (orthopedic surgeon). Additionally, RN#6 stated that she told the facility covering physician (MD#4) via telephone that in her opinion, the dressing was for protection. She requested an order to utilize AND pads under the immobilizer. RN#6 never called MD#1 for directions on care of the fracture or permission to remove the wrap/soft cast. Physician telephone orders dated 5/31/12 directed that staff may loosen the right leg immobilizer every shift for hygiene and skin inspection. Interview with RN#4 (the unit manager) on 7/26/12 at 11:15 AM identified that she called MD#1's office on 5/31/12 and spoke to "someone" in the office for an order to remove the immobilizer on the right leg for skin inspection and hygiene. RN#4 stated she received a call back from someone, whom she could not identify, in MD#1's office who gave an order directing staff may loosen the immobilizer for skin inspection and hygiene. RN#4 stated that she never spoke with the orthopedic surgeon for orders on care of the fracture or follow up. Interview with the DNS on 7/26/12 at 1:00 PM identified that facility staff can take a telephone order from a nurse in a physician's office; however, the name of the nurse giving the order should be added to the physician order [REDACTED]. Interview with MD#1's receptionist on 7/26/12 at 12:50 PM noted she had no record of the facility calling (for orders) on 5/31/12. Although the discharge summary from the hospital dated 5/24/12 directed staff to immobilize the resident's right leg, interviews, written statements and documentation identified the following; a. Interview with LPN#2 on 7/26/12 at 11:00 AM identified that on 6/10/12 and 6/11/12 on the 7-3 shift when caring for the resident, she removed the immobilizer, cleansed the leg and the immobilizer/AND pads were replaced. b. Interview with RN#3 on 7/25/12 at 3:00 PM identified that on 6/9/12 and 6/11/12 during the 3-11 shift, she would open the immobilizer, remove it and apply cream to the whole right leg before re-applying the immobilizer. c. Interview with RN#2 on 7/25/12 at 3:05 PM identified that on 6/10/12 during the 3-11 shift, the assessment of the resident's right leg included removing the whole immobilizer to to look at the leg. Additionally, RN#2 stated there was no AND padding or any other dressings under the immobilizer. d. A nurse's note dated 6/11/12 at 4:32 AM identified the resident's immobilizer was released for a while, and the leg kept elevated. Review of hospital records noted that upon arrival in the emergency department on 6/13/12, the resident's temperature was 104 degrees. The history and physical done at 12 AM on 6/14/12 indicated that the resident had a recent femur fracture treated by MD#1 and now has an open femur fracture with a call to the nursing home indicating that there had been no documentation of any fall or open fracture. The H&P indicated that the open fracture had brownish discharge and surrounding redness. The physical indicated that the "fracture looks old with brownish discharge and surrounding [DIAGNOSES REDACTED]. Also there were gauzes soaked in brownish discharge when I saw the pt". Interview the hospital emergency department RN on 7/31/12 at 12:25 PM noted that he never opened the immobilizer when he did the skin assessment on 6/13/12 at 10:31 PM. He noted that his skin assessment did not include anything under a dressing as well. He stated that he never saw the resident's leg and never called the facility. Interview with the hospital risk manager on 7/31/12 at 12:30 PM identified that the first person to open the immobilizer was the resident physician who conducted the history and physical at 12 AM. He noted that the physician was the one who called the facility to find out how long the leg had been that way. MD#1's hospital progress note/assessment on 6/14/12 at 8 AM indicated that the distal femur was protruding through the skin and was infected and an above the knee amputation was recommended. MD#1 further documented "need to discuss with (nursing home) events surrounding". A hospital wound care note dated 6/14/12 at 8:30 AM indicated an open fracture with exposed, desiccated bone. The resident was diagnosed with [REDACTED]. Hospital operative reports indicated that