Every finding on record at Ayer Valley Rehab and Nursing

Based on observation, records reviewed, and interviews, the facility which is licensed for a total of 123 beds, and admits residents with psychosocial care needs associated with, but are not limited to, mental illness, substance use disorder and behavioral issues, failed to ensure that they employed a full-time qualified Social Worker (SW), from 5/28/26 after terminating their SW, up to and including the dates of survey, to adequately meet and provide the necessary and appropriate services for each residents individual psychosocial care needs. therefore, placing their current resident census of 99 residents, at risk for unmet psychosocial care needs due to the lack of having a qualified SW in place, as required.Findings include:Review of the Facility Policy Titled Social Services-Behavioral Health Services- Including Substance Abuse, dated as revised 02/05/25, indicated all residents receive the necessary behavioral health care and services, including substance abuse services, to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care. The Policy further indicated that Social Services should serve as the Facility's contact person for questions regarding behavioral services provided by the Facility and outside sources.Review of the Facility's Resident Census, dated 06/23/26, indicated that 99 of the Facility's 123 licensed beds were occupied.Review of a Resident Responses Analyzer Report, dated 06/25/26, indicated that among the Facility's 99 residents, five had a diagnosis of substance use disorder and 81 had one or more mental health diagnoses.Review of Social Worker #1's Employee File indicated she was suspended on 05/28/26, during an investigation into an abuse allegation and her employment was terminated on 06/03/26.Review of the Social Worker Assistant's Employee File indicated she worked full-time at the facility; however, she was not licensed, did not possess a bachelor's degree in any of the acceptable fields identified in the federal regulations and, therefore, did not meet the qualifications to fulfil the requirements as a full-time qualified social worker.On 06/23/26 at 2:15 P.M., the surveyor observed and heard the Social Worker Assistant discussing advanced directives with a resident's family member. The surveyor heard the Social Worker Assistant tell the family member that she would follow up with the resident to determine whether the resident had changed his/her mind regarding their code status (resuscitation preferences).During an interview on 06/23/26 at 2:21 P.M., the Social Worker Assistant said she has been working full-time at the Facility since January 2025. The Social Worker Assistant said that her responsibilities included but were not limited to arranging services for residents' discharges, writing progress notes in residents' medical records, sending discharge/transfer and room change notices, documenting discharge instructions and submitting referrals for community-based services. The Social Service Assistant said she did not have oversight from a social worker and that she was the only social service staff member employed by the Facility since the departure of SW #1. The Social Worker Assistant further said there were no qualified social workers employed by the Facility and that the Facility did not contract with any outside social service providers. During an interview on 06/23/26 at 3:37 P.M., the Administrator said the Facility had not employed a full-time qualified social worker since 05/28/26, when their full-time social worker (SW #1) was suspended. The Administrator said that SW #1's employment was terminated following her suspension. The Administrator further said that the Facility did not have an agreement with any outside social service providers to provide social services during the vacancy.

Based on interview and record review, the facility failed to develop, implement and maintain a Quality Assurance and Performance Improvement (QAPI) program, which focuses on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to ensure a QAPI plan was implemented to a.) address concerns regarding resident grievance process and b.) failed to evaluate and implement a safe smoking environment for six residents identified as active smokers. Findings include:Review of the facility policy titled Quality Assurance Plan, dated as revised 11/5/19, indicated but was not limited to the following:-The facility shall develop, implement and maintain an ongoing program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality care, and to resolve identified issues. 1. To provide a means whereby negative outcomes, relative to resident care and safety can be identified and resolved through interdisciplinary approach, and effective systems of services and positive care measures rendered can be informed and expanded to improve care given;2. To establish and provide a system whereby a specific process, and the documentation relative to it, is maintained to support evidence of an ongoing Quality Assessment and Assurance Program, encompassing all aspects f [SIC] resident care including safety, infection control, and quality of life applicable to nursing home residents;5. To develop plans of correction and evaluate corrective actions taken to obtain the desired results.a. During the survey, sources including the Ombudsman, resident interviews, staff interviews, and resident group meeting notes indicated continuous concerns related to resident concerns not being addressed. Review of the Grievance Log, dated January 2026 through May 27, 2026, failed to include documentation to support the Resident's concerns were addressed from the Resident Council. The facility failed to promptly respond to resident grievances brought up during the 2/18/26, 3/24/26, 4/28/26, and 5/20/26 Resident Council meeting minutes.During the Resident Group Interview on 5/27/26 at 11:00 A.M., seven of seven participants said they feel that their concerns brought forward during Resident Council are not resolved.During the QAPI task interview on 5/28/26 at 1:50 P.M., the Administrator said the QAPI committee meets monthly and said the last meeting was held on 4/22/26. The Administrator said the grievance process, including the reported issues from resident council meetings, were not identified or discussed during the QAPI meetings when it should have been. The Administrator further said he was aware of the issues but did not put a plan in place to monitor the grievance process or concerns reported during the Resident Council meetings.b. Throughout the survey period six residents were observed to be smoking unsupervised and had access to smoking materials without proper supervision.For Residents #81, #25, and #61 the facility failed to ensure supervision was provided during smoking breaks and failed to ensure smoking materials were disposed of properly. For Residents #66, and #109, the facility failed to ensure supervision was provided during smoking breaks and failed to ensure smoking materials were not shared between residents. For Resident #50 the facility failed to ensure smoking materials were not left unsupervised in the Resident's roomDuring an interview on 5/27/26 2:25 P.M., Certified Nursing Assistant (CNA) #7 said resident smoking has been an ongoing issue in the building and said there was a list of staff that would rotate smoking times to provide supervision and said a binder would be updated and checked but there has been no one overseeing the smokers for a few months.During an interview on 5/27/26 at 3:26 P.M., the Administrator said smoking materials must be stored behind the North One nurses station in the Unit Managers office. The Administrator said smoking assessments and agreements must be followed and the care plan must be updated to reflect the level of supervision. The Administrator said staff must provide supervision while smoking if it is indicated in the assessment. The Administrator said Residents should not be going outside unsupervised and said the door is locked and Residents should not have access to the smoking area and should not know the code to get outside.During an interview on 5/28/26 at 1:45 P.M., The Administrator said smoking has been an ongoing issue for a while that needs to be addressed and said coordination of staff and smoking schedules need to be followed and implemented. The Administrator said the smoking program and management of smoking materials, including supervision requirements, were not identified or discussed in the QAPI meetings when it should have been.During the QAPI task interview on 5/28/26 at 1:50 P.M., the Administrator and the surveyor reviewed the QAPI meeting binder. The months of the December 2025 and February 2026 QAPI Agenda/Meeting sign in sheet contained an exact copy of the signatures page except the top had white out covering the month of December and [DATE] was handwritten in blue ink. Further review of the QAPI binder had photocopied maintenance log reports, housekeeping reports and kitchen reports dated September 2025 and October 2025 located in the December 2025 and February 2026 sections of the binder. The April 2026 meeting files contained printed reports from miscellaneous maintenance reports dated from 2025. There were no 2026 meetings or QAPI reports available for review. The Administrator said he does not know why that information is in there and said he is the one who puts the meeting agenda and reports together in the binder. The Administrator said he does not have any documentation for the recent April QAPI meeting and said it should be in the binder. The Administrator said he does not know why the February sign in sheet was photocopied from the December sign in sheet. The Administrator said the QAPI committee meets monthly and said the last meeting was held on 4/22/26. The Administrator said the grievance process, including the reported issues from resident council meetings, were not identified or discussed in the March or April QAPI meetings when it should have been.

Based on observation, interview, and document review, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day-to-day care of the population the facility currently serves. Specifically, the facility failed to include information related to safe smoking practices and a safe smoking environment for ten residents identified as active smokers, out of a total census of 109. Findings include:Review of the Facility Assessment, last updated 10/1/25 and reviewed with the QAPI Committee on 10/15/25, failed to include an evaluation of the smoking population and services necessary to meet the needs of the residents, including how the facility needs to be equipped and maintained to protect and promote the health and safety of residents.Throughout the survey period six residents were observed to be smoking unsupervised and had access to smoking materials without proper supervision. Review of Facility Assessment, dated 10/1/25, failed to indicate that the facility:-thoroughly evaluated and documented the needs of its resident population who were smokers.-identified the required resources to provide safe care and services for the resident population that smoked.-identified and implemented staff competencies necessary to provide safety and the skill sets needed for the resident population who smoke.During an interview on 5/27/26 at 2:16 P.M., Certified Nursing Aide (CNA) #6 said was asked to provide smoking supervision for the residents who are outside smoking and said she has not reviewed any information on smoking and is not aware of any smoking assessments or training. During an interview on 5/27/26 at 3:30 P.M., the Administrator said the Facility assessment dated [DATE] was the most recent version. The surveyor and the Administrator reviewed the Facility Assessment, and the Administrator said the Facility Assessment did not address residents who smoke and should have. The Administrator said nurses will tell the CNA's the level of supervision needed and further said the facility has not educated staff on safe smoking or completed any competencies.

Based on observations, record reviews and interviews, the facility failed to keep six Residents (#50, #81, #25, #61, #66, and #109) free from hazards while at the facility. Specifically:1. For Resident #81, #25, and #61 the facility failed to ensure supervision was provided during smoking break and failed to ensure smoking materials were disposed of properly. 2. For Resident #66, and #109, the facility failed to ensure supervision was provided during smoking break and failed to ensure smoking materials were not shared between residents. 3. For Resident #50 the facility failed to ensure smoking materials were not left unsupervised in the Resident's room.Finding include: Review of the facility policy titled Smoking, dated as revised 10/1/25 indicated but was not limited to the following: To ensure compliance with regulatory guidelines and safety protocols, the Facility prohibits smoking except for in specifically designated areas. To protect the safety of other residents and employees, the use of medical oxygen is prohibited in smoking areas. Residents deemed to need assistance to smoke should have this designation noted in the care plan. 1. A Each resident should be individually assessed to determine whether or not he/she can safely smoke without supervision. The determination should be noted in the resident's care plan and in a smoking log to keep on each residential floor. B. Residents are not permitted to have any smoking paraphernalia in their room or on their person. All smoking paraphernalia should be given to the nursing staff for safekeeping. Nursing staff should maintain records of resident's property and distribute accordingly. Residents are required to confirm the resident's smoking status in the smoking log before distributing smoking materials to the resident. Residents who have been determined to require supervision must be actively supervised by a staff member while in the designated smoking area. D. Residents may not provide other residents with cigarettes or other smoking paraphernalia and may not light a cigarette for another resident. E. Residents must sing a Smoking Agreement as part of the admission process. F. The facility will review with the resident council/or separate smokers meeting potential smoking times to ensure that the residents have assistance. 2. Designated areas2. C Designated areas will have:a. signage to indicate that smoking is allowed;b. easy access to fire extinguishersc. a design which limits secondhand smoke exposure to other residents; andd. ashtrays on noncombustible materials in sufficient numbersf. metal containers with self-closing cover devices into which ashtrays can be emptied shall be available to all areas where smoking is permitted.5. Responsible partyA. The Compliance and Ethics officer is responsible for ensuring compliance with this policy. 1a. Resident #81 was admitted to the facility in February 2021 with diagnoses including essential primary hypertension, alcohol dependence with alcohol-induced persisting dementia (neurocognitive deficits, including memory loss, impaired executive function, and difficulties in daily living activities), nicotine dependence- cigarettes. Review of Resident #81's Minimum Data Set assessment, dated 2/18/26, indicated severe cognitive impairment as evidenced by a BIMS score of 6 out of 15. Further review of the MDS indicated the Resident requires supervision/touching assistance from staff with activities of daily living care and currently uses tobacco. Review of the list of Residents who currently smoke in the facility provided by the facility on 5/26/26, failed to indicate that Resident #81 smokes. Review of medical record failed to indicate a smoking agreement was signed. Review of Resident #81's Smoking Evaluation Assessment - V 15, dated 5/11/26, indicated:N. Care plan reviewed and revised for appropriate supervision and smoking directions to include:a. Independent b. General Supervision Review of Resident #81's plan of care related to smoking, dated as revised 5/28/25, indicated: -Resident is a smoker.- Educate on smoking times as needed.- Cigarettes (or other smoking materials) and lighter are required to be stored in thesmoking cart.- Notify nursing managers immediately if it is suspected resident has violated facility smoking policy.- Resident requires general supervision while smoking but is independent. Dated as last revised 5/26/26. On 5/27/26 at 10:06 A.M., the surveyor observed Resident #81 outside the facility smoking a cigarette unsupervised. The Resident was flicking ashes onto the ground. There was no ashtray or cigarette receptacle located near the resident. On 5/27/26 at 10:18 A.M., the Administrator walked outside to the smoking area approached another resident who was sitting in a wheelchair and was observed pushing the Resident into the facility. Resident #81 was left smoking unsupervised. There was no ashtray or cigarette receptacle located near the resident. During an observation and interview on 5/27/26 at 10:25 A.M., the Administrator walked outside to the smoking area and said he did not know Resident #81 had a cigarette in his hand and said he/she should not be outside unsupervised smoking. During an interview on 5/27/26 at 2:25 P.M., Certified Nursing Assistant (CNA) #7 said Resident #81 should not be left alone without supervision and said he/she has memory and cognition issues and must be supervised while smoking. During an interview on 5/27/26 at 2:27 P.M., Nurse #3 said Resident #81 requires supervision and should not be left unsupervised smoking. During an interview on 5/27/26 at 3:35 P.M., the Assistant Regional Nurse said Resident #81 must be supervised during smoking and said he/she should not be out in the smoking area unsupervised. During an interview on 5/27/26 at 5:00 P.M., the Social Worker said Resident #81 needs constant supervision and should not be left alone due to his/her medical condition and requires supervision especially with smoking. 1b. Resident #25 was admitted to the facility in February 2026 with diagnoses including nicotine dependence- cigarettes, memory deficit following other cerebrovascular disease, other symptoms and signs involving cognitive functions and awareness, chronic obstructive pulmonary disease, and essential primary hypertension. Review of Resident #25's Minimum Data Set assessment, dated 2/25/26, indicated intact cognition as evidenced by a BIMS score of 15 out of 15. Further review of the MDS indicated the Resident requires supervision/touching assistance from staff with activities of daily living care and currently uses tobacco. Review of Resident #25's Smoking Evaluation Assessment - V 15, dated 5/21/26, indicated:N. Care plan reviewed and revised for appropriate supervision and smoking directions to include:a. Independent Review of Resident #25's Resident Smoking Agreement, signed and dated 5/26/26, indicated:1. This facility prohibits smoking in its facility except for specifically designated areas. Designated areas include:a. Space one (Area to the right of the back outdoor smoking area permitted)b. Space two (Area to the left of the back outdoor area is a non-smoking sitting area) 2. Residents are not permitted to have any smoking or e-cigarette paraphernalia in their room or on their person. All smoking paraphernalia should be given to the nursing staff for safekeeping. Residents wishing to smoke should request the materials from the nursing staff. Review of Resident #25's plan of care related to smoking, dated as initiated on 5/26/26, indicated: -Resident is a smoker.- Educate on smoking times as needed.- Cigarettes (or other smoking materials) and lighter are required to be stored in the smoking cart.- Resident can smoke unsupervised. On 5/26/26 at 12:49 P.M., the surveyor observed Resident #25 exit the facility and walk outside to the back outdoor area, to (Space two) to the left (non-smoking area) and sit on a chair under a tree on the grass. Resident #25 was observed smoking cigarettes and flicking the cigarette ashes onto the grass. There was no ashtray or cigarette receptacle located near the resident. A propane tank was located attached to a gas grill approximately 15 feet from the resident. Resident #25 had a box of cigarettes and a lighter in his/her hand. During an interview and observation on 5/26/26 at 1:06 P.M., the surveyor observed the Administrator walk outside to the back outdoor area, to the left (non-smoking area) and walked over to Resident #25 while he/she was smoking under a tree on the grass near the propane gas grill and requested to have the cigarettes and lighter. Resident #25 was observed exchanging words with the Administrator and threw the lighter at the Administrator. Resident #25 then got up and walked back into the facility. The Administrator said Residents should not have cigarettes and lighters in his/her pockets and said a staff member must observe residents during scheduled smoking times. The Administrator said Residents should put cigarettes in the smoking receptacle located at the end of the outdoor walkway. There were no staff present inside the doorway, and the Resident was able to walk back onto the unit with cigarettes in his/her pocket. On 5/27/26 at 10:12 A.M., the surveyor observed Resident #25 exit the facility and walk outside to the back outdoor area, to the left (non-smoking area) and sat on a chair, under a tree on the grass. Resident #25 was observed smoking a cigarette and flicking the cigarette ashes onto the grass. There was no ashtray or cigarette receptacle located near the resident. A propane tank was located attached to a gas grill approximately 15 feet from the resident. Resident #25 had a box of cigarettes and a lighter in his/her hand. On 5/27/26 at 10:27 A.M., the surveyor observed the Administrator walk outside and talk with Resident #25 while he/she was smoking outside in the non-smoking area sitting under a tree on the grass near the propane gas grill. The Administrator then walked back into the facility. Resident #25 remained smoking on the grass under the tree near the propane gas grill. On 5/27/26 at 2:06 P.M., the surveyor observed Resident #25 sitting on a chair outside to the left (non-smoking area) under a tree on the grass. Resident #25 was observed smoking a cigarette and flicking the cigarette ashes onto the grass. There was no ashtray or cigarette receptacle located near the resident. A propane tank was located attached to a gas grill approximately 15 feet from the resident. Resident #25 had a box of cigarettes and a lighter in his/her hand. There were no staff present and Resident #25 was smoking unsupervised. During an interview and observation on 5/27/26 at 2:22 P.M., the surveyor observed CNA #6 walking out to the smoking and non-smoking area. CNA #6 observed Resident #25 smoking and said Resident #25 likes to sit under the tree and said Residents should put ashes and cigarettes into the cigarette trash container when they are done and not on the grass or ground because it is dry and could catch fire. CNA #6 said there is mulch around the patio where residents sit, and it could catch fire if the cigarettes are not put out all the way and left on the ground. 1c. Resident #61 was admitted to the facility in November 2021 with diagnoses including cerebral infraction, dementia, chronic obstructive pulmonary disease, and major depressive disorder. Review of Resident #61's Minimum Data Set assessment, dated 3/24/26, indicated Resident #61 had intact cognition as evidenced by a BIMS score of 15 out of 15. Further review of the MDS indicated the Resident requires supervision/touching assistance from staff with activities of daily living care and did not indicate the use of tobacco. Review of Resident #61's Smoking Evaluation Assessment - V 15, dated 3/21/26, indicated:N. Care plan reviewed and revised for appropriate supervision and smoking directions to include: b. General Supervision Review of Resident #61's plan of care related to smoking, dated as revised 5/8/24, indicated: - Resident is an assisted smoker per smoking evaluation.- Resident will smoke safely per smoking assessment.- Smoking supplies will be kept in facility lockbox.- Inform and remind patient of location of smoking areas and times.- Reassess patients' ability to smoke independently with any change in condition.- Ensure that appropriate cigarette disposal receptacles are available in smoking areas. Review of Resident #61's Resident Smoking Agreement, signed and dated 3/19/24, indicated:1. This facility prohibits smoking in its facility except for specifically designated areas. Designated areas include:a. Space one b. Space two2. Residents are not permitted to have any smoking or e-cigarette paraphernalia in their room or on their person. All smoking paraphernalia should be given to the nursing staff for safekeeping. Residents wishing to smoke should request the materials from the nursing staff. 3. Residents designated as requiring supervision while smoking must be accompanied by a staff member while smoking. Review of Resident #61's Resident Smoking Policy, signed and dated by Resident # 61, dated 9/14/23, indicated:1.4 Ashtrays made of non-combustible materials and safe design, and metal containers with self-closing covers into which ashtrays can be emptied, shall be provided in all designated smoking areas as well as at all entrances.2. Supervision of a staff member is required, unless supervision can be provided by a pre-screened/pre-approved resident representative/family member. 2.1 The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke. 2.2. A patient's smoking status- independent, supervised, or not permitted to smoke- will be documented in the care plan. 2.3 Smoking supplies (including, but not limited to, tobacco, matches, lighters, lights fluid, etc.) will be kept behind the nurse's station, in the smoking box. 6. The smoking times will be 10 A.M., 2 P.M., and 6 P.M.-Supervised smoke breaks entail staff supervision the residents for a maximum of 2 cigarettes each, time should not exceed 20 minutes.6.1 Any pre-scheduled smoke time can be canceled at the discretion of leadership, if there is an urgent/emergent situation going on at the time that makes smoking supervisory staff unavailable (must be approved by the Administrator or Director of Nursing). On 5/26/26 at 12:49 P.M., the surveyor observed Resident #61 outside the facility smoking a cigarette unsupervised. The Resident had a lighter in his/her hand and one unlit cigarette sticking out of his/her pocket.-At 12:58 P.M., the surveyor observed Resident #61 drop ashes onto the ground and then bent forward to put the cigarette out on the ground next to his/her walker. Resident #61 left the cigarette on the ground then walked back to the outside door, entered the code and walked back into the facility. There was no ashtray or cigarette receptacle located near the resident. There were no staff present and the Resident was able to walk back onto the unit with cigarettes and lighter in his/her pocket. During an interview on 5/26/26 at 1:13 P.M., CNA #6 said nurses and CNA's will supervise residents during scheduled smoke breaks and said Residents get their cigarettes and lighters from nurses' station because the items need to be locked up. CNA #6 said Resident #61 smokes and needs supervision while smoking. On 5/27/26 at 10:06 A.M., the surveyor observed Resident #61 outside the facility smoking a cigarette unsupervised. The Resident had a lighter in his/her hand. The surveyor observed Resident #61 drop ashes onto the ground and then bent forward to put the cigarette out on the ground next to his/her walker. There was no ashtray or cigarette receptacle located near the resident. Resident #61 left the cigarette on the ground then walked back to the outside door, entered the code and walked back into the facility. During an observation and interview on 5/27/26 at 10:20 A.M., the Administrator walked outside to the smoking area and said Resident #61 should not be left unsupervised while smoking and said Resident #61 should not have cigarettes or lighters in his/her pockets. During an observation and interview on 5/27/26 at 2:13 P.M., the surveyor observed Resident #61 outside the facility smoking a cigarette unsupervised. The Resident had a lighter in his/her hand. Resident #61 said, I had my cigarettes on me, but they gave me the lighter inside. Resident #61 then placed the lighter and pack of cigarettes into his/her pocket. On 5/27/26 at 2:20 P.M., the surveyor observed CNA #6 walking out to the smoking area. CNA #6 observed Resident #61 smoking and holding on to a lighter and cigarettes and said Resident #61 should not have cigarettes or lighters in his/her pockets and said she did not give the Resident those items and does not know how he/she got them. CNA #6 said Resident #61 requires supervision and should not be out here smoking unsupervised and said she does not know how Resident #61 got outside to the smoking area. During an interview on 5/27/26 at 2:23 P.M., CNA #7 Resident #61 should not be outside smoking unsupervised and said she did not give Resident #61 any cigarettes or lighters and said he/she should not have those items in his/her pockets. CNA #7 said Residents should be given smoking materials once they are outside with supervision and said items are kept in a lock box behind the nurse's station. CNA #7 said there is a smoking lock box in the unit managers office that holds all the smoking materials in the facility and said staff check the smoking binder to see what level of supervision is needed for residents that smoke. During an interview on 5/27/26 at 2:26 P.M., Nurse #3 said Resident #61 requires supervision with smoking and said he/she should not be left unsupervised or have cigarettes or lighters in his/her pockets. Nurse #3 said Resident #61 went outside to smoke and said she did not give Resident #61 any smoking items from the lock box. Nurse #3 said the care plan must be followed if it indicates a resident needs supervision with smoking. 2a. Resident #66 was admitted to the facility in November 2025 with diagnoses including syncope and collapse, mood disorder due to know physiological condition with manic features, post-traumatic stress disorder and major depressive disorder. Review of Resident #66's Minimum Data Set assessment, dated 5/4/26, indicated Resident #66 had intact cognition as evidenced by a BIMS score of 15 out of 15. Further review of the MDS indicated the Resident requires setup/cleanup assistance from staff with activities of daily living care and did not indicate the use of tobacco. Review of Resident #66's Smoking Evaluation Assessment - V 15, dated 5/1/26, indicated:N. Care plan reviewed and revised for appropriate supervision and smoking directions to include:a. Independent b. General Supervision Review of Resident #66's plan of care related to smoking, dated as revised 7/15/25, indicated: - Resident is a smoker.- Educate on smoking times as needed.- Cigarettes (or other smoking materials) and lighter are required to be stored in thesmoking cart.- Educate on smoking times as needed.-Resident requires general supervision while smoking but is independent. Review of Resident #66's Resident Smoking Agreement, signed and dated 5/26/26, indicated:1. This facility prohibits smoking in its facility except for specifically designated areas. Designated areas include:a. Space one b. Space two2. Residents are not permitted to have any smoking or e-cigarette paraphernalia in their room or on their person. All smoking paraphernalia should be given to the nursing staff for safekeeping. Residents wishing to smoke should request the materials from the nursing staff. 3. Residents designated as requiring supervision while smoking must be accompanied by a staff member while smoking. On 5/26/26 at 1:00 P.M., the surveyor observed Resident #66 outside the facility smoking a cigarette unsupervised. The Resident had a lighter and one box of cigarettes in his/her hand. During an interview and observation on 5/26/26 at 1:06 P.M., the Administrator was observed walking outside to the smoking area and removed the cigarettes and lighter from Resident #66. Resident #66 was observed flicking ashes on the ground and bending over to put the cigarette out on the ground. There was no ashtray or cigarette receptacle located near the resident. The Resident left the cigarette on the ground and then was observed walking back into the facility. Review of the nursing progress note dated 5/26/26 at 4:56 P.M., indicated: Resident was witnessed smoking during a nonsmoking time and without supervision. Resident was reeducated about policy and safety concerns. Resident smoking materials were given to management staff. Resident is willing to comply with smoking policy On 5/27/26 at 2:13 P.M., the surveyor observed Resident #66 outside the facility smoking a cigarette unsupervised. The Resident had a lighter and several cigarettes in his/her hand. The Resident was observed flicking ashes on to the ground. Resident #66 then lit a second cigarette with the cigarette he/she was already smoking and passed the newly lit cigarette to Resident # 109 who was standing next to him/her in the smoking area. During an interview and observation on 5/27/26 at 2:20 P.M., the surveyor observed CNA #6 walking out to the smoking area. CNA #6 observed Resident #66 smoking and holding on to a lighter and cigarettes and said Resident #616requires supervision and should not be out here smoking unsupervised and said she does not know how Resident #66 got outside to the smoking area. CNA #6 said Resident #66 should not be lighting or sharing cigarettes with other residents. CNA #6 said residents put the ashes and cigarettes out on the ground because there is no other place to dispose of them. CNA #6 said the residents don't use the smoking receptacle located near the walkway. During an interview on 5/27/26 at 3:32 P.M., the Assistant Regional Nurse said Resident #66 requires supervision with smoking and said Resident #66 should not be sharing and lighting cigarettes for other residents. The Assistant Regional Nurse said staff providing supervision must monitor the residents to ensure safety. During an interview on 5/27/26 at 3:26 P.M., the Administrator said Resident #66 requires supervision with smoking and should not be left unsupervised or sharing smoking materials with other residents. 2b. Resident #109 was admitted to the facility in May 2026 and has diagnoses that include essential primary hypertension, epilepsy, and bipolar disorder. Review of the medical record indicated the most recent Minimum Data Set assessment wasn't available. Review of the list of Residents who currently smoke in the facility provided by the facility failed to indicate that Resident #109 smokes. Review of Resident #109's medical record indicated the following nursing progress note dated 5/25/26: Resident's family member came in stating that Resident #109 can become aggressive due to the history of alcohol and drugs overuse. Family member brought one pack of cigarettes if needed. Resident displayed anger at family few times for not bringing the stuff that he/she requested. Resident threw the walker on the floor. Resident was educated of the safety protocols and was helped with orientation of the room/bathroom, phone, dining and other important needs. Resident can be forgetful, reorientation helps. Review of Resident #109's Smoking Evaluation Assessment - V 15, completed on 5/26/26 at 3:20 P.M., indicated: A. Does the resident smoke? No. Review of Resident #109's Smoking Evaluation Assessment - V 15, completed on 5/27/26 at 10:59 A.M., indicated:A. Does the resident smoke? Yes.N. Care plan reviewed and revised for appropriate supervision and smoking directions to include:b. General Supervisione. All smoking materials secured at nursing station. Review of the medical record failed to indicate a baseline care plan for smoking was created for Resident #109. Further review of the medical record failed to indicate a smoking agreement was reviewed and signed by Resident #109. On 5/26/26 at 12:58 P.M., Resident #109 was observed outside smoking unsupervised with two other Residents. On 5/27/26 at 10:06 A.M., Resident #109 was observed smoking in the outdoor area, in (Space one) to the left (non-smoking area) unsupervised with one other Resident. There was no ashtray or cigarette receptacle located near the resident. A propane tank was located attached to a gas grill approximately 15 feet from the resident. On 5/27/26 at 2:05 P.M., Resident #109 was observed asking a staff member for a cigarette at the Nurses station and then walked down the hall and exited out the back door to the designated smoking area. The staff member said, We will bring them out to you in a little while. On 5/27/26 at 2:13 P.M., the surveyor observed Resident #109 sitting next to Resident #66 who lit a second cigarette with the cigarette he/she was already smoking and passed the newly lit cigarette to Resident #109. During an interview and observation on 5/27/26 at 2:20 P.M., the surveyor observed CNA #6 walking out to the smoking area. CNA #6 observed Resident #109 smoking and said Resident #109 requires supervision and should not be out here smoking unsupervised and said she does not know how Resident #109 got outside to the smoking area. CNA #6 said Residents should not be lighting or sharing cigarettes with other residents. During an interview on 5/27/26 at 3:20 P.M., the Administrator said Resident #109 was evaluated as non-smoking but was then reassessed for smoking after family brought in smoking materials and said he/she requires supervision with smoking and should not be left unsupervised. The Administrator said Residents should not be sharing smoking materials outside and should not be going outside unsupervised and said the door is locked and Residents should not have access to the smoking area and should not know the code to get outside. During an interview on 5/27/26 at 3:32 P.M., the Assistant Regional Nurse said Resident #109 requires supervision with smoking and said Resident #109 should not be obtaining cigarettes from other residents. During interviews on 5/27/26 at 3:35 P.M. and on 5/28/26 at 11:32 A.M., the Assistant Regional Nurse said that Resident #109 must be supervised while smoking and should not be out in the smoking area unsupervised. The Assistant Regional Nurse said that smoking assessments and care plans should be followed. The Assistant regional nurse said residents who require supervision while smoking should be receiving supervision and all smoking materials should be kept in at the nurses station and dispensed appropriately. The Assistant Regional Nurse said that cigarette ash and discarded cigarettes should be disposed of properly to prevent a possible fire. During interviews on 5/27/26 at 3:28 P.M., 3:40 P.M and 5/28/26 at 11:56 A.M., the Administrator said that Residents who require supervision during smoking should be supervised. The Administrator said that smoking assessments and smoking agreements must be followed and care plans should reflect the individual resident needs for supervision. The Administrator said that Residents should be putting out cigarettes in the receptacle and not flicking ashes on the ground or putting them out on the ground as it is a fire hazard and a hazard for burns. The Administrator said that smoking materials should be kept at the nurses station along with a binder so staff are aware of who requires supervision and can dispense smoking materials appropriately. During an interview on 5/28/26 at 12:18 P.M., the Medical Director said Residents must be supervised while smoking and said not providing supervision when needed could cause harm and put others at risk. The Medical Director said that he was not aware of Residents being unsupervised during the smoking. The Medical Director said Residents should not have access to smoking materials and said it has been an ongoing problem and something needs to be done. The Medical Director said there is a concern for safety if residents have access to smoking materials and are sharing them especially for residents who have been assessed and require supervision. 3. Resident #50 was admitted to the facility in March 2022 with diagnoses cerebral infarction, dementia, chronic obstructive pulmonary disease, and major depression. Review of Resident #50's Minimum Data Set assessment, dated 2/24/26, indicated had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 10 out of 15. This MDS indicated Resident #50 did not reject care and he/she used tobacco. Review of Resident #50's Smoking Evaluation Assessment - V 15, dated 5/21/26 as a late entry completed on 5/26/26 at 11:33 A.M., indicated: N. Care plan reviewed and revised for appropriate supervision and smoking directions to include: C. Supervision and assist of 1 for smoking. Review of Resident #50's plan of care related to smoking, dated as revised 10/16/23, indicated: Maintain Resident smoking materials at nurses' station. Review of Resident #50's Resident Smoking Policy, signed and dated 9/14/23, indicated: 2.3 Smoking supplies (including, but not limited to, tobacco, matches, lighters, lights fluid, etc.) will be kept behind the nurse's station, in the smoking box. Review of Resident #50's Smoking Agreement, dated 3/19/24, indicated: Residents are not permitted to have any smoking paraphrenia in their room or on person. All smoking materials should be given to the nursing staff for safekeeping. On 5/26/26 at 8:32 A.M., the surveyor observed an open box of cigarettes on Resident #50's overbed table, an open box of cigarettes on Resident #50's nightstand, and one smoked cigarette on Resident #50's floor. Resident #50 said that he/she is a smoker and he/she keeps his/her cigarettes on him/herself. The Resident said that he/she keeps additional cigarettes in his/her dresser and Resident #50 allowed the surveyor to look in his/her dresser. There were two cartons of cigarettes and 5 boxes of cigarettes in the top dresser drawer next to personal clothing and facility linens. On 5/27/26 at 6:57 A.M., the surveyor observed Resident #50's open box of cigarettes on his/her overbed table and an open pack on the nightstand. On 5/27/26 at 2:05 P.M., the surveyor observed Resident #50's open box of cigarettes on his/her nightstand. During an interview on 5/27/26 2:44 P.M., CNA #5 said Resident #50 smokes, but she isn't sure where Resident #50 is supposed to keep his/her smoking materials. During an interview on 5/27/26 at 2:50 P.M., Unit Manager #1 said cigarettes are locked on the North 1 unit and cigarettes are not stored in the Resident rooms. On 5/27/26 at 4:22 P.M. and on 5/28/26 at 6:43 A.M., the surveyor observed Resident #50's open pack of cigarettes on his/her nightstand. On 5/28/26 at 12:48 P.M., the surveyor and Unit Manager #1 observed Resident #50's open pack of cigarettes on his/her nightstand. There were 10 cigarettes in the box, two half smoked cigarettes and a lighter stored in the box. Unit Manager #1 asked the Resident if he/she had any additional cigarettes in his/her room and the resident allowed Unit Manager #1 to check his/her dresser. Unit Manager #1 removed three cartons of cigarettes each with 10 boxes of cigarettes and five individual boxes from two different dresser drawers. Unit Manager #1 said that cigarettes are to be stored on the North 1 unit and she would follow up with Resident #50's family member. During an interview on 5/28/26 at 1:21 P.M., the Assistant Regional Nurse said that Resident #50's cigarettes should be stored in the Nort

