Every finding on record at Autumn Lake Healthcare at the Willows

Based on observation, review of facility documentation, facility policy and interview, the facility failed to ensure ophthalmic medications were labeled properly after opening. The findings include:Observation on 9/16/25 at 10:20 AM of 4 of 6 medication cart inspections identified the following ophthalmic medication, which were open, had no documented dates regarding when they were open. a. Medication cart identified as 2nd floor long hall.1 bottle of brimonidine tartrate 0.2% eye drops.1 bottle of Systane eye drops.1 bottle of Refresh eye drops. b. Medication cart identified as 2nd floor short hall.1 bottle of Dorzolamide hydrochloride/timolol maleate 2%/0.5% eye drops.1 bottle of Latanoprost 0.005% eye drops.2 bottles of Brimonidine tartrate 0.2% eye drops.1 bottle of Ciprofloxin 0.3% eye drops.1 bottle of Latanoprost 0.005% eye drops.1 bottle of Timolol eye drops 0.5% eye drops. c. Medication cart identified as private short hall.1 bottle of Brimonidine tartrate 0.2% eye drops.2 bottles Latanoprost 0.005% eye drops.1 bottle of Refresh eye drops. d. Medication cart identified as private long hall.1 bottle of Latanoprost 0.005% eye drops. Interview with the Pharmacy Consultant on 9/16/25 at 1:05 PM identified ophthalmic medications should be dated according to facility policy. Interview with the DNS on 9/16/25 at 1:13 PM identified she would expect eye drops to be dated after opening according to policy. Review of the facility policy for Medication Storage directed ophthalmic medications are to be dated at the time of opening. Although requested, a list of specific ophthalmic medications with specified discard dates after opening was not provided.

Based on review of facility documentation, facility policy and interviews for 4 of 5 residents, (Resident #3, 9, 12 and 75) reviewed for pneumococcal and influenza vaccine administration, the facility failed to ensure informed consent and documented administration of pneumococcal and influenza vaccinations was done according to policy. The findings include: 1. Resident #3 was admitted to the facility in April 2022 with diagnoses that included cerebral palsy and mitral insufficiency. Resident #3 was self-responsible.A review of Resident #3's immunization record identified the pneumococcal vaccine (PV20) was administered on 4/28/23.The Pneumococcal Vaccine Informed Consent form dated 4/28/23 identified no documented signed consent for the pneumococcal vaccine. 2. Resident #9 was admitted to the facility in March 2021 with diagnoses that included chronic obstructive pulmonary disease and atherosclerotic heart disease. Resident #9 was not self-responsible.Review of the clinical record failed to identify documentation the influenza vaccine was offered to Resident #9 or the responsible party in 2024. 3. Resident #12 was admitted to the facility in May 2024 with diagnoses that included atherosclerotic heart disease and type II diabetes. Resident #12 was not self-responsible.The Pneumococcal Vaccine Informed Consent dated 9/11/24 identified consent was obtained from the responsible party to administer the pneumococcal vaccine.Review of the clinical record failed to identify documentation the vaccine had been administered. 4. Resident #75 was admitted to the facility in December 2022 with diagnoses that included history of bronchitis. Resident #75 was self-responsible.The Pneumococcal and Influenza Informed Consent dated 12/11/23 identified Resident #75 gave consent for administration of both vaccines, pneumococcal and influenza.The clinical record failed to identify documentation the pneumococcal or influenza vaccine had been administered following consent. Additionally, the clinical record had no documentation the influenza vaccine was offered in 2024. Interview with RN #1 (Infection Preventionist) on 9/18/25 at 2:19 PM identified she has held the role since April 2024 and was responsible for overseeing the facility's vaccination program. RN #1 identified she relied solely on clinical records to monitor vaccination status, had not implemented a tracking system, and could not provide information on any prior systems. RN #1 was also unable to explain how resident vaccination status was monitored over time.Interview with the DNS on 9/18/25 at 3:25 PM identified all immunizations should be offered on admission and annually as indicated, tracked over time and remain up to date with documented refusals.Review of the facility policy for Pneumococcal Vaccines directed each resident to be offered the pneumococcal vaccine with informed consent unless contraindicated, the resident is up to date or the resident/representative refuses.Review of the Influenza Vaccine policy directed each resident be offered the vaccine annually from October 1st through March 31st with informed consent unless medically contraindicated or the resident/representative refuses.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #2) reviewed for pressure ulcers, the facility failed to ensure the implementation of appropriate measures to prevent the possible worsening of pressure ulcers for a dependent resident. The findings include: Resident #2's diagnosis included diabetes type 2 with diabetic neuropathy, venous insufficiency, and dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment and required maximal/substantial assistance to turn in bed, to sit to stand, and chair to bed to chair transfers. Additionally, Resident #2 had 1 stage 2 pressure ulcer present on admission and was at risk for pressure ulcer development.The Resident Care Plan dated 4/9/25 identified an actual impairment to the resident's skin, new deep tissue injuries (pressure ulcers) to the bilateral heels. Interventions included to ensure socks were in place with offload heel boots to prevent rubbing/friction, offload heel boots when resident was in bed and encourage use, wrap entire foot with kerlix wrap followed by a sock followed by offload heel boots.A resistance to care Resident Care Plan dated 5/21/25 identified Resident #2 would, at times, kick off his/her multi-podus boots, and staff were to leave and return at a later time, try again, and review outcomes of noncompliance.A pressure ulcer Resident Care Plan dated 9/2/25 identified bilateral unstageable heels unchanged. Interventions included to offload heels and assist with bed mobility.A Pressure ulcer risk assessment dated [DATE] identified a score of 12 indicating Resident #2 was at high risk for pressure ulcer development.The facility provided, in-house pressure ulcer list as of 9/16/25 identified Resident #2 had a community acquired pressure ulcer to the right and left heels with an onset date of 4/9/25. Review of the Nurse Aide (NA) Care Card (Resident Care Plan directing NAs) dated 9/23/25 directed to wrap the resident entire foot with kerlix wrap followed by a sock, followed by offload heel boots and if the resident resisted treatment, re-approach and re-offer care when behavior subsided.Review of physician orders in effect from 9/1/25 through 9/23/25 directed the use of heel boots when in bed. A physician wound care progress note dated 9/19/25 identified pressure ulcers of the left and right heels, both measuring 1.2 centimeters (cm) by 1 by 0 depth, unstageable with 100% eschar (dead, dry, hard, leathery tissue). The Plan to Address Factors Affecting Wound Healing included turning and repositioning, off-load pressure per facility protocol, and heel off-loading. The Plan of Care was discussed with facility staff and the resident.Review of the September Treatment Administration Record indicated Resident #2's heel boots were identified as in place or intermittently refused, however the nurse's notes failed to indicate all the refusals or reason for refusals.Intermittent observations on 9/23/25 at 6:35 AM, 7:05 AM, and 7:34 AM identified Resident #2, lying in bed on his/her back without the benefit of off-loading (relief of pressure) of his/her bilateral heels. A pillow was observed at the end of the bed not in use, and the resident did not have off-loading boots on his/her feet. Observation at 8:04 AM noted that the resident was boosted up in bed for breakfast by Nurse Aide (NA) #1 and another NA still being positioned on his/her back. The NA's failed to place the pillow at the end of the bed under Resident #2's legs, failed to place the physician ordered off-loading boots, and failed to offer the resident any type of off-loading prior to exiting the room. Continued intermittent observations at 8:30 AM and 9:00 AM identified Resident #2's bilateral heels lacked any type of off-loading. Interview and observation with RN #2 on 9/23/25 at 9:32 AM identified that Resident #2 often refused to wear his/her boots or were kicked off. When the boots were kicked off by the resident, staff were told to store the boots in the closet because it would be hazardous to leave the boots with the resident. RN #2 stated that Resident #2 also kicked the pillow out from under his/her legs despite being educated by staff and the wound physician. When the resident refused, RN #2 would wrap the heels in kerlix to keep pressure from the resident, but he/she would also unravel the kerlix. RN #2 indicated that the facility has made no further attempts to provide Resident #2 with alternative methods of off-loading which Resident #2 may have preferred and/or tolerated. RN #2 located the boots in the closet, noted the flattened pillow (no off-loading capacity) at the end of the bed, and failed to find evidence that kerlix had been used but the physician orders did direct the use of heel boots.Interview with NA #1 on 9/23/25 at 10:05 AM identified Resident #2's assigned NA was NA #2. NA #1 indicated that she worked on different units throughout the facility. NA #1 stated Resident #2 would frequently refuse his/her boots and when this happened, she would reassure him/her and notify the nurse. Further NA #2 indicated that she had not noticed Resident #2's heels on the bed.Interview with LPN #10 Resident #2's charge nurse, on 9/23/25 at 10:08 AM identified that staff had not informed her Resident #2 refused to wear his/her boots, refused an off-loading pillow, or that he/she did not have kerlix covering his/her heels. LPN #10 stated she would go speak with the resident to try to get him/her to accept an off-loading device and if the resident still refused, she would tell the supervisor. Interview with NA #2 on 9/23/25 at 10:10 AM identified that she had not seen Resident #2 yet during her shift. She indicated that 2 NA's had been in earlier to check on the resident and boosted him/her up for breakfast. Although NA #2 initially indicated that she had not seen the resident yet, she stated that she had been to see him/her once but failed to check if his/her heels were off-loaded. NA #2 stated that Resident #2 wore his/her boots for the most part but frequently removed the devices, noting that she was on her way to see Resident #2 now.Interview and review of the clinical record with RN #2 on 9/23/25 identified that when a resident refused care performed by a NA, she had developed a form to show the resident's refusal. Once the form had been completed by the charge nurse, the supervisor was informed, would sometimes go see the resident, and the refusal document was filed in the back of the paper record. RN #2 was unable to recall being told the Resident #2 had refused to off-load this shift or previous shifts. After looking in her office and reviewing the clinical record, RN #2 indicated she had failed to locate her documentation form that Resident #2 had refused off-loading boots or pillows during the months of August and September 2025. Interview with the Regional Nurse, RN #4 on 9/23/25 at 2:22 PM identified that although Resident #2 had been refusing his/her current off-loading devices, other mechanisms were available and should have been attempted. Additionally, RN #4 identified that the Resident should not have been left for 3 hours without off-loading attempts.Subsequent to surveyor inquiry a physician's order dated 9/23/25 was implemented to direct heel boots in place when the resident was in bed, if refused, use pillows followed by gel pillows under a fitted sheet every shift for skin protection.Review of the facility Repositioning/Bed and Wheelchair undated policy directed, in part, residents who are in bed should be turn and repositioned and that if the resident refused to notify the supervisor and identify and evaluate for potential alternatives.Review of the Prevention of Pressure Ulcers/Injuries policy dated 1/2018 directed, in part, to reposition more frequently based on the condition of the ski and comfort, provide support devices, and review the interventions and strategies for effectiveness on an ongoing basis.

Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #65) reviewed for enteral feeding, the facility failed to provide enteral feeding according to professional standards to prevent aspiration. The findings include:Resident #65 was admitted to the facility in January 2025, with a readmission in May 2025, after a hospitalization. Diagnosis included Parkinson's disease, dysphagia and gastrostomy tube. Physician's orders for September 2025 (original order date 6/3/25) directed to administer the following enteral feeding; Jevity 1.5 at 75mg/hour for 16 hours, on at 6:00 AM, off at 10:00 PM. Additionally, the September 2025 physician's orders directed to elevate the residents head of bed 30 - 45 degrees during feeding and for at least 30 - 45 minutes after feedings, and elevate head of bed 60 minutes after medication administration via feeding tube. The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, fluctuating disorganized thinking, had a feeding tube while a resident at the facility, and received 51% or more proportion of total calories through the feeding tube.Review of the care plan on 9/16/25 failed to reflect the residents feeding tube. Observation on 9/16/25 at 11:40 AM identified the resident was in bed with the tube feed infusing at 75cc/hour. The head of the bed was less than 30 degrees (almost flat) and the resident was alone in the room. Observation on 9/16/25 at 11:53 AM with LPN #12 identified the resident was flat in bed receiving tube feeding at 75cc/hour while receiving care by NA #11. Interview with LPN #12 on 9/16/25 at 11:53 AM identified the residents head of the bed was flat but should be up between 30 - 45 degrees if the tube feeding is infusing. Subsequently, LPN #12 turned off the tube feeding. Interview with NA #11 on 9/16/25 at 12:00 PM indicated she did not know that the tube feeding should be paused while the resident is flat in bed receiving care. Subsequent to the observation of Resident 65 flat in bed with the tube feeding infusing, the facility initiated staff training including to ensure the head of bed is elevated when the feeding is infusing. Although a policy on tube feeding was requested, the policy provided did not speak to ensuring the head of the bed is elevated when a resident is receiving tube feeding.

Based on review of the clinical record, policy, and interviews for the only sampled resident (Resident #7) reviewed for a specialized treatment, the facility failed to ensure that a recommendation for a change in medication received from the specialized treatment center was acted upon. The findings include:Resident #7's diagnosis included end stage renal disease, schizoaffective disorder and multiple myeloma. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 had a Brief Interview of Mental Status score of 15 indicating no cognitive impairment and was independent with bed mobility, dressing, and transfers. The Resident Care Plan dated 9/2/25 identified impaired renal function at risk for complications related to specialized treatments. Interventions included to monitor laboratory values and report abnormal values to the physician and send the communication book to the specialized treatment center and review upon return.Review of specialized treatment communication book identified a request to decrease Sevelamer Carbon to 800 mg from 2 tables to 1 table 3 times daily with meals. Review of the physician orders from 9.1.25 through 9/23/25 failed to identify any changes to the order for Sevelamer Carbon to 800 mg 2 tablets ordered 3 times per day with meals.Interview with the Facility Administrator at the specialized treatment center on 9/23/25 at 9:22 AM identified that there was an order written on 9.10.25 directing the Sevelamer Carbon 800 mg from 2 tables to 1 table 3 times daily with meals but that the dietician would have more information. Interview with the specialized treatment center dietician on 9/23/25 at 9:45 AM identified that Resident #7's phosphorus was trending down so there was a recommendation, per the protocol, to decrease the Sevelamer Carbon 800 mg from 2 tables to 1 table 3 times daily with meals. The specialized treatment center dietician stated she spoke with the facility dietician on 9.16.25 and informed her of the recommendation. Additionally, this was communicated to the facility via the resident communication binder on 9/17/25.Interview with Registered Nurse (RN) #2, the Unit Manager on 9/23/25 at 9:49 AM identified that the process for specialized treatment center recommendations was to make a copy of the recommendation and place it in the APRN book for review and order approval. RN #2 indicated that the APRN would sign off the recommendation as approved then a nurse would enter the new physician order into the system. Review of the APRN book failed to identify that the recommendation had been given to the APRN. RN #2 indicated that the facility uses agency and that the agency staff probably just took the communication book and set it down without looking to see if there were any recommendations. Subsequent to surveyor inquiry, during a reinterview with RN #2 on 9/23/25 at 10:22 AM she contacted the APRN, who was unaware that there was a recommendation. RN #2 indicated after speaking with the APRN she was going to change the Sevelamer Carbon to 800 mg from 2 tables to 1 table 3 times daily with meals.Review of the Outside Consultants undated policy directed, in part, the facility supports residents' right to obtain care and services from outside consultant or providers. When a resident receives services off-site the facility will coordinate care, ensure safe transport, and document all findings, recommendation, and follow up actions in the resident's medical record. The facility staff schedules the appointment with the external provider. Any new medications or treatment orders from the external provider must be reviewed and signed by the attending physician. The facility must support residents and families in coordinating safe and appropriate care transitions.