the resident's right leg was amputated due to an "infected right femoral fracture". The hospital pathology report indicated a final [DIAGNOSES REDACTED]. "right above knee amputation: large soft tissue abscess involving the distal femur, with a fracture and acute osteo[DIAGNOSES REDACTED] of the distal femur." The femur was detached and softened. Interview with MD#1 (orthopedic surgeon) on 7/25/12 at 3:40 PM identified the resident was discharged from the hospital on [DATE] with the right distal femur fracture stable and immobilized in good alignment, wrapped with bulky "Jones" dressings, cotton webbing and a wrap. MD#1 stated the wrapping on the right leg was not to be removed by staff as it was like a cast and it kept the fracture stable and in good alignment. The dressing should have been left alone and the resident should have followed up with MD#1, two weeks post hospitalization . MD#1 noted that he documented clearly in the hospital notes that the resident's immobilizer was not to be touched. MD#1 stated that if the facility staff had questions related to the care of the immobilizer, they should have called for clarification. MD#1 indicated that the open fracture could be due to lack of proper immobilization. MD#1 stated that the open (compound) [MEDICAL CONDITION] femur discovered in the emergency department of the hospital on [DATE], had not just happened. He stated that the condition of the bone and skin indicated that the (compound) fracture was 5-7 days old. The bone was dead and the skin around the wound was dead. The bone was sticking out through the skin on the lateral side of the knee. MD#1 stated that the fracture was stable when the resident was discharged from the hospital on [DATE] and the knee was immobilized. He noted that if the immobilizer and dressing were on where they should have been, this (the open fracture) would not have happened. The above deficiency resulted in a finding of immediate jeopardy for failure to consult the orthopedic physician for appropriate treatment orders and/or removal of a fracture stabilizing dressing/wrap/soft cast, and/or manipulation of the fracture without the immobilizer in place. Based on clinical record reviews and staff interviews for seven of seven resident's observed with skin conditions (R #6, #136, # 264, #260, # 194, # 213, # 248), the facility failed to assess and/or document the resident's change in skin condition and/or conduct body audits and/or obtain physician orders [REDACTED]. 1. Resident # 264 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A body audit dated 7/20/12 indicated the resident had an open wound on the left chest clavicular documented as "unstageable pressure ulcer". An observation on 7/24/12 at 12:15 PM noted an open wound on the resident's left clavicle. The wound was not covered. R #4 was evaluated on 7/25/12 by wound care physician MD#1 and the ADNS. Subsequent to assessment, physician directed treatment to open area on the left clavicle. Interview with RN #4 on 7/25/12 at 12:20 PM indicated PA #1 diagnosed the open area on the left clavicle as a sebaceous cyst that was irritated by a left arm immobilizer. She Indicated an I&D was performed with specimen sent to the lab for culture. She further indicated the facility should have obtained treatment orders on the resident's admission (7/20/12). An interview with the DNS on 7/26/12 at 11:30 a.m. indicated the expectation for residents admitted with open areas on skin is to perform a body audit and contact the physician for clarification of treatment orders. 2. Resident #136's [DIAGNOSES REDACTED]. Physician monthly orders for July 2012 directed weekly body audits during the 7 A.M. to 3 P.M. shift on Thursdays. In addition, physician orders [REDACTED]. On 7/26/12 at 11:10 A.M., an interview and review of the clinical record with the Unit Manager (RN #5) indicated that although the licensed staff were signing off on the treatment kardex with their initials that they had completed the resident's weekly body audit as directed by the physician, on 7/5, 7/12, and 7/19, 2012, a review of the resident's body audit tool for July of 2012, lacked documentation to reflect the date of onset and/or resolution of the aforementioned wounds. On 7/26/12 at 2:40 P.M. an interview and review of the clinical record with the ADNS (Wound Nurse) in the presence of Regional Nurse #2 indicated that the licensed nurse was to have completed the resident's body audit on a weekly basis. 