Based on interview, and record review, the facility failed to act upon, provide timely responses, and document written responses and rationale to grievances of resident care and services brought to facility administration by the Resident Council. Specifically, the facility failed to promptly respond to resident grievances brought up during the 2/18/26, 3/24/26, 4/28/26, and 5/20/26 Resident Council meeting minutes. Findings include: Review of the facility policy titled, Resident Council Meeting and Agenda, dated as revised 3/3/26, indicated the facility supports residents' desires to be involved and have input in the operation of the facility through the Resident Council. 8. The Administrator reviews the minutes and any responses from departments within the facility. Responses will be presented no later than the next council meeting. 9. Minutes include concerns or problems; issues discussed; recommendations from the council; and follow up on prior issues. Review of the Resident Council Meeting Minutes, dated 2/18/26, indicated the following concerns:-Nurses and CNA's always on the phone talking about personal life. They close the door and act like they are doing care.-Shower rooms are cold and residents say the shower rooms smell of mold and mold is visible including on the shower curtains. -Residents feel shower rooms are dirty and they don't want to shower in there. They would like to see both shower stalls on S2 in operation.-CNA's come in room shut off call light and tell them they are not my patient, and I'll go get your aid and no one comes back for what seems like hours.-They continually hear I'm not your CNA-Resident that is independent and does her own bathing has had a CNA refuse to let her wash herself in shower and continually gets soap in her eyes.-Residents not receiving showers.-Female residents not wanting male aids to clean them.-Residents want to be able to fill out a menu and pick items they would like on the tray.-They said the kitchen is constantly running out of milk and most want milk on tray for every meal.-Trays come with 1 creamer and no sweeteners. [sic] Review of the Resident Council Meeting Minutes, dated 3/24/26, indicated the following: Nursing Complaints/Concerns/Comments:-Resident witnessed CNA at front desk on personal phone chatting while several call lights were going off. CNA ignored lights for several minutes.-One particular CNA is always on her phone arguing with her girlfriend, tells her resident she will return in a minute, and the CNA will not be seen again for over an hour.-CNA's not making beds and leaving them for 2nd shift-Resident states no one came to get him out of bed for the day until 2:30 pm. Then aid gave him a bucket of water with nothing to wash with. When resident asked for wash cloth and towel, he was told they had none. Before CNA came to get resident out of bed resident asked another resident to let them know he wanted to get up and resident overheard staff complaining saying They are sick of him.-Again, CNA's always on phone while call lights are going off and residents hearing staff say 'I'm not answering the call light because of excessiveness.-CNA's coming in and when they do answer call light they shut it off, say I'm not your aid but I tell them or they say your CNA is on break and now no one shows up for resident's needs.-When resident's ask to go to bed they make them wait for very long time.-CNA came into a room with a tray of food and the roommate told the CNA that the resident that the tray was for eats in the dining room and CNA placed tray on bedside table and walked out. No one come back for tray for over 45 minutes. Roommate timed it.-CNA's discuss their personal business with residents making them uncomfortable.-Residents feel CNA's have a terrible attitude towards them and feel they are treated like children.-Resident complaining she doesn't get changed once up for day until she goes to bed. Resident is soaked-Residents complaining that when given a shower the water is cold, they don't use soap or shampoo. Aids ignore when asked why.Housekeeping:-Residents complaining rooms not being cleaned, not emptying the trash, and especially not cleaning the bathrooms.-Finding ants in bathroomKitchen:-Resident said she did not receive milk on her tray 20 times in month.-Resident usually doesn't eat what's on tray but they usually show him the tray to see if there is something he will eat but they have stopped asking him and leaving it in the food truck. This happens on 2nd shift.-Resident said they are not supposed to get chicken on the tray but always get chicken on tray.-Resident feel as though that they don't care what they feed them when dietary manager is not in the house.Maintenance:-Ants in bathroom. [sic] Review of the Resident Council Meeting Minutes, dated 4/28/26, indicated: Nursing Complaints:-CNA's always on personal phones during care, and some even eat while doing care.-Resident went to the nurse's station to ask for morning meds and the nurse replied, when I'm done eating breakfast I'll bring you your meds.-Resident asked to be changed due to being wet and the CNA told resident that they had just been changed and that they will now wait until they have time.-Nurses aides speak rudely to them and treat them like children.-Residents that cannot verbalize being left in day room/dining room on neighborhoods to sleep in wheelchairs and not put into bed until 10 o'clock or later.-Resident asked to be put into bed was told I'll be right back and did not return for 2 hours.-There is a nurse that works on North 1 that is always using vulgar profanity.-Weekend CNA told resident they don't know how to turn hot water on and proceeded to wash resident with cold water.-CNA's are not knocking on bathroom doors before they enter.-Residents complaining that they are receiving showers at 9/10 pm or go without getting a shower if they refuse. They said they are usually sleeping at that time and want showers earlier.-CNA's always using other residents bath wash on other residents and not returning it so resident has none that family has brought for them.Maintenance:-ants and mold in shower stalls-In the evening residents complain that there is never any hot water.Housekeeping:-Showers are always dirty, Bathrooms not being cleaned on the weekend. [sic] Review of the Resident Council Meeting Minutes, dated 5/20/26, indicated: Nursing Complaints:-CNA left resident alone in the shower for a few minutes.-CNA's are always on their personal phones while doing care.-Nurses and CNA's are not knocking on bathroom doors before entering. No privacy.-CNA's going through residents' drawers and taking personal hygiene items that were privately bought and taking it for another resident and not asking first or returning the item.-CNA's are still telling residents that they have no time to give them a shower.-Nursing staff not waking residents for breakfast and leaving tray on table for them when they wake.-Nurses & CNA's sitting around nurse's desk looking at phones while call lights are going off.-CNA's leaving dirty depends in bathroom trash not disposed properly.Housekeeping Complaints:-Bathroom cleaning sign off sheet not being signed off letting resident know bathroom was cleaned.-Weekend housekeeping staff is not doing job properly.-Residents that are able are wiping down their bathroom to keep it clean.Maintenance:-Bee's every time a window is opened. Residents want to open window for fresh air. [sic] Review of the Grievance Log, dated January 2026 through May 27, 2026, failed to include documentation to support the Resident's concerns were addressed from the Resident Council. During the Resident Group Interview on 5/27/26 at 11:00 A.M., 7 of 7 participants said they feel that their concerns brought forward during Resident Council are not resolved.During an interview on 5/27/26 at 3:26 P.M., the Activities Director said she attends the Resident Council meeting every month and she said that each month the Residents have the same concerns. The Activities Director said that she types up the meeting minutes, and then she and the Resident Council President review and sign off on the meeting minutes. The Activities Director said once she and the Resident Council President sign off on the meeting minutes, she then gives the minutes to the Administrator and Director of Nursing for follow up with the respective departments.During an interview on 5/27/26 at 3:48 P.M., the Administrator said that he reviews the Resident Council meeting minutes after each meeting. The Administrator said that after each meeting there should be follow-up, including education and grievances related to concerns from the meeting. The Administrator said he reviewed the Resident Council meeting minutes from 2/18/26, 3/24/26, 4/28/26, and 5/20/26 and said that he was aware of the meeting minutes, and he said there was no follow-up attached, and he said there has been no Staff Development Coordinator (responsible for education) since March 2026. The Administrator said he would look to see if there was any documentation or education or grievances for the Resident's concerns. During a follow-up interview on 5/28/26 at 8:50 A.M., the Activities Director said she was unable to provide any additional education for the Resident Council and she said she would use a new form to ensure follow-up was completed. During a follow-up interview on 5/28/26 at 9:26 A.M., the Administrator said he was unable to locate any education or grievances from the Resident Council, and he said there is a follow-up form that should have be completed after each group, but the form was not completed.

Based on observations, record review, and interviews, the facility failed to ensure one Resident (#9) received treatment and care in accordance with professional standards of practice, out of total sample of 28 residents.Specifically for Resident #9 who was diabetic the facility failed to a. ensure that nursing documented alterations in skin integrity according to the diabetic foot care order, b. failed to ensure nursing transcribed and implemented recommendations from the consultant wound physician, and c. failed to document skins checks accurately when the resident had wounds on both feet. Findings include: Review of the facility policy titled, Skin Prevention, Assessment and Treatment, dated as revised 10/24/25, indicated: Purpose:-To identify factors that place the residents at risk for the development of pressure ulcers-To implement appropriate interventions to prevent the development of clinically avoidable wounds.-To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown.Procedure:5. All residents should have their skin integrity examined thoroughly routinely by a licensed nurse to identify existing pressure ulcers.a. Findings from the weekly skin assessment should be documented by the licensed nurse.Treatment Guidelines:1. Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, in the Medical Record.a. Documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues, and a description of any drainage, eschar, necrosis, odor, tunneling, or undermining. Resident #9 was admitted to the facility in February 2024 with diagnoses including diabetes, dementia, and obstructive uropathy (a blockage in the urinary tract). Review of the most recent Minimum Data Set (MDS) assessment, dated 5/4/26, indicated Resident #9 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 12 of 15. Further review of the MDS indicated Resident #9 had an infection of the foot, and a diabetic foot ulcer. On 5/26/26 at 2:51 P.M., the surveyor observed Resident #9 in bed, his/her feet were exposed and there were no dressings on either foot. Resident #9's left foot second toe had a diabetic ulcer, and Resident #9's right foot had a diabetic ulcer on the right great toe and there was an open area on the right foot second toe. a. Review of Resident #9's care plan related to diabetes, dated as revised 5/6/25, indicated:-Inspect feet daily for open areas, sores, pressure areas, blisters, edema (swelling) or redness. Review of Resident #9's physician's order, dated 3/5/24, indicated:-Diabetic Foot Care/Check Daily Observation of feet, toes, ankles, soles Noting any alteration in skin integrity, color, temperature, and cleanliness. Inspect shoes for proper fit and excessive wear, check Pedal Pulses (blood flow felt in the foot), every evening shift for diabetes.CODE: 1= no alteration notedCODE: 2= New alteration notedCODE: 3= Previously noted alterationPedal Pulse (PP): P=Palpable NP=Non-Palpable (not felt by touch). Review of Resident #9's Treatment Administration Record, dated April 2026 and May 2026, failed to include documentation to support nursing was documenting the coding as required for alterations in skin integrity. b. Review of Resident #9's care plan related to actual skin, dated as revised 5/20/26, indicated: -Treatment as ordered.-Wound team as ordered. Review of Resident #9's telephone consultant note, dated 4/29/26, indicated: -left foot wound second toe ulcer. -right foot great toe plantar ulcer, clean dry and intact. Review of Resident #9's physician's order, dated 4/30/26, indicated:-Clean left second toe with saline, pat dry and apply betadine (topical solution to prevent infections), two times a day for wound care. Review of Resident #9's consultant podiatry note, dated 5/6/26, indicated: Ulcer(s) Treatments:-Left second toe PIPJ (proximal interphalangeal joint): evaluated only, under care of primary care physician.-Right great toe: didn't remove dressing, under care of primary care physician. Review of Resident #9's wound care consultant note, dated 5/12/26 and 5/19/26, indicated:WOUND ASSESSMENT:-Wound: 1Location: Right, Distal, Great toePrimary Etiology: DiabeticStage/Severity: Stage 2Wound Status: StableOdor Post Cleansing: NoneSize: 2.2 centimeters (cm) x 2.2 cm x 0.3 cm. Calculated area is 4.84 square cm.Wound Base: 100% granulation (wound healing). Exudate: Small amount of Serosanguineous (pale pink drainage).-Wound: 2Location: Left, Right, Dorsal (back or underside), Second toePrimary Etiology: DiabeticStage/Severity: 100% NGT (normal granulation tissue)Wound Status: StableOdor Post Cleansing: NoneSize: 1.6 cm x 1.6 cm x 0 cm. Calculated area is 2.56 sq cm.Wound Base: 100% granulationExudate: Moderate amount of Serosanguineous-Wound # 1 Right, Distal (away from), Great toe DiabeticTreatment Recommendations:1. Cleanse with normal saline.2. apply Honey alginate, calcium alginate (absorbent material) to base of the wound.3. secure with ABD (abdominal) pad, Rolled gauze.4. change Daily.-Wound # 2 Left, Right, Dorsal, Second toe DiabeticTreatment Recommendations:1. Cleanse with normal saline.2. apply Honey alginate, calcium alginate to base of the wound.3. secure with ABD pad, Rolled gauze.4. change Daily. Review of Resident #9's physician's orders and Treatment Administration Record, dated May 2026, failed to include documentation to support these recommendations were implemented. c. Review of Resident #9's care plan related to actual skin, dated as revised 5/20/26, indicated: -Skin checks weekly. Review of Resident #9's physician's order, dated 3/8/24, indicated: -Skin Check weekly on Wednesday 7-3, every day shift, every Wednesday for preventative document in progress note. Review of Resident #9's Weekly Nursing Skin Review - V 2 assessments, dated 5/6/26, 5/13/26, and 5/20/26, indicated the following alteration:-Right toe, great toe scab. Review of Resident #9's Weekly Nursing Skin Review - V 2 assessment, dated 5/27/26, indicated the following alterations: -Right toe, great toe scab, second toe scab. Upon comparative review of the podiatry note dated 5/6/26, and the wound consultant notes dated 5/12/26 and 5/19/26, there is no documentation to support that nursing documented the left second toe diabetic foot ulcer in the weekly skin checks. On 5/27/26 at 3:09 P.M., the surveyor and Nurse #2 observed Resident #9's feet. Nurse #2 said that she is a regular nurse on the unit and she provides care to Resident #9 including skin checks and diabetic foot care. Nurse #2 said there are three wounds on Resident #9's feet, one on the left foot second toe, one on the right foot great toe, and one on the right foot second toe, and these areas have been there for greater than one month. Nurse #2 said that the physician's order is for betadine for one foot, but we do the three areas on both feet. Nurse #2 said that she should have updated the orders for betadine, but she did not. Record review indicated Nurse #2 completed Resident #9's skin check assessment on 5/13/26 and did not document the left foot wound. During an interview on 5/28/26 at 10:13 A.M., Unit Manager #1 said that Resident #9's wound rounds are completed by the floor nurses and the wound consultant. Unit Manager said she doesn't love the betadine for a treatment to Resident #9's left foot second toe. Unit Manager #1 said that she received a report after the wound consultant leaves the facility and Unit Manager #1 said she was not aware of any other recommendations for Resident #9's wounds other than the betadine. Unit Manager #1 printed the wound consultant's recommendations which indicated dressing recommendations as outlined in the notes dated 5/12/26 and 5/19/26 for Resident #9. On 5/28/26 at 10:20 A.M., the surveyor and Unit Manager #1 observed Resident #9 in bed, his/her feet were exposed and there was no dressing on either foot. Resident #9's left foot second toe had a diabetic ulcer, and Resident #9's right foot had a diabetic ulcer on the right great toe and there was an open area on the right foot second toe. The right great toe and right second toe were red. During an interview on 5/28/26 at 12:03 P.M., Nurse #4 said for Resident #9 she applies betadine for the left foot second toe wound. Nurse #4 said that Resident #9's right foot second toe is more red, and the right great toe open area - looks like it's coming back. Record review indicated Nurse #4 completed Resident #9's skin check assessment on 5/6/26 and 5/20/26, and she did not document the open area on the left second toe. During a follow-up interview on 5/28/26 at 12:55 P.M., Unit Manager #1 said skin checks are important to be accurately completed and documented because skin checks catch changes in skin condition and then nursing can put interventions into place. Unit Manager #1 said it is important complete diabetic foot care and for nursing to document findings to check for changes and nursing can put interventions in place. Unit Manager #1 said she was not aware of Resident #9's wound consultant recommendations from 5/12/26 and 5/19/26, and she would speak with the Nurse Practitioner about Resident #9's feet. During an interview on 5/28/26 at 1:10 P.M., the Assistant Regional Nurse said that nursing should follow up and implement wound consultant recommendations weekly. The Assistant Regional Nurse said that nursing should complete and accurately document diabetic foot care. The Assistant Regional Nurse said that nursing should accurately complete skin checks to check for skin breakdown; this is importing in identifying new areas and new areas can be reported to the medical providers. During an interview on 5/28/26 at 12:22 P.M., the Physician said he was not sure why nursing didn't implement the wound consultant recommendations. The Physician said Resident #9 is not always compliant, but nursing should have obtained orders based on the wound consultant's recommendations.

