Every finding on record at Barre Gardens Nursing and Rehab, LLC

Based on interview and record review, the facility failed to report an incident of alleged abuse in the required timeframe for 1 of 3 sampled residents (Resident #1). Findings include: A facility investigative summary report dated 7/29/26 revealed an allegation of resident-to-resident abuse between Resident #! and Resident #2. The incident occurred on 7/28/26 at approximately 9:00 PM and was not reported to the State Licensing Agency until 7/29/26 at 4:22 PM, exceeding the required 2-hour reporting window. Per interview with the Administrator on 8/19/26 at 11:40 AM, she confirmed that the incident in question was not reported until Sunday afternoon. She had been under the understanding that she had up to 24 hours to report allegations of abuse. The facility abuse policy (no revision date) states on Pg. 5 that an alleged violation of abuse should be reported immediately and not later than Two (2) hours if the alleged violation involves abuse.

Based on interview and record review the facility failed to revise the person-centered care plan for 1 of 3 sampled residents (Resident #3) to address the risks of wandering behavior and resident-to-resident altercations. The findings include: Record review shows that Resident #3 has diagnoses that include dementia and generalized anxiety. Resident #3 has an MDS (Minimum Data Set, a resident assessment tool) dated 1/27/26, showing a BIMS (Brief Interview for Mental Status) result of 1 on a scale of 1 to 15, indicating severe cognitive impairment (the ability to perceive, learn, remember, reason, and problem-solve). Per record review, a nursing note on 2/27/26 states, Reported by short hall nurse that resident was in another residents [Resident #2] room, and the other resident pulled [her/him] away from the dresser and resident [Resident #3] fell on the floor. range of motion done and the short hall nurse stated resident held [her/ hand] and got off the floor. Per the facility investigative summary report submitted on 3/5/26 at 4:00 PM, a witness noted that Resident #2 was vocalizing loudly in his/her room and she entered to investigate. Resident #3 was observed standing up out of his/her wheelchair at Resident #2's dresser with a drawer open. Resident #2 was grasping Resident #3's hands to remove them from her/his dresser while stating out, causing Resident #3 to lose her/his balance and fall backwards. Per review of Resident #3's care plan, no focus or interventions were found addressing this resident-to-resident incident or addressing her/his wandering behavior and associated risk. Per interview with the Director of Nursing on 8/19/26 at 11:25 AM, she stated that Resident #3 has a history of wandering into other resident's rooms. This behavior has decreased but is ongoing. She confirmed that Resident #3's care plan does not address wandering or resident-to-resident interactions.

Based on observation, interview, and record review, the facility failed to follow, maintain, implement their legionella water management plan and implement the use of personal protective equipment when required. This has the potential to impact all residents. This is a repeat deficiency for this facility, with the violation cited during a previous partial survey, dated 11/13/25. Findings include: 1. Review of the facility's Legionella Water Management Plan included an assessment to identify areas for Legionella spread and measures to prevent growth and how to monitor them. Per interview with the Maintenance Director on 6/17/26 at 10:30 AM and 1:09 PM, he was unable to provide evidence of measures to prevent Legionella growth put in place and how the facility was monitoring them. He was unable to say what standards the facility was following for water safety practices. He said he disagreed with the plan and had thrown it away. Per interview with the Infection Preventionist and Director of Nursing (DON) on 06/16/2026 at 9:49 AM, when asked what water safety standards they were following, the DON reported that she would have to ask the Administrator and look to find out. Per review of the Legionella Water Management Plan, the first page identifies numerous dead legs (areas of water with no or minimal water movement that increases the risk for microbial growth) and states that the dead ends should be eliminated; however doing so is difficult because there is no practical way to isolate and valve them individually. It then states that stored water temperature is being stored at 120 degrees Fahrenheit and that the laundry storage tank is experiencing temperature issues and that it's temperature of 110 degrees Fahrenheits is below the expect range. It then states to effectively control Legionella, hot water should reach at least 140 degrees Fahrenheit, and states that the bacteria thrive in temperatures between 77-degree Fahrenheit and 122-degree Fahrenheit. It then states that unused fixtures and eyewash stations will be identified and incorporated into a routine flushing schedule as part of preventative maintenance. Additionally, it states All visible dead-end lines will be identified and documented. We will maintain records of their locations and obtain estimates for their removal to eliminate stagnant sections of the system. The plan then identifies that standardized forms and logs will be created and maintained like cleaning logs documenting dates, times, and specific access points serviced, as well as records of chlorine levels and overall sanitation . Per interview with the Administrator on 6/17/26 at 11:50 AM, she was unable to provide evidence that all identified measures and monitoring plans were being implemented from their Legionella Water Management Plan, other than the plans for the eye wash station and ice machine. Per review of the facility policy titled Legionella Water Management Program revised 9/2022 it states that the water management plan includes A system to monitor control limits and the effectiveness of control measures. It also identifies water storage tanks, water heaters, water stagnation, and water temperature fluctuations as being contributors to potential Legionella growth. It identifies that the water management team is the infection preventionist, the administrator, medical director or designee, the director of maintenance, and the director of environment services. 2.) Per observation of the laundry area on 6/16/26 at 8:54 AM, there were multiple washed Hoyer sling pads drying on top of each other. Additionally, there were cleaned mop heads drying in the dirty clothing/linen processing section of the laundry room. Per interview with a laundry staff employee on 6/16/26 at 8:54 AM, she reported that those were clean mop heads drying in the dirty section of the linen processing room. She also confirmed that there were multiple Hoyer Sling pads drying wet on top of each other. 3.) Per interview with a laundry staff employee on 6/16/26 at 8:54 AM, When asked how she processes dirty linen, she reported that she rolls up her sleeves and wears gloves. When asked if she wears a gown, she reported that she typically only wears gloves and that you can't always tell if linens are soiled until you are already handling them. Per interview with the Infection Preventionist on 06/16/2026 at 9:49 AM, when asked about the process for laundry staff handling dirty linens, she reported that she expected staff to wear gloves when handling linen and if there was a concern of bodily fluids that they should be wearing a gown. When discussing the potential for dirty linen to come in contact with the staff members clothes and then the staff member transitioning to handle clean clothes, she confirmed that it could be an infection control concern if the staff members clothes came in contact with dirty linen, and then handled clean clothes. She also confirmed that dirty linen should be kept away from clean linen. Per interview with the Infection Preventionist and Director of Nursing (DON) on 6/17/26 at 10:57 AM, they both confirmed that it's an infection control concern having wet Hoyer slings drying on other wet Hoyer slings. Per review of Centers for Disease Control and Prevention (CDC) G.Laundry and Bedding recommendations posted on 1/8/24, it states that Laundry workers should wear appropriate personal protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles. Per review of the facility policy titled Laundry Department Administration with an effective date of 3/2015, it states 13. Infection control rules and regulations shall be enforced for the laundry service .19. The collection, packaging, transportation and storage of soiled, contaminated, and clean linen is in accordance with all applicable infection control rules and procedures. Per review of the facility policy titled Personal Protective Equipment- Using Gowns revised on 9/2010 it states that the purpose is to guide the use of gowns with the identified objectives being to prevent the spread of infections, prevent soiling of clothing with infectious material, prevent splashing or spilling of blood or body fluids onto clothing or exposed skin. 4.) Per record review, Resident #10's care plan, last revised on 3/16/26, reveals s/he is on Enhanced Barrier precautions related to indwelling catheter use and nephrostomy tube. Interventions include: Implement Enhanced Barrier Precautions per CDC guidance [related to] foley catheter, nephrostomy. Staff to wear gown and gloves during high-contact care (e.g., bathing, dressing, toileting, wound or device care). Per observation on 6/15/2026 at approximately 12:43 PM, a nurse came into Resident #10's room without performing hand hygiene and moved the catheter bag, which was on the floor, without the appropriate protective personal equipment (PPE) and hooked it on to the bed.

Based on observation and interview, the facility failed to ensure that food items were stored in accordance with professional standards, that the kitchen was kept neat and orderly, and that food service equipment were clean or dry. This is a repeat deficiency for this facility, with the violation cited during the previous three recertification surveys, dated 6/25/25, 5/9/24, and 4/26/23, and partial survey dated 11/13/25. Findings include:During a tour of the kitchen with the Kitchen Manager on 6/15/2026 at approximately 9:56 AM, the following observations were made:sandwiches on a plate in the walk-in fridge, not dated. The Kitchen Manager confirmed that they were not dated.a bag of opened chicken cutlets in freezer, not dated. The Kitchen Manager confirmed that they were not dated.multiple juice spill puddles in the kitchen fridge. Per interview with the kitchen manager, he stated that the fridge gets cleaned at the end of each day.the standing mixer had dried food particles on it. The Kitchen Manager stated that they don't use it often, but confirmed that it was dirty and could use some attention.the kitchen floors were audibly sticky and dirty with particles on the floor. The kitchen manager verbalized that the floor is cleaned 2x day after lunch and at the end of the day.in the dry food storage room two dented cans were found, one of which was holding the door open as a door stop. The Kitchen Manager stated that they should not be there or used as a door stop.stored wet pans stacked on each other were found. The Kitchen Manager verbalized that he will educate his staff to ensure that they are completely dry before storing.The following kitchen observations were made on 6/16/2026 at approximately 8:28 AM:the kitchen floor was still audibly sticky, the standing mixer was still dirty. The Kitchen Manager confirmed that the floor and the mixer were still dirty.the pots were found to be stacked and stored wet. The Kitchen Manager confirmed that the pots were still wet and that he had not reviewed with the staff the importance of drying them before storing them. the kitchen fridge still had the same spill puddles as the previous day. The Kitchen Manager confirmed that the fridge was still dirty and that they did not get to clean it the day before.two more dented cans were found as a door stopper for the dry food storage room. The Kitchen Manager confirmed that the cans should not be there. Per observation on 6/17/2026 at approximately 12:00 PM, the kitchen floor was still sticky and the standing mixer was still dirty. Per the facility General Food Preparation and Handling Policy Revision Date 7/2023: 1. The kitchen is kept neat and orderly. A. the kitchen and equipment are clean.2. Food Storage. a. Foods are received, checked and stored properly as soon as they are delivered.c. Food in broken packages or swollen cans, cans with a compromised seal.4. Food Services.Leftovers must be dated, labeled.Use leftovers within 3 days or discard . 5. Equipment. a. All food service equipment should be cleaned, sanitized, dried, and reassembled after each use.