Based on review of the clinical record, policy, observation, and interviews for the only sampled resident (Resident #85) reviewed for dental services, the facility failed to act upon a dental recommendation for a consultation with an oral surgeon. The findings include:Resident #85's diagnosis included prostate and bone cancer, anxiety and depression.The comprehensive Minimum Data Set assessment dated [DATE] identified Resident #85 was cognitively intact and required substantial to maximal assistance with bed mobility, was independent with eating, and required set-up/clean-up assistance with oral hygiene. The assessment failed to identify Resident #85 had dental irregularities including broken teeth.The Resident Care Plan in effect from 7/8/25 through 9/16/25 failed to identify Resident #58 had dental issues. Interview and observation on 9/16/25 12:37 PM with Resident #85 identified that he/she had been seen by the in-house dentist a few months ago and was told that he/she needed to be seen by an oral surgeon outside of the facility. Resident #85 opened his/her mouth, and 2 broken teeth were noted.Review of physician orders dated 6/28/25 directed a referral to an oral surgeon.Review of Resident #85's clinical record identified 2 consultation reports by the in-house dentist who had examined the resident on 3/13/25 and 5/14/25. The consultation dated 3/13/25 identified Resident #85 required a referral to an oral surgeon. The consultation dated 5/14/25 identified that no extractions had been performed and the order would be rewritten with the recommendation to see an oral surgeon for extractions as the resident could not be treated on site.Review of Nurse Practitioner notes dated 5/21/25, 6/2/25, 6/26/25, and 7/7/25 indicated that a referral to a dental oral surgeon for extraction consult was in place.Interview with the Regional Nurse, RN #4, on 9/23/25 at 1:10 PM identified that Resident #85 had not had an appointment scheduled since the in-house dentist referred the resident to see an oral surgeon but should have been scheduled. Subsequent to surveyor inquiry, Resident #85 was scheduled to see an oral surgeon for possible extraction of broken teeth.Review of the Outside Consultants undated policy directed, in part, the facility supports residents' right to obtain care and services from outside consultants or providers. When a resident receives services off-site the facility will coordinate care, ensure safe transport, and document all findings, recommendations, and follow up actions in the resident's medical record. The facility staff schedules the appointment with the external provider. Any new medications or treatment orders from the external provider must be reviewed and signed by the attending physician. The facility must support residents and families in coordinating safe and appropriate care transitions.

Based on observation, review of facility policy and interview for 1 resident (Resident #43) reviewed for food, the facility failed to serve meals at a palatable temperature. The findings include:Resident #43's diagnosis included heart disease, emphysema, and chronic obstructive pulmonary disease.The admission Minimum Data Set (MDS) dated [DATE] identified Resident #43 as cognitively intact, required set-up assistance for eating and partial moderate assistance for bathing. Also, Resident #43 required substantial, maximal assistance for toileting and transfers.Interview with Resident #43 on 09/17/2025 at 2:25 PM identified that the food was cold at times.On 9/23/25 at 12:32 PM, a test tray was conducted. The following was identified.The lunch meal was plated from a warming plate which was placed in a blue-plate holder with a blue enclosed lid and left the dietary department at 12:25 PM in a metal cart which was enclosed all around and filled with 7 to 8 meals. The Administrator transferred the last cart, 6, with meal trays to the first floor. The test temperature tray was followed to the first-floor unit and arrived quickly on the unit and trays were passed in an efficient manner. The last tray was served to a resident at 12:31 PM and temperatures were obtained at 12:32 PM with the Dietary Manager identifying the following. a. The pork entrees' internal temperature was 127 degrees F with the surveyor's thermometer and 129 degrees F with the Dietary Manager's thermometer. b. The beef's internal temperature was 135 degrees with both the Dietary Manager and surveyor's thermometer.c. The cooked carrot's internal temperature was 119 degrees with the surveyor's thermometer and 122.5 degrees with the Dietary Manager's thermometer.The food temperature log was reviewed with all foods identified at appropriate temperatures for each item on the steam table.An interview with the Dietary Manager on 9/23/25 at 12:35 PM identified the serving temperature for hot food items should be no less than 135 degrees. Also, identifying the cooks are responsible for making sure food was kept at the appropriate serving temperature and she would check the working status of the steam table in the kitchen.Review of the service line check list identified hot temperatures for food items should be at 135 degrees or higher.Review of the Food Quality and Palatability policy directed food should be at the appropriate temperature as determined by the type of food to ensure residents' satisfaction and minimize the risk of scalding and burns.