3. Resident #260 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident careplan (RCP) identified that the resident was at risk for pressure ulcer development and to follow facility policies for prevention of skin breakdown. Review of the treatment kardex dated July 2012 identified that the weekly body audits were not complete and the clinical record lacked body audits since July 4,2012. Interview with the ADNS on 7/26/12 at 6:45 AM and review of the documentation failed to reflect that skin assessments were completed weekly as per facility policy. 4. Resident #194 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident careplan (RCP) dated 6/16/12 identified that the resident was at risk for pressure ulcer development. Review of the treatment kardex dated July 2012 identified that the weekly body audits were not completed since July 3, 2012 and the clinical record lacked body audits since July 3, 2012. Interview with the ADNS on 7/26/12 at 6:45 AM and review of the documentation failed to reflect that skin and body audits were completed weekly as per facility policy. 5. Resident #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Review of the treatment kardex dated July 2012 identified that the weekly body audits were not completed since July 4, 2012 and the clinical record lacked body audits. Interview with the ADNS on 7/26/12 at 6:45 AM and review of the documentation failed to reflect that skin and body audits were completed weekly as per facility policy. 6. Resident #248 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident careplan (RCP) dated 4/6/12 identified that the resident was at risk for pressure ulcer development and to follow facility policies for prevention of skin breakdown. Review of the treatment kardex dated July 2012 identified that the weekly body audits were not completed since July 2, 2012 and the clinical record lacked body audits since July 2, 2012. Interview with the ADNS on 7/26/12 at 6:45 AM and review of the documentation failed to reflect that skin assessments were completed weekly as per facility policy. 7. Resident #6 's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified that the resident was severely cognitively impaired and totally dependent on facility staff for all activities of daily living (ADL). The RCP dated 12/27/11 identified the potential for alteration in skin integrity. Interventions included assess skin weekly and report changes and to update physician and family on changes in condition or treatment. Nurse's notes dated 2/9/12 at 6:21 PM identified that the R #6 had [MEDICAL CONDITION] (infection) to the left hand with the 2nd and 5 th fingers grossly swollen. It further identified that he/she had a temperature of 99 degrees and that intravenous (IV) antibiotics was started. Review of hospital discharge summary dated 2/17/12 identified that R#6 was admitted to the hospital on [DATE] with a 101.4 degree temperature and the [DIAGNOSES REDACTED]. It further identified that wound cultures were obtained after a bedside incision and drainage ( I & D) on left pinky and index finger which found [MEDICAL CONDITION] resistant staph aureus (MRSA) . An interview and review of facility incident documentation with the administrator and corporate nurse on 7/25/12 at 11:08 AM identified that on 2/8/12, R#6 was observed by staff with reddened knuckles on the left hand. The administrator indicated that the result of the facility investigation identified that facility nursing staff failed to notify the resident's physician in a timely manner and/or document comprehensive assessments as R#6's left arm became progressively infected ([MEDICAL CONDITION]) throughout the following days with resulting hospitalized from [DATE] through 2/18/12. During an interview with PA #1 on 7/25/12 at 12:41 PM he/she indicated that although it was the facility 's usual practice, he/she would expect that staff would notify the physician and/or his/herself in a timely manner when a resident experiences a change in condition.