Based on observation, interview, and record review, the facility failed to ensure resident medications were properly stored for 2 out of 27 residents (Resident #70 and Resident #71). This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 6/25/25 and partial survey dated 11/13/25. Findings include: 1.) Per observation on 6/15/26 at 2:57 PM, Resident #70 had a bottle of Artificial Tears at their bedside table. Per interview on 6/15/26 at 3:00 PM with a Registered Nurse (RN), he reported that the bottle of Artificial Tears should be in the medication cart. Resident #70 indicated that they were again due for more drops and then self-administered in front of the RN. The RN showed no indications that he knew when the next drops were due. The RN then left the room leaving the bottle of drops behind after stating that they should be in the medication cart. Per interview on 6/15/26 at 3:36 PM with the Licensed Practical Nurse (LPN) assigned to the medication cart, she reported that a prescription medication like the Artificial Tear Drops should not be at the bedside and discarded the bottle. Per review of the Medication Labeling and Storage policy revised on 2/2023, it states that The Facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls . 2. Per observation of medication administration for Resident #71 on 6/17/2026 at 8:10 AM, the nurse placed medications on the bedside table and then left the room. Per observation, the resident self-administered the medications while the nurse was absent. Upon reentering the room, the nurse did not ask the resident if s/he had taken the medications. Per interview with the nurse on 6/17/2026 at 8:15 AM, she confirmed she should have remained with the resident to ensure medications were administered. Per interview with the Director of Nursing (DON) on 6/17/2026 at 8:20 AM, she confirmed that the nurse should have stayed with the resident to ensure medication administration. Per review of the facility's policy on medication administration, it states that a resident may self-administer medications with a written order from the physician. Per review of Resident #71's physician orders, there is no order for self-administration of medications.

Based on observation, interviews, and record review, the facility failed to keep nails trimmed for 1 of 27 residents (Resident #39). Findings include:Per interview on 6/15/2026 at approximately 10:37 AM, Resident #39 was observed to have very long nails and verbalized that they do not like it. Per record review, Resident #39's care plan states that they need assistance with personal hygiene/care. Per interview on 6/17/2026 at approximately 10:26 AM, the Licensed Nursing Assistant (LNA) verbalized that nails are done with resident care. Per interview on 6/17/2026 at approximately 10:34 AM, the Registered Nurse (RN) explained that residents' nails get done as needed on shower days. When in the residents' room the nurse confirmed that Resident #39's nails were too long and probably had not been done in some time.Per interview on 6/17/2026 at approximately 11:31 AM, the RN showed the shower list with the resident listed for every Tuesday evening. Per record review Resident #39's last shower was on 6/16/26.Per the facility's Fingernails/Toenails, Care of Policy, last revision in February 2018, .1. Nail care includes daily cleaning and regular trimming.

Based on observation, interviews, and record review, the facility failed to ensure that a resident was treated with dignity for 1 of 27 sampled residents (Resident #41). This is a repeat deficiency for this facility, with the violation cited during a previous partial survey, dated 11/13/25. Findings include:1.) Per interview on 6/15/2026 at approximately 11:28 AM, Licensed Nurse Aide (LNA) #1 was asked to bring Resident #41 to their room to speak in private. LNA #1 stated that the resident only answers the same things over and over again and is not all there. When in the room with Resident #41 they stated that they needed to go to the bathroom and became a little agitated worrying about the chair and floor getting wet.At approximately 11:37 AM, LNA #1 and #2 were transferring Resident #41 with the Hoyer lift. During this process the resident was becoming more agitated, upset, and concerned about getting the floor wet and stated that they didn't know what they were doing around here. LNA #1 then responded, in hearing range of Resident #41, that she knew asking all of those questions would agitate them and again stated that the resident was not all there after having a stroke.Per record review resident has a traumatic brain injury (TBI) and did not have a stroke. Per care plan last revised on 5/9/26, the resident is care planned for history of trauma related to life experience-TBI. Interventions include: If resident becomes upset during care, stop, ask what the resident needs, validate feelings and follow instructions of the resident. Encourage resident participation and encourage decision making.2.) Per observation on 6/16/2026 at approximately 8:22 AM, during breakfast Resident #41 requested for more coffee and was told no by LPN (Licensed Practical Nurse) #1 who stated that they already had 3 cups and was asked if they wanted some juice or water. Resident #41 stated no, more coffee please. The nurse said no and offered some water instead.Per record review Resident #41 is not on fluid restrictions and per their care plan, last revised on 5/9/26, Resident #41 has nutrition problem or potential nutritional problem related to hemiplegia, epilepsy, depression, anxiety, and TBI. Interventions include: Provide.with personal preferences.Per interview on 6/17/2026 at approximately 9:05 AM, the nurse verbalized that Resident #41 isn't difficult to understand and does not need any special tools of communication. She verbalized that the resident is able to verbalize their needs with no problem and that they love their coffee.Per the facility's Resident Rights Policy Revised Date June 2023: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:a. a dignified existenceb. be treated with respect, kindness, and dignity.h. exercise his or her rights as a resident of the facility and as a resident or citizen of the United Statesi. be supported by the facility in exercising his or her rights.t. be informed of and participate in development, planning and implementation of the resident's person-centered plan of care and treatment. receive the services and items included in the president's plan of care.

Based on observations and interviews, the facility failed to maintain a clean and homelike environment for residents who use the common areas by failing to maintain clean air vents for three out of three common areas. Findings include:Per review of the facility policy titled Departmental (Maintenance)-Plumbing, HVAC and Related Systems revised 2011, it states to clean air vents and air handling units at least annually.Per review of a NADCA (National Air Duct Cleaners Association) certified company, [NAME] Duct and Dryer Vent Cleaning LLC website (Duct and Vent Cleaning in Nursing Homes and Hospitals | [NAME] Duct & Dryer Vent Cleaning, LLC), they identify that air ducts (a system that distributes air throughout a building) can accumulate dust debris, allergens, and pathogens overtime and that in hospitals and nursing homes it can pose an increased risk to residents with compromised immune systems or respiratory issues leading to serious health risks. Additionally, it states that dirty ducts can circulate contaminants throughout a facility, potentially exacerbating chronic respiratory health conditions like asthma, allergies and other respiratory illnesses.Per observation at approximately 9:40 AM on 4/20/26 of the three resident common areas, there were 14 ceiling air vents that were observed to have a black and brown substance on them that appeared dark black, speckled, and fuzzy. In all three dining areas, all 14 air vents had black material on them covering a significant portion of the air vent about 50-75 percent.Per observation and interview with the Maintenance Director on 4/20/26 at 10:22 AM, he confirmed that the 14 ceiling air vents had a black and brown residue on them, with multiple ceiling tiles having brown stains. He stated that the brown stains appeared to be old water damage and that the ceiling vent fans appeared to be dusty. He stated that he did not have records on when they were last cleaned. He also confirmed that four sprinklers had a grey substance on them which he believed was dust in the wing 2 dinning area.Per interview with the Director of Nursing (DON) on 4/20/26 at 11:40 AM, she confirmed that there are 27 residents in the facility with chronic respiratory diagnoses. There was a total of 87 residents admitted .Per interview with the Infection Preventionist on 4/20/26 at 3:49 PM, she confirmed that the ceiling vents needed to be cleaned.Per interview with the Administrator and Maintenance Director on 4/20/26 at 3:54 PM, the Administrator stated that the ducts are cleaned annually per their policy and that it is the responsibility of the maintenance team. When asked if they should be cleaned when they become dusty, she indicated that they should be as well. The Maintenance Director reported that he was unaware of when the vents were last cleaned as they had not been cleaned since he came on to this role (approximately four months).

Based on interview, record review of the facility's Quality Assurance and Performance Improvement Program (QAPI), and facility policy review, the facility failed to address all systems of care in a comprehensive manner by identifying problems and opportunities for improvement in the areas of infection control, environment, and Medical Director. As a result, GAS (group A strep) spread through the facility and 12 residents developed symptoms of GAS. 2 of 3 sampled residents with symptoms of GAS were hospitalized with sepsis due to cellulitis (Residents #1 and #2). This citation is at the immediate jeopardy level as these failures put all residents at risk for serious harm and/or death. Findings include:Facility policy titled Quality Assurance and Performance Improvement, last revised 9/2022, reads Our facility will. Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.Steps for designing and implementing QAPI include, Our leadership team, which consists of the administrator, director of nursing, medical director, and key department managers, is responsible for creating and sharing the focus of QAPI. The leadership team in collaboration with QAPI teams will determine what data to monitor routinely so that performance targets can be established and benchmarks identified.Systemic action will be Based on the identified root cause of a problem, corrective action will be taken. The goal is to achieve improvement and prevent recurrence of the problem.Regarding QAPI Feedback, Data Systems, and Monitoring, Performance indicators will be developed for each aspect of care and services being monitored. A data collection and monitoring plan will be developed. Goals will be established. A complaint survey dated 11/13/25 revealed that the facility was found to have deficient practice related to the following regulatory requirements: safe, clean, comfortable, homelike environment (F584), food storage (F812), responsibilities of the Medical Director (F841), and infection prevention and control (F880). During a revisit and complaint survey dated 1/26/26, the facility remained out of compliance with the above regulatory requirements. See F584, F812, F841, and F880 for more information. 1. Review of QAPI meeting notes reveals the following:On 11/4/25, the team met to discuss a QAPI plan initiated on 11/3/25. Meeting notes reveal the areas of focus to be Group Strep A Outbreak/Prevention and IP (infection prevention) implementation. The plan identified action items for testing and discussion of education for hand hygiene, appropriate use of PPE (personal protective equipment) and appropriate cleaning methods were discussed to help stop the spread. The plan does not discuss performance indicators, a data collection plan, or goals.12/23/25 and 1/5/26 QAPI monthly Meeting notes include sections for regulatory issues, infection control, housekeeping, maintenance. Discussion notes describe regulatory deficiencies from the 11/13/25 and briefly describe some action items for housekeeping and maintenance. Notes do not include performance indicators, a data collection plan, or goals for these areas. Infection control notes do not include any information about the GAS outbreak.There is no evidence that the Medical Director or a designee participated in any of the 3 QAPI meetings listed above.2. Per phone interviews on 1/22/26 at 8:39 AM and 1/23/26 at 3:19 PM, the Administrator confirmed she was unable to provide performance indicators, a monitoring plan, or goals for the areas above in QAPI documentation. In regard to the GAS outbreak not being addressed in either the 12/23/25 or 1/5/26 QAPI meeting, she reveled that it was not addressed in QAPI as it was discussed during morning meetings. She confirmed that [NAME] Department of Health recommendations were not incorporated into the QAPI meetings.3. Per phone interviews on 1/21/26 at 1:04 PM and 1/26/26 at 8:08 AM, the Medical Director confirmed he was not in attendance for the 11/4/25, 12/23/26, or 1/5/26 QAPI meetings and does not have a designee. When asked how he was working with the clinical team to provide surveillance and help design or approve data collection instruments such as infection control reports, he explained that he is only involved if the facility asks for a review or alerts him to issues.