Based on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were stored in accordance with manufacturer's guidelines (i.e. in the fridge), dated once opened according to manufacturer's guidelines and ensure expired medications were removed in one out of three medication carts reviewed. Findings include:Review of facility policy titled Storage, Labeling of OTC (over the counter) Medication, Destruction & Disposal of Medication, dated as revised November 5, 2025, indicated the following:-3. No discontinued, outdated or deteriorated medications should be available for use in the facility. All such medications are destroyed per policy.-4. Expired medications are to be removed from areas medication carts prior to or at the time of expiration.-9. Medications requiring refrigeration should be stored in the refrigerator located in the drug room at the nurses' station. Medications should be stored separately from the food and must be labeled. Please refer to package insert for specific temperature requirements of medication. On 5/27/26 at 9:46 A.M., the surveyor made the following observations in the North 1-unit medication cart (A). -A Lispro insulin pen unopened labeled to refrigerate until opening.-A Lantus insulin pen labeled with an open date of 4/25/26 and an expiration date of 5/23/26 in the medication cart and available for administration.-An insulin glargine pen labeled with an open date of 4/26/26 and an expiration date of 5/24/26 in the medication cart and available for administration.-An insulin glargine pen labeled with two different open dates of 4/1/26 and 5/9/26.-An open bottle of liquid protein without an open date. The bottle indicates to use within three months. During an interview on 5/27/26 at 9:50 A.M., Nurse #3 said that expired insulins should have been removed from the medication carts. She also said that if an insulin has two open dates, there is no way of knowing which one is accurate. Nurse #3 also said that the liquid protein should have been labeled with an open date because it's only good for three months after opening it. During an interview on 5/27/26 at 1:27 P.M., the Assistant Regional Nurse said that she would expect staff to label medications that have a shortened expiration date when they are opened and that she would expect nurses to remove expired medications from the medication cart. The Assistant Regional Nurse further said that insulin should be stored in the fridge until opened.

Based on record review and interviews, the facility failed to ensure laboratory services were provided for one Resident (#55) out of a sample of 28 Residents. Specifically, the facility failed to ensure routine labs were obtained and the results were reported to the medical provider.Findings include:Review of the facility policy titled Diagnostic Services, dated as revised 11/5/25, indicated but was not limited to the following: Access to radiologic and clinical laboratory diagnostic services will be available 24 hours a day, Seven days a week, to ensure diagnostic tests relevant to the residents' health status is provided and reported as required by physician. Resident #55 was admitted to the facility September 2022 with diagnoses including folate deficiency (a shortage of vitamin B9, which can lead to anemia and symptoms like fatigue and pale skin), muscle weakness, type two diabetes mellitus, and dysphagia (difficulty swallowing).Review of the most recent Minimum Data Set (MDS) assessment, dated 2/18/26, indicated that Resident #55 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 10 out of 15. Review of Resident #55's outside blood lab result dated 3/27/26, indicated a Vitamin D level was 13ng/ml (Units) and was L (low), reference range is 30 -100. Review of Resident #55's physician's order, dated 3/27/26, indicated: Vit D 5000 IU daily x 3 days Discuss ongoing rx (prescription) with in house team Monday.Review of Resident #55's Nurse Practitioner progress note dated 3/28/26, indicated the following: Primary Chief Complaint: Lab Review: Abnormal results and/or requiring provider assessment. History Present Illness: Lasbs [SIC] reviewed, Vit D (Vitamin D) low, will add D (Vitamin D) for a few days then nurse to discuss with in house team Monday [SIC] for ongoing rx (prescription).Diagnosis, Assessment/Plan: Vitamin D deficiency, unspecified (Primary) Condition is stable, will give Vit D for a few days and have in house team eval Monday and decide ongoing rx Orders (prescription orders): Vit D 5000 IU (international units of measurement) daily x 3 days.Review of the nursing progress note dated 3/30/26 indicated Vitamin D level to be checked 4/1/26.Review of Resident #55's physician's order, dated 4/1/26, indicated: Vit (Vitamin) D level lab to be drawn. Please check (lab services) to make sure order is placed one time only for low vitamin D level for 1 day. Start date 4/1/26. Review of the Electronic Medication Administration Record indicated nursing had documented (checked off) that the Vit D lab was drawn. Further review of Resident #55's medical record failed to indicate the results from the laboratory order, dated 4/1/26. There were not nursing or provider notes regarding the Vitamin D labs. During an interview on 5/28/26, at approximately 6:51 A.M., Nurse #9 said Resident #55's Vitamin D levels were low in March, and he/she was started on 5000 units of Vitamin D for three days and needed his/her levels to be checked on 4/1/26. Nurse #9 said laboratory result should be in the medical record and said Resident #55 had an order for a Vitamin D lab draw on 4/1/26 but there is no lab result or progress note indicating the lab result. Nurse #9 said he would need to access an outside service to obtain the results because there were no results documented or located in the electronic medical record. Nurse #9 then showed the surveyor an online website containing the lab results for Resident #55 and said the lab draw needs to be followed up on because there is nothing in Resident #55's medical chart to show this lab result was reviewed by the physician or nurse practitioner and said no additional lab draws have been done since 4/1/26. Nurse #9 said there is no follow up information after the lab draw on 4/1/26. Nurse #9 said the lab result from 4/1/26 was 22 and still low and needs to be reported because Resident #55 has not been on Vitamin D supplements since March. Review of the progress notes dated from 4/1/26 to 5/28/26, failed to indicate the 4/1/26, laboratory results were received, reviewed, or that the physician/nurse practitioner (NP) was notified of the laboratory results. During an interview on 5/28/26 at 7:14 A.M., Nurse Practitioner (NP) #2 said she could not locate the laboratory results report or see any follow-up documentation for the Vitamin D lab drawn on 4/1/26 for Resident #55. NP #2 said she does not know why there is no follow up information and said Residet #55 should have his/her levels rechecked and have supplements ordered if he/she is still low. NP #2 said Vitamin D level of 22 on 4/1/26 is still low and needs to be rechecked because it is now the end of May and the levels could drop lower without supplements. During an interview on 5/28/26 at 9:46 A.M., NP #1 said she was not aware of the low Vitamin D level and said she was not aware of the Vitamin D lab draw on 4/1/26. NP #1 said the lab result should have been reported and followed up on, but it was not. During an interview on 5/28/26 at 10:05 A.M., the Assistant Regional Nurse said the lab result should have been followed up on and said the lab faxes the results report to the facility, the nurses receive the results, review the results with the NP or physician and must document the information in the medical record.During an interview on 5/28/26 at 12:18 P.M., the Medical Director said staff must follow physician orders to ensure labs are obtained and results are located in the medical record. The Medical Director said Resident #55 required oversight to monitor low Vitamin D levels. The Medical Director said there is no way to know the need for supplementation without a current Vitamin D level and said he would expect the facility to report and follow up on physician orders for lab draws.

Based on observation, record review and interview, the facility failed to provide dental services for three Residents (#50, #3 and #48) out of a total of 28 sampled Residents. Specifically: 1. For Resident #50 the facility failed to follow up with denture fabrication after Resident #50's teeth were extracted on November 3, 2025.2. For Resident #3, the facility failed to ensure he/she was seen for an annual dental exam. 3. For Resident #48, the facility failed to ensure dental services were provided since his/her admission to the facility in August 2025. Findings include: Review of the facility's policy titled Dental Services, dated 10/5/25 indicated: It is the policy of this facility to provide Dental Services for resident needs. 1. The facility will assist residents in obtaining routine and 24-hour emergency dental care. 2. The facility has routine and emergency dental services to meet the needs of each residents. [SIC] 6. If necessary or requested the facility will assist the resident: a. in making appointments and; b. arrange for transportation to and from the dental services location. 8. The facility will provide or obtain from an outside resource, dental services to meet the needs of each resident: a. Routine dental services (to the extent covered under the state plan) and, b. Emergency dental services, awaiting dental services and the extenuating circumstances that led to the delay. c. The facility will assist residents who are eligible and wish to participate to apply for reimbursement of dental services as incurred medical expense under the State plan. 1. Resident #50 was admitted to the facility in March 2022 with diagnoses cerebral infraction, dementia, chronic obstructive pulmonary disease, and major depression. Review of Resident #50's Minimum Data Set assessment, dated 2/24/26, indicated Resident #50 had a moderate cognitive impairment as evidenced by a Brief Interview of Mental Status score of 10 of 15. The MDS indicated resident #50 did not reject care, had no natural teeth and Resident #50 required supervision/touching assistance for oral hygiene. On 5/26/26 at 8:32 A.M., the surveyor observed Resident #50 in his/her chair eating scrambled eggs and pureed bread. The diet slip indicated NDD Level 2 (National Dysphagia Diet, consists of moist, soft textured foods that are easy to chew and form into a bolus, suitable for individuals with mild to moderate dysphagia). Resident #50 had no teeth. During an interview on 5/26/26 at 11:24 A.M., Resident #50's Family Member #1 said that he/she was unaware of the status of Resident #50's dentures. Family Member #1 said that Resident #50's teeth were removed back in November 2025, and Resident #50 was supposed to get dentures. Family Member #1 said that he/she would regularly communicate with a Nurse (later determined to be Nurse #5) about Resident #50's teeth/denture plan and Family Member #1 thought that the Nurse had left because of high turnover of staff in the facility. During an interview on 5/26/26 at 1:05 P.M., Resident #50 said he/she wanted dentures and he/she was waiting to get dentures. Review of Resident #50's dental group consultant form, dated 7/14/25, indicated: -Resident has no complaint; no sores or pathology noted; oral hygiene fair, moderate debris present; teeth are in poor condition. Refer out to oral surgery for full mouth extractions. Resident is not a candidate for onsite treatment. Review of the hospital after visit summary, dated 11/3/25, indicated Resident #50 had his/her teeth extracted. Review of Resident #50's plan of care DENTAL/ORAL HEALTH - Resident exhibits or is at risk for oral health or dental care problems as evidenced by poor dentition - I have had all my teeth removed, dated as revised 11/5/25, indicated: - Obtain dental consult as ordered. During an interview on 5/27/26 at 2:46 P.M., Unit Manager #1 said that all of Resident #50's teeth were pulled in November 2025 and that plan was for Resident #50 get dentures. Unit Manager #1 said that Nurse #5 was working with Resident #50's Family Member #1 on dental plans. During an interview on 5/27/26 at 5:27 P.M., Nurse #5 said Resident #50 had long standing issues with his/her teeth including pain. Nurse #5 said she has not worked at the facility since December 2025 and she helped facilitate the appointment for Resident #50's teeth removal. Nurse #5 said that the plan was for Resident #50 to be seen by the consultant dentist after his/her teeth were removed and Resident #50 was supposed to get dentures. Nurse #5 said that it was Unit Manager #1 responsibility to follow up on the dentures. During an interview on 5/28/26 at 7:50 A.M., the Assistant Regional Nurse said that she was unable to find any follow up consultant dental evaluations for Resident #50's dentures. During a follow-up interview on 5/28/26 at 1:20 P.M., the Assistant Regional Nurse said she was not sure what happened with Resident #50's dental plan and she said the consultant dentist was in the facility in December 2025 and again in March 2026. 2. Resident #3 was admitted to the facility in January 2024 with diagnoses including chronic pain and unspecified dementia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #3 is cognitively intact evidenced by a score of 14 out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated that Resident #3 had no broken or loosely fitting full or partial dentures and no mouth or facial pain, discomfort or difficulty with chewing. Review of Resident #3's clinical record indicated his/her health care proxy was activated and he/she was not his/her own decision maker. On 8/26/25 at approximately 8:15 A.M., the surveyor observed Resident #3 resting in bed. Resident #3 was observed to be missing teeth. Review of the physician orders indicated: Ancillary and specialty care will be provided as needed, 1/17/24. Review of Resident #3's Dental/Oral Health care plan dated 2/20/24 indicated: Focus: Dental/Oral Health; I currently have altered oral/dental health r/t (related to) edentulous, 2/20/24Interventions: Administer medications and treatments as ordered by MD and monitor for side effects to current medication regimes. Monitor/document/report PRN any s/sx (signs/symptoms) of oral/dental problems needing attention. Review of the Nurse Progress note dated 11/12/25 indicated: HCP (health care proxy) was in to sign (contracted dental provider) consent for audiology and dental, in addition to podiatry. Review of Resident #3's Dental Services notes indicated he/she was last seen on 10/8/24. The note indicated: Pt (patient) has no complaint; dentures not worn or indicated. No sores or pathology noted, oral hygiene adequate: Annual exam: 10/8/25. The medical record failed to indicate Resident #3 had been seen since October 2024. During an interview on 5/28/26 at 9:14 A.M., Family Member #5 said that he had told staff at the facility he was concerned about Resident #3's teeth and that Resident #3 had partial dentures before he/she came to the facility. Family Member #5 said he had told staff he wanted Resident #3 to be seen by the dentist a number of times. During an interview on 5/28/26 at 11:16 A.M., Unit Manager #2 said Unit Managers were responsible for arranging appointments with dental service and there had been issues with communicating with the agency to arrange for services. Unit Manager #2 could not speak to any concerns Family Member #5 had related to Resident #3's dental care or why he/she had not been seen since October 2024 as she was newly assigned to the unit. During an interview on 5/28/26 at 1:35. P.M. the Assistant Regional Nurse said that residents should be seen timely for dental services. 3. Resident #48 was admitted to the facility in August 2025 with diagnoses including lymphedema, and dementia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #48 is cognitively intact evidenced by a score of 14 out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated Resident #48 had no broken or loosely fitting full or partial dentures and no mouth or facial pain or discomfort while chewing. Review of the clinical record indicated Resident #48's health care proxy was activated and he/she is not his/her own decision maker. On 5/26/26 at 8:08 A.M., the surveyor observed Resident #48 had natural teeth and some were missing. Review of Resident #48's care plans failed to include a care plan related to dental status. Review of the physician order dated 8/30/25 indicated: Ancillary and specialty care will be provided as needed. Review of the Nursing assessment dated [DATE] indicated: Dental Status: natural teeth Review of the Ancillary Service request form dated 8/30/25 indicated Resident #48 had requested dental services. The form included a handwritten addendum indicated the request form had been faxed on 9/4/25. Additional review of the clinical record failed to indicate Resident #48 had been seen by dental services since his/her admission to the facility. During an interview on 5/28/26 at 9:03 A.M., Family Member #4 said he would like Resident #48 to be seen for routine dental services but was unsure if he/she had been seen since being at the facility. During an interview on 5/28/26 at 11:16 A.M., Unit Manager #2 said Unit Managers were responsible for arranging appointments with dental service and there had been issues with communicating with the agency to arrange for services. Unit Manager #2 could not speak as to why Resident #48 had not been seen by a dentist as she was newly assigned to the unit. During an interview on 5/28/26 at 1:35 P.M., the Assistant Regional Nurse said that residents should be seen timely for dental services, and the facility was restructuring how appointments are made.

Based on observation, record review and interview, the facility failed to consistently accommodate resident food preferences for one Resident (#88) out of a total sample of 28 residents. Specifically, for Resident #88, the facility failed to ensure the kitchen consistently honored his/her meal preferences.Finding include: Review of the facility policy titled, Resident Food Preferences, dated as revised 11/5/25, indicated nutritional assessments will include an evaluation of individual food preferences.-Policy Interpretation and Implementation1. Upon the resident's admission or within seventy-two (72) hours after his/her admission, the dietitian or designee will identify a resident's food preferences. When possible, this will be done by direct interview with the resident.2. The dietitian will discuss resident food preferences with the resident when such preferences conflict with a prescribed diet. The resident has the right not to comply with prescribed diet or dietary restrictions.3. The clinical dietitian and nursing staff, assisted by the physician, will identify any nutritional issues or dietary restrictions that might affect the facility's efforts to accommodate resident preferences. Whenever possible, the staff and physician will strive to minimize dietary restrictions in order to accommodate those preferences. In conjunction with the physician, the dietitian or nursing staff will document reasons why restrictions are necessary and/or why the facility cannot accommodate resident preferences.4. The resident's clinical record (orders, care plan, or other appropriate locations) will document the resident's likes and dislikes and special dietary instructions or limitations such as altered food consistency and caloric restrictions.5. The dietitian will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests.6. The food services department will offer a limited number of food substitutes for individuals who do not want to eat the primary meal.7. The facility's quality improvement (Ql) program will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc. Resident #88 was admitted to the facility in March 2026 with diagnoses including diabetes, heart failure, and asthma. Review of the most recent Minimal Data Set assessment, dated 3/11/26, indicated Resident #88 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. This MDS assessment indicated Resident #88 was on a therapeutic diet. Review of Resident #88's physician's orders, dated 3/11/26, indicated: LCS (Low Concentrated Sweets) diet. Regular texture, Regular/Thin (0) consistency, + NO ADDED SALT. Review of Resident #88's Dietary evaluation Assessment - V 10, dated 3/14/26, indicated: Diet/Supplements: LCS (Low Concentrated Sweets) Review of Resident #88's plan of care related to nutrition, dated as revised 3/27/26, indicated: Honor food preferences within meal plan, update regularly and as needed with resident and caregiver(s). Review of Resident #88's Dietary Progress Note, dated 3/20/26, indicated: - Consulted today with Resident to discuss meal preferences. Voiced significant desire to carb count, explained that we don't carb count here, but agreeable to adjust menu accordingly. Fruit instead of dessert; no rice, half portion pasta/potato/garlic bread/bread. Add side salad with oil and vinegar or Italian dressing instead of veggies at lunch, hot veggies at dinner fine. No glazed carrots. All meals would like coffee, creamers, 2% milk; no juice. No hot cereal, cheerios instead. Would only like cheerios/1 slice toast some days and eggs/meat/1 slice toast some days (I encouraged him/her to avoid breakfast meats related to several cardiac conditions) and French toast/pancakes some days. Sandwiches= only tuna/chicken salad/egg salad, must be scooped in a bowl with 1 slice toast bread on the side. Resident asked several times during this 30 minute visit for selective menus or how to choose his/her meal - I explained to him/her that the daily menu is posted and he/she is welcome to request to be brought to the menu and/or have a staff member bring him/her a copy of the menu to make daily choice; I explained that he/she need to inform the kitchen at least 1 hour before meal service. He/she verbalized understanding but remained unhappy with this system. All of this information was communicated to the kitchen manager today as well. Consult Registered Dietitian as needed. [sic] During an interview on 5/26/26 at 8:20 A.M., Resident #88 said that dietary does not consistently honor his/her preferences. Resident #88 showed the surveyor a collection of diet slips with handwritten notes on them that Resident #88 has been collecting and making notes on about what the kitchen is not sending him/her. Review of Resident #88's daily meal ticket indicated:-Give Cheerios and 1 Slice of Toast (Sunday, Tuesday, Thursday, Saturday).-Give Eggs, Meat, 1 slice of toast (Monday, Wednesday, Friday)Further review indicated during breakfast:** No rice, carrots with any sauce on them.-Give Salad, Italian Dressing and Fruit for dessert only. This was not listed under lunch or dinner. On Tuesday 5/26/26 at 9:33 A.M., the surveyor observed eggs on Resident #88's breakfast tray. The diet slip indicated eggs on Monday, Wednesday, and Friday. On Tuesday 5/26/26 at 1:13 P.M., the surveyor observed Resident #88's lunch tray. There was white rice and cake served for dessert, both of which are listed as a dislike. There was no salad on his/her lunch tray. On Wednesday 5/27/26 at 8:46 A.M., the surveyor observed Resident #88's breakfast tray. There was no meat served with his/her breakfast as indicated on the tray ticket. On Wednesday 5/27/26 at 12:48 P.M., the surveyor observed Resident #88's lunch tray. There was no salad on the lunch tray and Resident #88 received cake and no fruit for dessert. On Thursday 5/28/26 at 8:53 A.M., the surveyor observed Resident #88's breakfast tray. There were five slices of bacon on his/her breakfast tray. There were no eggs on his/her tray according to his/her preferences for Thursday. During an interview on 5/28/26 at 9:33 A.M., the Food Service Director (FSD) said food preferences should be honored for Resident #88. The surveyor shared the observations of meals from 5/26/26, 5/27/26, and 5/28/26, and the FSD said that the dietary aide should be reading the slips correctly in the kitchen. Further the FSD reviewed the diet slip, and she said the likes and dislikes were not showing up correctly on the tray tickets, but the likes and dislikes should be. During an interview on 5/28/26 at 11:05 A.M., the Dietitian said she has several notes about Resident #88's likes and dislikes, and she said Resident #88 continues to remain unhappy. The Dietitian said she has offered menus for extended periods of times to Resident #88 to select meals, and she has educated the Resident to call the kitchen for requests, and Resident #88 is not happy with the process. The surveyor shared the observations of Resident #88's meals from 5/26/26, 5/27/26, and 5/28/26, and the Dietitian said she can understand why Resident #88 is unhappy and the Dietitian said it is very important to follow the likes the dislikes. The Dietitian said the FSD adds the likes and dislikes into the tray tracker system and the dietary aide calling the tray line should check for accuracy of likes and dislikes on the tray line. During an interview on 5/28/26 at 12:06 P.M., Nurse #4 said Resident #88 does not complain about the meals and she is not aware of any concerns. During a follow-up interview on 5/28/26 at 12:08 P.M., Resident #88 said that he/she stopped telling direct care staff who delivered the trays about things that were not honored. Resident #88 said that when he/she would point out issues to Certified Nursing Assistants and Nurses, and Resident #88 said the staff they would just laugh when the food was delivered. Resident #88 said that he/she thought that the company does not supply enough food or have the money to spend on fresh foods like his/her salad. During an interview on 5/28/26 at 1:18 P.M., the Assistant Regional Nurse said that the kitchen and nursing should honor Resident #88's meals and food preferences.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure that shared medical equipment was sanitized in between residents. Findings include:Review of facility policy titled Cleaning and Disinfection of Resident Care Equipment, dated as revised October 24, 2025, indicated the following:-Reusable resident care equipment includes but is not limited to: blood pressure cuff.-Reusable equipment will be cleared and disinfected after use of one resident and before use of another resident. During a continuous observation on 5/27/26 from 7:49 A.M. to 8:07 A.M., the surveyor observed Nurse #1 obtain a blood pressure on a resident prior to administering medications. The nurse did not sanitize the blood pressure cuff (wrist cuff) after use and placed it back on her medication cart. While dispensing medications for the resident, the nurse placed the potentially contaminated blood pressure cuff in the medication cart between medication cards to hold her spot in the cart and returned the medication cards back into the cart after she dispensed the medications.At 8:07 A.M., the surveyor observed Nurse #1 take the potentially contaminated blood pressure cuff and without sanitizing it, obtain a blood pressure on another resident. Nurse #1 obtained a blood pressure reading and without sanitizing the cuff placed it back on her medication cart. During an interview on 5/27/26 at 1:23 P.M., the Infection Preventionist (IP) and the Assistant Regional Nurse said that shared resident equipment should be sanitized and disinfected in between residents.

Based on record review and interview, the facility failed to promptly resolve grievances for two Residents (#88 and #65), out of a total sample of 28 residents. Specifically, 1. For Resident #88 the facility failed to resolve a grievance for missing pillowcases. 2. For Resident #65 the facility failed to resolve a grievance for missing clothing. Review of the facility policy titled, Resident and Family Concerns and Grievances, dated as revised 10/5/25, indicated to provide for the prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with applicable federal and state statutes and regulations -Policy Statement The Facility is committed to providing its residents with exceptional care and services. To ensure the continued provision of such exceptional care and services, the facility and any and all owners, directors officers, clinical staff, employees, independent contractors, consultants and others working for the facility, have an established grievance process to address resident and family member concerns or dissatisfaction about the facility provision of care and services. -Procedure Filing of Grievances A. Residents or their family members, guardian, or representative may voice a grievance to the facility staff in person, by telephone, or via written communication. B. Should a resident require assistance in voicing a grievance, facility associates shall provide any needed assistance to the resident. C. The facility shall provide a grievance report form to facilitate the voicing of a grievance if requested by a resident or family member. -Documentation of Grievances A. The facility Compliance and Ethics Officer or a designated staff will document and keep a log of all grievances expressed either orally and/or in writing on the day that it is received or as soon as possible after the event or events that precipitated the grievance. -Investigation of Grievances A. The facility's Compliance and Ethics Officer shall notify the management or supervisory staff responsible for the services or operations which are the subject of the grievance. The management or supervisory staff will commence a formal investigation of the grievance as soon as is practicable. -Responses to and Resolution of Grievances A. The facility will follow up with resident or their family members, guardian, or representative within 72 hours of the filing of the grievance. B. The Facility will make reasonable efforts to ensure that all grievances are adequately resolved within thirty (30) calendar days from the day the grievance is received. 1. Resident #88 was admitted to the facility in March 2026 with diagnoses including diabetes, heart failure, and asthma. Review of the most recent Minimal Data Set assessment, dated 3/11/26, indicated Resident #88 was cognitively intact as evidenced by a Brief Interview of Mental Status score of 15 out of 15. During an interview on 5/26/26 at 8:20 A.M., Resident #88 said he/she filed a grievance for two missing grey pillowcases that had not been returned. Review of Resident #88's Suggestion/Complaint/Grievance Communication Form, dated 4/16/26, completed by the Director of Social Services, indicated: -Resident is missing two grey silk pillowcases. -The grievance was confirmed/substantiated. -Corrective action, search of room and laundry. Continued search of pillowcases. The form was signed by both the Director of Social Services and the Administrator on 4/16/26. On 5/27/26 at 3:53 P.M., the surveyor and the Administrator reviewed Resident #88's grievance dated 4/16/26, and he said that Resident #88's grievance was not resolved and the Resident should have been provided resolution since the pillowcases were not located. On 5/27/26 at 3:56 P.M., the surveyor and the Director of Social Services reviewed Resident #88's grievance dated 4/16/26, and she said that Resident #88's grievance was not resolved and the Resident should have been provided resolution. The Director of Social Services asked the surveyor, what should I have done, since they were unable to find the pillowcases?. During a follow up interview on 5/28/26 at 9:27 A.M., Resident #88 said he/she is still missing the two grey pillowcases. During an interview on 5/28/26 at 1:15 P.M., the Assistant Regional Nurse said that grievances should be fully investigated and resolved. 2. Resident #65 was admitted to the facility in April 2026 with diagnoses including essential primary hypertension, anemia, polyneuropathy and insomnia. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/27/26, indicated Resident #65 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 5/26/26 at 9:18 A.M., Resident #65 was observed sitting in his/her bed eating breakfast. The Resident said he/she lost several items of clothing including a shirt, two undershirts and pants over two weeks ago and that he/she has reported the missing items to staff and has not gotten them back. Resident #65 said he/she told the Social Worker about the missing clothing and the Resident said the facility has done nothing to help him/her get them back. Resident #65 said the Social Worker offered to give him/her used pants and tops in place of the items missing and he/she told them he did not want the used items. Review of the facilities binder titled 'Grievance Log', section dated May 2026, on 5/26/26, failed to indicate any grievances were filed for Resident #65's missing clothing During an interview on 5/27/26 at 3:56 P.M., the Social Worker said Resident #65 reported to her that he/she was missing some shirts and a pair of pants and said she looked through the missing clothing items and asked the laundry staff and housekeeping staff about them, but they were not found. The Social Worker said she offered Resident #65 some pants and shirts that she found that do not belong to any other residents, but he/she refused and said she doesn't know what else to do because she offered to replace the items and he/she said no. The Social Worker said she has the grievance form in her office. On 5/27/26 at 4:06 P.M., the Social Worker gave the surveyor a grievance form dated 5/21/26 that indicated the following:Date: 5/21/26 Resident reports missing clothing including a black/gray flannel, gray tank top and blue PJ pants (labeled). During an interview on 5/28/26 at 9:32 A.M., the Administrator said items reported missing by a resident should have a grievance form completed. The Administrator said he was not aware of the missing clothing and said he does not review the grievances because the Social Worker is responsible for following up with the Resident.