Based on clinical record review and staff interview for one of five residents in the survey sample reviewed for accidents (R #130) and for the only resident in the survey sample reviewed with an infection (R # 6), the facility failed to notify the physician of the resident's change in condition. 1. Resident #130 ' s [DIAGNOSES REDACTED]. The MDS dated [DATE] identified intact cognition, required extensive assistance of two staff for transfers and toilet use and non-ambulatory. The corresponding care plan directed to transfer the resident via a hoyer lift. Accident/incident report dated 5/24/12 at 3:30 PM identified the resident slid out of the wheelchair. After physician notification, an x-ray was ordered. Nurse ' s note dated 5/24/12 at 6:53 PM identified the resident complained of severe pain in the right knee, a 10 on a scale of 1 - 10. Additionally, the note identified that one [MEDICATION NAME] was administered for pain. X-ray report of the right knee dated 5/24/12 identified the resident sustained [REDACTED]. Several attempts were made to interview RN#7, the nurse on duty 5/24/12 at 6:53 PM, but an interview was not obtained. Interview with RN#2 on 7/24/12 at 3:25 PM identified that she was not made aware the resident had complaints of severe pain by 6:53 PM, 3 hours after the fall. Additionally, RN#2 stated she would have notified the doctor at that time. Interview with MD#2 on 7/25/12 at 12:08 PM identified that when the resident complained of severe pain at 6:53 PM the night of the fall, he should have been notified. Additionally, MD#2 would have sent the resident to the hospital at that time. 2. Resident #6 's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified that the resident was severely cognitively impaired and totally dependent on facility staff for all activities of daily living (ADL). The RCP dated 12/27/11 identified a problem with potential for alteration in skin integrity. Interventions included assess skin weekly and report changes and to update physician and family on changes in condition or treatment. Nurse ' s notes dated 2/9/12 and at 6:21 PM identified that the R #6 had [MEDICAL CONDITION] (infection) to the left hand with the 2nd and 5 th fingers grossly swollen. It further identified that he/she had a temperature of 99 degrees and that intravenous (IV) antibiotics were started. Review of a hospital discharge summary dated 2/17/12 identified that R#6 was admitted to the hospital on [DATE] with a 101.4 degree temperature and the [DIAGNOSES REDACTED]. It further identified that wound cultures were obtained after a bedside incision and drainage ( I & D) on left pinky and index finger which identified [MEDICAL CONDITION] resistant staph aureus (MRSA) . An interview and review of facility documentation with the facility administrator and corporate nurse on 7/25/12 at 11:08 AM identified that on 2/8/12, R#6 was observed by staff with reddened knuckles on the left hand. The administrator indicated that the result of the facility investigation identified that facility nursing staff failed to notify the resident ' s physician in a timely manner and/or document comprehensive assessments as R#6 ' s left arm became progressively infected ([MEDICAL CONDITION]) throughout the following days with resulting hospitalized from [DATE] through 2/18/12. During an interview with PA #1 on 7/25/12 at 12:41 PM he/she indicated that although it was the facility 's usual practice, he/she would expect that staff would notify the physician and/or his/herself in a timely manner when a resident experiences a change in condition.

Based on observation, clinical record review and staff interview for one of five sampled residents reviewed for accidents/injuries (Resident # 264), the facility failed to reposition the resident in a wheelchair in a safe manner resulting in an injury. The findings include: Resident # 264 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] indicated R # 264 was dependent with bed mobility and required extensive assist with transfers. The resident was noted to have a left humerus raw pink wound. A resident care plan dated 7/20/12 indicated R #264 had a problem with ADL self care related to a fractured humerus. Interventions included transfer with physical assistance. An observation on 7/23/12 at 3:10 PM noted R # 264 in a wheelchair in the 1st floor dining room. The resident was noted to be slouched in the chair with his/her buttocks at the end of the wheelchair seat. At that time LPN # 8 and RN # 15 entered the dining room. LPN # 8 placed her arm under the resident's right arm pit and RN # 15 placed her arm under the resident's left arm pit. As the resident was pulled up in the wheelchair by his/her arms, the left arm flew up hitting the wheelchair arm. The resident yelled "watch it". The resident was noted to be actively bleeding from skin tears sustained on the left forearm, left upper arm and right elbow. Physician orders [REDACTED]. An interview on 7/23/12 at 3:20 PM with RN # 15 indicated the resident was new and she was not aware he/she was paralyzed on the left side. She further indicated she usually likes to know resident's before she helps them. An interview on 7/245/12 at 10:00 AM with the physical therapy director indicated the correct way to reposition a resident in a wheelchair is to first get the resident to participate in the reposition with their arms and legs. If the resident is unable to participate a gait belt is to be applied and the resident repositioned using the gait belt. She further indicated a resident should not be pulled up in a wheelchair using the resident's arms.