Based on observations, record reviews, and interviews, the facility failed to provide a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to S483.71 and following accepted national standards. This has the potential to impact all residents. Findings include: A review of the facility's Coronavirus Disease- Infection Prevention and Control Measures Policy Statement [Version 2.0 Revised 2023] includes: This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. Policy Interpretation and Implementation:1.The infection prevention and control measures that are implemented to address the SARS-CoV-2 pandemic are incorporated into the facility infection prevention and control plan. These measures include: a. encouraging staff, residents and visitors to remain up-to-date with all COVID-19 vaccine doses; and following current environmental infection prevention and control recommendations.A review of the facility's documented COVID-19 outbreak line listing revealed that 16 residents tested positive for COVID-19 between 11/2/25 and 11/13/25.1. An interview was conducted with the facility's Medical Director on 11/13/25 at 2:02 PM.The Medical Director [MD] stated the facility's Acting Physician [APhys] notified him this morning [11/13/25] of a COVID outbreak in the facility. The MD defined an outbreak as a single case. The MD stated [APhys] reported the first case was identified as 7- 10 days ago. The MD said his expectation was to be notified when the first case appeared. Per facility Infection Control records, the first COVID cases were identified 11 days prior, on 11/2/25: one resident, one staff member. As of the day of the extended survey [11/13/25], 8 staff members and 16 residents had tested positive for COVID infection.Per record review, 10 of 16 residents who tested positive for COVID as of 11/13/25 were sampled regarding having signed consent forms in October to receive the COVID vaccine and then having received the vaccine. Per record review, 2 of the 10 residents sampled refused consent to be vaccinated. Further review revealed the remaining 8 sampled residents had all consented to be administered the COVID vaccine, but none had received it prior to being infected by the virusPer interview with the Director of Nursing on 11/13/25, the facility had only begun vaccinating residents for COVID on 11/12/25, 10 days after the initial infection was identified, and 55 days after the Quality Assurance Performance Improvement meeting noting the facility would be receiving the COVID vaccine.See F887 for more information.2. Multiple observations of environmental conditions on 11/4/25 and 11/13/25 demonstrated a lack of overall sanitation and cleanliness affecting infection prevention in the facility. On 11/4/25, the corridors and residents' rooms' floors were dirty; various types of debris were noted; bathroom fans were covered with thick dust; and toilets were dirty, not clean inside or out, or the floor around the toilets. In one of the shower rooms, a lift bar/rail with a disposable rubber glove tied to the rail, a corner bead (a protective strip, typically made of vinyl or metal, that is installed on outside corners where two pieces of drywall meet to reinforce and protect the corner) going into the shower room revealed broken, rusted, and jagged metal. Many broken floor and wall tiles were noted throughout this area between the shower room, the tub room, and the bathroom. Sun Room on Wing 1 revealed trash cans without trash bags inside, a coffee carafe that was dirty with a brown substance on all sides; a drawer within a cabinet that contained packets of condiments noted to have what appeared to be food debris throughout the drawer and a puddle of a brown sticky substance; a chair with fabric back, armrests and seat that had a dried reddish brown substance in droplet form on the seat that was still accessible for use; a yellow substance that appeared to be scrambled eggs under a table and on the windowsill next to the table; a pillow without a pillow case on the steam table; the floors appeared dirty with spills and debris; and cooler cover was dirty. Wing 1 of the nurse's station revealed a thick pile of crumbs/debris in front of the nurse's station that went the length of the nurses' station. There was a used blood glucose test strip on the floor. The overbed table by the door bed was covered on the wheels and the metal support with a thick, dried, white, milky substance. The privacy curtains had a dried, brown substance on the outer edge and about 2 feet in from it. There was an uncovered pillow on the bed next to the window, with its plastic cover torn in several places, revealing its contents. On 11/13, Floors were dirty; various types of debris were noted; bathroom fans were covered with thick dust; toilets were dirty, not clean inside or out, or the floor around the toilets. In the bathrooms, observations included light-colored caulk between tiles on both floors and walls, with a buildup of black debris that appears to be mold and mildew. A shower chair had a pinkish-orange buildup of debris at the connections. There was debris behind the doors, including spider webs and rust on the doorframes, with holes where the frames met the floors. The bathtub chair foot supports have white residue, and a walker has a used bedsheet. A chair located in the corner had used resident socks. Debris and a brown, dried liquid were noted in the whirlpool.See citation F584 for additional information regarding clean, sanitary environment observations.3. Per interview with the (IP) on 11/13/25 at 3:00 PM, she confirmed that the facility's cleanliness is an issue. She explained that short staffing (two members left without notice) in the Housekeeping department has impacted regular scheduled cleaning. The IP also stated that the Administrator has implemented a plan for the leadership team to assist the Housekeeping department by cleaning five resident rooms per week.4. Per interview with the Administrator on 11/13/25 at 3:50 PM, she confirmed that the Housekeeping department isn't adequately staffed and that leadership team members (ten members) are assisting the department with resident room cleaning by cleaning five rooms weekly. When asked about education, training, or audits for cleaning, she stated that these areas had not been addressed and said, all had to do it before. The Administrator also confirmed high-touch surfaces (i.e., bedrails, doorknobs, light switches, call buttons, bedside tables, remote controls, or surfaces in bathrooms) are not regularly disinfected.5. Per the Centers for Disease Control and Prevention (CDC) Nursing Home Infection Preventionist Training Course - WB4973, Module 11-B, titled Environmental Cleaning and Disinfection 2025, slide 24 states, Common areas in the facility should also be cleaned and disinfected. High-touch surfaces in the facility's common areas, such as the family room or lounge, should be cleaned and disinfected when soiled and on a regular basis, such as daily.6. Per the CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings (2024), core practice for Environmental Cleaning and Disinfection states Clean and disinfect surfaces in close proximity to the patient and frequently touched surfaces in the patient care environment on a more frequent schedule compared to other surfaces. Reference:Centers for Disease Control and Prevention. (2025, September 15). Environmental Cleaning and Disinfection 2025. https://www.train.org/cdctrain/course/1131818/details Centers for Disease Control and Prevention. (2024, April 12). CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings. https://www.cdc.gov/infection-control/hcp/core-practices/index.html#:~:text=Require%20routine%20and%20targeted%20cleaning,contaminate%20the%20patient%2Dcare%20environmentCenters for Disease Control and Prevention. 2024, June 24). Infection Control Guidance: SARS-CoV-2. https://www.cdc.gov/covid/hcp/infection-control/#:~:text=test%20or%20NAAT-,Environmental%20Infection%20Control,-Dedicated%20medical%20equipment

Based on interview and record review, the facility failed to develop and implement policies and procedures to ensure when COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized.Findings include:A review of the facility's Coronavirus Disease- Infection Prevention and Control Measures Policy Statement [Version 2.0 Revised 2023] includes: This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. Policy Interpretation and Implementation:1.The infection prevention and control measures that are implemented to address the SARS-CoV-2 pandemic are incorporated into the facility infection prevention and control plan. These measures include: a. encouraging staff, residents and visitors to remain up-to-date with all COVID-19 vaccine doses.A review of the facility's documented COVID-19 outbreak line listing revealed that 16 residents tested positive for COVID-19 between 11/2/25 and 11/13/25. An interview was conducted with the facility's Medical Director on 11/13/25 at 2:02 PM. The Medical Director [MD] stated the facility's Acting Physician [APhys] notified him this morning [11/13/25] of a COVID outbreak in the facility. The MD stated [APhys] reported the first case was identified as 7- 10 days ago. The MD said his expectation was to be notified when the first case appeared. Per facility Infection Control records, the first COVID cases were identified 11 days prior, on 11/2/25: one resident, one staff member. As of the day of the extended survey [11/13/25], 8 staff members and 16 residents had tested positive for COVID infection.Per record review, 10 of 16 residents who tested positive for COVID as of 11/13/25 were sampled regarding having signed consent forms in October to receive the COVID vaccine and then having received the vaccine. Per record review, 2 of the 10 residents sampled refused consent to be vaccinated. Further review revealed the remaining 8 sampled residents [Resident #4, #11, #12, #13, #14, #15, #16, & #17] had all consented to be administered the COVID vaccine, but none had received it prior to being infected by the virus.Per interview with the Director of Nursing on 11/13/25, the facility had only begun vaccinating residents for COVID on 11/12/25, 10 days after the initial infection was identified, and 55 days after the Quality Assurance Performance Improvement meeting noting the facility would be receiving the COVID vaccine.