Based on record review and interview, the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care for one Resident (#109) out of a total sample of 28 residents. Specifically, for Resident #109, the facility failed to develop a baseline care plan related to smoking and his/her need for supervised smoking. Findings include:Review of the facility policy titled Interim Care Plan, dated as last revised on 11/5/25, indicated but was not limited to the following:It is the policy of this facility to develop an interim care plan for each resident admitted . The purpose of the interim care plan is to guide care until the comprehensive care plan is complete.1. To assure that the resident's immediate care needs are met and maintained, a preliminary care plan is developed upon admission.2. The interdisciplinary team reviews the attending physician's orders (i.e. diet, mediations, treatments, etc.) and admitting assessments to develop and implement the interim plan of care.3. The interim plan of care should be implemented within forty-eight (48) hours of admission. 4. The interim plan of care will reflect severity of the resident's condition and related diseases. Resident #109 was admitted to the facility in May 2026 and has diagnoses that include essential primary hypertension, epilepsy, and bipolar disorder Review of the medical record indicated the most recent Minimum Data Set assessment wasn't available. On 5/26/26 at 12:58 P.M., Resident #109 was observed outside smoking unsupervised with two other Residents. On 5/27/26 at 10:06 A.M., Resident #109 was observed smoking unsupervised with two other Residents. On 5/27/26 at 2:05 P.M., Resident #109 was observed asking a staff member for a cigarette at the Nurses station and then walked down the hall and exited out the back door to the designated smoking area. The Resident was smoking unsupervised with two other Residents. Review of Resident #109's medical record indicated the following nursing progress note dated 5/25/26, indicated, Resident's family member came in stating that Resident #109 can become aggressive due to the history of alcohol and drugs overuse. Family member brought one pack of cigarettes if needed.Review of Resident #109's Smoking Evaluation Assessment - V 15, completed on 5/27/26 at 10:59 A.M., indicated:A. Does the resident smoke? Yes.N. Care plan reviewed and revised for appropriate supervision and smoking directions to include:b. General Supervisione. All smoking materials secured at nursing station.Review of the medical record failed to indicate a baseline care plan for smoking was created for Resident #109.During an interview on 5/28/26 at 12:39 P.M., the Assistant Regional Nurse said that a baseline care plan for smoking should have been developed and implemented by nursing on admission and said Residents who decide to smoke need to be evaluated and have the care plan implemented and appropriate interventions in place for supervision. Refer to F689

Based on observations, interviews, and record reviews for two Residents (#88 and #92) out of three residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Two out of two nurses observed made three errors out of 31 opportunities resulting in a medication error rate of 9.68%. Specifically, 1. For Resident #88, the nurse failed to ensure that insulin (an injectable hormone that lowers the level sugar in the blood) was administered in accordance with professional standards of practice (did not perform a safety test/prime the insulin pen) and administered the wrong probiotic medication.2. For Resident #92, the nurse administered the wrong form of aspirin. Findings include: Review of facility policy titled Administering Medications, dated as revised October 15, 2025, indicated the following:-Medications shall be administered according to physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified and the medication is labeled according to accepted standards. Review of the glargine pen manufacture's guidelines, dated August 2022, indicated to always perform the safety test before each injection.STEP 3. PERFORM A SAFETY TEST - Dial a test dose of 2 Units (priming the pen).- Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. - Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test.- If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. 1. Resident #88 was admitted to the facility in March 2026 with diagnoses that included chronic diastolic heart failure and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/11/26, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of active physician's orders indicated the following:-Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (milliliter) (Insulin Glargine), inject 30 units subcutaneously once daily, dated 3/24/26.-Lactobacillus Oral Capsule (Lactobacillus, a probiotic), give one capsule by mouth two times a day, dated 5/20/26. On 5/27/26 at 7:28 A.M., the surveyor observed Nurse #2 prepare and administer the following medications:-Insulin Glargine 30 units from an insulin pen. Nurse #2 did not prime the insulin pen prior to administration.-Probiotic acidophilus with pectin one capsule (serving size in two capsules includes: dicalcium phosphate 304 mg, acidophilus 200 million CFU and citrus cellulose pectin 20 mg). During an interview on 5/27/26 at 7:44 A.M., Nurse #2 said that she is supposed to prime the insulin pen, but she did not. 2. Resident #92 was admitted to the facility in July 2022 with diagnoses that included dysphagia and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/3/26, indicated a Brief Interview for Mental Status score of 12 out of 15, indicating moderate cognitive impairment. Review of active physician's orders indicated the following:-Aspirin tablet chewable, give 81 mg by mouth one time a day, dated 8/13/22. On 5/27/26 at 7:48 A.M., the surveyor observed Nurse #1 prepare and administer the following medication:-Aspirin 81 mg, one enteric coated tablet. During an interview on 5/27/26 at 1:20 P.M., the Assistant Regional Nurse said that insulin pens should be primed prior to use to ensure that the correct full dose is administered. She further said that medications should be administered as indicated in the physician's orders.

Based on record review and interview, the facility failed to implement Wound Consultant treatment orders for one Resident (#52) out of a total of 28 sampled Residents. Specifically, the facility failed to implement the use of Hydorfera blue (a broad-spectrum antibacterial foam wound dressing) to his/her sacral Stage IV pressure ulcer, (a severe, full-thickness wound where damage extends through the skin into muscle, bone, or supporting structures like tendons and joints) for approximately 11 days. Findings include:Review of the facility's policy titled Skin Prevention, Assessment and Treatment, dated 10/24/25 indicated:2. Interventions for prevention or active skin alterations may include but are not limited to: a. Wound Consultant review. Resident #52 was admitted to the facility in March 2026 with diagnoses including dementia, cognitive communication disorder and pressure ulcer of sacral region stage IV. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #52 is cognitively intact, evidenced by a score of 13 out of a possible 15 on the Brief Interview for Mental Status Exam. Additional review of the MDS indicated Resident #52 was admitted to the facility with a stage IV pressure ulcer. During an interview on 5/26/26 at approximately 8:15 A.M. Resident #52 said that he/she was not sure if he/she had any wounds. During an interview on 5/26/26 at 9:20 A.M., Family Member #3 said that Resident #52 was admitted to the facility with a pressure ulcer on his/her backside and the nursing staff are providing treatments. Review of the Wound Consultant note dated 5/19/26 indicated the following treatment for Resident #52's Stage IV pressure ulcer on his/her sacrum:Clean Wound With: Vashe (an antimicrobial wound cleanser)Primary Treatment: Hydrofera blue (a broad-spectrum antibacterial foam wound dressing).Other Dressings: Superabsorbent pad Review of the physician order dated 4/28/26 indicated: COCCYX: Apply wound cleanser solution and pat dry. Apply medihoney, pack with calcium alginate. Cover with border gauze/and or superabsorbent dressing. every evening shift for wound examination. As of 5/28/26, the Wound Consultant's treatment orders had not been implemented; approximately 11 days after the use of Hydrofera blue was indicated. During an interview on 5/28/26 at 9:10 A.M., Nurse #8 said that the Wound Consultant rounds the facility and inputs the treatment recommendations into the electronic record as orders. Nurse #8 said that Resident #52 has wounds and he has not heard of the attending physician disagree with the Wound Consultant treatment orders. During an interview on 5/28/26 at 9:54 A.M. Unit Manager #2 said that the Wound Consultant comes in weekly and she uploads the treatment note into the system and inputs the orders. Unit Manager #2 said that she alerted management about the Wound Consultant's treatment orders for Hydrofera blue because they did not have any in stock. During an interview on 5/28/26 at 10:10 A.M. Nurse Practitioner #1 said that she was not aware of any new treatment orders by the Wound Consultant in May 2026 for Resident #52. Nurse Practitioner #1 said that she could not recall a time where she had disagreed with treatments indicated by the Wound Consultant. During an interview on 5/28/26 at 1:30 P.M., the Assistant Regional Nurse said that if treatment recommendation supplies are not on hand or part of their formulary, they alert the provider. She said that Unit Manager #2 had brought this to her attention she had spoken to the provider this morning (5/28/26) regarding the use of Hydrofera blue. The Assistant Regional Nurse said that she would run the recommendation by the Medical Director.

Based on observation, interview, and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice, for five Residents (#66, #30, #84, #12 and #75), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #66: -ensure that the Resident had the appropriate oxygen adaptor to administer oxygen as ordered for use with the Continuous Positive Airway Pressure (CPAP - type of non-invasive device that administers a predetermined level of pressure through a mask worn over the nose and/or mouth to keep the airways open) machine resulting in CPAP therapy not being administered to the Resident as required. -obtain a Physician's order for the required settings for the use of the CPAP device. 2. For Resident #30 and #84, the ensure that the Residents' humidifier bottle attached to the oxygen concentrator contained humidified water. 3. For Resident #12, obtain Physician's orders for oxygen administration and maintenance of oxygen and respiratory equipment. 4. For Resident #75, clean the oxygen concentrator and date and label the Resident's oxygen tubing. Findings include: Review of the facility policy titled, CPAP and BIPAP Usage/Maintenance, revised 10/14/24 indicated the following: -Used to provide to spontaneous breathing with continuous positive airway pressure with or without supplemental oxygen. -To improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. -To promote resident comfort and safety. -Resident using CPAP/BIPAP will require a physician's order to include approved order setting, duration of use and use of humidifier, if necessary and a supporting diagnosis. -Notify the Physician if the resident refuses the procedure. -Document Adherence to treatment. Review of the facility policy titled, Oxygen Administration and Storage, revised 10/10/24 indicated: -Verify Provider's order for the procedure. -Label tubing connected to the oxygen cylinder with time and date. -Attach the appropriate delivery device. -Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. -The humidifier bottle is to be labeled with the date of application and changed weekly if refillable. If it is disposable (single use) humidification, bottle is to be changed at least weekly and more frequently as it is near empty to maintain humidification. -Filters should be removed and cleaned by rinsing with clear, cool water as needed to maximize flow rate of clean air. Review of the facility policy titled, Physician Orders, revised November 2024 indicated: -Physician orders must be documented clearly in the medical record including the required components of a complete order. -Orders that are missing required components, illegible or are unclear will be clarified prior to implementation. -Clear and complete orders will be transcribed to the appropriate administration record. Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf\ indicates: -All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. -Undesirable results or events may result from noncompliance with physicians' orders or inadequate instruction for oxygen therapy. -There is a potential in some spontaneously breathing hypoxemic patients with hypercapnia ([PaC02] Partial Pressure of carbon dioxide- high carbon dioxide levels in the blood) and chronic obstructive pulmonary disease that oxygen administration may lead to an increase in PaCO2. -Equipment maintenance and supervision: >All oxygen delivery equipment should be checked at least once daily >Facets to be assessed include proper function of the equipment, prescribed flowrates, remaining liquid or compressed gas content, and backup supply. Resident #66 was admitted to the facility in September 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #66: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of five out of 15 total possible points -had clear speech -was usually understood -was prescribed oxygen therapy Review of Resident #66's clinical record indicated the following: -The Resident completed a Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) naming Resident Representative (RR) #1 on 9/13/24. -The Resident was determined by a Physician to lack capacity to make health care decisions and the HCP was permanently invoked on 10/29/24. During an interview on 3/4/25 at 10:15 A.M., Resident #66 said that he/she was supposed to be using a CPAP machine at night.The Resident further said the CPAP machine was in the room, and the facility staff did not know how to use the machine. Resident #66 said the facility had not provided the adaptor that was needed to connect oxygen to the CPAP machine. Resident #66 said the facility staff attempted to place the CPAP mask over the nasal cannula on his/her face but the mask was not a good fit. Resident #66 said that he/she had been asking the facility staff about his/her need to use the CPAP machine but no one seemed to know or understand how to connect oxygen to the CPAP machine. During an interview on 3/5/25 at 1:28 P.M., RR #1 said he/she was aware that the CPAP machine was not being provided to Resident #66. RR #1 said that he/she had mentioned the concern to the facility staff but had not been informed of any resolution. Review of Resident #66's March 2025 Physician's orders indicated: -CPAP Mask Style Full Face Mask Size large, initiated 12/28/23. -CPAP: Oxygen setting: O2 (oxygen) at 2 liters via CPAP when in use every shift, initiated 12/28/23. -BIPAP: clean reservoir per manufacturer's instructions every night shift on Sundays, initiated 2/20/25. Review of Resident #66's December 2023 Physician's orders indicated: -CPAP AUTO: Pressure Settings: Home settings. Hours of Usage - HS to AM every shift, initiated 12/28/23. Further review of the December 2023 Physician's orders failed to indicate an order for AutoCPAP pressure settings as required. Review of updated Physician orders revised by the facility on 3/5/25 at 11:09 A.M., indicated: -CPAP face mask, humidifier, oxygen at 2 liters per minute (LPM), pressure settings: min 4.0 max 20.0. Further review of the updated Physician orders failed to indicate the appropriate mask type and the frequency of use for CPAP therapy. Review of Resident #66's Care Plan Report indicated: -the Resident had a diagnosis of Sleep Apnea -the following interventions: BIPAP/CPAP/VPAP SETTINGS: titrated pressure: (SPECIFY) cm H20 via (SPECIFY): nasal pillow, nose mask or full face mask) (SPECIFY FREQ), initiated 12/28/23 and revised 3/4/25. On 3/5/25 at 9:30 A.M., the surveyor and Nurse #3 reviewed Resident #66's CPAP machine. During an interview at the time, Nurse #3 said she did not work the overnight shift and had no idea whether the machine was a BIPAP or CPAP machine. Nurse #3 further said she did not know whether oxygen could be connected to the machine for the Resident's use, or what port the oxygen tubing would be attached to on the machine. On 3/5/25 at 9:35 A.M., the surveyor and the Assistant Director of Nursing (ADON) observed the Resident's CPAP machine. During an interview at the time, the ADON said she was unsure whether the machine was a BIPAP or a CPAP machine. The ADON also said she was unsure how the oxygen tubing would be attached to the machine. The ADON further said that she would have to ask another staff member and would update the surveyor. On 3/5/25 at 10:02 A.M., the surveyor, the ADON and the Staff Development Coordinator (SDC) observed Resident #66's machine. During an interview at the time, the SDC said she was unsure whether the machine was a BIPAP or CPAP, and that there was no way an oxygen tubing could be attached to the machine. During an interview on 3/5/25 at 11:45 A.M., the Medical Record Supply Staff said the Resident's machine was a [NAME] G3 machine and that it was a CPAP machine. The Medical Record Supply Staff said when an order was obtained by a Nurse, he would provide the PAP (Positive Airway Pressure) machine to the Nurse and the Nurse was expected to set the PAP machine up based on the settings ordered for the Resident. During an interview on 3/5/25 at 12:25 P.M. the Clinical Nurse Support (CNS) said she was unaware that Resident #66 was not receiving his/her CPAP treatment. The CNS said the Nurses documented the CPAP as being administered at night and the Nurses should not document as administered if the CPAP was not provided. The CNS said the facility should have provided the oxygen adaptor needed for the CPAP machine to properly function for the Resident, but they had not. During an interview on 3/5/25 at 2:28 P.M. Unit Manager (UM) #2 said she was asked to review the settings in the CPAP machine and update the Physician's orders with the settings on 3/5/25 at 11:09 A.M. UM #2 said she was not the Unit Manager for the South 2 Unit and that the manager for that unit was out sick. UM #2 further said she should have called the Physician to obtain orders for the settings, but she did not. 2a. Resident #30 was admitted to the facility in December 2021 with diagnoses of Chronic Systolic and Diastolic Congestive Heart Failure and COPD. Review of Resident #30's March 2025 Physician's orders indicated: -humidified oxygen to be given at 2 LPM (liters per minute) via nasal cannula, initiated 2/23/25. On 3/4/25 at 10:20 A.M., the surveyor observed that Resident #30 was awake, and lying in bed. Resident #30 was observed to have a nasal cannula in his/her nostrils with oxygen set at 2 LPM via an oxygen concentrator. The surveyor observed that an empty humidifier bottle was attached to the oxygen concentrator and dated 2/24/25. On 3/5/25 at 8:15 A.M., the surveyor observed that Resident #30 was awake, alert, and lying in bed. Resident #30 was observed to have a nasal cannula in his/her nostrils with oxygen set at 2 LPM via an oxygen concentrator, and the humidifier bottle attached to the oxygen concentrator was empty and dated 2/24/25. 2b. Resident #84 was admitted to the facility in November 2024 with diagnoses including COPD. Review of Resident #84's Physician orders indicated: -oxygen at 3 liters via nasal cannula for COPD, initiated 12/23/24. On 3/4/25 at 10:04 A.M., the surveyor observed that Resident #84 was awake, and lying in bed. The surveyor observed that the Resident had a nasal cannula in his/her nostrils with oxygen set at 3 LPM via an oxygen concentrator. The surveyor observed that the Resident's oxygen concentrator had an empty humidifier bottle attached and the bottle was undated. On 3/5/25 at 8:16 A.M., the surveyor observed that Resident #84 was awake, and lying in bed. The Resident was observed with a nasal cannula in his/her nostrils with oxygen set at 3 LPM via oxygen concentrator. The surveyor observed that an empty humidifier bottle was attached to the oxygen concentrator and was undated. During an interview on 3/5/25 at 8:31 A.M., the SDC said that she was the acting Unit Manager (UM) on the South 2 unit. The SDC said Resident's #30 and #84 were supposed to be on humidified oxygen and that the humidifier bottles should have been replaced, but they had not been replaced. 45429 3. Resident #12 was admitted to the facility in May 2022 with diagnoses including Dementia and COPD. Review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE], indicated: -the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 7 out of 15. -the Resident had received oxygen therapy. Review of the Resident's comprehensive medical record indicated: -No Physician's orders for oxygen administration or oxygen and respiratory equipment maintenance. -Physician's orders to keep the head of the bed elevated at 30 degrees as needed for shortness of breath. -a Care Plan indicating that the Resident was at risk for respiratory complications related to COPD. -a Care Plan intervention to observe the Resident's respiratory status and assess for changes. -a discontinue date of 2/19/25 for oxygen at 2 L (liters) via nasal cannula documented on the February 2025 Medication Administration Record (MAR ) -a Nurse's Progress Note dated 2/19/25 indicating the Resident had been noncompliant with the oxygen and new orders to wean the patient off oxygen. -a Nurse's Progress Note dated 2/23/25 indicating that the Resident continued to remove the oxygen from their nose. On 3/4/25 at 9:19 A.M., the surveyor observed Resident #12 lying in bed with oxygen flowing at 2 LPM (Liters Per Minute) via nasal cannula. The surveyor observed that the nasal cannula included the date 2/25/25 written on white tape and attached to the tubing. During an interview at the time, Resident #12 said that he/she did not have any concerns with his/her oxygen and that the staff changed the tubing weekly. On 3/5/25 at 9:44 A.M., the surveyor observed Resident #12's room and found that the oxygen concentrator, nasal cannula and tubing were no longer in the Resident's room. On 3/5/25 at 9:45 A.M., the surveyor observed Resident #12 seated next to Nurse #1 in the Unit dining area with no oxygen in use. During an interview at the time, Nurse #1 said that they typically place the Resident's oxygen on in the evenings because he/she had been non-compliant with oxygen use. Nurse #1 also said that she was unaware the Resident's oxygen supplies were no longer in his/her room. During an interview on 3/5/25 at 9:48 A.M., Unit Manager (UM) #2 said that the Physician recommended that staff wean Resident #12 off the oxygen on 2/19/25. UM #2 said that the Resident should not have been wearing the oxygen without a Physician's order. UM #2 further said that the Nurse assigned to the Resident had not been aware that the oxygen had been discontinued. 51571 4. Resident #75 was admitted to the facility in October 2021 with diagnoses including Dysphagia, Oropharyngeal Phase and Chronic Diastolic Congestive Heart Failure. Review of the facility policy titled Policy and Procedure Oxygen Administration and Storage initiated 10/16/23, revised 10/10/24, indicated the following: -Label the tubing connected to the oxygen cylinder with time and date. -The nasal canula and/or mask should be changed weekly or when soiled. -Filters should be removed and cleaned by rinsing with clear, cool water as needed to maximize flow rate of clean air. Review of the New Life Elite Oxygen Concentrator Service Manual, dated 03/06, retrieved at https://oxygenalliance.org/wp-content/uploads/2024/03/Airsep-NewLife-Elite-ServiceManual.pdf indicated: -To ensure accurate output and efficient operation of the oxygen concentrator, the user must clean the gross particle filter weekly, as described below: >Remove the dirty air intake particle filter from the back of the unit, and install the clean filter stored in the pocket on the back of the unit. >Wash the dirty filter in warm soapy water and rinse. >Use a soft absorbent towel to remove excess water. >Place the clean air intake gross particle filter in the pocket on the back of the unit. Review of the Minimum Data Set (MDS) Assessment, dated 1/15/25, indicated Resident #75: -was rarely/never understood and had short and long term memory loss. -had a memory impairment during the reference period. -received oxygen therapy during the reference period. Review of Resident #75's March 2025 Physician's orders, included the following: -change oxygen tubing weekly, date and initial and place in bag every night shift (11:00 P.M.-7:00 A.M) every Sunday, initiated 2/7/22. -clean filter on oxygen concentrator weekly, every night shift, every Sunday, initiated 2/20/25. -oxygen at 2 LPM via nasal cannula to maintain oxygen saturation level (measures the percentage of oxygen in the blood) over 92 percent (%), initiated 5/9/24. Review of Comprehensive Respiratory Care Plan, initiated 5/9/24 and revised 7/25/24, indicated Resident #75 had an alteration to his/her respiratory system which required oxygen therapy and included the following intervention: -Administer oxygen via NC (nasal cannula) at 2 LPM. Review of Resident #75's March 2025 Medication Administration Record (MAR), indicated: -Change oxygen tubing weekly, date, initial and place in a bag every night shift, every Sunday. Review of Resident #75's March 2025 Treatment Administration Record (TAR), indicated: -oxygen concentrator filter was cleaned on 3/2/25 as evidenced by the Nurse's signature of completion on the TAR. On 3/4/25 at 10:27 A.M., the surveyor observed Resident #75 lying in bed with eyes closed and oxygen being delivered via nasal cannula. The surveyor observed that the oxygen was set at 2 LPM on the oxygen concentrator which had a humidifier bottle attached. The surveyor observed that the oxygen tubing was not dated or labeled. On 3/5/25 at 10:15 A.M., the surveyor observed Resident #75 lying in bed, and was awake. The Resident was observed using 2 LPM oxygen via nasal cannula which was connected to the oxygen concentrator. Resident #75's oxygen tubing was not dated or labeled. During an interview on 3/5/25 at 2:47 P.M., Nurse #3 said that the 11:00 P.M - 7:00 A.M. shift Nurses were responsible for changing the oxygen tubing weekly on Sundays and ensure that the tubing was dated and labeled. The surveyor and Nurse #3 observed Resident #75 oxygen tubing and found there was no visible label and/or date on the tubing. Nurse #3 said that she was unable to indicate when the oxygen tubing was last changed and she will change the oxygen tubing, date, and label today. On 3/5/25 at 3:10 P.M., the surveyor observed Resident #75 lying in bed with eyes closed. The surveyor observed that the oxygen tubing was labeled and dated 3/5/25. During an interview on 3/5/25 at 3:44 P.M., the Staff Development Coordinator and Educator (SDC) said that oxygen tubing for residents requiring oxygen therapy are changed once a week on Sundays by the 11:00 P.M. - 7:00 A.M. shift Nurses. The SDC said that the expectation for Nurses is that they will change the oxygen tubing, date, and label the tubing and then report in change of shift report. On 3/6/25 at 7:55 A.M., the surveyor observed Resident #75 lying in bed with eyes closed, his/her oxygen was set to 2 LPM via the nasal cannula on the oxygen concentrator with humidification. The surveyor observed that the oxygen concentrator air intake particle filter on the back of the device had a layer of dust. During an interview on 3/6/25 at 9:07 A.M., Nurse #7 said that the oxygen concentrator filters and oxygen tubing are changed weekly on Sundays by the 11:00 P.M. -7:00 A.M. shift Nurses. The surveyor and Nurse #7 observed the air intake particle filter on the back of the oxygen concentrator, and Nurse #7 said that the filter is dirty and should have been changed, as it prevents air flow to the concentrator, but the filter was not changed. During an interview on 3/6/25 at 12:46 P.M., the SDC said that the filters on the oxygen concentrators are to be cleaned every week by the 11:00 P.M. -7:00 A.M. shift Nurses to help keep the air clean. The SDC also said that the expectation for Nurses on the 11:00 P.M. -7:00 A.M. shift is to clean the filters on the oxygen concentrators and change the oxygen tubing weekly.