Based on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for showers, the facility failed to provide a weekly shower in accordance with the plan of care. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis with neurogenic claudication, spondylolisthesis, diabetes mellitus, osteoarthritis, and depression. Review of the hospital Discharge summary dated [DATE] identified Resident #1 underwent a L3-L5 posterior spinal fusion on 7/11/24 without complications. Discharge wound instructions directed Resident #1 may shower on the 3rd day after the surgery. Review of the Shower List Schedule identified Resident #1 was scheduled to receive a shower on Fridays during the 3:00 PM to 11:00 PM shift. Clinical record review of the Nurse Aide Documentation for ADL (activities of daily living) regarding bathing, the month of July 2024 identified on 7/19/24, Resident #1 had received a bath at 10:11 PM. Additionally, Resident #1 received a shower on 7/26/24. Review of the nursing progress notes on 07/19/24 failed to reflect if Resident #1 had received or refused a shower. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made consistent and reasonable decisions regarding tasks of daily life and required substantial/maximal assistance for showers. The Resident Care Plan (RCP) dated 07/23/24 identified Resident #1 as at risk for falls related to deconditioning. Interventions include anticipating and meeting the residents' needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Physical Therapy to evaluate and treat as ordered and as needed. Interview with NA #1 on 8/13/24 at 12:55 PM identified she had never provided a shower to Resident #1. NA #1 indicated during resident's stay, she only provided incontinent care to Resident #1, but was not aware Resident #1 should have received a shower. NA #1 identified nobody had told her that Resident #1 required a shower on Fridays, and indicated she was new to the facility. Interview with DON on 08/13/24 at 2:25 PM identified nurse aides are responsible for documenting the task (shower/bath) in the electric charting system. DON identified if staff perform a task such as showers or ADL's, they must be documented in the electric charting system, otherwise the task is not identified as performed. If a resident refuses a shower, the nurse aide will notify the nurse and a nursing note documenting refusal of shower should be identified. Review of the Activities of Daily Living Policy (without a date) identified the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices. The facility will monitor residents' decline and implement interventions as needed. Care and services will be provided for the following activities of daily living: bathing, dressing, grooming, and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on clinical record reviews, observations, facility documentation, facility policy and interviews for two (2) of three (3) residents (Resident #1 and #2), reviewed for wounds and medication administration, the facility failed to perform wound care and administer medications as ordered. The findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis with neurogenic claudication, spondylolisthesis, diabetes mellitus, osteoarthritis, and depression. Physician orders dated 7/15/24 directed to provide wound care to mid-back and left flank surgical incision and to the drain sites. The orders directed to cleanse the areas with normal saline, pat dry, and cover with a dry clean dressing. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made consistent and reasonable decisions regarding tasks of daily life and required substantial/maximal assistance for showers. Review of the Treatment Administration Record (TAR) for the month of July 2024 identified Resident #1's mid-back/left flank surgical incision sites and drain sites were not documented as completed on 7/23/24. Interview with LPN #1 on 8/13/24 at 12:45 PM identified she was unable to recall treating Resident #1. LPN #1 identified if a resident required wound changes, she would do them at the beginning of the shift and document accordingly. LPN #1 indicated it's possible the nursing staff performed the wound care for LPN #1, but she was unable to confirm if the wounds were performed or if she forgot to document them. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses that included acute on chronic heart failure, acute respiratory failure, paroxysmal atrial fibrillation, chronic venous stasis dermatitis, cancer, and glaucoma. Physician orders dated 6/28/24 directed to administer Rocklatan Ophthalmic Solution 0.02-0.005% (Anti-hypertensive within the eyes), instill 1 drop in the right eye at bedtime for glaucoma. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 made consistent and reasonable decisions regarding tasks of daily life and required substantial/maximal assistance for all ADL's (activities of daily living) except eating. Physician progress note dated 7/10/24 identified Nurse Practioner (NP) #1 evaluated Resident #2 related to complaints of burning in right eye from eye drops. Assessment and plan indicated Resident #2 was complaining of burning in his/her right eye from yesterday. Reports eye drops this morning have helped as resident requested artificial tears due to burning sensation. Denies pain, no drainage noted, erythema to left eye improved since yesterday. Offered Resident #2 and Person #2 to have resident follow-up with eye physician in community. Person #2 requested Resident #2 to be seen immediately by the doctor or have resident transferred to hospital. Resident #2 was transferred to the hospital. Review of the Facility Incident and Summary Form dated 7/10/24 identified Resident #2 alleged LPN #2 accidentally put two drops of Rocklatan eye drops in his/her right eye, instead of one drop in accordance with physician orders. Facility interview with LPN #2 on 7/10/24 at 9:00 PM identified LPN #2 inadvertently administered two drops, instead of one, of Rocklatan eye drops. LPN #2 indicated the eye drops were administered between 9:15 PM and 10:00 PM. LPN #2 stated Resident #2 did not initially complain of discomfort, but later complained of burning to the right eye. LPN #2 reported the concerns to the RN Supervisor. LPN #2 checked on Resident #2 at the end of shift, and resident was sleeping. LPN #2 reported to the on-coming nurse during report of the event, however, did not document it. Interview with Pharmacist #1 on 8/13/24 at 1:40 PM identified Rocklatan eye drops are very particular, in that, they should only be administered with one drop to the affected eye. Pharmacist #1 identified many other eye drops can be given with two or more drops with no effect, but Rocklatan can cause irritation and burning if given too much. Pharmacist #1 identified that although irritation and burning are the common side effects of this medication, due to Resident #2 receiving this medication in the past without any side effects, it is more likely that Resident #2 did receive too much of the medication and now as caused the irritation/burning. Pharmacist #1 identified there is no information of the medication causing permanent damage, but indicated a one-time occurrence would not cause any harm to Resident #2's right eye. Review of the clinical records identified Resident #2 did not return to the facility. Although attempted, interview with LPN #2 was unable to be obtained. Interview with DON on 08/13/24 at 2:25 PM identified the nursing staff are expected to document the wound dressing being administered in the electronic treatment administration records (TAR), otherwise the task is not identified as performed. The DON identified on 7/10/24, Resident #2 had alleged he/she received two drops of Rocklatan, instead of one, causing burning and irritation. DON identified that LPN #2 indicated she may have inadvertently given Resident #2 two drops, instead of one. Resident #2 was seen by NP #1 the following day and offered multiple treatment plans, but ultimately, Resident #2/Person #2 decided to be sent out to the hospital. Education was provided to the nursing staff in medication administration. DON identified it's her expectation that nursing staff administered/performed wound changes per physician orders. Review of the undated Medication orders policy identified each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). Medications should be administered only upon the signal order of a person lawfully authorized to prescribe.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident # 1) reviewed for accidents, the facility failed to ensure weekly skin assessments were completed timely, failed to ensure a post fall risk assessment was completed timely. The findings include: Resident #1 was admitted with diagnoses that included dementia with agitation. A Resident Care Plan (RCP) dated 11/30/2023 identified Resident #1 was at risk for falls and skin breakdown with the potential for room becoming cluttered related to hoarding like behaviors, resident exhibits, or has the potential to exhibit physical behaviors related to cognitive loss/dementia and was non-compliant with transfer status and resistive of care. The RCP directed for staff to assist with transfers, pad rails/wheelchair or other equipment as necessary, to encourage to remove old items from her/his room, and to stress key words/present one question or direction at a time. A quarterly MDS assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, and required supervision or assistance for toileting, dressing, and transfers. A facility accident and incident report dated 3/6/2024 at 3:40 PM identified Resident #1 was noted sitting across the wheelchair leg rests with the wheelchair tilted forward. Resident #1 reported when he/she was self-transferring from the toilet to the wheelchair, Resident #1 slipped off the toilet and the wheelchair was locked and didn't move. A bruise was noted on the buttocks and left lower leg. Resident sent to the hospital emergency department (ED). A nursing progress note dated 3/6/2024 at 10:09 PM identified a left lower leg ecchymotic (bruised) area was identified measuring 26 centimeters (cm) by 6 cm. Clinical record review failed to identify weekly skin assessments were completed for the weeks of 3/12 and 3/19/2024. Interview and review of Resident #1's medical record with the DON on 4/11/2024 at 11:00 AM identified that she was aware that Resident #1 had an ecchymotic area identified after the fall on 3/6/2024. The DON indicated Resident #1's medical record lacked documentation that weekly skin assessments were completed for the weeks of 3/12 and 3/19/2024. A skin assessment dated [DATE] identified the ecchymotic area was resolved/not observed. The DON identified that weekly skin assessments should be completed as a part of the facility's approach to pressure injury and prevention. The DON stated if a Resident had an observed ecchymotic area such as identified for Resident #1 after a fall, she would expect the nursing staff to complete the weekly skin assessment to monitor for any further issues, and she was unable to indicate why this was not completed. Attempts to contact RN #3 were unsuccessful during the survey. Although requested, a policy for weekly skin checks was not provided for surveyor review. a. A facility incident report dated 3/14/2024 at 9:15 PM identified Resident #1 had a fall after using the toilet and attempting to self-transfer into the wheelchair. No injuries were noted. Clinical record review failed to identify a post-fall risk assessment was completed. Interview and record review with the DON on 4/11/2024 at 11:00 AM identified although she was aware Resident #1 had a fall on 3/14/2024, she indicated the medical record lacked a post fall risk assessment. The DON identified staff should complete a post fall risk assessment after a fall and was unable to identify why it was not completed. The facility policy Falls Management dated 8/7/2023, directed in part that all residents were assessed for risk of falls upon admission, with reassessments quarterly and post fall to determine ongoing need for fall prevention precautions.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one Resident (Resident # 1) reviewed for abuse, the facility failed to ensure care was provided in a dignified manner. The findings include: Resident #1 was admitted with diagnoses that included dementia with agitation. A quarterly MDS assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, and required supervision or assistance for toileting, dressing, and transfers. The RCP directed staff to assist with transfers and care. A facility incident report dated 3/15/2024 at 4:30 PM identified an allegation of staff to resident abuse without injury; Resident #1 reported to the Ombudsman that she/he was spoken to rudely and was not given incontinent care during the night two (2) night prior. A facility summary report dated 3/21/2024 identified Resident #1 required an assist of one (1) staff for ADLs and was independent with wheelchair mobility (self-propelled). Facility investigation identified NA # 2 was assigned to Resident #1 during the night shift on 3/13/2024 and Resident #1 was asleep twice when checked by NA #2. At 5:00 AM, NA #1 offered care and Resident #1 refused, and the refusal was witnessed by NA #3. NA #1 notified both the charge nurse and the supervisor that Resident #1 had refused care. Interview with the DON on 4/12/2024 at 10:00 AM identified the family provided several videos and pictures from a video camera in Resident #1's room (placed in the room on 3/29/2024 at the request of the family on 3/29/2024). The DON stated review of the videos identified instances where the staff approached Resident #1 using poor customer service and staff education was currently in progress. Videos labeled #8, 9, and 10 identified while staff were assisting Resident #1 from the bed to the wheelchair and into the bathroom, Resident #1 was dressed in a blouse/shirt and a brief. The video identified the privacy curtain was not pulled, and the door was opened to the hallway, exposing the resident to anyone passing by the room. The DON identified that the door or curtain should be drawn for privacy if Resident #1 had no pants covering her/his brief as staff assisted her/his to transfer to the wheelchair and then to the bathroom. Interview failed to identify why the privacy curtain was not pulled or the door closed during the transfer. The facility policy Residents' [NAME] of Rights dated July 2015 directed in part, residents have the right to privacy in accommodations in receiving personal care and treatment.