Based on observation and interview, the facility failed to ensure that all food was stored safely and to ensure that sanitary conditions for safe food handling were maintained. This has the potential to impact all residents. This is a repeat deficiency for this facility, with violations cited during the previous three recertification surveys, dated 4/26/23, 5/9/24, and 6/25/25. Findings include:A kitchen tour was conducted with a Dietary Staff Member on 11/13/25 at 11:40 AM. Per observation of the dry food storage area, the following items were found improperly stored:Gluten free pasta, (1) expired June 11, 2024, (3) expired July 20, 2024; Baking mix, expired 4/24/24; Pasta, expired May 3, 2025; Hormel Thick & Easy Clear Thickened Cranberry Juice Cocktail, dated 10/24, instructions on back of label discard if not used within 10 days of opening; andHormel Thick & Easy Clear Thickened Orange Juice Cocktail, dated 10/24, instructions on back of label discard if not used within 10 days of opening. Per interview on 11/13/25 at 11:55 AM, the Dietary Staff Member stated the above items should have been discarded and confirmed they were expired.Per observation of the walk-in refrigerator, the following item was found improperly stored: Two packages of deli ham stored on a tray with raw hamburger, sitting in raw meat juices. Per observation of the walk-in freezer, the following item was found improperly stored: A box of hamburger patties left open to air and not sealed. The Dietary Staff Member confirmed the observations in the walk-in refrigerator and freezer and stated that ready-to-eat foods should not be stored with/on/in raw meat and stated that prepared and open food containers and packages should be sealed. She/he confirmed that the above items were improperly stored. Per observation of the kitchen area the following were noted:Preparation trays, cups, and dishes were noted to be wet nesting (stored wet and not air dried). The floor fan facing the food preparation area noted to be covered with dust and debris. The Dietary Staff Member confirmed these observations.

Based upon observation, interview, and record review, the facility failed to ensure that areas used for bathing/showering, resident rooms, and a resident gathering area were clean, safe, and homelike. This deficient practice has the potential to affect all residents residing in the facility. This is a repeat deficiency for this facility, with the violation cited during the previous two recertification surveys, dated 6/25/25 and 5/9/24, and partial survey dated 4/17/25. Findings include: During the initial tour of the facility on 11/4/25 at approximately 10:40 AM the following observations were made: Wing 1 short hall, room [ROOM NUMBER] and room [ROOM NUMBER] appeared dirty with loose debris on the floor. At the end of Wing 1 short hall there was a room that contained a tub room, a bathroom, and a shower room. The tub room revealed a tub chair that had a loose white powdery substance on the seat and the foot pedals had a thick white and gray substance within the pattern of both foot pedals. The shower room area contained a rolling cart with the top shelf containing 3 bottles of hair conditioner, 2 bottles of shampoo, a bottle of body wash, a bottle of quaternary ammonium chloride disinfectant cleaner (a concentrated cleaning formula use to cut cleaning time and quickly wipe out a broad spectrum of bacteria, like viruses and fungi) and a handful of unboxed gloves. The second shelf on this rolling cart contained 2 boxes of gloves and 4 razors. The shower room revealed a lift bar/rail with a disposable rubber glove tied to the rail. The corner bead (a protective strip, typically made of vinyl or metal, that is installed on outside corners where two pieces of drywall meet to reinforce and protect the corner) going into the shower room revealed broken, rusted, and jagged metal. Many broken floor and wall tiles were noted throughout this area between the shower room, the tub room, and the bathroom. Per interview on 11/4/25 at approximately 10:55 AM with the travel LPN #1, they confirmed the noted concerns listed above. Observation on 11/4/25 at approximately 11:05 AM of the Sun Room on Wing 1 revealed trash cans without trash bags inside; a coffee carafe that was dirty with a brown substance on all sides; a drawer within a cabinet that contained packets of condiments noted to have what appeared to be food debris throughout the drawer and a puddle of a brown sticky substance; a chair with fabric back, armrests and seat that had a dried reddish brown substance in droplet form on the seat that was still accessible for use; a yellow substance that appeared to be scrambled eggs under a table and on the windowsill next to the table; a pillow without a pillow case on the steam table; the floors appeared dirty with spills and debris; and a cooler of ice with a gray coffee cup sitting on a cart next to the and the inside of the cooler cover was dirty. Outside the sunroom was a small area with a counter and a fridge. Upon the counter was a blue tray with partially eaten breakfast foods, coffee cups, and miscellaneous silverware. Per interview on 11/4/25 at approximately 11:30 PM with the travel LPN #1, they confirmed the above noted concerns. S/he stated that this sunroom is used as a dining area and housekeeping does not have enough staff. S/he stated, if I knew where they kept the brooms and mops, I could help when I had some time to do so. S/he confirmed that the tray with various partially eaten breakfast foods was there from breakfast and had to be taken down to the kitchen or they may wait until the next meal and send it back to the kitchen on one of the carts. Observation on Wing 1 of the nurse's station revealed a thick pile of crumbs/debris in front of the nurse's station that went the length of the nurses' station. Interview on 11/4/25 at approximately 11:50 AM with the travel LPN #1, they confirmed that these were cookie crumbs and that staff will give the residents cookies when they are sitting out in this area. S/he was asked about housekeeping staff, and s/he responded that s/he is aware that there are not enough housekeeping staff to keep the area clean and neat. Observation on 11/4/25 at approximately 12:10 PM residents were being brought to the sunroom for their lunch meal. The room had not been cleaned prior to the residents arriving to the sunroom for this meal. On 11/4/25 at approximately 12:20 PM the physician was asked about the poor conditions and how dirty the facility currently is, and s/he explained that s/he will be addressing that in her/his 6-month plan. S/he was asked for a copy of the 6-month plan and s/he stated, it's in draft form at this point. The physician confirmed that the facility was dirty and stated, yes, the residents here do have a right to live in a clean facility. S/he was asked if s/he considered the facility clean enough for the residents that lived there and s/he stated, no, it needs to be better. Observation on 11/4/25 at approximately 12:45 PM of Wing 1 Long Hall revealed room [ROOM NUMBER] with dirty floors, the overbed lights had 2 inch pull chords (used to turn the light on), a fan with a thick coat of dust on the back and front fan piece, the bathroom exhaust fan covered in a thick coat of dust, and cobwebs in all 4 corners of the bathroom. Observation on 11/4/25 at approximately 12:50 PM of room [ROOM NUMBER], the door to the room was broken at the hinge and revealed splintered wood fragments, there was a used blood glucose test strip on the floor, the overbed table by the door bed was covered on the wheels and metal support with a thick dried white milky type substance, the privacy curtains had a dried brown substance on the outer edge and about 2 feet in from the outer edge, the overbed lights for both beds only had a 2 inch pull chord, and there was an uncovered pillow on the bed next to the window with its plastic cover torn in many areas revealing the pillows contents. Observation on 11/4/25 between 1 PM and 1:20 PM of rooms 165 through 176 revealed various housekeeping issues specific to the cleanliness of each room. Floors were dirty, a lot of various types of debris were noted, bathroom fans were noted to be covered with thick dust, toilets were dirty and not clean inside or out or the floor around the toilets. Review of the housekeeping schedule from 11/9/25 to 11/15/25 revealed the following: 11/9/25 - 8 hours of housekeeping (1 staff); 11/10/25 - 13 hours between 2 staff; 11/1/25 - 8 hours (1 staff); 11/12/25 - 7 hours (staff orientee and no other staff listed to orient this new staff); 11/13/25 - 10 hours (1 staff); 11/14/25 - 7 hours (staff orientee and no other staff listed to orient this new staff); 11/15/25 - 7 hours (staff orientee and no other staff listed to orient this new staff). Per interview on 11/4/25 at approximately 3 PM with the Administrator, s/he confirmed that they did not have many housekeeping staff, 2 had recently walked out, and both the maintenance director and assistant maintenance director had left employment at this facility. S/he confirmed that the facility was not clean and that there was not enough housekeeping staff to clean the facility or maintain the facility at this time. 2. During the initial tour of the facility on 11/13/25 at approximately 10:00 AM the following observations were made: Wing 2 Long Hall, there was a trail of liquid down the hallway, and debris on the floor by the medication cart. Wing 2 Showers in the bathroom, the toilet safety bar was noted to have paper tape covering two holes. Light-colored caulk between tiles on both floors and walls was noted to have a buildup of black debris, which appears to be mold and mildew. A shower chair had a pinkish-orange buildup of debris at the connections. There was debris behind the doors, including spider webs and rust on the doorframes, with holes where the frames met the floors. The room with the bathtub had a Hoyer lift and cardboard boxes being stored in it. Wing 2 Short Hall, Resident room [ROOM NUMBER] revealed a strip of plastic-like material approximately 4-6 inches wide at chair rail level, which runs the full length of the right-hand side of the Residents' room. The strip was falling off the wall. In one of the alcoves, a dirty spoon was on the seat of a wheelchair In the Crossover area, a chair was noted to have worn off vinyl on both arms. Wing 1 Showers, the shower floors and walls had dark debris, which appeared to be mold and mildew, and there was a breach in the tile wall on the corner. The ceiling vent had a buildup of dust. The doorframe metal had a hole at the base, and debris is visible behind the door. There was yellow colored debris on the shower chair. In the bathroom, the call bell pull is a shoelace covered with paper tape, and the end has the shoelace material exposed. In the whirlpool room, there was a sticker, and a medication cup with white powder was located on the frame of the bathtub. Hair is in the wheels of a bath chair, and two black bundles of unknown substance were on the floor under the chair. There is a box of gloves on the floor, and a Broda chair (a type of wheelchair) with a resident gown. The bathtub chair foot supports have a white residue, and there is a walker with a used bedsheet. A chair located in the corner had used resident socks. Debris and a brown, dried liquid were noted in the whirlpool. Per interview on 11/13/25 at 3:00 PM, the Infection Prevention staff member confirmed housekeeping concerns. She stated two staff members had left abruptly and the Administrator has implemented leadership members assisting the remaining housekeeping staff with their duties by selecting five resident rooms weekly to clean. Per interview on 11/13/25 at 3:50 PM, the Administrator confirmed housekeeping staffing to be inadequate, and the leadership team is assisting the department with cleaning. When asked if there were education or audits for cleaning, she stated, all had to do it before. 3. During the initial tour of the facility on 11/13/25 at approximately 10:00 AM the following observations were made: In room [ROOM NUMBER] a trail of crumbs were on the floor, with a small partially crushed plastic cup. There was a trail of visible black residue on the floor from the doorway and extended approximately two feet out of the room In between room [ROOM NUMBER] and room [ROOM NUMBER] an alcohol wipe package was observed on the floor with a red piece of plastic and a white piece of plastic lying beside it In room [ROOM NUMBER] there were orange crumbs observed by the bottom of the bed Outside of room [ROOM NUMBER] there was a rubber band on the floor and a small piece of paper In room [ROOM NUMBER], the brown bumper guard against the wall was falling off the wall and was observed partially on the empty bed There was a clump of hair observed at the nurse's station by room [ROOM NUMBER] A dead brown, multilegged insect was observed on the floor and a partial footprint was noted adjacent to the insect The entrance to room [ROOM NUMBER] at the base on the doorframe was black and grey with residue on the floor, visible footprints and black and grey marks that appeared to be from shoes observed in the room and immediately outside of the room Outside room [ROOM NUMBER], immediately to the left, were brown stains extending down from the wall below the handrail. Additionally, there was a cluster of hair against the exterior frame of the door Between room [ROOM NUMBER]-119 two clumps of hair observed on the floor room [ROOM NUMBER] had black residue coming off the floor to the left and right of the doorframe room [ROOM NUMBER] had crumbs below the two dressers with one piece of paper balled up in front of the trash can near the door room [ROOM NUMBER] had visible brown and black matter on the floor that appears to be dirt The sunroom (near room [ROOM NUMBER]) had a clump of hair on the floor by the door. Next to the windows facing a small green yard, there was multiple brown clumps and crumbs on the floor. Additionally, the resident bedside table by the windows had brown matter on it. Opposing the windows facing the green yard, on the other side of the room, there was a rubber band on the floor. Outside room [ROOM NUMBER], to the left of the exterior door frame, below the handrail, there was a circular blob of a white and grey substance. There was one primary circular blob of this substance with two smaller circles of white and grey matter immediately next to it. Three circular like blobs of an unknown substance in total. In the shower room there was hair observed on the floor, brown residue smeared onto the wall, and brown residue on the shower chair. Additionally, hair was observed in the shower drain and there was a large amount of a brown smelly substance in the toilet that had not been flushed, on the seat of this toilet, there was also a brown residue. The shower wall had specks of black and grey on the tile and wall and the shower vent was covered in a thick white and grey substance.