Based on clinical record review, observation and interview for two of three sampled residents reviewed for falls (R#68, R#170) the facility failed to ensure interventions were implement measures to prevent injury. The findings include: 1. Resident # 68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident with short and long term memory problems, moderately impaired cognitive skills, and required extensive assistance with bed mobility, transfers, dressing and personal hygiene. A care plan dated 5/1/10 identified the resident with a potential for alternation in skin integrity. Interventions included to provide derma savers (protective skin covering) to lower extremities for all transfers. Additionally, a care plan dated 5/04/10 identified that the resident with a potential for falls. Interventions included to transfer with the assistance of two, ambulate with assistance of two and the wheelchair to follow. A physician's orders [REDACTED]. A nurse's note dated 10/22/10 at 7:00 PM identified that R# 68 sustained a laceration to the right lower leg. The resident was transferred to the hospital for evaluation and returned to the facility at 11:00 PM. The hospital discharge summary identified the resident sustained [REDACTED]. The facility investigative report dated 10/22/10 identified that NA#10 neglected to follow R# 68's plan of care and transferred the resident without assistance and without the benefit of derma savers to the resident's legs. As a result of the incident NA#10 was terminated. Interview with the NA #10 on 5/18/11 at 1:50 PM identified that she did not apply the derma savers as indicated on the resident's care card because they were not in resident's room. NA # 10 further indicated that she did not ask for assistance and transferred the resident by herself because the other staff members were busy. 2. a. R#170 ' s [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified short and long term memory deficits, moderately impaired cognition, required extensive assistance with transfers, required partial physical support for sitting and a history of falls in the last 31- 180 days. The Fall Risk assessment dated [DATE] identified R#170 as a 12 (total score of 10 or above represents (high risk). The Resident Care Plan 7/14/10 identified R#170 as a fall risk related to cognitive deficits, history of falls, unsteady gait and impaired mobility. Interventions directed to apply a bed alarm, a motion sensor in the room and a low bed with mats but failed to identify the implementation of an alarmed seat belt. Review of the post fall nurse's notes and facility documentation dated 8/20/10 identified at 8:00 PM identified that after NA#2 assisted R#170 in the bathroom and transported the resident back to his/her room, the resident leaned forward to pick up his/her pants and fell out of wheelchair. Although facility documentation identified that NA #2's statement reflected that he/she had applied the alarmed seatbelt, the facility concluded that the alarmed seatbelt had not been applied at the time of the fall. Review of the nurse's notes dated 8/21/10 identified that R#170 was sent to an acute care facility, returned at 12:30 AM via ambulance after receiving approximately six sutures. Interview with the DNS on 5/18/11 at 1:30 PM identified that after reviewing all the resident's records, the resident should have had an alarmed seat belt on while in the wheelchair. b. The Minimum (MDS) data set [DATE] identified a Brief Interview for Mental Status score as 2 (0-7 severe impairment). The resident care plan dated 11/16/10 identified the utilization of a lap tray to the wheelchair at all times including during meals. Review of the nurse's notes dated 4/9/11 at 9:00 AM identified R#170 was found on the floor outside the dining room and sustained a skin tear to the elbow. Interview with RN#1 on 5/19/11 at 11:15 AM identified that he/she was supervising that day when R#170 was observed on the floor. At that time, it was noted that the wheelchair did not have a lap tray on, and after further inspection, it was identified that R #170 was using another resident's wheelchair. R#170 had been placed in the wrong chair by NA#3 without the lap tray. Attempts to contact the NA#3 were unsuccessful. c. The Minimum (MDS) data set [DATE] identified a Brief Interview for Mental Status Score as 2 (0-7 severe impairment) and the presence of inattention and disorganized thinking. Review of the care plan dated 4/20/11 directed the utilization of a motion sensor. Observation on 5/18/11 at 1:30 PM identified R#170 in the bed, two half rails up, mats on the floor, bed alarm in place and the motion sensor was not turned on. Upon testing the motion sensor with NA #1, the motion sensor did not work. Interview with NA#1 on 5/18/11 at 1:30 PM identified that R#170 was transferred back to bed after lunch and he/she did not check the motion sensor.