Based on the tour of the Dietary Department and staff interview, the facility failed to ensure the Dietary department was maintained in a clean, sanitary manner and that food items were consistently labeled and stored to reflect their age or shelf life. The findings included: Tour of the Dietary Department on [DATE] at 11:10 AM during the initial walk through of the kitchen with the Dietary Manager (DM) identified the following: a. The dishwasher room was observed to have ceiling tiles with a brown substance noted on them and 1 was loose. b. The light panel in the dishwasher room had 2 cracks, 1 at each end of it along with having a brown substance on it. c. The windowsill above the lids for the tray line use and the toaster had debris noted with a brown substance throughout. d. The windowsill outside the DM's office near the refrigerator was noted with a heavy accumulation of dust. e. The coffee maker was stained with drip marks and discolored with debris noted. f. Tray carts #2 and #3 were both observed with a heavy accumulation debris and dirt on them. The DM stated the last time they were cleaned was on [DATE] despite having a heavy accumulation of dirt. g. The milk refrigerator was noted to be dusty and soiled. h. The windowsill behind the juice refrigerator was noted to have debris and dust, the vents of the juice machine vents had dust noted to it along with the motor beneath it. i. The wash station was noted to be soiled with stains and dust. j. The floor throughout the kitchen was noted to have dirt, debris and food under the mats that covered the floor. k. The spice shelf had a 16-ounce plastic container of ground turmeric ,d+[DATE] full which expired [DATE], 16-ounce ground clove ,d+[DATE] full which was expired [DATE]. A 16-ounce container which was half full of chives expired [DATE]. A 16-ounce container of cayenne pepper which was ,d+[DATE] full, the lid was full of dust. The spice shelf was also noted to have a heavy accumulation of debris. l. The sandwich refrigerator had a large container of open 1 gallon mustard, sliced yellow cheese and butter that was uncovered and not dated. Interview with the DM on [DATE] at 11:30 AM indicated that it was the responsibility of the second shift staff to clean the spice shelf and that she had a log of when it was cleaned but could not locate it. She stated that she does perform rounds but was unable to do rounds due to not having enough staff. The DM indicated that the floor was cleaned last night (although there was a heavy accumulation of particles and debris) and that it was swept and mopped every night. The DM agreed that the floor was not clean. Also, the DM stated that the windowsill behind the juice maker was not on the cleaning schedule. The DM stated that the juice machine was used earlier that day, and she was unsure when the last time it was cleaned.

Based on the tour of the Dietary Department and staff interview, the facility failed to ensure adequate staffing to carry out the functions for cleaning the kitchen. The findings included: Tour of the Dietary Department on [DATE] at 11:10 AM during the initial walk through of the kitchen with the Dietary Manager (DM) identified the following: a. The windowsill above the lids for the tray line and toaster was noted with dust, debris and observed with a brown substance. b. The windowsill outside the DM's office near the refrigerator was noted with a heavy accumulation of dust. c. The coffee maker and coffee maker station was stained and discolored with debris noted on the coffee pots and counter. d. Tray carts #2 and #3 were both noted to be soiled with dust/debris. The DM stated the last time they were cleaned was on [DATE]. e. The milk refrigerator was noted to be dusty and soiled. f. Behind the juice refrigerator on the windowsill, was noted to have debris and dust, the vents of the juice machine was noted to have a heavy accumulation of dust including the motor below. g. The wash station was noted to be soiled with stains and dust. h. The floor throughout the kitchen was noted to have dirt, debris and food under the mats that covered the floor. i. The spice shelf had a 16-ounce plastic container of ground turmeric ,d+[DATE] full which expired [DATE], 16-ounce ground clove ,d+[DATE] full which was expired [DATE]. A 16-ounce container which was half full of chives expired [DATE]. A 16-ounce container of cayenne pepper which was ,d+[DATE] full, the lid was full of dust. The spice shelf was also noted to have a heavy accumulation of debris. Interview with the DM on [DATE] at 11:30 AM indicated that it was the responsibility of the second shift staff to clean the spice shelf and that she had a log of when it was cleaned but could not locate it. She stated that she does perform rounds but was unable to do rounds due to not having enough staff. The DM indicated that the floor was cleaned last night (although there was a heavy accumulation of particles) and that it was swept and mopped every night. The DM agreed that the floor was not clean. Also, the DM stated that the windowsill behind the juice maker was not on the cleaning schedule. The DM stated that the juice machine was used earlier that day, and she was unsure when the last time it was cleaned. Interview with DM on [DATE] at 12:10 PM indicated she did not have enough staff to provide proper cleaning of the kitchen and needed another full-time staff to work 32 hours. She stated that call outs were an issue with staff and that they happen 2 to 3 times a week.

Based on a tour of the Dietary Department with the Dietary Director and interviews, the facility failed to provide lunch at appropriate and appetizing temperatures. The findings include: Interview with Resident #54 on 1/5/24 at 11:19 AM identified food was frequently bad, lacked taste and was cold. Interview with Resident #51 on 1/5/24 at 2:12 PM identified the food was cold at all meals, and had no taste. On 1/9/24 at 12:12 PM, a test tray was conducted with the Dietary Director. The following was identified: The lunch meal was plated and left the Dietary Department in #6 metal cart at 12:12 PM, arrived on the Long Hill Unit and placed in the hall outside of the resident rooms #115-120 at 12:15 PM. At 12:15 PM, Dietary Aides (DAs) were observed to begin passing out the meal trays to residents. The last tray was delivered at 12:20 PM, and temperatures were conducted with the Dietary Director at that time and identified the following: a. The fish Florentine's internal temperature was 127 degrees Fahrenheit from the surveyor's thermometer and 126.4 degrees Fahrenheit from the Dietary Director's thermometer. The Dietary Director identified the internal temperature should be 135 degrees Fahrenheit. b. The roasted potato medley's internal temperature was 125.8 degrees Fahrenheit from the surveyor's thermometer and 126.1 degrees Fahrenheit from the Dietary Director's thermometer. The Dietary Director identified the internal temperature should be 135 degrees Fahrenheit. c. The seasoned peas were tepid to touch and had an internal temperature of 120 degrees Fahrenheit according to the Dietary Director's thermometer. The Dietary Director identified the internal temperature should be approximately 135 degrees Fahrenheit. Review of the trayline steam table temperature logs with the Dietary Director on 1/9/24 at 12:30 PM indicated that the egg temperature on 12/18/23 was 156 degree Fahrenheit, on 12/23/23 was 148 degrees, on 12/29/23 was 146 degrees, on 1/6/24 was 151 degrees, and on 1/7/24 was 147 degrees. According to the steam table temperature log, the temperature for eggs should be at 160 to 180 degrees. Interview with the Dietary Director at 12:30 PM on 1/9/24 indicated that when food was not at the correct temperature it should be reheated and that her staff was aware of this.

Based on observation, clinical record review, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #10) reviewed for pressure ulcers, the facility failed to notify the licensed medical provider of a change in skin condition. The findings include: Resident #10's diagnoses included multiple sclerosis, hemiplegia (paralysis of left side), heart failure, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was severely cognitively impaired and was totally dependent on staff for toileting hygiene, repositioning left to right, and bathing. The MDS further identified Resident #10 had two Stage 4 pressure ulcers. A physician's order dated 1/5/24 directed to cleanse the left posterior thigh with normal saline, pat dry and apply collagen sheet, cut to size of wound bed, followed by foam dressing daily, and cleanse sacral pressure ulcer site with Vashe, apply hydrafera blue to wound bed, pat Triad in place to peri wound, followed by a dry, clean, dressing daily. The Resident Care Plan dated 1/6/24 identified a Stage 3 pressure ulcer to the sacrum and a Stage 4 pressure ulcer to the left posterior thigh. Interventions included to reposition Resident #10 side to side while in bed and Resident #10 may be out of bed for 60 minutes in the wheelchair to attend activities. Observation and interview with Licensed Practical Nurse (LPN) #1 and the ADNS on 1/10/24 at 8:35 AM identified Resident #10 had 3 wounds, 1 on the left thigh, 1 on the left buttocks, and 1 on the sacrum (coccyx). The left buttock wound was noted to measure 5.0 by 1.0 centimeters (cm). LPN #1 indicated that she identified the left buttock wound as a skin tear on 1/9/24 when she removed the old dressing, thinking the skin had been pulled off. The ADNS identified that she was not aware of the new skin tear. LPN #1 proceeded to cleanse the left buttock wound with Vashe, followed by collagen, covered by Optifoam dressing. The ADNS said she would notify the wound doctor 1/11/24 on wound rounds and classify the wound with the wound doctor. The physicians orders and RCP failed to identify Resident #10 had a third wound. Interview with Registered Nurse (RN) #1 on 1/20/24 at 12:49 PM on 1/10/24 identified that LPN #1 should have classified the new wound, should have notified the ADNS to conduct an assessment, and should have notified the APRN. Interview with LPN #1 on 1/10/24 at 1:30 PM identified that she had assumed that the wound would have been classified as part of the existing left thigh pressure ulcer, despite having intact skin between the existing and the new wound and previously identifying the left buttock wound as a skin tear. LPN #1 indicated that she had also used the previous treatment to dress the wound after identifying the area was present. Further LPN #1 identified that she had not notified an ADNS to conduct an assessment as she assumed the wound would have been included as part of the original wound. After speaking with the ADNS, LPN #1 stated that she should have classified the new wound as a separate wound, should have notified the ADNS to conduct an assessment, and should have notified the APRN. Interview with APRN #1 on 1/10/24 at 1:29 PM stated that she had not been notified of Resident #10's new wound that originated on 1/9/24 and that if she had, would have given an order for a treatment to the wound.