Based on interview and record review, the facility failed to ensure that the Medical Director fulfilled his/her responsibility to coordinate medical care with facility providers and assist the facility with the development and implementation of resident care policies. This deficient practice has the potential to affect all residents residing in the facility.Findings include:Per review of the facility's Medical Director Services policy [policy undated] on 11/13/25, the scope of services for the Medical Director will include:-Ensuring that each resident's responsible physician attends to the resident's medical needs--Periodic review and development of medical care policies and procedures as required to ensure compliance with Federal, State, and local laws, rules, and regulations.An interview was conducted with the facility's Medical Director on 11/13/25 at 2:02 PM. The Medical Director [MD] stated there was no system in place to monitor regulatory visits by physicians, and that they were working on a process regarding required regulatory visits. The MD stated, There is no excuse, they [regulatory visits] have to be done.Further review of the Medical Director Services policy includes: -Participation in policy decision-making and direct supervision regarding quality of care and delivery of medical services to residents-Performance of all necessary general administrative tasks including assigning medical duties and scheduling, and communication of this information to appropriate staff.Per interview on 11/13/25, the Medical Director [MD] stated there is no consistent or scheduled communication between medical providers regarding facility issues or resident status. The MD stated s/he had reviewed the Facility Assessment, dated 6/5/25. Per the facility assessment, Medical/Physician Services list Dr. [A] and Dr. [B] as Attending Physicians. The Medical Director stated s/he was not familiar with those physicians. The MD stated the facility's Acting Physician [APhys] was the eyes and ears of the facility. The MD stated we are working on a process regarding reporting on a weekly basis with [APhys] and other providers, but there was no process currently in place.Review of the Medical Director Services policy also includes: -Supervision of high-level quality of care delivered to residents, with supervision exercised over medical, nursing, and pharmaceutical services.Per interview with the Medical Director [MD] the MD stated the facility's Attending Physician [APhys] notified h/her this morning [11/13/25] of a COVID outbreak in the facility. The MD stated [APhys] reported the first case was identified as 7- 10 days ago. The MD said h/her expectation was to be notified when the first case appeared. Per facility Infection Control records, the first COVID cases were identified 11 days prior on 11/2/25: one resident and one staff member. As of the day of the extended survey [11/13/25], 8 staff members and 16 residents had tested positive for COVID infection.

Based on record review and interview, it was determined that the facility failed to ensure physician visits occurred every 30 days for the first 90 days after admission, and at least once every 60 thereafter for 12 of 25 residents (Resident # 1, 2, 3, 6, 7, 8, 11, 12, 13, 15, 16, and 17). Findings include: Per review of the facility policy titled Physician Services dated 2/21, it states that the medical care of each resident is supervised by a licensed physician and that supervising the medical care of residents includes. conducting routine required visits.Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations and facility policy. 1.Review of Resident #6's medical record shows that Resident #6 has not had a regulatory visit since 8/7/25, which was with a Nurse Practitioner (NP), and as of 11/13/25 did not have a regulatory visit within sixty days with a Physician. 2.Review of Resident #7's Physician visits revealed that Resident #7 was admitted on [DATE] and had their initial visit with a NP on 1/24/25 and then only had visits with a NP up until 10/23/25 with the current Physician, which was not a regulatory visit. 3. Review of Resident #8's Physician visits revealed that their last regulatory visit was on 5/30/25, with a Physician's Assistant (PA), and there was no in-person visit with a Physician until 10/16/25, which was not a regulatory visit. Resident #8 has not had a regulatory visit since 5/30/25. Per interview with the Medical Director on 11/13/25 at approximately 2:15 PM, he reported that he's aware that the regulatory visits are well behind and that the onsite Physician is trying to catch up stating there is no excuse it has to be done. Per interview with the facilities Physician on 11/13/25 at 3:30 PM, he reported that he is behind on regulatory visits. The Physician stated that he inherited an absolute just medical disaster here and that he hasn't had time to do anything except for crisis management. He reported that he has a choice of seeing a sick patient like someone with covid, an urgent medical need, or a regulatory visit, he is going to take care of the sick patients. The Physician also stated he has a list of residents that he knows need to be seen for their regulatory visits. The Physician also stated that they had a Nurse Practitioner (NP) but that they only lasted a week, but they have a new NP starting on Monday, 11/17/25. He reported his plan is to start doing regulatory visits once the NP starts, and that he has a list of residents who need to be seen. He also reported that he does not count acute care visits as regulatory visits, as regulatory visits are much more comprehensive than acute care visits, so that if it doesn't say regulatory visit, then he has not completed a regulatory visit for that resident. The Physician would not speak to if regulatory visits were performed prior to him being there, but he did confirm that Resident #7 needs a regulatory visit and has not had one yet, that Resident #8 needs a regulatory visit and he has not done one yet, and that for Resident #6 he has not done a regulatory visit and needs one, and he also confirmed the facilities policy states one of his responsibilities as a physician is supervising the medical care of residents includes. conducting routine required visits. 4. Review of Resident #2's Physician visits revealed that they were admitted on [DATE] and they did not receive an in-person regulatory visit with a Physician by 5/19/25. 5. Review of Resident #3's Physician visits revealed that their last regulatory visit was on 6/13/25 with a Physicians Assistant (PA) and there was no in-person regulatory visit with a Physician by 9/23/25. 6. Review of Resident #1's medical record shows that Resident #1 was admitted on [DATE] and her/his first regulatory visit was on 10/28/25 which does not meet the regulatory requirement of this regulation. 7. Review of Resident #11's Physician visits revealed that Resident #11 was admitted on [DATE] and had their initial physician visit on 11/13/25, which does not meet the regulatory requirement of this regulation. 8. Review of Resident #12's Physician visits revealed that Resident #12 was admitted on [DATE] and had their initial physician visit on 11/13/25, which does not meet the regulatory requirement of this regulation. 9. Review of Resident #13's Physician visits revealed that Resident #13 was admitted on [DATE] and had their initial physician visit on 11/10/25, which does not meet the regulatory requirement of this regulation. 10. Review of Resident #15's Physician visits revealed that Resident #15 was admitted on [DATE] and had their initial physician visit on 11/4/25, which does not meet the regulatory requirement of this regulation. 11. Review of Resident #16's Physician visits revealed that Resident #16 was admitted on [DATE] and had their initial physician visit on 9/23/25, which does not meet the regulatory requirement of this regulation. 12. Review of Resident #17's Physician visits revealed that Resident #17 was admitted on [DATE] and had their initial physician visit on 8/25/25, which does not meet the regulatory requirement of this regulation. Per interview on 11/13/25 at approximately 11:45 AM, the facility Physician confirmed that regulatory visits had not been completed timely and that s/he was working on getting them caught up. S/he stated that a new PA would be starting next week on Monday and this would help her/him stay caught up on visits. Per interview on 11/13/25 at approximately 2:00 PM, the Medical Director confirmed that s/he was aware that regulatory visits were behind and that the facility physician was working to get them all caught up. S/he stated they were working on the process and considering getting a tracking tool/system for regulatory visits but at this time had not secured any type of system for doing this. S/he stated, There is no excuse for these visits to not have been completed on time.

Based on observation, staff interview, and record review the facility failed to ensure that 1 resident in the applicable sample (Resident #6) received proper foot care.Findings include:Per observation on 11/13/25 at 10:21 AM, Resident #6 was sitting barefoot at the edge of the bed with his/her feet on the floor. Resident #6's feet appeared to be dry and had long discolored toenails that were thick.Per interview with Resident #6 on 11/13/25 at 10:21 AM, they reported that their toenails are very long and that it is an issue, they haven't had their nails trimmed in a long time or seen a podiatrist.Per record review of Resident #6's care plan dated 9/19/25, s/he is care planned for skin breakdown due to impaired mobility, DM (Diabetes Mellitus), and peripheral vascular disease. Interventions include Podiatry consult as needed with a date of 3/8/23. The care plan also identifies that the resident has an ADL (activities of daily living) self-care performance deficient and requires assistance with personal hygiene, dated 3/8/23.Per review of the facilities policy titled Fingernails/Toenails, Care of with a revision date of 2/18, it states that the purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming.Per interview with the Physician on 11/13/25 at 3:30 PM, he reported that he is having to triage work and is prioritizing the most urgent visits as there is only one provider for the residents. He reported that he hasn't time to do anything except for crisis management.Per interview with the Administer and Director of Nursing (DON) on 11/13/25 at 6:17 PM, they reported they don't have a podiatrist here and that the provider trims nails in house.Per interview with a Register Nurse (RN) on 11/13/25 at 6:29 PM, she confirmed that Resident #6's toenails were long and should be trimmed.