Based on interview, and record review, the facility failed to provide Physician visits at the required frequency for five Residents (#10, #28, #45, #51 and #68) for an applicable sample of six residents, out of a total sample of 23 residents. Specifically, the facility failed to provide alternating routine 60-day visits between the Physician and the Nurse Practitioner (NP) for Resident's #10, # 28, #45, #51 and #68, as required. Findings include: 1. Resident #10 was admitted to the facility in September 2022 with diagnoses including Dementia. Review of Resident #10's clinical record indicated that the Resident was seen by a Physician on 6/30/24. Further review of the clinical record indicated that Resident #10 was not seen again by the Physician until 10/20/24 (112 days after the previous Physician visit). 2. Resident #28 was admitted to the facility in March 2024 with diagnoses including Dementia. Review of Resident #28's clinical record indicated that the Resident was seen by a Physician on 4/20/24. Further review of the clinical record indicated that Resident #28 was not seen again by the Physician until 10/20/24 (183 days after the last Physician visit). 3. Resident #45 was admitted to the facility in March 2022 with diagnoses including Dementia. Review of Resident #45's clinical record indicated that the Resident was seen by a Physician on 5/14/24. Further review of the clinical record indicated that Resident #45 was not seen again by the Physician until 10/4/24 (143 days after the last Physician visit). 4. Resident #51 was admitted to the facility in March 2018 with diagnoses including Dementia. Review of Resident #51's clinical record indicated that the Resident was seen by a Physician on 5/24/24. Further review of the clinical record indicated that Resident #51 was not seen again by the Physician until 10/20/24 (149 days after the last Physician visit). 5. Resident #68 was admitted to the facility in March 2024 with diagnoses including Dementia. Review of Resident #68's clinical record indicated that the Resident was seen by a Physician on 4/20/24. Further review of the clinical record indicated that Resident #68 was not seen again by the Physician until 10/9/24 (172 days after the last Physician visit). On 3/12/25 at 3:13 P.M., the surveyor and the Corporate Nurse reviewed the Practitioner notes for Resident's #10, # 28, #45, #51 and #68. During an interview at the time, the Corporate Nurse said that each of the Resident's (#10, # 28, #45, #51 and #68) should have been seen by a Physician between the time periods documented here for each Resident and they had not been seen by a Physician.

Based on interview, and record review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed by the Physician as required for two Residents (#9 and #11), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #11, act upon the Consultant Pharmacist recommendation dated 11/27/23, to monitor serum Dilantin levels routinely every six months, putting the Resident at risk for elevated serum Dilantin levels and resulting in hospitalization to manage Dilantin toxicity. 2. For Resident #9, act upon the Consultant Pharmacist recommendations dated 10/16/24 and 12/15/24, to update the Physician's order for Breztri (combination inhaler consisting of inhaled steroid, anticholinergic and long acting beta adrenergic agonist medications) to instruct the Resident to rinse mouth after use to prevent the development of oral thrush (Candida Albicans) from inhaled steroid use. Findings include: Review of the facility policy titled Policy and Procedure Medication Regimen Review, initiated 11/1/15 and revised 11/5/24, indicated: -The Consultant Pharmacist shall review the medication regimen of each resident at least monthly. -Routine medication regimen reviews will be completed monthly. Additional reviews may be done as the request of the Physician and/ or the recommendation of the Interdisciplinary Team. -The Consultant Pharmacist will communicate his/her findings and recommendations in writing on a medication regimen review report. -Information on the medication regimen reviews and written recommendations will be reviewed by the Director of Nursing (DON). -The medication recommendations are sent to the Primary Provider to address the recommendation. 1. Resident #11 was admitted to the facility in September 2023 with diagnoses including Epilepsy, Benign Paroxysmal Vertigo of the Left Ear, and Metabolic Encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15. Review of the Federal Drug Administration Fact sheet for Dilantin, last revised March 2021, indicated: -Serum blood level determination may be necessary for optimal dosage adjustments. -The clinically effective Dilantin blood concentration range is 10 to 20 mcg/mL (micrograms per milliliter). -The most common adverse reactions are nervous system reactions including ataxia, slurred speech, decreased coordination, nystagmus and mental confusion. Review of a Consultant Pharmacist's Medication Regimen Review (MRR) document dated 11/27/23, indicated the following: -Resident is receiving Dilantin. Please consider Dilantin level with Resident's next scheduled lab and every 6 months thereafter. -Further review of the MRR indicated a Physician reviewed the Pharmacist's Medication Regimen Review document and a recommendation was forwarded to the Interdisciplinary Team (IDT). Review of Resident #11's Physician orders indicated the following: -Phenytoin Sodium Extended Capsule (Dilantin) 100 mg (milligrams). Give three (3) capsules by mouth one time a day for seizures. Initiated 9/8/23 and discontinued 10/22/24. -Phenytoin Sodium Extended Capsule (Dilantin) 100 mg (milligram). Give three (3) capsules by mouth two times a day for seizures. Initiated 10/22/24 and discontinued 3/10/25. -Phenytoin Sodium Extended Capsule (Dilantin)100 mg. Give two (2) capsules by mouth two times a day for seizures. Initiated 3/11/25. Further review of Resident #11's Physician's orders did not indicate any ongoing orders to monitor and obtain serum laboratory values for Dilantin levels. During an interview on 3/10/25 at 4:54 P.M., the Corporate Nurse said that Resident #11 had not had a serum Dilantin level obtained since 9/22/23 but should have had serum Dilantin level monitoring annually. The Corporate Nurse said that she did not know why the Pharmacy recommendation dated 11/27/23 for ongoing serum Dilantin level monitoring had not been implemented. Review of the Serum Dilantin level obtained by the facility on 3/10/25 after the surveyor investigation and interview, indicated that Resident #11 had a critically high serum Dilantin level of 35.7 mcg/ml. Review of a Physician progress Note dated 3/11/25 at 10:50 A.M., indicated the following: -Resident #11 had experienced moderate cognitive decline and altered mental status. -Resident #11 was unsteady and swaying back and forth. -Assessment/Plans indicated Dilantin toxicity with confusion -Transfer to hospital. During an interview on 3/12/25 at 10:15 A.M., the Consultant Pharmacist said that she has been reviewing records for the facility since December 2023. The Consultant Pharmacist said she provides all the recommendations to the DON and the DON forwards the recommendations to the Unit Managers (UMs). The Consultant Pharmacist said that serum Dilantin levels are usually monitored every three to twelve months, and the frequency of monitoring depends on the needs of the residents. The Consultant Pharmacist said that she has not recommended a serum Dilantin drug level to be obtained for Resident #11 because the Resident's clinical record indicated that he/she was stable and was not experiencing any adverse effects on the current Dilantin dosage. The Consultant Pharmacist said that the Medication Regimen Recommendation dated 11/27/23 was made by the previous Consultant Pharmacist. During an interview on 3/12/25 at 12:57 P.M., Physician #1 said that he reviews monthly Pharmacy Recommendations with the Nurse, determines whether he agrees or disagrees with the recommendations and writes the appropriate orders. The Physician further said that he was unaware of the Consultant Pharmacist Recommendation dated 11/27/23 and does not recall ever ordering a serum Dilantin level to be obtained for Resident #11. Physician #1 said that a serum Dilantin level should have been ordered and obtained a couple of months after the Resident was admitted to the facility to help establish a serum Dilantin baseline level. Physician #1 said that the Consultant Pharmacist should have notified him of the need to monitor serum Dilantin levels. 51571 2. Resident #9 was admitted to the facility in October 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #9's March 2025 Active Physician's orders indicated: -Breztri Aerosphere (Budesonide-Glycopyrrolate-Formoterol Fumarate) Inhalation Aerosol 160-9-4.8 micrograms (mcg).1 puff inhale orally one time a day for Shortness of Breath (SOB), initiated 10/11/24. Review of Resident #9's Pharmacist Progress Notes indicated the following: -10/16/24: Medication regimen reviewed. Recommendations made, please see report for details. -12/15/24: Medication regimen reviewed. Recommendations made, please see report for details. Review of Resident #9's Clinical Record indicated a Consultant Pharmacist Recommendation to Nursing indicated the following: -10/16/24: Resident receiving Breztri. In order to help prevent the development of thrush, please update order to instruct Resident to rinse mouth after use. -12/15/24: Resident receiving Breztri. In order to help prevent the development of thrush, please update order to instruct Resident to rinse mouth after use. Further review of Resident #9's medical record failed to indicate that the Physician had reviewed the 10/16/24 and 12/15/24 Pharmacy Recommendations. During an interview on 3/7/25 at 1:55 P.M., Nurse #4 said when a Physician orders an inhaler for a Resident, before she administers the medication, she checks the Physician order and uses the five rights of medication administration (right person, right drug, right dose, right time, right drug) for accuracy. Nurse #4 said prior to administering the inhaler to the Resident, she cleans the mouthpiece of the inhaler, administers the inhaler, and cleans the mouth of the inhaler, and stores it back in the medication cart. During an interview on 3/7/25 at 2:10 P.M., the Assistant Director of Nursing (ADON) said the DON was responsible for processing Pharmacy Consultant Recommendations. The ADON said the DON reviews the Pharmacy Recommendations by unit and distributes the recommendations to the UMs for a follow-up review with the Physician. The ADON said the Nurses on the unit will notify the Physician of the Pharmacy Recommendations and the UM will update the Resident record to reflect the recommendations made by the Pharmacy Consultant. The ADON said that the expectation for nursing staff administering inhalers to a resident was the Nurses will instruct the Resident to rinse their mouth after the administration of the inhaler to prevent the development of thrush. During an interview on 3/7/25 at 2:15 P.M.,with the Staff Development Coordinator (SDC) and DON, the DON said that Pharmacy Recommendations were given to the Physician, and the Physician will sign and indicate if they agree or disagree with the recommendation. The DON said that she kept a master list of all the Pharmacy Consultant Recommendations and distributed the recommendations to the UMs. The DON also said that the UM on the unit was responsible for updating Pharmacy Recommendations in the electronic medical record (EMR) after the recommendations were reviewed by the Physician. The surveyor, the SDC and the DON reviewed Resident #9's October 2024 and December 2024 Pharmacy Consultant Recommendations and the DON said that the Pharmacy Recommendations should have been added to the Resident's orders in October 2024 and December 2024.

Based on record review, and interview, the facility failed to notify the Physician of a change in condition for one Resident (#114) for a sample of three closed resident records reviewed. Specifically, the facility failed to notify Resident #114's Physician of the Resident's change in condition when the Resident died in the facility. Findings include: Review of the facility's Change in Condition Policy, dated [DATE] and revised [DATE], indicated the following: >Full assessment by nursing staff includes but is not limited to: -Full vitals (temperature, respirations, blood pressure and oxygen saturation level). -Level of consciousness. -Respiratory status . >Notify Physician of change and give assessment information. -Receive orders, if any. -If not during normal business hours for provider, place call to provider to update on resident's condition . if there is a significant change. -If unable to reach provider, contact Medical Director or Medical Director Associate. Review of the facility's Death of a Resident Policy, dated [DATE] and revised [DATE], indicated: -When a resident is identified without signs of life, the Physician will be notified of assessment findings. Review of the facility's Nursing Code Blue (medical emergency in which one's heart or breathing stops) Policy, [DATE] and revised [DATE], indicated the following: -The facility's policy was to ensure prompt and skilled cardiovascular and cerebral resuscitation of residents who suffer a cardiopulmonary arrest while on the premises. -Exceptions included residents with Do Not Resuscitate (DNR) status. -The facility was required to notify the Physician of the code blue as early as practically possible. Resident #114 was admitted to the facility in [DATE] with diagnoses including Hypertension. Review of Resident #114's electronic medical record (EMR) indicated the following: -An order, dated [DATE], for Full Code (one's directive for healthcare providers to use all available means to resuscitate and support their life). -A Medical Order for Life-Sustaining Treatment (MOLST) form, signed and dated on [DATE] by the Resident and the Nurse Practitioner (NP), to attempt resuscitation for the Resident if cardiac or respiratory arrest occurred. Review of Resident #114's Nursing Progress Note, dated [DATE], indicated the following: -The Resident was not responsive, with no pulse and absent breath sounds. -The Resident was a Full Code. -Facility staff initiated CPR and activated EMS (Emergency Medical Services). -EMS arrived at 3:30 A.M. and took over CPR (cardiopulmonary resuscitation) for the Resident. -EMS reported that the Resident was pronounced dead at 3:45 A.M. per a Physician at an area hospital. -EMS left the facility and facility staff prepared the Resident for pickup by the funeral home. -The Resident's family and the facility's Director of Nursing (DON) were notified. Further review of the Resident's Nursing Progress Note did not include any evidence the Resident's Physician was notified of the Resident's death. Review of Resident #114's February 2025 Physician orders indicated the following: -An order, dated [DATE], for: May do RN (Registered Nurse) pronouncement and release to funeral home. -The order was not created until [DATE]. During an interview on [DATE] at 12:57 P.M., Nurse #6 said she worked the overnight shift (11:00 P.M. to 7:00 A.M.) on [DATE], when Resident #114 expired. Nurse #6 said that she assessed the Resident to be unresponsive, without pulse and breath sounds. Nurse #6 said CPR was initiated, and EMS was activated. Nurse #6 said she could not remember what time it was when she assessed the Resident and CPR was initiated, and that EMS took over CPR for the Resident somewhere around 3:15 A.M. Nurse #6 said that EMS provided CPR to the Resident for a while, then stopped. Nurse #6 said one of the EMS personnel informed her that they spoke with a hospital Physician and the hospital Physician said EMS could tell Nurse #6 to pronounce the Resident dead. Nurse #6 said she completed the RN pronouncement form and indicated the hospital Physician as the Physician informed of death. Nurse #6 said she was unsure whether she needed to contact Resident #114's Physician to notify him/her of the Resident's death and that she did not call the Resident's Physician. During an interview on [DATE] at 1:20 P.M., the DON said Nurse #6 should have called Resident #114's Physician or the on-call Provider to notify the Physician of the Resident's death when the Resident expired on [DATE]. During an interview on [DATE] at 2:57 P.M., the Corporate Nurse said that she did not recall entering the order into Resident #114's EMR for RN pronouncement on [DATE], and when she reviewed the record, realized that she did enter the order for the Physician to approve. The Corporate Nurse said the reason she would have entered the order on [DATE] for a death that occurred on [DATE] was if she reviewed the record and identified that an order had not been obtained. The Corporate Nurse also said that Nurse #6 should have notified the Resident's Physician of the Resident's death.

Based on record review, and interview, the facility failed to resolve a grievance timely for one Resident (#66), out of a total sample of 23 residents. Specifically, for Resident #66, the facility failed to ensure that a reported grievance by the Resident, the Resident's Representative (RR), and the Nurse Practitioner (NP), regarding two missing hearing aids was documented and the grievance process initiated to resolve the concern within a reasonable timeframe. Findings include: Review of the facility policy, titled Resident and Family Concerns and Grievances, revised 10/5/24, indicated: -Residents or their family members, guardian, or representative may voice a grievance to the facility staff in person, by telephone, or via written communication. -The facility shall provide a grievance report form to facilitate the voicing of a grievance if requested by a resident or family members. -The facility will follow up with the resident or their family members, guardian, or representative within 72 hours of the filing of the grievance. -The facility will make reasonable efforts to ensure that all grievances are adequately resolved within thirty (30) calendar days from the day the grievance is received. -The facility will advise the resident of the outcome of the grievance investigation and shall make reasonable efforts to contact the resident's family members to advise them of the outcome of the grievance investigation. -The facility will provide the resident with a written grievance decision. -The facility will document all steps of the grievance resolution in the facility's records, including whether the resident/family was satisfied with the resolution. Resident #66 was admitted to the facility in September 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Major Depressive Disorder, Unspecified symptoms and signs involving cognitive functions following Cerebral Infarction, Metabolic Encephalopathy, and Diabetes Mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #66: -was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of five out of 15 total possible points. -had clear speech. -was usually understood. Review of Resident #66's clinical record indicated the following: - The Resident completed a Health Care Proxy (HCP- a legal document identifying a resident's preference for surrogate medical decision makers if they become incapacitated) naming Resident Representative (RR) #1 on 9/13/24. -The Resident was determined by a Physician to lack capacity to make health care decisions and the HCP was permanently invoked on 10/29/24. During an interview on 3/4/25 at 10:15 A.M., Resident #66 said that he/she was missing hearing aids, and the facility staff were not responding to him/her anytime he/she would inquire about the missing hearing aids. During an interview on 3/5/25 at 1:28 P.M., RR#1 said he/she had reported the missing hearing aids to the facility staff about four months prior, but the facility had not responded to him/her as yet. Review of Resident #66's Physiatry Progress Note, dated 1/7/25, indicated the Resident still had no hearing aids, therefore communication with the Resident was difficult. The Physiatry Progress Note further indicated that the Physiatrist followed up with the nursing manager about the Resident's hearing aids, as well as the Social Worker (SW), and the Unit Manager (UM) and the Social Worker said a grievance would be initiated for the missing hearing aids. During an interview on 3/5/25 at 2:21 P.N., the SW said she was aware of Resident #66's concern about the missing hearing aids but she had not documented a formal grievance, had not followed the grievance process, and the Resident's concern of the missing hearing aids remained unresolved. The SW further said she should have documented the missing hearing aids as a formal grievance, investigated the concern, and followed up for resolution, but she had not done so.