Based on observation, interviews, clinical record review, and facility policy for 1 of 3 sampled residents ( Resident #19) reviewed for falls, the facility failed to revise the Resident Care Plan (RCP) after Resident #19 fell . The findings include: Resident #19's diagnosis included nonrheumatic aortic stenosis, hypertension, diabetes and urinary tract infection. The Resident Care Plan (RCP) dated 9/1/23 identified a problem with falls with interventions that included to place personal items within reach, reposition items within visual field, and place call light within reach. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was moderately cognitively impaired, required extensive assistance of 2 with bed mobility, transfers, and toilet use. The MDS further identified Resident #19 required extensive assistance of 1 for personal hygiene and set up for eating. The MDS also identified Resident #19 had no prior falls. A facility Reportable Event (RE) document dated 10/30/23 at 12:47 AM identified Resident #19 was observed lying on the floor, next to his/her bed, stated he/she was attempting to go to the bathroom and slipped to the floor. The RE form further identified Resident #19 did not sustain any injury from the fall. Interview with the MDS Coordinator (RN #2) on 1/9/24 at 1:50 PM identified that the RCP was not reviewed/revised to include additional interventions for falls after Resident #19 fell on [DATE]. The MDS Coordinator further indicated that any nursing staff member could up date the RCP and the RCP should be updated at the time of the fall. Additionally, the MDS Coordinator identified the RCP needed to be updated as soon as the fall occurred and that would be identified in the fall policy. Review of the fall policy directed to implement and document resident centered interventions according to individual risk factors in the resident's plan of care. The policy also stated to adjust and document individual intervention strategies as resident condition changes.

Based on observations, clinical record review, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #10) reviewed for alteration in skin integrity, the facility failed to report a new open skin area to the physician, failed to conduct an assessment by a Registered Nurse, and failed to obtain a licensed practitioner order for treatment to the open skin area in a timely manner. Additionally, for 1 of 5 sampled residents (Resident #19) reviewed for unnecessary medication, the facility failed to follow Advanced Practice Registered Nurse (APRN) orders directing daily weights. The findings include: 1. Resident #10's diagnoses included a disease of the protective nerve coverings, depression, heart failure, and left hemiplegia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #10 was severely cognitively impaired and was totally dependent on staff for toilet hygiene, repositioning left to right, and bathing. Resident #10 was also noted to have two Stage 4 pressure ulcers. The Resident Care Plan dated 1/6/24 identified a Stage 3 pressure ulcer to the sacrum and a Stage 4 pressure ulcer to the left posterior thigh. Interventions included repositioning side to side while in bed and out of bed for 60 minutes in a wheelchair to attend activities. Observation and interview with LPN #1 and RN #1 (ADNS) on 1/10/24 at 8:35 AM identified Resident #10, had 3 wounds, 1 on the left thigh, 1 on the left buttocks, and 1 on the sacrum (coccyx). LPN #1 indicated that she identified the left buttock wound as a skin tear on 1/9/24 when she removed the old dressing, thinking the skin had been pulled off. RN #1 identified that she had not been made aware of the new open area and an assessment had not been conducted. LPN #1 proceeded to cleanse the left buttock wound with Vashe, followed by collagen, and then covered by an Opti foam dressing prior to obtaining a physician order. The physician's orders failed to identify Resident #10 had a new wound. Interview with RN #1 at 12:49 PM on 1/10/24 identified that LPN #1 should have classified the wound as a new wound (not part of the sacral wound), should have notified the RN to conduct an assessment, and should have obtained a new physician's order for treatment. Interview with APRN #1 on 1/10/23 at 1:29 PM stated that she had not been notified of Resident #10's new wound that originated on 1/9/23 and that if she had, would have given an order for a treatment to the wound. 2. Resident #19's diagnosis included nonrhemumatic aortic stenosis, congestive heart failure, diabetes and hypertension. The Resident Care Plan dated 9/12/23 identified Resident #19 was at risk for cardiovascular complications related to diagnosis of congestive heart failure, and hypertension. Interventions included to monitor labs, report abnormal labs to the physician, and monitor weights as ordered. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #19 was moderately cognitively impaired and required extensive assistance of 2 with bed mobility, transfers, and toilet use. The MDS further identified Resident #19 required extensive assistance of 1 for personal hygiene, and set up for eating. Additionally, the MDS indicated Resident #19 did not have a significant weight loss/gain. A physician's order dated 12/9/23 directed to have Resident #19 weighed daily. A review of the clinical record for documenting weights identified that daily weights had not been completed 14 of 31 days from 12/9/23 through 1/8/24. Interview with the DNS on 1/9/24 at 9:50 AM identified Resident #19's daily weight record was not completed and the nurse on the unit was responsible for entering this data. She was unsure if there was a policy regarding daily weights. Interview with APRN #1 on 1/9/24 at 1:30 PM identified that daily weights were performed to look for subtle changes of indications for congestive heart failure. Review of the policy regarding weights and heights directed additional weights may be obtained at the discretion of the interdisciplinary care team and the purpose was to determine possible causes of significant weight changes. 50059

Based on staff/resident interview, record review and review of facility documentation for 1 of 1 sampled resident (Resident #3) reviewed for audiology, the facility failed to ensure audiology recommendations were responded to by the physician. The findings include: Resident #3's diagnoses included depression, dementia without behavioral disturbance and psychotic/mood disturbances. A Resident Care Plan dated 9/26/23 identified Resident #3 required assistance/was dependent for activities of daily living with interventions that included to provide extensive assistance of 1 for transfers from the bed to the wheelchair with a rolling walker, provide set-up supervision for personal hygiene and provide Resident #3 with extensive assistance of 1 for bed mobility and transfers. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #3 had intact cognition and required set up for eating and oral/personal hygiene. Additionally, the MDS identified Resident #3 required maximal assistance with toilet hygiene, shower and lower body dressing. The MDS further identified Resident #3 had adequate hearing without the use of hearing aides or hearing appliances. Physician order dated 11/10/23 directed an Audiology consult for 11/27/23 (at an Audiologist outside of the facility). Interview with Resident #3 on 1/5/24 at 10:22 AM identified that he/she requested to see an ear doctor, had told the nurse, but was not sure when. On 1/10/24 at 10:38 interview and record review with the ADNS failed to identify Resident #3 was seen by an Audiologist on 11/27/23, per physician order. Additionally, although she could not recall the reason Resident #3 was not seen on 11/27/23, she remembered Resident #3 was seen by the in house Audiologist, but could not recall the date, and there was no documentation in the clinical record. Subsequent to surveyor inquiry on 1/10/24, the ADNS called the facility contracted Audiology group and obtained an Audiology report dated 12/5/23 (because the report was not at the facility). The Audiology report identified Resident #3 complained of newly decreased hearing and tinnitus in both ears. Resident #3 was evaluated, a hearing test performed, had tinnitus and required wax removal. The Audiology consultative report further identified to notify Resident #3's physician for wax removal orders of the right ear and audiology to re-evaluate after wax removal. Additional interview and review of the physician orders with the ADNS on 1/10/24 at 2:00 PM failed to identify physician orders were obtained for wax removal per Audiology recommendations on 12/5/23. Subsequent to surveyor inquiry on 1/10/24, a physician order was obtained which directed to instill 4 drops of Carbamide Peroxide Otic Solution (Otic) in both ears two times a day for wax removal for 4 days.