Based on review of employee training records and interview, the facility failed to provide evidence of the minimum 12 hours of nurse aide training per year required to ensure the continuing competence of the LNAs (Licensed Nursing Assistants) for 1 (LNA #1) of 3 LNAs sampled. Findings include:Per review of the training records, three LNAs sampled were noted to have start dates before the 2025 calendar year. LNA #1's education file lacked documentation of evidence of the 12 hours of training per year required to meet identified staff or resident needs.Per interview on 11/13/25 at 5:18 PM, the Director of Nursing (DON) was unable to provide evidence that the LNA #1 had completed their required 12-hour annual training.

Based on observation and interview, the facility failed to ensure only authorized personnel had access to the medication storage rooms. This is a repeat deficiency for this facility, with the violation cited during the previous recertification surveys, dated 6/25/25. Findings include:Per observation on 11/4/25 at 12:45 PM, a pharmacy delivery was accepted by an LPN (Licensed Practical Nurse). The delivery person and LPN went into the medication room together. The LPN emerged without the delivery person who remained alone in the medication room for approximately 5 minutes before exiting.Per interview on 11/4/25 at 1:00 PM, the LPN confirmed that the delivery person should not go into the medication room alone. The LPN confirmed that he/she was left alone in the medication room. Per interview with the Administrator on 11/4/25 at 2:45 PM, they confirmed the delivery person should not have been in the medication room alone.

Based on observation, interview, and record review, the facility failed to implement interventions to address the residents' dementia care needs for 1 of 1 residents (Resident #10).Findings include:Per an observation on [DATE] at 6:43 PM at a nurse's station, Resident #10 was asking to call his/her family member. A Licensed Practical Nurse (LPN) was observed telling Resident #10 that she couldn't call his/her family member because they had died. Upon hearing this, Resident #10 got visibly upset and again asked for the LPN to call Resident #10 's family member and called the LPN a liar. The phone started ringing and Resident #10 was asking for them to pick it up saying it might be their family member, and the nurse was dismissive towards the Resident saying that it couldn't be. At 6:45 PM, the Resident #10 again asked to call the family member to which the LPN again stated that they had passed and that we told you this months ago, but you keep on forgetting. Resident #10 then stated that they were going to try and walk home and hoped they would be killed.Per interview with the LPN on [DATE] at 6:48 PM, when asked how she redirects Resident #10 when s/he forgets that their family member has died, the LPN reported that sometimes we say maybe later, sometimes we tell her the truth, and that the Resident #10 calls us liars when we tell him/her that their family member is dead. The LPN also reported Resident #10 has dementia and s/he just gets like this sometimes. The LPN confirmed that each time she reminded Resident #10 that the family member had died, that Resident #10 became visibly upset.Per record review of Resident #10 medical diagnosis on [DATE], s/he has a diagnosis of Alzheimer's disease, adjustment disorder with anxiety, and depression. Per review of a progress note dated [DATE], the resident was informed by their family of a family member's death.The Resident's progress notes from [DATE] to [DATE] document that the Resident was reminded by staff of his/her family member's death on seven different documented occasions since [DATE], with resulting behaviors of yelling, crying, wandering, and exist seeking.Per Review of the Resident #10 care plan, it revealed they are care planned for a family member's death on [DATE] with interventions of assisting the resident with their grief to help the resident identify care needs, encourage the resident to express feelings of anger and concern, encourage the resident to recognize grief situation, observe for contributing factors that may delay the grief process, assist the resident to identify, access and use support systems, for consults to be placed to pastoral care, social services, home health, psychiatry as needed, describe to the resident the stages and how to identify grief, and to assist the resident with problem solving. The Resident #10 is also care planned for dementia, for which interventions include allowing the resident time to talk and express feelings. An intervention related to the Resident #10's anxiety and trauma is to engage the resident in conversations that will help them to remain calm.The observation on [DATE] did not demonstrate that care plan interventions were being utilized for this resident regarding assisting with grief, allowing time to talk and express feelings, or engaging the resident in conversation to help them remain calm.

Based on record review and interview it was determined that the facility failed 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 her/his quality of life, recognizing each resident's individuality for 1 resident in a sample of 9 residents. (Resident #4).Findings include:Per record review, Resident #4 has diagnoses that include Alzheimer's disease, dementia, bipolar disease, schizophrenia, and need for assistance with personal care. Per Resident #4's care plan, revised 11/4/25, EATING: [She/he] requires extensive assist from staff participation to eat. Staff please encourage resident to open hand to engage in self-feeding and holding cup during meals. On 11/4/25 at 12:55 PM, an observation was conducted of Resident #4 during lunch. An LNA (licensed nursing assistant) was observed assisting the resident with eating. She/he was standing next to resident and leaning over to place the food in the resident's mouth. The LNA repeated the process of standing next to the resident and assisting with feeding. On 11/4/25 at 12:57 PM, an interview was conducted with the LNA. She/he was asked if they should be sitting at eye level with the resident. She/he stated, I choose not to do that. Upon further inquiry about facility practice with regard to sitting next to residents while assisting in eating, She/he responded, 'I don't do that. Facility policy titled Resident Rights, revised June 2023, states that Federal and state laws guarantee basic rights to all residents of this facility. These rights include the right to a dignified existence and to be treated with respect, kindness and dignity. On 11/4/25 at 2:45 PM, an interview was conducted with the Administrator. They confirmed that facility practice is to sit at eye level with a resident while assisting them with eating, and that this was communicated to staff when they go through orientation.

Based on observations, resident and staff interview, and record review the facility failed to prevent abuse for one (1) of three (3) residents (Resident #1). Findings include: Per record review, a Nursing Incident Note dated 1/6/2020 at 9:30 PM states that the LNA went to answer (Resident #1's) call light and noticed that the door to her/his room was closed. When the LNA opened the door, s/he saw Resident #2 in the room, standing over (Resident #1's) bed, in the dark. S/he had a blanket wrapped around (Resident #1's) head, face, and arms. Per a Social Service Note dated 1/7/2020, Resident #1 reported that Resident #2 came in and beat on her/him. A Nursing Note dated 1/13/20 at 10:21 PM states that Resident #1 stated Do you know the (woman/man) who tried to kill me, he hit me in the back of my head and I stopped fighting back and then (s/he) stopped. Do you know (his/her) name? The nurse sat with the resident for greater than 20 minutes while resident cried and again offered additional emotional support. On 1/15/20 at 12:32 PM during an interview the Director of Nursing Services (DNS) confirmed that Resident #2 had a history of [REDACTED]. Per interview on 1/15/20 at 3:50 PM with the Licensed Practical Nurse (LPN), Resident #2 had been on 15 minute checks due to aggressive behaviors. (S/he) was violent and aggressive to female staff. I was very afraid of (her/him), for staff, self, and residents. The LPN also stated that when s/he was giving Resident #2 her/his 8:00 PM medications that evening, Resident #2 said to her/him My mother hates you and she must die. When the LPN entered Resident #1's room after the incident she noted her/him to be very upset, crying, face very red, and visibly shaking and that (S/he) reported in (her/his) statement that (s/he) played dead to survive. During an interview with an LNA on 1/15/20 at 4:11 PM, the LNA stated that the next couple days (s/he) was scared and asked is (s/he) coming home, is (s/he) coming back?. On 1/15/20 at 4:30 PM, during an interview with Resident #1 s/he stated someone tried to kill me. (S/he) isn't here anymore. They told me (s/he) was never coming back, I hope that's true.

Based on staff interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 2 applicable residents regarding wound care (Resident #2). Findings include: Per record review for May and June 2017, Resident #2 had a worsening in condition of wounds to his/her left foot, during a period of time when physician's orders [REDACTED]. Per skin/wound note on 6/8/17, wound on lateral, distal left great toe: Black, moist, necrotic area measures 3 cm (centimeters) long X 2 cm. wide and depth unknown. Resident #2 was seen by a podiatrist 6/8/17 who ordered continue present wound care with addition of lamb's wool weaved between toes 2-5 on left foot. Per interdisciplinary note 6/27/17, resident did not have his/her dressing on his/her left great toe this morning (only the [MEDICATION NAME]), replaced the dressing. Small amount of bloody, tan drainage, dried on the [MEDICATION NAME] (a type of wound dressing) which was between the toes. Per skin/wound note dated 6/29/17, Regarding wound on lateral, distal left great toe: Black, necrotic area measures 3 cm. long X 5.5 cm. wide and depth unknown. Noted another wound on medial aspect of left 4th toe, measuring 0.5 cm. long X 0.3 cm. wide. Also noted a wound between left 4th and 5th toes, measuring 0.5 cm. long X 0.5 cm. wide. There is also another open area noted on medial aspect of left 5th toe, measuring 0.2 cm. long X 0.1 cm. wide. Depth of these latter 3 wounds is superficial. As per MD visit on 6/28/17, MD recommended application of Ag foam applied to open, draining areas, and lamb's wool between digits where there is no open areas, changing every other day. A follow up visit to the podiatrist 6/28/17 noted a marked worsening in condition, noting ulcers to left great toe (distal, lateral and plantar), medial 2nd toe, lateral 3rd toe, medial 4th toe and medial 5th toe. Review of nursing notes between 6/8/17 - 6/29/17 indicate that the lambs wool was not utilized as ordered. Per interview with the facility Unit Manager (UM) on 7/5/17 at 11:45 AM, the UM Confirmed that the nurse taking off the 6/8/17 order from the podiatrist did not note the lambs wool order and confirmed that the lambs wool treatment was not done until 6/30/17. Podiatry nursing staff confirmed via telephone interview during the investigation that there was development of new wounds on the left foot.