Based on observation, interview, record and policy review, the facility failed to notify the Physician/Non Physician Practitioner (NPP: Nurse Practitioner) of changes in condition related to a pressure wound for one Resident (#60) out of a total sample of 26 residents, who was identified to be at risk for skin breakdown. Specifically, the facility staff failed to notify the Physician/NPP when: 1. The Resident developed a pressure injury (PI: localized damage to the skin and/or underlying soft tissue usually over a bony prominence presenting as intact skin) on his/her left hip on 2/6/24. 2. The Resident's pressure injury deteriorated to a pressure ulcer (PU: open ulcer, the appearance of which occurs as a result of intense and/or prolonged pressure or pressure in combination with shear) on 2/19/24. Findings include: Review of the facility policy titled Skin Prevention, Assessment and Treatment, dated 5/2/22, indicated the following: -The purpose included to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown, and to promote healing of existing PUs. -Nursing staff should keep the attending Physician aware of the progress of all ulcers, especially those in higher risk residents, . -The Physician should be notified and consulted if an ulcer does not show signs of healing after 14 days of the same treatment. Review of the facility's policy titled Change in Condition Procedure, dated 9/21/22, indicated: -The facility would provide guidelines for the appropriate handling of a resident's change in condition. -The facility recognized each situation must be handled in the manner that would be most appropriate at the time and for the nature of the change in condition. -Staff were to notify the Physician of the change and give assessment information. -Staff were to receive orders if orders were provided. Resident #60 was admitted to the facility in July 2023, with diagnoses including unspecified Protein-Calorie Malnutrition (occurs when one does not consume enough protein and calories which can lead to muscle loss, fat loss, and your body not working as it usually would), Muscle Weakness, and Dementia (group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident #60's Skin Risk Care Plan, initiated 7/17/23, indicated: -The Resident was at risk for skin breakdown related to advanced age and being frail and fragile. -Provide wound treatments as ordered. Review of Resident #60's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 possible points, and that the Resident was at risk of developing PUs. Review of Resident #60's February 2024 Physician's orders included the following active order: -Follow initial wound care dressing guidelines if Provider not in office, dated 1/5/24. -May utilize wound care dressing guidelines until Provider examines or other orders are obtained ., dated 1/5/24. -Skin check weekly . for preventative, dated 1/5/24. Review of Resident #60's Weight/Skin Note, dated 2/6/24 and written by the Dietitian, indicated the Resident had a healed left hip pressure area. Review of Resident #60's Nursing Note, dated 2/6/24 and written by Nurse #2, indicated: -Left hip area over bony prominence is beginning to break down from friction (the mechanical force exerted on skin that is dragged across any surface) again. -Skin Prep (water-proof liquid that forms a transparent film over the skin to protect it from possible irritation while allowing visible inspection of skin) and foam dressing applied to prevent further pressure/friction injury. Further Review of Resident #60's Nursing Notes, indicated: -the area to the Resident's left hip was pink, blanchable (the area turns white when pressed on) and intact, and that a foam dressing was applied, dated 2/8/24 -the Resident had a dime-sized open area to his/her left hip bony prominence, dated 2/19/24 -the open area to the Resident's left hip persisted and the area was covered with a foam dressing, dated 2/21/24 -there was an open area to the Resident's left hip, the foam dressing was changed, and scant (small amount) cream/tan colored drainage from the wound was noted, dated 2/22/24 -the Resident's left hip open area was covered with Zinc Oxide (medicated cream or paste used to treat minor skin irritations) and a foam dressing was applied, dated 2/26/24 -the Resident's left hip open area persisted and was covered with Zinc Oxide and a foam dressing, dated 2/28/24 and 2/29/24 Review of Resident #60's February 2024 Treatment Administration Record (TAR) indicated that staff completed a weekly skin check for the Resident on 2/12/24, but there was no documentation in the clinical record of the findings for the completed skin checks and no evidence that the Weekly Skin Check form had been completed. Review of the Weekly Skin Checks, dated 2/19/24 and 2/26/24, indicated: -The Resident's skin was dry and flaky. -The Resident had a dime-sized open skin ulcer on his/her left hip. Review of Resident #60's clinical record included no evidence the Physician or NPP had been notified of: -The Resident's initial change in skin condition on 2/6/24 -Facility staff initiating a new form of treatment of Skin Prep to the Resident's left hip PI on 2/6/24 -Deterioration of the Resident's skin condition to an open pressure ulcer on 2/19/24 -Further change in the Resident's skin condition when drainage from the wound was observed on 2/22/24 -Facility staff initiating Zinc Oxide as a new form of treatment to the Resident's left hip pressure ulcer on 2/26/24 During an interview on 2/29/24 at 12:59 P.M., Nurse #2 said Resident #60 had a superficial open area to his/her left hip. Nurse #2 said the Resident had an open area like this in the past and that the open area had healed pretty quickly. Nurse #2 said there was no treatment ordered for the Resident, but she had been applying Zinc Paste and a foam dressing over the open area. Nurse #2 said the Physician would determine whether a treatment was required for open areas on a resident's skin. Nurse #2 further said an order probably should have been obtained for the treatment that was being provided to Resident #60's left hip. On 3/1/24 at 9:28 A.M., the surveyor observed Nurse #2 completing a dressing change to Resident #60's left hip and determined the wound status as documented. Resident #60 was positioned in bed, and an area of skin alteration directly over the hip bone was present, approximately 2.5 cm length by (x) 2.5 cm width, with an approximate 0.5 cm scab-like area in the wound bed. The surveyor observed scant serosanguinous (red blood cells and fluid secreted in response to tissue damage) drainage on the old dressing, the wound edges (where intact skin meets the wound bed) were dry and flaky and the skin surrounding the wound was dimpled with some redness. During an interview 3/1/24 at 9:28 A.M., Nurse #2 said she was using the facility's skin protocol to manage Resident #60's left hip wound. When the surveyor asked where the facility's skin protocol could be found, Nurse #2 said she believed each resident had an order for the skin protocol (and did not provide specifics of the facility skin protocol) and said if a resident had a wound that did not improve within a couple of weeks, then the facility staff would alert the Physician. Resident #60 had a PI that was identified on 2/6/24, that subsequently deteriorated to a PU, which was identified on 2/19/24, almost two weeks after the initial change in condition. During an interview on 3/1/24 at 10:32 A.M., with the Director of Nurses (DON) and the Regional Nurse, the DON said if any change in skin condition was identified for a resident, the Nurse was required to alert the Physician or NPP. The Regional Nurse then said the facility's house skin protocol was for preventative measures and if there was a change or deterioration in skin condition, the Nurse was required to notify the Physician or NPP and, if necessary, obtain orders. The Regional Nurse further said the order to follow initial wound care dressing guidelines was entered in all resident EMRs to indicate that the facility's electronic order set for wound care could be used. When the surveyor requested the initial wound care dressing guidelines, the Regional Nurse said there was no specific guidelines, that the order was a place holder to alert the staff that if a resident developed a wound, staff should follow the process to alert the Physician/NP and obtain orders/add orders that were in the electronic order set. The Regional Nurse also said if a treatment was being administered, then an order should have been obtained and entered into the Resident's record for all applicable staff to administer the treatment, monitor the Resident's condition, and know to alert the Physician/NPP of any changes. Based on observation, interview, record and policy review, the facility failed to notify the Physician/Non Physician Practitioner (NPP: Nurse Practitioner) of changes in condition related to a pressure wound for one Resident (#60) out of a total sample of 26 residents, who was identified to be at risk for skin breakdown. Specifically, the facility staff failed to notify the Physician/NPP when: 1. The Resident developed a pressure injury (PI: localized damage to the skin and/or underlying soft tissue usually over a bony prominence presenting as intact skin) on his/her left hip on 2/6/24. 2. The Resident's pressure injury deteriorated to a pressure ulcer (PU: open ulcer, the appearance of which occurs as a result of intense and/or prolonged pressure or pressure in combination with shear) on 2/19/24. Findings include: Review of the facility policy titled Skin Prevention, Assessment and Treatment, dated 5/2/22, indicated the following: -The purpose included to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown, and to promote healing of existing PUs. -Nursing staff should keep the attending Physician aware of the progress of all ulcers, especially those in higher risk residents, . -The Physician should be notified and consulted if an ulcer does not show signs of healing after 14 days of the same treatment. Review of the facility's policy titled Change in Condition Procedure, dated 9/21/22, indicated: -The facility would provide guidelines for the appropriate handling of a resident's change in condition. -The facility recognized each situation must be handled in the manner that would be most appropriate at the time and for the nature of the change in condition. -Staff were to notify the Physician of the change and give assessment information. -Staff were to receive orders if orders were provided. Resident #60 was admitted to the facility in July 2023, with diagnoses including unspecified Protein-Calorie Malnutrition (occurs when one does not consume enough protein and calories which can lead to muscle loss, fat loss, and your body not working as it usually would), Muscle Weakness, and Dementia (group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident #60's Skin Risk Care Plan, initiated 7/17/23, indicated: -The Resident was at risk for skin breakdown related to advanced age and being frail and fragile. -Provide wound treatments as ordered. Review of Resident #60's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 possible points, and that the Resident was at risk of developing PUs. Review of Resident #60's February 2024 Physician's orders included the following active order: -Follow initial wound care dressing guidelines if Provider not in office, dated 1/5/24. -May utilize wound care dressing guidelines until Provider examines or other orders are obtained ., dated 1/5/24. -Skin check weekly . for preventative, dated 1/5/24. Review of Resident #60's Weight/Skin Note, dated 2/6/24 and written by the Dietitian, indicated the Resident had a healed left hip pressure area. Review of Resident #60's Nursing Note, dated 2/6/24 and written by Nurse #2, indicated: -Left hip area over bony prominence is beginning to break down from friction (the mechanical force exerted on skin that is dragged across any surface) again. -Skin Prep (water-proof liquid that forms a transparent film over the skin to protect it from possible irritation while allowing visible inspection of skin) and foam dressing applied to prevent further pressure/friction injury. Further Review of Resident #60's Nursing Notes, indicated: -the area to the Resident's left hip was pink, blanchable (the area turns white when pressed on) and intact, and that a foam dressing was applied, dated 2/8/24 -the Resident had a dime-sized open area to his/her left hip bony prominence, dated 2/19/24 -the open area to the Resident's left hip persisted and the area was covered with a foam dressing, dated 2/21/24 -there was an open area to the Resident's left hip, the foam dressing was changed, and scant (small amount) cream/tan colored drainage from the wound was noted, dated 2/22/24 -the Resident's left hip open area was covered with Zinc Oxide (medicated cream or paste used to treat minor skin irritations) and a foam dressing was applied, dated 2/26/24 -the Resident's left hip open area persisted and was covered with Zinc Oxide and a foam dressing, dated 2/28/24 and 2/29/24 Review of Resident #60's February 2024 Treatment Administration Record (TAR) indicated that staff completed a weekly skin check for the Resident on 2/12/24, but there was no documentation in the clinical record of the findings for the completed skin checks and no evidence that the Weekly Skin Check form had been completed. Review of the Weekly Skin Checks, dated 2/19/24 and 2/26/24, indicated: -The Resident's skin was dry and flaky. -The Resident had a dime-sized open skin ulcer on his/her left hip. Review of Resident #60's clinical record included no evidence the Physician or NPP had been notified of: -The Resident's initial change in skin condition on 2/6/24 -Facility staff initiating a new form of treatment of Skin Prep to the Resident's left hip PI on 2/6/24 -Deterioration of the Resident's skin condition to an open pressure ulcer on 2/19/24 -Further change in the Resident's skin condition when drainage from the wound was observed on 2/22/24 -Facility staff initiating Zinc Oxide as a new form of treatment to the Resident's left hip pressure ulcer on 2/26/24 During an interview on 2/29/24 at 12:59 P.M., Nurse #2 said Resident #60 had a superficial open area to his/her left hip. Nurse #2 said the Resident had an open area like this in the past and that the open area had healed pretty quickly. Nurse #2 said there was no treatment ordered for the Resident, but she had been applying Zinc Paste and a foam dressing over the open area. Nurse #2 said the Physician would determine whether a treatment was required for open areas on a resident's skin. Nurse #2 further said an order probably should have been obtained for the treatment that was being provided to Resident #60's left hip. On 3/1/24 at 9:28 A.M., the surveyor observed Nurse #2 completing a dressing change to Resident #60's left hip and determined the wound status as documented. Resident #60 was positioned in bed, and an area of skin alteration directly over the hip bone was present, approximately 2.5 cm length by (x) 2.5 cm width, with an approximate 0.5 cm scab-like area in the wound bed. The surveyor observed scant serosanguinous (red blood cells and fluid secreted in response to tissue damage) drainage on the old dressing, the wound edges (where intact skin meets the wound bed) were dry and flaky and the skin surrounding the wound was dimpled with some redness. During an interview 3/1/24 at 9:28 A.M., Nurse #2 said she was using the facility's skin protocol to manage Resident #60's left hip wound. When the surveyor asked where the facility's skin protocol could be found, Nurse #2 said she believed each resident had an order for the skin protocol (and did not provide specifics of the facility skin protocol) and said if a resident had a wound that did not improve within a couple of weeks, then the facility staff would alert the Physician. Resident #60 had a PI that was identified on 2/6/24, that subsequently deteriorated to a PU, which was identified on 2/19/24, almost two weeks after the initial change in condition. During an interview on 3/1/24 at 10:32 A.M., with the Director of Nurses (DON) and the Regional Nurse, the DON said if any change in skin condition was identified for a resident, the Nurse was required to alert the Physician or NPP. The Regional Nurse then said the facility's house skin protocol was for preventative measures and if there was a change or deterioration in skin condition, the Nurse was required to notify the Physician or NPP and, if necessary, obtain orders. The Regional Nurse further said the order to follow initial wound care dressing guidelines was entered in all resident EMRs to indicate that the facility's electronic order set for wound care could be used. When the surveyor requested the initial wound care dressing guidelines, the Regional Nurse said there was no specific guidelines, that the order was a place holder to alert the staff that if a resident developed a wound, staff should follow the process to alert the Physician/NP and obtain orders/add orders that were in the electronic order set. The Regional Nurse also said if a treatment was being administered, then an order should have been obtained and entered into the Resident's record for all applicable staff to administer the treatment, monitor the Resident's condition, and know to alert the Physician/NPP of any changes. The Regional Nurse said there were no standing orders or protocol in place for staff to initiate skin prep or Zinc and that any treatments for a deterioration in skin condition required an order. During an interview on 3/1/24 at 3:07 P.M., Unit Manager (UM) #2, who was also the designated Wound Nurse, said she assessed Resident #60's skin on 3/1/24, after being alerted by facility management that the Resident had a PU on his/her left hip. UM #2 said she observed the area to be open and she contacted the NPP to obtain treatment orders on 3/1/24 (24 days after the PI was identified). UM #2 further said that any time a Nurse identified a change in skin condition, the Nurse was required to alert the Physician/NPP and, if needed, obtain orders if treatment was necessary. UM #2 said that the Nurse should have notified the Physician/NPP when the change in the Resident's skin condition was initially identified on 2/6/24 and when any change or deterioration occurred on 2/19/24. During an interview on 3/5/24 at 9:22 A.M., the Physician said if staff identified a change in a resident's skin condition, staff were expected to notify him or the NPP and, if needed, obtain treatment orders. The Physician said he began working with residents at the facility a couple of weeks prior and did not recall being notified about Resident #60 having developed a PU on his/her left hip. During an interview on 3/5/24 at 10:22 A.M., the NPP said he could not recall being notified that Resident #60 had developed a PU on his/her left hip. Please refer to F686 and F726.

Based on record and policy review, and interview, the facility failed to provide necessary pressure ulcer (PU: localized damage to the skin and/or underlying soft tissue usually over a bony prominence) treatment and services, consistent with professional standards of practice, to promote healing for one Resident (#60), out of a total sample of 26 residents. Specifically, the facility staff failed to: 1. Adequately assess Resident #60's change in skin condition when the Resident was identified to have a PU on his/her left hip. 2. Consult with the Physician/Non Physician Practitioner (NPP: Nurse Practitioner [NP]) when the Resident was identified to have a PU on his/her left hip, and obtain treatment orders from the Physician/NPP for Resident #60's left hip PU, to prevent further deterioration of the PU. Findings include: Review of the facility policy titled Skin Prevention, Assessment and Treatment, dated 5/2/22, indicated the following: -The purpose included to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown, and to promote healing of existing PUs. -Any skin impairments, including PUs, . should be assessed and documented weekly by the Wound Nurse, or designee, in the medical record. -Interventions for prevention or active skin alterations may include but are not limited to: Wound Consultant review . -Upon identification of the development of a wound, the wound assessment/treatments will be documented in the medical record and start the Weekly Wound Log. -Nursing staff should keep the attending Physician aware of the progress of all ulcers, especially those in higher risk residents, . -The Physician should be notified and consulted if an ulcer does not show signs of healing after 14 days of the same treatment. Resident #60 was admitted to the facility in July 2023 with diagnoses including unspecified Protein-Calorie Malnutrition (occurs when one does not consume enough protein and calories which can lead to muscle loss, fat loss, and your body not working as it usually would), Muscle Weakness, and Dementia (group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident #60's Skin Risk Care Plan, initiated 7/17/23, indicated: -The Resident was at risk for skin breakdown related to advanced age and being frail and fragile. -Provide wound treatments as ordered. -The Skin Risk Care Plan was not updated when the wound was identified or when it deteriorated in February 2024. Review of a Minimum Data Set (MDS) Assessment, dated 10/19/23, indicated the Resident was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15 possible points. Further review of the MDS Assessment indicated Resident #60 was at risk of developing PUs. Review of Resident #60's February 2024 Physician orders included the following: -Follow initial wound care dressing guidelines if Provider not in office. -May utilize [wound care dressing guidelines] until Provider examines or other orders are obtained. Place order individually for documentation of the wound as needed for wound care standing order ., dated 1/5/24. -May be followed by in-house wound Provider for wound evaluation and treatment, dated 1/5/24. -Skin check weekly . for preventative, dated 1/5/24. Review of Resident #60's Nursing Note, dated 2/6/24, indicated: -Left hip area over bony prominence is beginning to break down from friction (the mechanical force exerted on skin that is dragged across any surface) again. -Skin Prep (water-proof liquid that forms a transparent film over the skin to protect it from possible irritation while allowing visible inspection of skin) and foam dressing applied to prevent further pressure/friction injury. Further Review of Resident #60's Nursing Notes, indicated: -the area to the Resident's left hip was pink, blanchable (the area turns white when pressed on) and intact, and that a foam dressing was applied, dated 2/8/24 -the Resident had a dime-sized open area to his/her left hip bony prominence, dated 2/19/24 -the open area to the Resident's left hip persisted and the area was covered with a foam dressing, dated 2/21/24 -there was an open area to the Resident's left hip, the foam dressing was changed, and scant (small amount) cream/tan colored drainage from the wound was noted, dated 2/22/24 -the Resident's left hip open area was covered with Zinc Oxide (medicated cream or paste used to treat minor skin irritations) and a foam dressing was applied, dated 2/26/24 -the Resident's left hip open area persisted and was covered with Zinc Oxide and a foam dressing, dated 2/28/24 and 2/29/24 Review of Resident #60's Weekly Skin Check Form, dated 2/7/24 indicated: -The Resident's general skin condition was warm, dry, flaky, and fragile. -The Resident had a pink and blanchable area over the bone on the left hip. -A foam dressing was applied to the blanchable area to prevent breakdown. Review of Resident #60's February 2024 Treatment Administration Record (TAR) indicated a Weekly Skin Check was completed for the Resident on 2/12/24, but there was no documentation in the clinical record of the findings for the completed skin checks and no evidence that the Weekly Skin Check form had been completed. Review of Resident #60's Weekly Skin Check Form, dated 2/26/24, indicated: -The Resident's skin was dry and flaky. -The Resident had a dime-sized open skin ulcer on his/her left hip. Review of Resident #60's clinical record included no evidence that the Physician had been made aware of the Resident's left hip pressure ulcer or any treatment orders had been obtained from the Physician/NPP for care of the Resident's left hip pressure ulcer. During an interview on 2/29/24 at 12:59 P.M., Nurse #2 said Resident #60 had a superficial open area to his/her left hip. Nurse #2 said the Resident had an open area like this in the past and that it usually healed pretty quickly. Nurse #2 said there was no treatment ordered for the Resident, but that she had been applying Zinc Paste and a foam dressing over the open area (for which there were no Physician/ NP orders and Nurse #2 could not indicate why she initiated the treatment). Nurse #2 said it was her opinion that Resident #60's open area did not require the Wound Consultant's services because it was superficial, with the first layer of skin gone. On 3/1/24 at 9:28 A.M., the surveyor observed Nurse #2 completing a dressing change to Resident #60's left hip. Resident #60 was positioned in bed, and an area of skin alteration directly over the hip bone was present, approximately 2.5 cm length by (x) 2.5 cm width, with an approximate 0.5 cm scab-like area in the wound bed. The surveyor observed scant serosanguinous (red blood cells and fluid secreted in response to tissue damage) drainage on the old dressing, the wound edges (where intact skin meets the wound bed) were dry and flaky and the skin surrounding the wound was dimpled with some redness. The surveyor was able to observe that the wound status was a PU as documented in the Nursing notes. During an inteview on 3/1/24 at 9:28 A.M., Nurse #2 said she was using the facility's skin protocol to manage Resident #60's left hip wound. When the surveyor asked where the facility's skin protocol could be found, Nurse #2 said she believed each resident had an order for the facility's skin protocol. Nurse #2 was unable to describe the facility's skin protocol to the surveyor. Nurse #2 further said she did not measure the Resident's wound when she completed the dressing change and she thought the wound looked like a Stage Two (partial-thickness loss of skin, presenting as a shallow open ulcer with no eschar [dead or devitalized tissue that is hard or soft in texture, usually black, brown, or tan in color, and may appear scab-like] present) PU. Nurse #2 said she usually wrote a note in the Resident's record to document the wound care so that other staff would know how to care for the wound because the information would be passed on during verbal report. Nurse #2 said if a resident had a wound that did not improve within a couple of weeks, then the facility staff would alert the Physician and the Wound Team. Nurse #2 did not alert the Physician or Wound Team regarding Resident #60's wound when it was well past the 14 days/ couple of weeks since the wound was identified. During an interview on 3/1/24 at 10:32 A.M., with the Director of Nursing (DON) and the Regional Nurse, the DON said if any change in skin condition was identified for a resident, the Nurse was required to complete a Change in Condition Event Report in the resident's electronic medical record (EMR), alert the Physician or NPP, and obtain treatment orders. The DON further said when the Change in Condition Event Report was completed, notification of the change would transfer over to the facility's electronic dashboard and reviewed in the daily clinical meeting. The Regional Nurse then said the Change in Condition Event Report and notification in the electronic dashboard would be done for any identified change in skin condition and that if a change in skin condition was identified as pressure, the Wound Nurse would be alerted, and the resident would be evaluated by the Wound Physician. The DON said the Change in Condition Event Report and notification in the electronic dashboard was not completed for Resident #60. The Regional Nurse said the facility's house skin protocol was for preventative measures only and if there was a change or deterioration in skin condition, the Nurse was required to make the Physician or NPP aware and obtain orders. The Regional Nurse said Unit Manager (UM) #2 was the designated Wound Nurse at the facility and the Regional Nurse would request that the Wound Nurse assess Resident #60's skin. The Regional Nurse also said if a treatment was being administered, then an order should have been obtained and entered into the Resident's record for all applicable staff to administer the treatment, monitor the Resident's condition, and know to alert the Physician/NPP of any changes. Review of Resident #60's Nursing Progress note, dated 3/1/24 and written by UM #2, indicated: -The Resident was seen for a re-opened PU on the left hip, which re-opened on 2/19/24. -The area was approximately 1.0 cm length x 1.0 cm width x 0.1 cm depth. -The area was pink and the periwound (skin around the wound that has been affected by the wound) was intact. -New orders had been obtained. -The Resident was to be followed weekly by the Wound Team. During an interview on 3/5/24 at 8:32 A.M., UM #2 said she assessed Resident #60's left hip PU on 3/1/24, while the Resident was sitting in his/her wheelchair, by pulling the Resident's pants down to view the wound. UM #2 said she measured the wound and that the wound bed looked clean and pink. UM #2 further said that she did not see a scab in the center of the wound bed on Resident #60's left hip or observe any drainage when she assessed the wound. UM #2 said her inability to observe the scab in the center of the wound may have been related to her view of the wound since the Resident was sitting in his/her wheelchair when he/she was assessed. UM #2 said after she assessed the wound on 3/1/24, she contacted the NPP and obtained orders for Calcium Alginate (advanced wound care dressing for the management of highly draining wounds) and a bordered gauze to be applied to the Resident's hip wound daily. UM #2 said the Calcium Alginate would help to pull any drainage away from Resident #60's wound bed and promote healing. During an interview on 3/5/24 at 9:37 A.M., the Regional Nurse said in order to assess a wound adequately, UM #2 would need to ensure the resident was positioned in a way that the entire wound could be visualized. The Regional Nurse said the position in which Resident #60's left hip wound was assessed by UM #2 on 3/1/24 was not ideal. For Resident #60, the Change in Condition Event Report should have been completed when the PI was identified to initiate the Physician notification, the Physician/NP should have been notified so treatment orders could be obtained, the Wound Nurse should have been alerted, and the Resident should have been added to the Wound Physician's list, for the wound to be monitored, managed appropriately and prevent any further deterioration. Please refer to F726.