Based on observations, clinical record review, review of facility policy, and interviews for 3 of 3 sampled residents (Resident #5, #10, and #60 ) reviewed for pressure ulcers, the facility failed to conduct Braden Scale Assessments per the facility policy and failed to report a new open skin area to the facility Registered Nurse to conduct an RN assessment, and failed to get a licensed practitioner order for treatment in a timely manner related to Resident #10. The findings include: 1. Resident #5 's diagnoses included Alzheimer's disease, diabetes, and a condition in which high levels of a hormone cause the body to retain water called syndrome of inappropriate antidiuretic hormone secretion. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 as severely cognitively impaired and required limited assistance for bed mobility with a one-person physical assist. Additionally, the MDS assessment identified Resident #5 needed supervision for transfers, dressing, and toilet use. Furthermore, the MDS identified no current pressure injury, but that Resident #5 was at risk for a pressure injury. The Resident Care Plan (RCP) dated 7/28/23 identified Resident #5 was at risk for skin breakdown related to his/her incontinence and decreased bed mobility. Interventions included using moisture-barrier creams as ordered, a weekly skin assessment to be completed by a licensed nurse, and the use of a pressure redistribution bed. A physician's order in effect at this time directed to apply a moisture-barrier cream to the buttocks and tailbone area each shift with incontinence care and as needed. Furthermore, a physician's order in effect at this time directed to reposition the resident 4 times in each shift. Review of the clinical record from 8/1/23 through 1/10/24 identified 13 out of 23 expected weekly nurse skin assessments. The clinical record throughout this time had documentation that reflects the resident was repositioned regularly. The facility provided documentation of one Braden Scale for Predicting Pressure Sore Risk for Resident #5, dated October 18, 2017. Review of the LPN observations, evaluation, and recommendations note dated 8/16/23 identified a Nurse Aide reported observing an open area on the resident's right buttock measuring 5 centimeters (cm) by 3 cm. The LPN documented that she did not observe any drainage or bleeding, but the area around the wound was reddened and that she notified the APRN. Review of the APRN note dated 8/16/23 identified that staff had asked her to see the resident's open area to right buttock. The APRN's order dated 8/16/23 directed staff to cleanse the open area on right buttock, followed by Calcium Alginate (an absorbent dressing), followed by a dry protective dressing (DPD). They were also to apply a moisture-protection cream around the wound each 7:00 AM to 3:00 PM shift. Review of the wound care consult dated 8/17/23 identified a Stage 2 pressure ulcer to the coccyx (tailbone) measuring 2.0 cm by 2.5 cm by 0.1 cm. The same orders to care for the wound were continued. The RCP was updated on 8/21/23 to include Resident #5 was at nutritional risk related to increased needs for pressure injury. Interventions included providing high calorie foods, monitoring intake at all meals, and alerting the dietitian and physician to any decline in intake. Review of the wound care consult dated 9/7/23 identified Resident #5's coccyx wound deteriorated to a Stage 3. The wound care APRN added directions to fill the wound with Medihoney (a gel for wounds) prior to using the Calcium Alginate, and then to cover with a DPD. The wound care consult note dated 9/14/23 identified an additional Stage 2 pressure ulcer measuring 1.0 cm by 1.0 cm by 0.1 cm on the resident's right buttock, in addition to the previously identified Stage 3 on his/her coccyx. Review of the wound care consult dated 10/26/23 identified the wounds were resolved. Interview with RN #1 on 1/10/24 at 10:40 AM identified that the facility's policy was for a Braden Scale for Predicting Pressure Sore Risk to be done on admission, quarterly, and again if there was a change in status, such as a newly identified pressure injury. RN# 1 also identified that weekly skin checks would be completed on shower days each week. Review of the Skin Integrity and Wound Management policy dated 2/1/23, directed, in part, for a licensed nurse to document a skin assessment weekly. Further, the policy directed, in part, to complete a skin risk assessment weekly for the first month, quarterly, and with significant change in condition. 2. Resident #10's diagnoses included multiple sclerosis, depression, heart failure, and left hemiplegia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #10 was severely cognitively impaired and was totally dependent on staff for toileting hygiene, repositioning left to right, and bathing. Resident #10 was noted to have 2 Stage 4 pressure ulcers. The Resident Care Plan dated 1/6/24 identified Stage 3 pressure ulcer to the sacrum and a Stage 4 pressure ulcer to the left posterior thigh. Interventions included repositioning side to side while in bed and out of bed for 60 minutes in wheelchair to attend activities. Review of the clinical record identified the last Braden Scale (pressure ulcer risk prediction tool) was dated 9/30/23. Interview with RN #1 on 1/10/24 at 10:40 AM identified that the facility's policy was for a Braden Scale for Predicting Pressure Sore Risk to be done on admission, quarterly, and again if there was a change in status, such as a newly identified pressure injury. 3. Resident #60's diagnosis included pyoderma gangrenosa, peripheral vascular disease and rheumatoid arthritis. A Braden Scale completed on 3/20/21 identified Resident #60 was a risk for the development of a pressure sore (there were no subsequent Braden Scale assessments completed). The quarterly Minimum Data Set assessment dated [DATE] and 10/12/23 identified Resident #60 had intact cognition, required extensive assistance of 1 for bed mobility, toilet use and personal hygiene. The MDS further identified Resident #60 was non ambulatory, was occasionally incontinent, was at risk for developing a pressure ulcer and had open lesions on the foot. The Resident Care Plan dated 10/21/23 identified Resident #60 was at risk for skin breakdown. Interventions included elevating legs as Resident #60 allowed, reposition and off load heels 4 times per shift, and assist resident in turning and repositioning frequently. Interview and review of facility policy regarding Skin Integrity and Wound Management with RN #1, (the Infection Preventionist) on 1/10/24 at 1:15 PM identified Residents #5, #10 and #60 had not had Braden risk assessments conducted per the facility policy. Resident #5 had last had a Braden assessment on 10/18/17, Resident #10 had last had a Braden assessment on 9/30/23 and the last documented Braden score on Resident #60 was 3/20/21. RN #1 indicated that it was the responsibility of the licensed charge nurse or the unit manager to ensure Braden assessments were conducted according to the facility policy. RN #1 was unable to identify the reason the facility policy was not followed. Review of the policy directed that the facility would complete a risk evaluation quarterly and with a significant changes.