Based on staff interview and medical record review the facility failed to ensure that 1 of 5 sampled residents, (Resident #4) was free from accidents and that each resident receives adequate supervision to prevent accidents. The findings include the following: Per medical record review, progress notes and incident report dated 12/22/14 evidence written documentation by the Licensed Practical Nurse (LPN) identifying that at approximately 1530 (3:30 PM), staff heard Resident #4 yelling "No...No...Oh God No". Resident #1 "was observed coming out of Resident #4's room with a catheter that still had a drainage bag attached and an inflated balloon on the catheter, with bright red drainage noted to end of catheter in (his/her) right hand". LPN observed and documented that Resident #4 was "visibly distraught, tears streaming down cheeks and sobbing hysterically, continuously rubbing head and face with hands and repeatedly stating don't let her near me again, I am too scared here, please don't leave me, I don't want to be here anymore. Oh God, keep that woman away from me." LPN cleansed the affected area, applied pressure to stop bleeding and notified physician, administrator, director of nurses and responsible party. Resident was transferred to another Unit within the facility. Per review of Resident #4's Interdisciplinary Care Plan, page 3 of 18 identifies a focus of "Foley Catheter removed traumatically by another resident who suffers from dementia. Dated 12/22/14 by Unit Manager" (UM). Per care plan review on 2/17/15, Resident #1 has a care plan focus dated 12/8/14, created by the UM, identifying that the resident has made physical contact with another resident. Interventions include that the nursing staff and social services are to be under mindful observation for signs and symptoms of aggressive behaviors and staff will be mindful of Resident #1's intrusive behaviors and redirect his/her attention elsewhere if invading another residents personal space. Per review of Behavior Interventions on 2/17/15, identifies recent interactions with other residents. The document evidences that Resident #1 wanders and enters others personal space. This document was reviewed with the Unit Manger and confirms the incident dated 12/22/14. Per interview with the Director of Nurses (DNS) on 2/17/15 at 8:45 AM, confirms that the incident was reviewed with the Administrator. The result of the traumatic removal of the Foley Catheter caused pain and mental anguish to Resident #4, as identified in the progress notes and continued through 1/21/15. Per conversation with the DNS on 2/17/15, confirmation is made that the resident's care plan identifies that Resident #1 is a known wanderer as documented on both Care Plan and Minimum Data Set Assessment.

Based on observation, record review, and staff interviews, the facility failed to ensure that residents were free from abuse for three of four residents sampled (Residents #1, #2, and #3). Findings include: Per observation, interview, and record review on 5/12 - 5/13/14, Residents #1, #2, and #3 have advanced dementia, and require extensive assistance with many activities of daily living. According to written statements of staff, on the afternoon/evening of 2/15/14, an newly hired Licensed Nursing Assistant (LNA #1) was orienting with an experienced LNA #2, working as a team to prepare residents for supper by getting them up from bed, and/or toileting them. According to the written statement of LNA #1, they were providing care to Resident #1 by transferring them by mechanical lift to the bed to be checked for incontinence. Per the written statement, LNA #2 had the mechanical lift bar so tight against the resident's legs that the resident cried out in pain, and LNA #2 said to Resident #1, "Shut up (name), we are helping you cuz you're wet". The resident reacted by drawing back a fist and swearing at LNA #2. LNA #1 stated that the resident was treated roughly "manhandled" after that by LNA #2. The written statement also went on to say that Resident #1 was so upset that they did not want to eat supper. The next incident described in LNA #1's written statement was pertaining to the provision of care to Resident #2. They described LNA #2's assistance with toileting of the resident as roughly tossing him/her around like a rag doll, grabbing them under the arms, yanking him/her off the toilet, and yelling at Resident #2 to "stand up, stand up", to which the resident replied "I can't stand up any higher." LNA #1 was pulling up his/her pants and stated that Resident #2 had a frightened look on their face and was almost in tears. LNA #1 wrote that s/he told LNA #2 to go easy because s/he was frail, and LNA #2 replied that they needed to hurry and get them up. The third example given in the written statement was regarding Resident #3, who allegedly was dragged by the arms/hands to the sitting position without the use of a gait belt. At that time LNA #1 told the other LNA to be gentle but was ignored. LNA #1 asked another LNA if they had ever witnessed any rough treatment of [REDACTED].#2 and they said no. LNA #1 went to the Licensed Practical Nurse (LPN) on duty on that wing and reported the rough treatment. There were no specific timelines for each of these incidents in the written statement of the LNA, however s/he only worked from 3-5 PM. Per review of the written statement of the LPN working on that hall on 2/15/14, s/he stated that they arrived at 4:30 PM for their shift, and LNA#1 and #2 were assisting residents as a team preparing them for supper. LNA #1 approached him/her and asked if LNA #2 was usually rough with residents, and the LPN replied "Do you mean that (s/he) doesn't know their own strength while caring for them?" as a clarification, and LNA #1 said no that s/he had been rough while handling Resident #2. The LPN told LNA #1 that s/he would report this to the acting supervisor on duty, a Registered Nurse. Per the written statement by the RN supervisor, the LPN spoke to him/her at about 6:30 PM, vaguely asking about an LNA being rough with a patient. When the RN inquired who they were speaking of, the LPN stated that it was LNA #2 and that they think they do not know their own strength. When the supervisor asked the LPN if they felt the residents were in danger of being harmed, the nurse replied "well, no." After supper, at approximately 7:30 PM, the RN supervisor approached the LPN and asked if they knew what the procedure was if they felt someone was being abused, and the LPN shook their head yes, as the RN supervisor continued to explain "first you remove the staff member immediately, call the Director of Nursing and Administrator, and assess the resident completely." The LPN nodded in agreement, and the RN stated that the LPN did not approach them again that evening. LNA #2 continued to work the remainder of his/her scheduled shift, caring for residents with no further incidents reported by other LNAs who were partnered with him/her that evening. It was the following morning on 2/16/14 that LNA #1 told another nurse working the day shift what had happened the evening before, and this nurse told a supervisor who apparently called the Director of Nursing. LNA #2 was scheduled to work later that day, however was suspended and did not come in again, and was terminated from employment after the incident was investigated. Per interview on 5/13/14 at 2:15 PM, the Regional Manager who had been the acting Director of Nursing in February 2014 confirmed that any allegation of abuse should have been reported immediately to the DNS, and the employee sent home for protection of the residents. S/he also confirmed that LNA #1, LNA #2, and all nursing staff involved had attended inservices regarding abuse reporting protocols, and that the protocol for protecting residents had not been followed.

Based on staff interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 1 of 6 sampled residents (Resident # 4). Findings include: Per review of facility investigative documentation regarding a fall Resident #4 sustained on [DATE], the facility administration failed to conduct a thorough investigation and failed to take action to ensure residents were being properly assessed and monitored by staff. Per record review on [DATE] at 10:40 AM, nursing staff failed to properly assess and monitor Resident # 4 after sustaining a fall on [DATE]. Resident # 4 was found lying in a hallway flat on his/her stomach at approximately 7:30 PM. Per a [DATE] 7:44 PM incident note, the Resident had a hematoma with skin abrasion on the right side of his/her chin. Per interview with the Unit Manager (UM) on [DATE] at 12:40 PM, facility policy after a fall is to obtain neurological vital signs (NVS) every 15 minutes for 1 hour, every 30 minutes for 4 hours, every hour for 2 hours then every shift for 72 hours. Review of the facility Neurological Evaluation Flow Sheet indicates that NVS were done one time (exact time not recorded) on the 3:00 PM - 11:00 PM shift and not again after that. The UM confirmed that the NVS were not done per protocol on both the evening and night shifts after the Resident's fall. Per review of a written statement by a facility Registered Nurse (RN), a facility Licensed Nursing Assistant (LNA) reported that h/she was asked by "the nurse" to do vital signs on the Resident and stated that NVS were supposed to be done by the nurse. The LNA then told the nurse that the night nurse had in fact made her do the vitals. The UM confirmed that doing NVS were outside an LNA's scope of practice and that NVS were to be done by a licensed nurse only. During a [DATE], 1:00 PM telephone call to the above mentioned LNA, the LNA stated that h/she had indeed been asked by the nurse to do NVS but when h/she tried the Resident refused. The LNA stated that h/she had been asked by nurses in other instances to do NVS and that h/she agreed to do them because h/she wanted to help. Per review of nursing notes from [DATE], the Resident was found unresponsive at 5:30 AM and was transferred via EMS to the hospital at approximately 6:00 AM. Per review of hospital records, the Resident was unresponsive while at the hospital and was placed on comfort care. Review of hospital diagnostic imaging reports show that the Resident was admitted with a right sided subdural hematoma and a right maxillary sinus fracture. The Resident expired on [DATE] at approximately 8:00 PM On [DATE] at 1:55 PM, the facility Executive Director (ED), who is also the Licensed Nursing Home Administrator, confirmed that h/she was not aware that Resident # 4 had not been properly assessed despite a written statement from a facility Registered Nurse indicating this. The ED also confirmed that the facility had not taken steps to ensure that resident were being properly assessed. The ED also confirmed that a complete investigation had not been conducted.

Based on staff interview and record review, the facility failed to assure each resident receives the necessary care and services to maintain the highest practicable physical well-being for 1 of 6 sampled residents (Resident # 4) regarding proper monitoring after a potential head injury. This is cited at the Immediate Jeopardy level. Findings include: Per record review on [DATE] at 10:40 AM, nursing staff failed to properly assess and monitor Resident #4 after sustaining a fall on [DATE]. Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Resident required extensive assistance with most activities of daily living. Fall risk assessments on [DATE] and [DATE] were scored at 19 and 22 respectively, indicating high fall risk. Resident # 4 was found lying in a hallway flat on his/her stomach at approximately 7:30 PM. Per a [DATE] 7:44 PM incident note, the Resident had a hematoma with skin abrasion on the right side of his/her chin. Per interview with the Unit Manager (UM) on [DATE] at 12:40 PM, facility policy after a fall is to obtain neurological vital signs (NVS) every 15 minutes for 1 hour, every 30 minutes for 4 hours, every hour for 2 hours then every shift for 72 hours. NVS is an evaluation by a licensed professional that include level of consciousness, pupil response, motor functions, pain response and vital signs. Review of the facility Neurological Evaluation Flow Sheet indicates that NVS were done one time (exact time not recorded) on the 3:00 PM - 11:00 PM shift and not again after that. The UM confirmed that the NVS were not done per protocol on both the evening and night shifts after the Resident's fall. Per review of a written statement by a facility Registered Nurse (RN), a facility Licensed Nursing Assistant (LNA) reported that h/she was asked by "the nurse" to do vital signs on the Resident and stated that NVS were supposed to be done by the nurse. The LNA then told the nurse that the night nurse had in fact made her do the vitals on [DATE] and [DATE]. The UM confirmed that doing NVS were outside an LNA's scope of practice and that NVS were to be done by a licensed nurse only. During a [DATE], 1:00 PM telephone call to the above mentioned LNA, the LNA stated that h/she had indeed been asked by the nurse to do NVS but when h/she tried the Resident refused. The LNA stated that h/she had been asked by nurses in other instances to do NVS and that h/she agreed to do them because h/she wanted to help. Per review of nursing notes from [DATE], the Resident was found unresponsive at 5:30 AM and was transferred via EMS to the hospital at approximately 6:00 AM. Per review of hospital records, the Resident was unresponsive while at the hospital and was placed on comfort care. Review of hospital diagnostic imaging reports show that the Resident was admitted with a right sided subdural hematoma (an accumulation of blood on the brain's surface beneath the skull) and a right maxillary sinus fracture. The Resident expired on [DATE] at approximately 8:00 PM.