Based on records reviewed, review of facility surveillance camera video footage, and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff for care, the Facility failed to ensure he/she was free from abuse from a staff member. Review of the surveillance camera video footage from 08/24/23 during the evening shift, showed Resident #1 pick up a cup containing yellow-tinted liquid off a medication cart, put it up to his/her mouth, Nurse #1 quickly goes over to him/her, grabs the cup of liquid from Resident #1's hand and throws the liquid into Resident #1's face, and Nurse #1 also engaged in a verbal altercation with him/her, the incident was witnessed by another staff member who stepped into intervened. Resident #1 was visibly upset after the incident, was crying, and was cleaned up and comforted by staff. Findings include: Review of the Facility's Policy titled, Abuse Prohibition, dated as revised 10/24/22, indicated the following: -the Centers (Facilities) prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation of all patients (residents), -abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, injury, or mental anguish, and -instances of abuse of all patients (residents), irrespective of any mental or physical condition, cause physical harm, pain, and mental anguish. Review of the Facility's Investigation Report, undated, indicated that on 08/24/23 at approximately 10:45 P.M., Nurse #1 threw water into Resident #1's face. Resident #1 was admitted to the Facility in December 2021, diagnoses included unspecified mood disorder, unspecified psychosis, generalized anxiety, and unspecified dementia with behavioral disturbances. Review of Resident #1's Quarterly Minimum Set Data (MDS) Assessment, dated 06/08/23, indicated he/she had severe cognitive impairment, and required supervision for ambulation in hallways. Review of Resident #1's Behavior Care Plan, reviewed and renewed with his/her June 2023 MDS, indicated that he/she exhibited or had the potential to demonstrate verbal behaviors, and included the following interventions: -remove resident from environment, if needed. Gently guide the resident from the environment while speaking in a calm, reassuring voice, -if resident becomes combative or resistive, postpone care/activity and allow time for him/her to regain composure, -allow time to expression of feelings; provide empathy, encouragement, and reassurance. On 9/26/23 at 11:06 A.M., the Surveyor reviewed the Facility's surveillance camera video footage (video only, there are no audio recordings) with the Administrator and the Director of Nurses, who identified Resident #1 and Nurse #1 in the video. The footage dated and time stamped 08/24/23 from 10:49 P.M. to 10:51 P.M., illustrated the following: 10:49:06 P.M., Resident #1 approaches a medication cart in the hallway on his/her unit. A cup of yellowish liquid can be seen sitting on the medication cart, towards the back of the cart. 10:49:12 P.M., Resident #1 picks up a pen case from the medication cart, tips it over, and pens, a high lighter, and a pair of surgical scissors fall out onto the cart. Resident #1 can be seen slowly trying to put the objects back into the pen case. 10:49:58 P.M., Nurse #1 quickly comes into the camera's view and grabs the pen case out of Resident #1's hand. Nurse #1 quickly picks up the contents of the pen case that Resident #1 had spilled out, and puts them back into the pen case while Resident #1 stands and watches. Nurse #1's demeanor and body language in the video looks like she is irritated. 10:50:24 P.M., Resident #1 picks up a cup with a yellowish tinted liquid from the medication cart that had been there since the start of the video. Resident #1 then raises the cup toward his/her lips and attempts to drink the liquid. 10:50:27-29 P.M., Nurse #1 quickly grabs the cup from Resident #1's hand, and Resident #1 swings his/her right hand at Nurse #1 (it is unclear from the video if Resident #1 struck her). Nurse #1 then throws the contents of the cup into Resident #1's face. Resident #1 leans forward, puts his/her head down and wipes his/her face with his/her right hand. Resident #1 is visibly angry, becomes aggressive and moves toward Nurse #1 swinging his/her right fist at her. Nurse #1 can then be seen grabbing Resident #1's right forearm with her right hand. 10:50:42 P.M., Nurse #1 is out of the camera's view, but Resident #1 can still be seen and has his/her right fist raised. 10:50:46 P.M., Nurse #1 comes back into the camera's view, walks around Resident #1 and proceeds to clean the medication cart. 10:50:53 P.M., Another person out of the camera's view (later identified as CNA #1) reaches his/her hand out to Resident #1, he/she moves and follows the person (CNA #1) and then is out of the camera's view. During an interview on 10/03/23 at 3:08 P.M., and review of Certified Nurse Aide (CNA) #1's Written Witness Statement, undated, CNA #1 said that she knew Resident #1 well, and said he/she wandered at night and typically touched and grabbed everything. CNA #1 said Resident #1 could become combative, but could be redirected, and said all staff needed to do was offer Resident #1 their hand, and he/she would take it and follow them. CNA #1 said that on 08/24/23 at approximately 10:45 P.M., Resident #1 walked over to the medication cart and picked up a pen case and took the pens out. CNA #1 said that Nurse #1 then walked over to him/her and snatched the pens from Resident #1's hands. CNA #1 said Resident #1 asked Nurse #1 why she did that, and that Nurse #1 said to him/her, because you ain't touching my shit. CNA #1 said Resident #1 then picked up a cup that was on the medication cart, and Nurse #1 grabbed the cup out of his/her hand. CNA #1 said that Resident #1 hit Nurse #1 and then Nurse #1 threw the cup of liquid into Resident #1's face, and said, that will teach you not to touch my stuff. CNA #1 said Resident #1 yelled, you bitch! at Nurse #1. CNA #1 said Resident #1 was angry and was tried to punch Nurse #1. CNA #1 said she went over to help Resident #1 and guided him/her away from Nurse #1. CNA #1 said she dried Resident #1 off and then he/she sat in a chair with the towel around his/her head and cried. CNA #1 said Nurse #1 walked by him/her and said, too bad, you got what you deserved. During an interview on 09/29/23 at 10:03 A.M., Nurse #1 said she was familiar with Resident #1 and said he/she could be intrusive. Nurse #1 said Resident #1 had been pacing back and forth in the hallway in front of the nurses' station. Nurse #1 said Resident #1 stopped in front of the medication cart and took her pouch of pens, so she took it from him/her. Nurse #1 said Resident #1 picked up a cup from the medication cart and was about to drink the liquid inside, which she said was juice and Risperidone (anti-psychotic medication). Nurse #1 said if the cup had contained water, she would have just let Resident #1 have it. Nurse #1 said it all happened so fast, and said she threw the cup containing juice and Risperidone at Resident #1. Review of CNA #2's Written Witness Statement, dated 08/25/23, indicated she saw Nurse #1 sitting at the nurses' station and then saw Nurse #1 look up to see Resident #1 standing at the medication cart, and Nurse #1 said to him/her, those are my personal things. The Statement indicated that Nurse #1 walked over to the medication cart, but she (CNA #2) did not see what happened next. The Statement indicated that CNA #2 heard someone say Resident #1 was wet and she saw CNA #1 go over and take care of Resident #1. The Statement indicated CNA #2 heard Nurse #1 say you're going to learn to stay away from my things. The Statement also indicated that Resident #1 was angry and he/she said, did you see what she did? During an interview on 09/29/23 at 10:53 A.M., and review of Nurse #2's Written Witness Statement, Nurse #2 said she worked the night shift beginning on 08/24/23, and CNA #1 worked a double shift (3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M.), so she was with her at the beginning of the night when CNA #1 told her that she felt badly for Resident #1 because Nurse #1 had thrown water at him/her. Nurse #2 said she asked CNA #1 if she had reported the incident to anyone, and CNA #1 said she had not. Nurse #2 said she sent CNA #1 to go see the Night Supervisor immediately to report the allegation. Nurse #2 said Resident #1 could be physically and verbally abusive as well as intrusive. Nurse #2 said Resident #1 took food and drinks if he/she saw them and would take water and applesauce from the medication cart sometimes. Nurse #2 said sometimes staff left Resident #1 alone if what he/she was doing was harmless, and other times staff would need to redirect him/her. During an interview on 09/27/23 at 1:23 P.M., and review of Nurse #3's Written Witness Statement, Nurse #3 said Resident #1 was on her assignment on 08/24/23 during the 3:00 P.M. to 11:00 P.M. shift Nurse #3 said Resident #1 was confused and got agitated at times. Nurse #3 said Resident #1 touched everything, and said if a nurse left applesauce on the medication cart, he/she would eat it. Nurse #3 said she did not see or hear the incident involving Resident #1 and Nurse #1. During an interview on 09/27/23 at 2:40 P.M., (which included review of the Facility's surveillance camera video footage), the Director of Nurses (DON) said Nursing Supervisor #1 notified her that CNA #1 alleged that Nurse #1 threw water at Resident #1. The DON said that the statements she gathered were so vivid, that she requested the video surveillance footage. The DON said when she watched the video footage, she saw Resident #1 calmly go through a pen case on the medication cart. The DON said Nurse #1 grabbed the pen case and Resident #1 got upset. The DON said Resident #1 then grabbed the cup of liquid and lifted the cup to his/her lips when Nurse #1 grabbed the cup, had full control of it, and then threw liquid in Resident #1's face. The DON said Nurse #1 told her that the cup contained medication. The DON said if there was medication in the cup, there should not have been. The DON said the liquid in the cup did not look like water. During an interview on 09/27/23 at 3:03 P.M., The Administrator said that when she and the DON interviewed Nurse #1 she denied throwing a cup liquid at Resident #1. The Administrator said she substantiated the allegation of physical abuse based on the surveillance video footage, where she saw that Nurse #1 had thrown a cup of liquid into Resident #1's face. Although Resident#1's impaired cognition minimized his/her understanding of the incident, an unimpaired individual would have experienced physical pain and mental anguish after being treated by a caregiver in this manner. On 09/27/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A. Nursing assessed Resident #1 for potential injuries and the Facility continues to provide emotional support. B. The Facility recognized that all residents have the potential to be affected by the same deficient practice. C. Nurse #1 was suspended pending an investigation. D. Effective 09/01/23 Nursing completed skin checks on all residents on the affected unit. E. Effective 08/25/23, the SDC completed. house-wide training on the Facility's Abuse Policy. Education will be ongoing to ensure all facility staff were educated/reeducated as needed. F. Starting effective 08/28/23 weekly random resident abuse audits which included resident interviews were initiated. G. On 08/31/23 the area of concern was presented at the facility's Quality Assurance Performance Improvement (QAPI) Committee Meeting, and the Adminstrator will continue to bring the results of the Audits to the QAPI Committee meetings. H. The Administrator, the Director of Nursing and/or their designees will be responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was cognitively intact, made his/her own decisions, who resided in a room where he/she occupied and enjoyed having the bed closest to the window, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 06/08/23 at approximately 2:30 P.M., while Resident #1 was off the unit and outside the facility participating in a scheduled smoke break, Unit Manager #1 directed unit staff to change his/her room (which included moving all of his/her personal belongs) to one in which he/she would then occupy the bed closest to the door. Resident #1 was not consulted by anyone about the move, was not provided any sort of notification, and his/her consent had not been obtained by Unit Manager #1, prior to the move. Resident #1 said Unit Manager #1 falsely accused him/her of smoking in his/her room. Resident #1 said Unit Manager #1 scolded him/her at the nurses' station (in front of staff and other residents also sitting nearby) and that she made him/her feel like a child and a liar. Resident #1 also reported to staff that the experience made him/her extremely frustrated, that he/she felt like Unit Manager #1 targeted him/her, and that she treated him/her very poorly. Findings include: Review of the Facility's Policy titled Resident Rights Under Federal Law, dated as revised 02/01/23, indicated the purpose included: -To to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. -To incorporate the residents' goals, preferences, and choices into care. -To recognize each residents' individuality as well as honor and value his/her input. -To protect and promote the rights of the resident. Resident #1 was admitted to the Facility in March of 2023, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 04/02/23, indicated he/she was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Review of Resident #1's Medical Record indicated he/she made his/her own health care decisions, and that his/her Health Care Proxy had not been activated. Review of Resident #1's Social Service Note, dated 04/07/23, indicated a vape pen was confiscated from him/her and he/she was educated that vape pens were not allowed in the facility. Review of Resident #1's Smoking Assessment, dated 04/19/23, indicated he/she was safe to smoke independently, and smoking materials/e-cigarette device (s) must be maintained at the nurses' station. The Assessment indicated Resident #1 had no history of unsafe smoking habits. Review of Resident #1's Smoking Care Plan, dated as initiated 04/19/23, indicated he/she was able to smoke independently per the smoking evaluation with a goal to smoke safely for 90 days. The Care Plan included the following interventions: -Educate Resident #1 on the Facility's Smoking Policy. -E-cigarette charging must occur at the nurses' station. - Smoking materials/e-cigarette device (s) must be maintained at the nurses' station. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/19/23, indicated an incident occurred on 06/12/23 at 2:30 P.M. (however, it was later determined the incident occurred on 06/08/23) that involved potential verbal abuse of Resident #1 by Unit Manager #1. The Report indicated that the Social Worker Assistant interviewed Resident #1 as a follow up to a grievance from his/her family member regarding a phone call from Unit Manager #1. The Report indicated that Resident #1 alleged Unit Manager #1 had yelled at him/her and had targeted him/her by changing his/her room while he/she was smoking outside of the facility. The Report also indicated that Nurse #1 witnessed Resident #1 yell at his/her roommate (Resident #4) in the hall, for stealing his/her cigarettes and Unit Manager #1 came out of her office and loudly told Resident #1, not to yell at his/her roommate, and accused him/her of smoking in his/her room. The Report indicated that Nurse #1 alleged Unit Manager #1 was screaming at Resident #1 and told him/her Call your daughter to come pick you up. The Report also indicated Resident #1 could not recall if Unit Manager #1 told him to call his/her daughter. The Report indicated that Resident #1 said he/she felt like he/she was walking on eggshells whenever Unit Manager #1 was around and said that she treated him/her poorly. Review of the Police Department's Report, dated 06/19/23, indicated Resident #1 alleged he/she was abused by Unit Manager #1. The Report indicated Resident #1 told the Officer he/she felt that Unit Manager #1 was retaliating against him/her by moving his/her room because she knew he/she liked looking out the window, liked being close to the air conditioner, and his/her new room didn't have those luxuries. The Report indicated Resident #1 told the Officer that Unit Manager #1 accused him/her of smoking in his room, which he/she denied. The Report indicated Resident #1 told the Officer the reason he/she kept cigarettes in his/her room was because if they are left at the nurses' station, the nurses' will steal them. The Report indicated that Resident #1 told the Officer that he/she was uncomfortable around Unit Manager #1 because of his/her verbal argument with her, he/she feels as though he/she was now walking on eggshells. Review of Resident #1's Nurse Progress Note, written by Unit Manager #1 and dated/time stamped 06/08/23 at 2:57 P.M., indicated Resident #1's room was changed for the safety and well being of Resident #4. The Note indicated Resident #1's Family Member was notified by phone of the room change and she discussed with the Family Member the numerous occasions of removing vape's and other cigarette paraphernalia from him/her and continued reminders of the smoking policy, as he/she continues to obtain and utilize vape's and other smoking products. Review of Resident #1's Medical Record indicated there was no documentation to support Unit Manager #1's allegation that staff had witnessed him/her smoking and/or vaping in his/her room. Review of a Facility Grievance Form, dated 06/13/23, indicated Resident #1's Family Member alleged that Unit Manager #1 called her on the phone (date not indicated on the form) and threatened that Resident #1 would be thrown out of the facility if his/her behaviors didn't stop and indicated that Unit Manager #1 used the expression I am tired of his/her shit. During an interview on 07/08/23 at 1:51 P.M., Resident #1's Family Member said she received a call from Unit Manager #1, who told her that she suspected Resident #1 was smoking and/or vaping in his/her room and she (Unit Manager #1) threatened that she could go through Resident #1's belongings at any time and if a vape pen was found, Resident #1 would get thrown out. The Family Member said that Unit Manager #1 told her [referring to Resident #1], We are not going to put up with his/her shit. The Family Member said Unit Manager #1 told her she was moving Resident #1 to a room where his/her bed was away from the window and he/she was not going to like that, but that he/she will just have to get along. The Family Member said that her husband and a friend both listened in on the call. The Family Member said she reported Unit Manager #1's unprofessional attitude and threats made during the phone call to the Social Worker Assistant on 06/12/23. The Family Member said that Resident #1 liked sitting by the window, with it slightly open because he/she liked the breeze. The Family Member said Resident #1 preferred to keep his/her cigarettes in his/her room because when they were kept at the nurses' station, sometimes cigarettes were missing. The Family Member said Resident #1 kept his/her cigarette lighter at the nurses' station until he/she went outside to smoke. The Family Member said Resident #1 told her that he/she felt as though Unit Manager #1 was targeting him/her, and told her that Unit Manager #1 often yelled, or snapped at him/her, and falsely accused him/her of smoking in his/her room. The Family Member said Resident #1 told her that he/she felt Unit Manager #1 moved him to another room, away from the window, as punishment for something he/she had not done (smoke in his/her room). During an interview on 07/05/23 at 12:30 P.M., Resident #1 said he/she was in the outdoor smoking area a few weeks ago when an unidentified staff member told him that his/her roommate (Resident #4) had gone through his/her personal belongings and found his/her cigarettes. Resident #1 said he/she re-entered the Facility and yelled at Resident #4 for going through his/her personal belongings, when Unit Manager #1 came out of her office and shushed him/her, yelled, and acted in a threatening manner toward him/her. Resident #1 said Unit Manager #1 scolded him/her for arguing with his/her roommate and then accused him/her of smoking in his/her room. Resident #1 said that a short while later, while he/she was in the outdoor smoking area, Unit Manager #1 changed his/her room without first providing reason for the change, that she had not shown him /her the room, had not given him/her choice, and never asked him/her about the moving. Resident #1 said that Unit Manager #1 changed him/her from a room where his/her bed was by the window, to a room where his/her bed was away from the window, while he/she was outside smoking. Resident #1 said that when he reentered the Facility, all of his/her belongings had already been moved to the new room. Resident #1 said that a Certified Nurse Aide (CNA, exact name unknown) told him/her that she was instructed by Unit Manager #1 to hurry up and change his/her room before he/she came back from his/her smoking break. Resident #1 further said that since the incident, he/she had not been offered a room change back to a room with a bed near the window. During an interview on 07/08/23 at 8:09 A.M., Certified Nurse Aide (CNA) #1 said that while she worked the day shift on 06/08/23, she observed Resident #4 walking in the hallway at around 1:00 P.M., with a cigarette in his/her mouth. CNA #1 said Resident #4 was confused at baseline and he/she was unable to tell her where he/she found the cigarette. CNA #1 said she took the cigarette away from Resident #4 and later followed him/her to his/her room (which he/she shared with Resident #1) where she observed him/her open Resident #1's bureau and pull out a pack of cigarettes. CNA #1 said she reported to Unit Manager #1 that cigarettes were found in Resident #1's bureau. CNA #1 said that Resident #1 did have a lighter but it was at the nurses' station and she had not found one in the room. CNA #1 said that when Resident #1 returned from his/her smoking break, he/she yelled at Resident #4, near the nurses' station, for going through his/her belongings. CNA #1 said Unit Manager #1 came out of her office and told Resident #1 not to yell at Resident #4. CNA #1 said that Unit Manager #1 leaned over the nurses' station toward Resident #1, pointed her finger at him/her, scolded him/her like a child, and used an unprofessional tone of voice. CNA #1 said that when Resident #1 went back outside to the smoking area, after the confrontation, that was when Unit Manager #1 gave staff directive to quickly change his/her room before he/she returned from the smoking break. CNA #1 said she felt as though the room change was retaliation, for Resident #1 having smoking materials in his/her room. CNA #1 said she worked full time on Resident #1's unit and had never witnessed Resident #1 smoke in his/her room and had never smelled smoke or suspected him/her of smoking inside the facility. During an interview on 07/05/23 at 2:56 P.M., the Social Worker Assistant said that the Social Services Department was unaware of Unit Manager #1's plan to change Resident #1's room on 06/08/23, and said that a social worker was usually involved in the room change process to ensure consent was obtained, that all necessary parties are notified prior to the room change and to monitor and ensure the resident adjusts to the new room. The Social Worker Assistant said she received a call from Resident #1's Family Member on or around 06/12/23, who alleged that Resident #1 was being targeted by Unit Manager #1. The Social Worker Assistant said that the Family Member told her that Unit Manager #1 said words to the effect of she was sick of [Resident #1's] shit. The Social Worker Assistant said that she spoke with Resident #1 around 06/12/23 (exact date unknown) but said she could not confirm the date. The Social Worker Assistant said she had not documented her conversation with Resident #1 in his/her medical record. The Social Worker Assistant said Resident #1 told her that he/she did not understand the sudden change in rapport that he/she had with Unit Manager #1 and told her that he/she felt that he/she was being falsely accused by Unit Manager #1, of smoking in his/her room. The Social Worker Assistant said that Resident #1 had said that he/she had been caught with smoking materials in his/her room but had never smoked in the room and he/she felt Unit Manager #1's accusations insinuated he/she was a liar. The Social Worker Assistant said that to her knowledge Resident #1 had never been caught smoking in his/her room. During an interview on 07/6/23 at 12:47 A.M., Unit Clerk #1 said that on 06/08/23 during the day shift, Unit Manager #1 was very loud and stern during an argument she had with Resident #1 near the nurses' station. Unit Clerk #1 said in the early afternoon that day, (exact time unknown) Unit Manager #1 had an argument with Resident #1 about cigarettes that were found in his/her room that day. Unit Clerk #1 said that Unit Manager #1 told him that she was suspicious that Resident #1 was cracking open the window and smoking in his/her room and said that she thought he/she should not be allowed to have a bed next to the window. Unit Clerk #1 said he wasn't aware that Resident #1 had ever been caught smoking in his/her room. Unit Clerk #1 said he and CNA #2 were directed by Unit Manager #1 to move Resident #1's belongings from his/her room where his/her bed was by the window, to a room where the bed would now be by the door (not the window). Unit Clerk #1 said Unit Manager #1 told him we need to get this done, and the urgency was because she wanted the room changed before Resident #1 came back from his/her smoking break. During an interview on 07/05/23 at 2:05 P.M., Certified Nurse Aide (CNA) #2 said that she was directed by Unit Manager #1 to move Resident #1's belongings from his/her room where his/her bed was by the window, to another room where his/her bed would be by the door. CNA #2 said that she was not aware, at the time of the move, that Unit Manager #1 had not provided Resident #1 with notification of the room change or that he/she had not given his/her consent. CNA #2 said that she later (shortly after the move) heard Unit Manager #1 say words to the effect she was teaching Resident #1 a lesson by moving him/her. During an interview on 07/06/23 at 4:41 P.M., Unit Manager #1 said Resident #1 had a history of smoking and vaping in his/her room. Unit Manager #1 said she went to see Resident #1's roommate on the morning on 06/08/23, and through the mirror on the wall, she noticed Resident #1 was sitting next to the window and it appeared as though he/she was hiding something. Unit Manager #1 said it looked like he/she took something from his/her mouth and put it in his/her wheelchair and she suspected he/she was possibly smoking by the window with a vape pen. Review of Unit Manager #1's Progress Notes, dated 06/08/23, indicated she witnessed Resident #1 using a vape pen that morning. However, during the Surveyors interview with Unit Manager #1, she said that while she suspected Resident #1 had used a vape pen that morning, said she had not recovered one. Unit Manager #1 said that later that day, CNA #1 reported to her that Resident #4 found cigarettes in Resident #1's bureau. Unit Manager #1 said Resident #1 was supposed to keep his/her cigarettes at the nurses' station. Unit Manager #1 said someone must have told Resident #1 because he/she came back into the facility from smoking outside and he/she was very upset. Unit Manager #1 said Resident #1 yelled at Resident #4 for going through his/her things and taking a cigarette. Unit Manager #1 said she decided in the afternoon of 06/08/23, to move Resident #1 away from his/her window bed and to keep his/her roommate safe at approximately 1:50 P.M., after texting the administrator for permission. Unit Manager #1 said she had not involved social services in the room change, and had not obtained his/her consent before moving him/her to a new room, away from the window. Unit Manager #1 further said it was her understanding that residents residing on a Medicare Unit and receiving skilled services could be moved without notification or consent. Unit Manager #1 said Resident #1's room was changed while he/she went outside for a second time that afternoon to smoke, at around 1:50 P.M. During an interview on 07/08/23 at 12:55 P.M., Nurse #2 said that Resident #1 told him he/she was very frustrated and upset for being accused by Unit Manager #1 of smoking in his/her room when she had no proof that he/she had ever done that. Nurse #2 said he worked full time on Resident #1's unit, was often Resident #1's assigned nurse and he had never witnessed him/her smoke in his/her room. During an interview on 07/05/23 at 1:30 P.M., Nurse #1 said she worked full time, four days per week on the Resident #1's Unit and said that she worked the day shift on 06/08/23. Nurse #1 said Unit Manager #1 accused Resident #1 of smoking in his/her room and that she heard Unit Manager #1 say to Resident #1 words to the effect of I know you are vaping in your room, I know you have been breaking the rules. Nurse #1 said there was no proof that Resident #1 had been smoking in his/her room. Nurse #1 said Unit Manager #1 openly argued with Resident #1, had not treated him/her with dignity or respect and said that when Resident #1 got louder, Unit Manager #1 yelled even louder at him/her. Nurse #1 said that when Resident #1 became upset about his/her room being changed while he was outside smoking, he/she yelled at Unit Manager #1, and said words to the effect of you are colluding against me, and that Unit Manager #1 responded to him/her saying go call your daughter to pick you up. During an interview on 07/05/23 at 4:53 P.M., the Administrator said that Unit Manager #1 sent her a text that indicated she wanted to change Resident #1's room and that she agreed, thinking it was the beginning of a conversation. The Administrator said she had not anticipated that Unit Manager #1 would immediately carry out the room change without involving social services or following Facility Policy. The Administrator said Unit Manager #1 was suspicious that Resident #1 may have been smoking or vaping in his/her room but he/she had never been caught smoking inside the facility. The Administrator said a vape was found in his/her room, around the date he/she was admitted but it had been taken away and there had never been any incidents involving Resident #1 smoking in his/her room. The Administrator said that Unit Manager #1 should have involved social services when Resident #1 was arguing with his roommate, allegedly smoking in his/her room, and/or exhibiting verbal outbursts. The Administrator said the room change should have been part of an interdisciplinary team discussion and decision versus a knee jerk reaction by Unit Manager #1. The Administrator further said that a lock box had been issued to Resident #1 since the incident, to safely keep his/her cigarettes in his/her room, however they had not considered offering him/her a change back to a room where his/her bed would again be by the window.

Based on observation, interview and record review, the facility failed to ensure staff notified the physician of: (1) A change in the treatment plan, specifically a missed hemodialysis (procedure used to remove waste and fluid from the blood when the kidneys stop working) visit, for one Resident (#205) out of one applicable sampled resident, and (2) A change in condition, specifically a new pressure ulcer, for one Resident (#88) out of three applicable sampled residents. Findings include: 1. Resident #205 was admitted to the facility in June 2022 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's progress note, dated 6/14/22, indicated the Resident requested to see the physician due to increased [CONDITION(S)] (swelling) over the legs and face, and also some shortness of breath. The assessment plan included documentation to continue with hemodialysis three days a week. Further review indicated the Resident had anasarca (generalized swelling) as evidenced by fluid overload and the physician discussed this finding with the nephrologist (kidney specialist) who agreed to evaluate the Resident and perhaps remove more fluid at hemodialysis. During an interview on 6/15/22 at 9:15 A.M., with the Resident, the Resident said that he/she was supposed to get picked up for [CONDITION(S)] at 9:00 A.M. but a nurse told him/her that there was a problem with transportation. Review of the progress notes for 6/15/22 did not indicate the physician was notified of the missed hemodialysis visit. During an interview on 6/16/22 at 7:59 A.M., Nurse #6 said she had Resident #205 on her assignment but she wasn't regular staff (worked for an agency) and didn't really know the residents. She said she could get someone else to answer questions. During an interview on 6/16/22 at 8:34 A.M., with the Director of Nurses (DON) and the Corporate Clinical Specialist, the surveyor asked if there was evidence that the physician was notified of the missed [CONDITION(S)] appointment yesterday and the DON and Clinical Specialist said no. The Corporate Clinical Specialist said there should have been a note written if the physician was notified. The DON said she understood the resident was not medically stable so physician notification was very important. Review of a progress note, dated 6/16/22 at 9:04 A.M., indicated the Resident had 2+ pitting [a measurement done by applying pressure to the affected area and then measuring the depth of the pit (depression) and how long it lasts (rebound time)]. (Grade 2+ indicates 3-4 millimeters of depression rebounding in 15 seconds of less) [CONDITION(S)] to both lower extremities (below the knees) and complained of shortness of breath. The physician was notified that the Resident did not receive [CONDITION(S)] yesterday as scheduled due to transportation and a new order was obtained to send the Resident to the hospital if unable to get to [CONDITION(S)] today. During an interview on 6/16/22 at 10:10 A.M., the DON said the Resident was sent to the hospital via ambulance to receive [CONDITION(S)] treatment. Refer to F 698 2. Resident #88 was admitted to the facility in May, 2022. Review of the facility policy for Skin Integrity Management, revised 6/1/21, indicated the following: Notify physician to obtain orders. Review of the Minimum Data Set assessment, dated 5/26/22, indicated the resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of 15, required extensive assistance for bed mobility and transfers, had no pressure injuries but was at risk of developing them. Review of a nursing progress note, dated 6/1/22, indicated Resident #88 was readmitted from the hospital that day. The writer, the Director of Nurses, observed a Stage II pressure injury with a foam dressing to the left heel. There was no further documentation to indicate the physician had been notified, or further orders obtained to treat the Stage II pressure injury. Review of the 6/1/22 physician's orders indicated no orders for a pressure injury to the left heel as of 6/14/22 at 8:00 A.M., when reviewed by the surveyor. During an interview and observation on 6/14/22 at 4:38 P.M with Nurse #3, Nurse #3 removed the dressing from Resident #88's right heel (initially documented as the left heel). Nurse #3 removed the dressing and said the resident had an unstageable pressure area with 100% slough, making the wound unstageable. Nurse #3 said she was unaware of the wound, and that the physician had not been notified as far as she knew. No wound was observed on the left heel. During an interview on 6/15/22 at 7:30 A.M., Nurse #4 said he worked last Sunday, 6/12/22, on the 11:00 P.M. to 7:00 A.M. shift, on the unit where Resident #88 resides. Nurse #4 said he put a dressing on the resident's right heel after Certified Nurses Aide (CNA) #1 had reported the wound to him. Nurse #4 said he did not have, or obtained, a physician's order for the right heel dressing. Nurse #4 said he did not observe a previous dressing on the right heel. He described the area to the surveyor as a Stage I pressure injury (intact skin with non-bleachable redness), going to a Stage II pressure injury. During an interview on 6/15/22 at 8:06 A.M. with the DON, she said she was working on the unit the evening Resident #88 was readmitted from the hospital. She said the resident returned with a foam dressing on his/her heel because of a Stage II pressure area. She said she could not recall obtaining physician's orders or notifying the physician of the wound. See F656