Based on observation, interviews, and review of facility policy regarding medication administration, the facility failed to ensure the medication cart was locked when unattended. The findings include: Observation on 1/5/24 at 9:15 AM identified the medication cart on 2nd floor Short Hall wing the medication cart drawers were facing the walkway of the hallway, unattended, and unlocked. Upon further observation, the drawers were able to be opened and contained stock medication, resident blister packs with medications and two insulin syringes were filled and sitting inside the top drawer. Additionally, a resident was identified to be seated in his/her wheelchair approximately 15 feet from the unlocked medication cart. Interview with LPN #1 on 1/5/24 at 9:17 AM indicated she filled the 2 syringes with Insulin, placed them in the medication cart, went to help another resident (in another room, down the hallway) and was not aware the medication cart was unlocked. Review of Facility policy regarding Medication Storage indicated the facility should ensure that all medications and biologicals, including treatments items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on clinical record reviews, review of facility policy, and interviews for one of three sampled residents (Resident #1) who was at risk for skin breakdown due to limited mobility, the facility failed to implement an intervention prior to development of a Deep Tissue Injury pressure ulcer, to conduct weekly assessments after the pressure area was identified, and failed to notify the Dietician of the pressure ulcer per the facility policy. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Nursing Skin assessment dated [DATE] identified Resident #1 had no alterations in skin integrity, the Braden Skin Risk Assessment score was 19 that indicated Resident #1 was a low risk for pressure ulcer development, and the Musculoskeletal Systems review identified an impairment, limitation, and weakness of the left lower extremity due to a left hip fracture. The admission Resident Care Plan dated 1/9/21 identified Resident #1 was at risk for skin breakdown related to decreased activity and limited mobility. Interventions directed to provide preventative skin care i.e. lotions, barrier creams as ordered, apply barrier cream with each cleansing and pat, do not rub skin when drying. The physician's admission history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made consistent decisions regarding tasks of daily life, required extensive assistance of two (2) staff with turning and repositioning while in the bed and transfers in and out of the bed and chair, was at risk for the development of pressure ulcers and had no open areas. The weekly skin check dated 1/16/21 identified Resident #1 did not have any skin injuries or wounds. The Situational Background Assessment Recommendation (SBAR) change in condition nurse's note dated 1/17/21 at 2:22 PM identified Resident #1 was observed with a discoloration to the left heel, pink and dark purple in color, no [CONDITION(S)] was noted, positive pedal pulse, circulation motion and sensation. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the January 2021 Treatment Administration Record failed to reflect a preventive intervention was put into place on admission to off-load the heels until 1/17/21 when the left heel DTI was noted. Review of the weekly bath and skin report failed to reflect documentation Resident #1's skin was assessed on 1/30/21. Interview and review of the clinical record with the Director of Nursing (DON) on 7/12/21 at 12:13 PM identified Resident #1's skin was intact on admission and on 1/17/21, Resident #1 developed a left heel DTI, eight (8) days after admission. The DON identified Resident #1 required assistance with bed mobility and transfers due to Resident #1's left hip fracture, limitation in mobility requiring staff assistance, Resident #1 was at an increased risk of pressure ulcer development, and off-loading the heels should have been implemented on admission. The DON indicated the Nursing Admission assessment dated [DATE] had an area to designate interventions on the admission care plan to include off-loading, floating the heels and the admitting nurse failed to trigger the intervention. The DON was unable to provide documentation that the DTI identified on 1/17/21 was initially measured or weekly thereafter. The DON indicated Resident #1 was discharged to the hospital on 2/5/21, and the first evidence of pressure ulcer measurement of Resident #1's left heel was completed when Resident #1 was readmitted on the 2/16/21. Interview with Registered Dietician #1 (RD) on 7/13/21 at 1:10 PM identified the first notification she received that Resident #1 had a pressure ulcer was on 2/4/21. RD #1 indicated the facility policy was to notify her when a pressure wound was discovered, via a consultative form placed in her mailbox. RD #1 identified she worked at the facility two (2) days per week and although she had been present in the building on 1/19/21, 1/21/21, 1/26/21, 1/28/21 and 2/2/21 she did not receive notification regarding Resident #1. RD #1 stated had she been notified she would have started Resident #1 on supplemental protein to assist with wound healing prior to 2/4/21. Review of facility Skin Integrity Management Policy identified, in part, that the facility would provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. The facility was responsible to identify resident's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. Wound observations and measurements would be completed on the skin integrity report upon initial identification of altered skin integrity, weekly and with anticipated decline of the wound. Additionally, the facility would implement pressure ulcer prevention for identify risk factors, and notify the dietitian as indicated.

Based on review of the clinical records, facility documentation, facility policy and procedure and interviews for two of six sampled residents reviewed for accidents (Residents #169 and # 32), the facility failed to provide the necessary assistive devices to prevent an accident during a transfer. The findings include: 1. Resident #169's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified severe cognitive impairment with BIMS score of 6, signs and symptoms of delirium with behaviors of inattention, disorganized thinking and altered level of consciousness. Additionally, noted the resident was non-ambulatory, required extensive assistance with all ADLs and required assistance of one person for mobility with use of a wheel chair. The Resident Care Plan (RCP) for falls risk related to limited mobility and generalized weakness updated on 5/18/15. Intervention directed staff not to leave the fall group ( which provide visual observation of residents) until another staff arrive. The Nurse Aide Care Card dated 4/19/16 updated on 7/5/15 directed to remind the resident to use the call bell when attempting to ambulate or transfer, bilateral floor mats, to provide the assistance of two people for transfers and one person assistance with locomotion off and on the unit. Additionally, for fall prevention directed staff to check the resident's seat belt and the resident frequently and to provide supervision when out of the bed. The Nursing assessment completed on 7/9/15 indicated the resident's fall risk score was 15 ( indicating a score of 12 or above) notes high risk for falls. A Reportable Event dated 7/14/15 at 6:40 A.M. identified Resident #169 had an unwitnessed fall from his/her wheel chair which resulted in a right femur fracture. The Reportable Event further noted the nurse aide after completing the resident's morning care brought the resident to the dining room for close supervision as (outlined in the plan care) when the nurse aide turned away from Resident # 169 (not within direct eyesight/ supervision of the resident ) she/he heard a thumb and noticed the resident was on the floor next to his/her wheelchair. Additionally, noted the resident was assessed by a RN and noted with no visible injury, able to move all extremities, denied any pain and indicated neurological checks were initiated . The nurse's note dated 7/14/15 recorded at 6:40 A.M. identified Resident # 169 was seated in the wheelchair with seat belt in place. Staff heard a noise and the supervisor and the nurse ran down to the lounge and saw the resident on the floor with seat belt off. The nurse's note dated 7/14/15 recorded at 10:40 P.M. identified the resident complained of pain and was medicated with Tylenol with good results. The nurse's note dated 7/15/15 record at 6:40 identified after the fall Resident # 169 experienced pain in his/her bilateral hip and was noted guarding his/her pelvis while making grimacing faces when repositioned. The physician was notified of the resident's change of condition. The physician's orders [REDACTED]. The nurse's notes dated 7/15/15 recorded at 11:18 identified Resident # 169 had a right femoral fracture , the resident denied pain, noted decrease mobility in right hip and indicated the APRN was notified of the x ray results. Additionally, noted a new order to transport the resident to the emergency room for an evaluation. The facility investigation dated 7/16/15 identified when the NA was standing next to Resident # 169 in the wheelchair, the NA turned his/her back to the resident at which time, the resident stood up and fell . The nurse's note dated 7/20/15 recorded at 6:39 P.M. identified Resident # 169 was readmitted to the facility status [REDACTED]. Facility documentation dated 8/10/15 at 3:35 P.M. identified that all staff had been re-educated on never leaving residents alone and instructed to keep residents within eyesight. Facility documentation of the fall group NA assignment given to the surveyor on 31/31/16 notes 6 Nurse Aides are assigned to watch residents in the lounge/TV room area every half an hour from 8:30 A.M. to 2:30 P.M. However, the fall group NA assignment lacked documentation and /or evidence staff monitoring of residents occurred on the 3-11 P.M. and the 11-7 A.M. shift. Interview with NA #4 on 3/31/16 at 9:20 A.M. indicated he/she provided A.M. care to Resident #169 on 7/14/15 on the 11-7 shift. The NA # 4 indicated the facility policy for falls prevention was to place the resident near the nurses station or in the dining room when out of bed for close supervision. NA # 4 further indicated Resident #169 was assisted to the dining room following A.M. care on 7/14/15. However, she/he could not recall who was monitoring the fall group in the dining room when he/she turned his/her back to the resident and/or if he/she communicated to another staff member that he/she needed to step away. Interview with RN #3 the 11-7 A.M.shift RN supervisor on 3/31/16 at 1:15 P.M. indicated she/he could not recall details about the incident and/or if other staff members were present when the resident was found on the floor. 2. Resident #32's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified the resident as severely cognitively impaired , noted the resident required extensive assistance from two staff for transfers and indicated extensive assistance of one staff for bed mobility, toileting and personal hygiene. The RCP updated on 1/12/16 for fall prevention . Interventions directed to provide the assistance of two (staff) with transfers and to closely monitor resident during toileting. The Reportable Event dated 3/16/16 at 1:00 P.M. identified in part when NA #7 attempted to toilet Resident # 32 mid way through the transfer the resident's leg became weak and the resident fell to the floor. The Reportable Event further indicated the nurse aide in an effort to prevent the resident from striking his/her head held onto the resident to break the impact of his/her fall. Although there was no fracture sustained as a result of the fall, the resident complained of right hip pain. Subsequent to the resident's fall an x-ray was obtained on 3/16/16. The results of the x-ray identified no fracture, dislocation and osteoarthritis. On 4/1/16 at 9:50 A.M. during an interview and review of the Reportable Event dated 3/16/16 with NA #7 identified he/she waited in the bathroom with Resident #32 for a long time for an additional aide to come to help him/her transfer the resident. NA # 7 indicated while waiting for assistance Resident # 32 started to become impatient and stood up. Therefore she/he proceeded to assist the resident with the transfer and in the middle of the transfer the resident's legs became weak. NA#7 indicated when the resident's leg became weak she/he lower the resident's to the floor. NA #7 further indicated Resident # 32's plan of care directed two nurse aides for transfer at the time of the resident's fall. Additionally indicated she/he received re-education and training on transfers after the incident .