Based on observation, interview and record review the facility failed to provide appropriate care and services for two Residents (#88 and #69) out of a total sample of 23 residents, by failing to obtain and implement physician's orders and provide appropriate assessment of existing wounds. Findings include: Review of the facility policy for Skin Integrity Management, revised 6/1/21, indicated the following: -Perform skin inspection on admission/re-admission and weekly. Document on the Treatment Administration Record (TAR) or in the electronic health record (EHR). -Implement special wound care treatment/techniques as ordered -Notify physician to obtain orders -Perform wound observations and measurements upon initial identification of altered skin integrity, weekly and with anticipated decline of wound. 1. Resident #88 was admitted to the facility in May, 2022. For Resident #88 a wound, observed upon readmission from the hospital, on his/her heel progressed from a Stage II pressure injury (sore that has broken through the top layer of skin and part of the layer below, and may appear as a shallow open wound, or a blister containing clear or yellow fluid), to an unstageable heel wound (full thickness tissue loss covered with slough or eschar-dead tissue). Review of the Minimum Data Set (MDS) assessment, dated 5/26/22, indicated the resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of 15, required extensive assistance for bed mobility and transfers, had no pressure injuries but was at risk of developing them. Review of the care plan for skin risk indicated an intervention for weekly skin checks, initiated on 5/13/22, to be done by a licensed nurse, as well as an intervention to observe skin condition daily with care, also initiated on 5/13/22. Review of the EHR did not indicate that any weekly skin check had been done since the resident's most recent date of admission. Review of a nursing progress note, dated 6/1/22, indicated Resident #88 was readmitted from the hospital that day. The writer, the Director of Nurses (DON), observed a Stage II pressure injury with a foam dressing to the left heel. There was no further documentation to indicate the physician had been notified, or further orders obtained to treat the Stage II pressure injury. Review of the 6/1/22 physician's orders indicated no orders for a pressure injury to the left heel as of 6/14/22 at 8:00 A.M., when reviewed by the surveyor. On 6/14/22 at 9:37 A.M. the surveyor observed Resident #88 lying in bed. He/she had socks on and a pair of Velcro style sandals with rubber soles and a Velcro strap across the back of each heel and Achilles tendon. During an interview on 6/14/22 at 4:22 P.M., Certified Nurses' Aide (CNA) #1 said she cared for Resident #88 often. She said she noticed a wound on Resident #88's right heel (as opposed to the left, that was documented in the 6/1/22 progress note) and reported it to Nurse #4, who put a dressing on it. CNA #1 said the resident wanted to wear his/her sandals in bed. During an interview and observation on 6/14/22 at 4:38 P.M. with Nurse #3, Nurse #3 removed the dressing from Resident #88's right heel. She said the dressing had no date or time on it so she could not say how long the dressing had been there. Nurse #3 said the back strap of the resident's sandal was exactly where the wound was and was likely causing pressure. Nurse #3 removed the dressing and said the resident had an unstageable pressure area with 100% slough, making the wound unstageable. Nurse #3 said she was unaware of the wound, and that the physician had not been notified as far as she knew. No wound was observed on the left heel. During an interview on 6/14/22 at 5:01 P.M., CNA #1 said that when she first saw the wound last it was just a little skin tear on the right heel, but she couldn't remember exactly when that was, just that it was when Nurse #4 last worked on the unit. During an interview on 6/15/22 at 7:30 A.M., Nurse #4 said he worked last on Sunday, 6/12/22, on the 11:00 P.M. to 7:00 A.M. shift, on the unit where Resident #88 resides. Nurse #4 said he put a dressing on the resident's right heel after CNA #1 reported the wound to him. Nurse #4 said he did not have, or obtain, a physician's order for the right heel dressing, and did not write a progress note or report the wound to the next shift. He said there was one nurse and one CNA working on the unit that night for the entire shift and they felt overwhelmed. He said there were about 32 residents on the unit as best as he could recall. Nurse #4 said he did not observe a previous dressing on the right heel. He described the area to the surveyor as a Stage I pressure injury (intact skin with non-bleachable redness), going to a Stage II pressure injury. During an interview on 6/15/22 at 8:06 A.M. with the DON, she said she was working on the unit the evening Resident #88 was readmitted from the hospital. She said the resident returned with a foam dressing on his/her heel because of a Stage II pressure area. She said she could not recall obtaining physician's orders or notifying the physician of the wound. During an interview on 6/15/22 at 3:38 P.M. with the Corporate Clinical Nurse, he said no weekly skin checks could be located since the resident's admission in May 2022. See F725 2. For Resident #69 the facility failed to ensure staff: (a) measured two pressure ulcers weekly, (b) provided the physician ordered wound care and (c) obtain wound care orders for a pressure ulcer on the sacrum. Resident #69 was admitted to the facility in January 2022 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . a. Review of a progress note, dated 3/4/22, indicated the Resident had a deep tissue injury (DTI-defined by the National Pressure Injury Advisory Panel (NPIAP) as a purple or maroon localized area of discolored skin or blood filled blister due to damage of underlying soft tissue from pressure or shear) on the right heel. Review of a Nurse Practitioner's (NP) note on 4/22/22 indicated the Resident had a right lateral foot, under the 5th toe, DTI; looked like the bootie was causing the pressure due to malalignment of the right leg. The NP spoke with physical therapy about an alternative boot. On 6/15/22 at 7:24 A.M., the surveyor, along with Nurse #1 observed the Resident's right foot. The surveyor observed Nurse #1 provide wound care to the right foot. Nurse #1 removed a prevalon boot to right foot and an undated kling wrap (there was no Xeroform on the wound). The right lateral foot had a darkened area (scab like) under the small toe. The right heel had dark tissue with a dry open area, and no drainage. Nurse #1 applied skin prep to both areas and DPD with kling (the physician's orders indicated to apply Xeroform). During an interview on 6/15/22 at 8:24 A.M., Nurse #1 said she understood there were concerns about how confusing the orders were and she would straighten them out. Review of the clinical record indicated no wound measurements for either areas. During an interview on 6/15/22 at 1:09 P.M., the DON said the wounds were considered to be pressure related and should have been measured weekly but weren't. b. Review of an Orthopedic consult, dated 4/29/22, indicated the Resident was seen for a follow up appointment related to right hip surgery done in January 2022. Further review indicated the physician noted a bandage to the right foot, and the area looked to be almost a fracture blister on the dorsal lateral aspect of the foot by the base of the fifth metatarsal at the tarsal metatarsal joint. The right foot was washed with alcohol and prepped with [MEDICATION(S)], a blade was used and the blister was unroofed and debrided. The wound was then thoroughly irrigated with saline, Xeroform and a dry dressing applied. The plan included saline rinse daily and Xeroform dry sterile bulky dressing, keep the pressure off of the foot in bed. Review of the June 2022 physician's orders indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Review of a wound consult note, dated 6/10/22, indicated the Resident had a new stage three pressure ulcer (defined by NPIAP as full thickness loss) on the sacrum (bottom of spine) that measured 0.8 cm x 0.8 cm x 0.1 cm depth with moderate amount serous exudate. The wound bed was 80% yellow necrosis (dead tissue) and 20% granulation (healing). The wound was debrided (damaged tissue removed) at the bedside. The plan included to apply Alginate (highly absorbent, non-occlusive dressing) and foam to the sacrum wound daily and as needed. Review of the June 2022 physician's orders, indicated an order to cleanse the right buttock (the wound referenced above is on the sacrum, not right buttock) with wound cleanser, pat dry and apply foam dressing daily. Further review indicated no treatment orders for the sacral wound. On 6/15/22 at 7:24 A.M., the surveyor observed Nurse #1 provide wound care. Nurse #1 removed a foam dressing from the sacral area. Nurse #1 said it was odd that the dressing was in that location since the order indicated it was on the right buttock. Upon removal of the dressing, the surveyor observed an open area with a yellow wound bed and some redness surrounding the wound. Nurse #1 cleansed the wound with saline, applied sure prep (topical skin protectant) to surrounding skin and then applied a foam dressing with border. There was a small reddened area on the right buttock which was intact. During an interview on 6/15/22 at 1:09 P.M., the DON said per the wound consult the sacrum should have been Alginate with a foam dressing. She reviewed the physician's orders and said there were no orders put in place after the wound consult and there should have been. She said she understood there were multiple concerns related to the resident's wounds.

Based on observation, interview and record review, the facility failed to ensure staff provided [CONDITION(S)] services; specifically, failed to (1) provide transportation to a [CONDITION(S)] treatment appointment, (2) obtain post [CONDITION(S)] weight from [CONDITION(S)] center, (3) monitor hemodialysis catheter site, and (4) obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #205) out of one applicable sampled resident. Findings include: Resident #205 was admitted to the facility in June 2022 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Review of a physician's progress note, dated 6/14/22, indicated the Resident requested to see the physician due to increased [CONDITION(S)] (swelling) over the legs and face, and also some shortness of breath. The assessment/plan included to continue with hemodialysis three days a week. Further review indicated the Resident had anasarca (generalized swelling) as evidenced by fluid overload and the physician discussed this finding with the nephrologist (kidney specialist) who agreed to evaluate the Resident and perhaps remove more fluid at hemodialysis. During an interview on 6/15/22 at 9:15 A.M., the Resident was lying in bed awake and said that he/she was supposed to get picked up for [CONDITION(S)] at 9:00 A.M. but a nurse told him/her that there was a problem with transportation. During an interview on 6/16/22 at 8:34 A.M., with the Director of Nurses (DON) and the Corporate Clinical Specialist, the DON said there was a problem getting transportation and that's why the Resident missed the [CONDITION(S)] treatment scheduled for 6/15/22. The DON said they called around and arranged for wheelchair transport to start on Friday 6/16/22. The surveyor asked how they were able to arrange transportation for 6/17/22 but were unable to for 6/15/22 and she said that they probably couldn't do it yesterday (6/15/22) because it was short notice. The surveyor asked if the facility offered to pay for the transportation and the DON said she didn't think that was an option due to insurance. Review of a transportation service agreement, provided by the facility and dated 4/8/22, included that transportation would be provided for non-emergency medical transportation ([CONDITION(S)] included). The facility will pay the transportation company for services provided unless other arrangements were made. 2. Review of the June 2022 Treatment Administration Record (TAR) indicated an order to record post [CONDITION(S)] weight from the [CONDITION(S)] center book on Mondays/Wednesdays/Fridays. Review of the [CONDITION(S)] center communication books, indicated a communication form was completed on 6/10/22 and the Resident's post [CONDITION(S)] weight was 72.8 kilograms (kg). There was no communication form from the [CONDITION(S)] treatment on 6/13/22. Review of the June 2022 TAR indicated on 6/10/22 and 6/13/22 the post [CONDITION(S)] weight was recorded at 72.8 kg. Review of the progress notes for 6/13/22 did not indicate the [CONDITION(S)] center was called to obtain the post weight information. During an interview on 6/16/22 at 8:34 A.M., the Corporate Clinical Specialist said it would be very unlikely that the weight was exactly the same on both days. He said he would look into and see if any other information could be found. No further information was provided to the surveyor during the survey period. 3. On 6/15/22 at 9:41 A.M., the surveyor observed the Resident lying in bed. The Resident told the surveyor he/she had a port (tube placed in a large vein to be used for [CONDITION(S)]) that was used for [CONDITION(S)]. The surveyor observed a port with two lumens (the accessible ends of the port) to the right chest wall with a dressing over it, dated 6/8/22. There was a moderate amount of dried blood around the insertion site. The Resident said the dressing care was provided by the [CONDITION(S)] center staff. Review of the June 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Further review of the June 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/15/22 at 3:18 P.M., the Corporate Clinical Specialist said the [CONDITION(S)] port should have been monitored to ensure the dressing was intact, for signs or symptoms of infection, and to ensure the lumens were clamped. He said there should have been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure staff provided Resident #1 (who required two staff members to assist with personal care) with the required assistance to prevent an accident that resulted in Resident #1 falling out of bed and hitting his/her head. Resident #1 was transferred to the hospital as a result of the fall and diagnosed with [REDACTED]. Findings include: The Facility Policy titled, Accidents/Incidents, dated 11/26/16, indicated that: -an accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident/patient. -Staff will use the Risk Management System (RMS) to report, review, and investigate all accidents/incidents which occurred, or allegedly occurred or involved a patient who is receiving services. Resident #1's Face Sheet indicated that he/she was admitted to the Facility in (MONTH) (YEAR) and [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 12/19/18, indicated that he/she had moderately impaired cognition, required extensive assistance from two staff members for personal hygiene, dressing, bed mobility, and toilet use. Resident #1's Activities of Daily Living (ADL), Plan of Care, dated 01/02/19, indicated that Resident #1 was dependent on ADL care due to multiple comorbidities resulting in limited mobility, weakness, and fatigue. The Plan of Care indicated Resident #1's ADL care would be anticipated and met by two staff providing assistance with personal hygiene, dressing, bed mobility, and toilet use. The Event Summary Report, completed by Nurse #3, dated 01/07/19, indicated that while Certified Nurses Aide (CNA) #1 provided care to Resident #1 by herself, Resident #1 fell out of bed, sustained a head injury, and was sent out to the hospital for an evaluation. Resident #1's Hospital Discharge Summary, dated 01/07/18, indicated Resident #1 sustained a right femoral neck fracture as a result of his/her fall. The Surveyor interviewed CNA #4 at 12:22 P.M. on 01/30/19. CNA #4 said that approximately 5:45 A.M. on 01/07/19, she provided personal care to Resident #1 by herself because she forgot to ask another staff member for assistance. CNA #4 said she knew Resident #1's Plan of Care required two staff members to provide personal care for Resident #1. The Surveyor interviewed the Director of Nurses (DON) at 11:33 A.M. on 01/18/19. The Director of Nurses said she interviewed CNA #4 regarding the events that occurred prior to Resident #1's fall out of bed. The DON said CNA #4 admitted to providing care to Resident #1 by herself, despite having known that Resident #1's Plan of Care required two staff members to provide personal care.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that two staff members provided personal care to Resident #1, as indicated on his/her Plan of Care, when CNA #4 provided personal care to Resident #1 without assistance and Resident #1 fell out of bed and sustained a [MEDICAL CONDITION]. Findings include: The Facility Policy titled, Accidents/Incidents, dated 11/26/16, indicated that: -an accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident/patient. -Staff will use the Risk Management System (RMS) to report, review, and investigate all accidents/incidents which occurred, or allegedly occurred or involved a patient who is receiving services. -Any incident that may be considered an allegation of abuse or neglect against an elderly person is managed in accordance with the Abuse Prohibition Policy. Resident #1's Face Sheet indicated that he/she was admitted to the Facility in (MONTH) (YEAR) and [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 12/19/18, indicated that he/she had moderately impaired cognition, required extensive assistance from two staff members for personal hygiene, dressing, bed mobility, and toilet use. Resident #1's Activities of Daily Living (ADL), Plan of Care, dated 01/02/19, indicated that Resident #1 was dependent on ADL care due to multiple comorbidities resulting in limited mobility, weakness, and fatigue. The Plan of Care indicated Resident #1's ADL care would be anticipated and met by two staff providing assistance with personal hygiene, dressing, bed mobility, and toilet use. The Risk Management System (RMS) Event Summary Report, completed by Nurse #3, dated 01/07/19, indicated that while Certified Nurses Aide (CNA) #1 provided care to Resident #1 by herself, Resident #1 fell out of bed, sustained a head injury, and was sent out to the hospital for an evaluation. Resident #1's Hospital Discharge Summary, dated 01/07/18, indicated Resident #1 sustained a right femoral neck fracture as a result of his/her fall. The Surveyor interviewed Resident #1 at 10:45 A.M. on 01/18/19. Resident #1 said that a few days ago (prior to this interview), a CNA, later identified as CNA #1, came into his/her room around 3:00 A.M. to change his/her brief. Resident #1 said CNA #1 tried to move him/her in bed, so he/she tried to grab onto the bed rail because he/she was nervous about slipping out of bed. Resident #1 said he/she fell out of bed and then had to go to the hospital for several x-rays. The Surveyor interviewed CNA #4 at 12:22 P.M. on 01/30/19. CNA #4 said that on or about 5:45 A.M. on 01/07/19, she provided personal care to Resident #1 by herself because she forgot to ask another staff member for assistance. CNA #4 said she knew Resident #1's Plan of Care required two staff members to provide personal care for Resident #1. CNA #4 said Resident #1 was lying in bed on his/her side and facing her direction as she had just removed Resident #1's soiled brief and washed him/her up. CNA #4 said she started to put a clean brief on Resident #1 and just as she noticed Resident #1's bed sheets and mattress was wet, Resident #1 fell out of bed and onto the floor. The Surveyor interviewed Nurse #3 at 12:44 P.M. on 01/30/19. Nurse #3 said CNA #4 came to tell him that Resident #1 had an accident, so he walked to Resident #1's room and he saw Resident #1 lying on the floor with a bleeding [MEDICAL CONDITION]. Nurse #3 said that Resident #1 was sent to the hospital for an evaluation of his/her head injury. The Surveyor interviewed the Director of Nurses (DON) at 11:33 A.M. on 01/18/19. The Director of Nurses said she interviewed CNA #4 regarding the events that occurred prior to Resident #1's fall out of bed. The DON said CNA #4 admitted to providing care to Resident #1 by herself, despite having known that Resident #1's Plan of Care required two staff members to provided personal care. The DON said CNA #4 said that she was not thinking at the time she provide care by herself to Resident #1 but she was able to recognize that she had made a mistake by providing care to Resident #1 by herself.

Based on interviews and records reviewed, for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure that Resident #1 remained free from restraints imposed for convenience of staff. Sometime in the early morning on 10/31/16, CNA #1 restrained Resident #1 to his/her reclining wheelchair by securing a gait belt (a belt used to assist in walking and transferring) around Resident #1's waist and the back of the reclining wheelchair, to prevent Resident #1 from getting out of the reclining wheelchair. Findings include: Facility policy titled Restraints: Use of indicated patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and, if the device cannot be easily removed by the patient and/or restricts freedom of movement, a restraint evaluation will be completed. Facility policy titled Abuse Prohibition defined abuse as the wilful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Resident #1's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) evaluation, dated 8/31/16, indicated, Resident #1 had severe cognitive impairment. Resident #1 resided on the locked unit of the Facility. A Nurse Progress Note, dated 10/31/16, indicated, Resident #1 was found with a gait belt around him/her in the chair in the morning. CNA #1 was interviewed at 11:36 A.M., on 12/5/16. CNA #1 said she had worked the 11:00 P.M., to 7:00 A.M., shift starting 10/30/16 and ending on 10/31/16. CNA #1 said Resident #1 was restless throughout the shift, and was in his/her reclining wheelchair, near the Nurses' station for safety. CNA #1 said she asked Nurse #1 if she could put a gait belt around Resident #1 so he/she would not fall, and Nurse #1 said do what you have to do or words to that effect. CNA #1 said around 5:00 A.M., on 10/31/16, she fastened a gait belt around Resident #1's waist and around the back of the reclining wheelchair while she provided care to other residents on the unit, and she forgot to remove the gait belt at the end of the shift. CNA #1 said she did not think of the gait belt being secured around Resident #1's waist and the back of the chair as a restraint, but as a way to keep him/her from falling, or words to that effect. This was inconsistent with Facility policy. Nurse #1 was interviewed at 9:47 A.M., on 12/5/16. Nurse #1 said in the early morning on 10/31/16, Resident #1 was in his/her reclining wheelchair near the Nurses' station, and was restless and trying to get up from the wheelchair. Nurse #1 said CNA #1 told her she was going to put a safety belt on Resident #1, and she thought CNA #1 meant Resident #1 had an order for [REDACTED].#1 said she did not check for a physician's orders [REDACTED]. Nurse #1 denied knowing CNA #1 had restrained Resident #1 to his/her reclining wheelchair using a gait belt. CNA #2 was interviewed at 10:25 A.M., on 12/5/16. CNA #2 said when she reported to the unit at 6:00 A.M., on 10/31/16, Resident #1 was sleeping, covered in a blanket, in his/her reclining wheelchair in the hallway near the Nurses' station. CNA #2 said she brought Resident #1 to his/her room and when she removed the blanket she noticed there was a gait belt around Resident #1's waist that was fastened around the back of his/her reclining wheelchair, restraining Resident #1 in the reclining wheelchair. CNA #2 said CNA #3 was in the room and witnessed the gait belt secured around Resident #1's waist and the back of the reclining wheelchair. CNA #3 was interviewed at 3:07 P.M., on 12/5/16. CNA #3 said, at the beginning of her shift, around 6:00 A.M., on 10/31/16, she witnessed Resident #1 asleep in his/her reclining wheelchair in the hallway near the Nurses' station, with a blanket covering him/her. CNA #3 said she noticed a gait belt around Resident #1's waist, but did not see that it was around the back of the reclining wheelchair until she and CNA #2 were about to transfer Resident #1 to bed, CNA #2 removed the blanket, and noticed the gait belt was fastened around the back of the reclining wheelchair, restraining Resident #1 to the reclining wheelchair. Resident #1 was unable to be interviewed, due to cognitive loss, therefore, he/she was unable to express emotional harm from having been restrained to his/her wheelchair, however, a reasonable person would have suffered emotional harm and upset from being restrained.

Based on interviews and records reviewed, for 1 of 3 sampled residents (Resident #1) the Facility failed to ensure that Resident #1 remained free from restraints imposed for convenience of staff. Sometime in the early morning on 10/31/16, CNA #1 restrained Resident #1 to his/her reclining wheelchair by securing a gait belt (a belt used to assist in walking and transferring) around Resident #1's waist and the back of the reclining wheelchair, to prevent Resident #1 from getting out of the reclining wheelchair. Findings include: Facility policy titled Restraints: Use of indicated patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and, if the device cannot be easily removed by the patient and/or restricts freedom of movement, a restraint evaluation will be completed. Resident #1's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) evaluation, dated 8/31/16, indicated, Resident #1 had severe cognitive impairment. Resident #1 resided on the locked unit of the Facility. A Nurse Progress Note, dated 10/31/16, indicated Resident #1 was found with a gait belt around him/her in the chair in the morning. CNA #1 was interviewed at 11:36 A.M., on 12/5/16. CNA #1 said she had worked the 11:00 P.M., to 7:00 A.M., shift starting 10/30/16 and ending on 10/31/16. CNA #1 said Resident #1 was restless throughout the shift, and was in his/her reclining wheelchair, near the Nurses' station for safety. CNA #1 said she asked Nurse #1 if she could put a gait belt around Resident #1 so he/she would not fall, and Nurse #1 said do what you have to do or words to that effect. CNA #1 said around 5:00 A.M., on 10/31/16, she fastened a gait belt around Resident #1's waist and around the back of the reclining wheelchair while she provided care to other residents on the unit, and she forgot to remove the gait belt at the end of the shift. CNA #1 said she did not think of the gait belt being secured around Resident #1's waist and the back of the chair as a restraint, but as a way to keep him/her from falling, or words to that effect. This was inconsistent with Facility policy. Nurse #1 was interviewed at 9:47 A.M., on 12/5/16. Nurse #1 said in the early morning on 10/31/16, Resident #1 was in his/her reclining wheelchair near the Nurses' station, and was restless and trying to get up from the wheelchair. Nurse #1 said CNA #1 told her she was going to put a safety belt on Resident #1, and she thought CNA #1 meant Resident #1 had an order for [REDACTED].#1 said she relied on CNA #1's knowledge of the residents, and did not check for a physician's orders [REDACTED]. Nurse #1 denied knowing CNA #1 had restrained Resident #1 to his/her reclining wheelchair using a gait belt. CNA #2 was interviewed at 10:25 A.M., on 12/5/16. CNA #2 said when she reported to the unit at 6:00 A.M., on 10/31/16, Resident #1 was sleeping, covered in a blanket, in his/her reclining wheelchair in the hallway near the Nurses' station. CNA #2 said she brought Resident #1 to his/her room and when she removed the blanket she noticed there was a gait belt around Resident #1's waist that was fastened around the back of his/her reclining wheelchair, restraining Resident #1 in the reclining wheelchair. CNA #2 said CNA #3 was in the room and witnessed the gait belt secured around Resident #1's waist and the back of the reclining wheelchair. CNA #3 was interviewed at 3:07 P.M., on 12/5/16. CNA #3 said, at the beginning of her shift, around 6:00 A.M., on 10/31/16, she witnessed Resident #1 asleep in his/her reclining wheelchair in the hallway near the Nurses' station, with a blanket covering him/her. CNA #3 said she noticed a gait belt around Resident #1's waist, but did not see that it was around the back of the reclining wheelchair until she and CNA #2 were about to transfer Resident #1 to bed, CNA #2 removed the blanket, and noticed the gait belt was fastened around the back of the reclining wheelchair, restraining Resident #1 to the reclining wheelchair. Resident #1 was unable to be interviewed, due to cognitive loss, therefore, he/she was unable to express emotional harm from having been restrained to his/her wheelchair, however, a reasonable person would have suffered emotional harm and upset from being restrained.

Based on observation, record review and interviews, the facility failed to identify and provide the necessary care and services to attain or maintain the highest practible physical, mental, and psychosocial well-being for 1 resident (#1) in a sample of 21 residents. For Resident #1, the facility failed to identify and treat 3 scabbed areas on 2 toes on the right foot and 1 scabbed area on the left shoulder. Findings include: Resident #1 was admitted to the facility with [MEDICAL CONDITIONS] and convulsions. An annual minimum data set (MDS) completed on 2/20/13 and a subsequent quarterly MDS's completed on 5/16/13 and 8/7/13, indicated the resident's cognition could not be assessed due to being in a vegetative state. The resident is totally dependent on staff for all aspects of activities of daily living (ADL) and had no skin issues. Review of the record indicated an initial Occupational Therapy (OT) Evaluation was conducted on 9/3/13. According to the evaluation, the resident was referred to OT services by nursing due to the resident's headrest not always being aligned properly and the lower part has been pressing on the resident's neck. Nursing also stated that at times the resident gets some red pressure areas on his/her neck from the headrest. In addition, the evaluation noted the resident had impaired skin integrity including a scab on the top left shoulder, scab on the interphalangeal joints (joint between the first and second phalanges) on the 2nd and 3rd toe right foot and red area on top of the left foot. The treatment administration record (TAR) for the month of September 2013, indicated the resident was to have a weekly skin assessment conducted on Thursday 3:00 P.M. - 11:00 P.M. shift by a licensed nurse. Review of the TAR indicated skin checks were conducted on 9/5/13, 9/12/13 and 9/19/13. There was no documentation regarding the areas on the resident's toes. In addition, there was no treatment for [REDACTED]. On 9/24/13 at 9:45 AM., Nurse #1 was interviewed regarding the resident's skin condition. Nurse #1 stated the resident's skin is clear. The resident did have a scab on the left shoulder, but it is healed. On 9/24/13 at 9:50 A.M., Resident #1's skin was observed with Nurse #1. It was noted the resident had 2 scabbed areas on the 2nd toe of the right foot and 1 scabbed area on the 3rd toe of the right foot. The 2nd toe had a scabbed area approximately 0.3 x 0.4 centimeters (cm) on the upper part of the toe and a scabbed area approximately 0.2 x 0.2 cm on the lower part of the toe. The third toe on the right foot had a scabbed area approximately 0.3 x 0.2 cm. All the areas were unstagable. In addition, the residents left shoulder was observed and a small scabbed area was noted. At that time Nurse #1 was interviewed as to the cause of these areas. Nurse #1 stated sometimes the resident's feet press against the footboard of the bed due to the resident being so long. The scab on the left shoulder was caused by the headrest on the resident's wheelchair. On 9/24/13, the physician's orders [REDACTED]. After the surveyor and Nurse #1 observed the resident's area on 9/24/13, a physician's orders [REDACTED]. On 9/25/13 at 8:00 A.M., the Director of Nurses stated a longer bed and longer scoop mattress had been supplied to the resident the evening before. On 9/25/13 at 11:00 A.M., the nurse practitioner stated he/she was not aware of the areas on the resident's toes or shoulder. In addition, the corporate clinical nurse stated the areas on the resident's toes were arterial ulcers, not pressure sores. On 9/25/13, the Nurse Practitioner wrote a progress note indicating the areas on the toes are vascular [MEDICAL CONDITION] not pressure sores.