Based on staff interview and record review, the facility failed to ensure services provided meet professional standards of quality for 1 of 6 residents in the sample regarding monitoring of a resident with a potential head injury (Resident #4). This citation is at the Immediate Jeopardy level. Findings include: Per record review on [DATE] at 10:40 AM, nursing staff failed to properly assess and monitor Resident #4 after sustaining a fall on [DATE]. Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Resident required extensive assistance with most activities of daily living. Fall risk assessments on [DATE] and [DATE] were scored at 19 and 22 respectively, indicating high fall risk. Resident #4 was found lying in a hallway flat on his/her stomach at approximately 7:30 PM on [DATE]. Per a [DATE] 7:44 PM incident note, the Resident had a hematoma with skin abrasion on the right side of his/her chin. Per interview with the Unit Manager (UM) on [DATE] at 12:40 PM, facility policy after a fall is to obtain neurological vital signs (NVS) every 15 minutes for 1 hour, every 30 minutes for 4 hours, every hour for 2 hours then every shift for 72 hours. NVS is an evaluation by a licensed professional that includes an assessment of the resident's level of consciousness, pupil response, motor functions, pain response and vital signs. Review of the facility Neurological Evaluation Flow Sheet indicates that NVS were done one time (exact time not recorded) on the 3:00 PM - 11:00 PM shift and not again after that. The UM confirmed that the NVS were not done per protocol on both the evening and night shifts after the Resident's fall. Per review of a written statement by a facility Registered Nurse (RN), a facility Licensed Nursing Assistant (LNA) reported that h/she was asked by "the nurse" to do vital signs on the Resident and stated that NVS were supposed to be done by the nurse. The LNA then told the nurse that the night nurse had in fact made her do the vitals on [DATE] and [DATE]. The UM confirmed that doing NVS were outside an LNA's scope of practice and that NVS were to be done by a licensed nurse only. During a [DATE], 1:00 PM telephone call to the above mentioned LNA, the LNA stated that h/she had indeed been asked by the nurse to do NVS but when h/she tried the Resident refused. The LNA stated that h/she had been asked by nurses in other instances to do NVS and that h/she agreed to do them because h/she wanted to help. Per review of nursing notes from [DATE], the Resident was found unresponsive at 5:30 AM and was transferred via EMS to the hospital at approximately 6:00 AM. Per review of hospital records, the Resident was unresponsive while at the hospital and was placed on comfort care. Review of hospital diagnostic imaging reports show that the Resident was admitted with a right sided subdural hematoma (an accumulation of blood on the brain's surface beneath the skull) and a right maxillary sinus fracture. The Resident expired on [DATE] at approximately 8:00 PM.

Based on observations, interviews, and record reviews, the facility failed to assure that one of three residents in the sample (Resident #1) remained free of physical restraints imposed for purposes of convenience and not required to treat the resident's medical symptoms. Findings include: 1. On 9/19/13, the surveyor reviewed the facility's internal investigation documents, written staff statements, and the medical record of Resident #1. Resident #1 (who is age [AGE] years) is assessed and care planned for urinary incontinence, anxiety, behaviors such as hitting, yelling, and throwing things, intermittent resistance to care, and forgetfulness related to advanced age. Resident #1 is assessed and care planned for transfer by two staff using a stand and pivot technique. Written evidence indicates that during the evening of 9/15/13, Resident #1 was agitated, hallucinatory, and resistive to care by nursing staff (as evidenced by yelling at staff and throwing things).Witness statements by the nurse on duty that evening, and three Licensed Nurse Assistants (LNA A, B, and C) who were on duty, indicate that Resident #1 had been incontinent of urine and had resisted multiple approaches and efforts to clean and change him/her during the evening shift. In a statement dated 9/16/13, the nurse related that s/he was unable to administer an as needed dose of an anti-anxiety medication ([MEDICATION NAME]) and instructed staff to allow Resident #1 to calm down. Written statements by LNA staff A, B, and C, as well as interview and re-education documentation by the Assistant Director of Nurses (ADNS), indicate that the three LNA staff elected to provide personal care to Resident #1, despite having been instructed by the nurse to let him/her calm down. Further, LNA A elected to wrap Resident #1 around the hands and feet with a draw sheet before moving him/her, allegedly to prevent harm during combativeness. The three LNA staff transferred Resident #1 from the wheelchair to the bed while wrapped in draw sheet, then removed the sheet. At this time, LNAs A and C held the arms of Resident #1 while LNA C changed the wet brief and provided personal hygiene. On 9/19/13 at 9:45 AM, Resident #1 was observed to have purple bruising on the left and right wrist areas. When asked how this happened, Resident #1 stated to this surveyor, "they tried to make me do something when I wanted to do something else". Resident #1 further stated that this had happened "about two days ago". At 2:45 PM on 9/19/13, the ADNS confirmed that LNA A used a drawsheet to restrain Resident #1 during the transfer on the evening of 9/15/13, and that LNA B witnessed LNA A holding the arms of Resident #1 during personal care. The ADNS further confirmed that LNA A had been suspended and re-educated, as well as reported to the Board of Nursing, related to the use of a draw sheet as a restraint.

Based on interviews and record reviews, the facility failed to assure that one of three residents in the sample (Resident #1) was treated by staff in a manner which maintained his/her dignity and respect in full recognition of his/her individuality. 1. On 9/19/13, the surveyor reviewed the facility's internal investigation documents, written staff statements, and the medical record of Resident #1. Resident #1 (who is age [AGE] years) is assessed and care planned for urinary incontinence, anxiety, behaviors such as hitting, yelling, and throwing things, intermittent resistance to care, and forgetfulness related to advance age. Resident #1 is assessed and care planned for transfer by two staff using a stand and pivot technique. Written evidence indicates that during the evening of 9/15/13, Resident #1 was agitated, hallucinatory, and resistive to care by nursing staff (as evidenced by yelling at staff and throwing things).Witness statements by the nurse on duty that evening, and three Licensed Nurse Assistants (LNA A, B, and C) who were on duty, indicate that Resident #1 had been incontinent of urine and had resisted multiple approaches and efforts to clean and change him/her during the evening shift. In a statement dated 9/16/13, the nurse related that s/he was unable to administer an as needed dose of an antianxiety medication ([MEDICATION NAME]) and instructed staff to allow Resident #1 to calm down. Written statements by LNA staff A, B, and C, as well as interview and re-education documentation by the Assistant Director of Nurses (ADNS), indicate that the three LNA staff elected to provide personal care to Resident #1, despite having been instructed by the nurse to let him/her calm down. Further, LNA A elected to wrap Resident #1 around the hands and feet with a draw sheet before moving him/her, allegedly to prevent harm during combativeness. The three LNA staff transferred Resident #1 from the wheelchair to the bed while wrapped in the draw sheet, then removed the sheet. At this time, according to written statements, LNAs A and C held the arms of Resident #1 while LNA C changed the wet brief and provided personal hygiene. On 9/19/13 at 9:45 AM, Resident #1 was observed to have purple bruising on the left and right wrist areas. When asked how this happened, Resident #1 stated to this surveyor, "they tried to make me do something when I wanted to do something else". Resident #1 further stated when asked twice, approximately 5 minutes apart, that this had happened "about two days ago". During an interview on 9/19/13 at approximately 10:00 AM, LNA D (who worked on the unit from 10:30 PM 9/15/13 to 3:15 PM on 9/16/13) confirmed his/her written statement that LNA A had told him/her that "they had to manhandle (Resident #1) to get (him/her) changed and to bed". LNA D further stated that s/he had provided care to Resident #1 on 9/13/13 and that no bruises were present on the arms/wrists. LNA D also confirmed having provided care during the night shift and throughout the day 9/16/13, having first noticed bruising on the arms of Resident #1 while providing morning personal hygiene care on 9/16/13 at approximately 9:00 AM. At that time, LNA D reported to the day charge nurse both the bruises and the statement made by LNA A regarding "manhandling" Resident #1 on the evening of 9/15/13. On 9/19/13 at 11:45 AM, the Director of Social Services (who is also a Licensed Practical Nurse) confirmed having interviewed and observed Resident #1 on the morning of 9/16/13 immediately after being informed of the alleged "manhandling" on the evening of 9/15/13. S/he confirmed that both arms/wrists of Resident #1 had purpura (appearance of bleeding under the skin) such as is common with fragile skin in the elderly. During an interview at 2:45 PM on 9/19/13, the ADNS confirmed that LNA A used a drawsheet to restrain Resident #1 during the transfer on evening of 9/15/13, and that LNA B witnessed LNA A holding the arms of Resident #1 during personal care.

Based on record review, observation and staff interview the facility failed to provide treatment and services to promote healing of a pressure ulcer for 2 of 25 residents in Stage 2 survey sample. Findings include: 1. Resident #58 presented with a posterior medial Left knee Stage 2 pressure ulceration on 4/8/2013 that measured 7.5 x 1.0 cm and with a posterior lateral Left knee Stage 2 measuring 8.0 x 1.5 cm. These areas were to be cleansed and apply No Sting and [MEDICATION NAME] Foam to be changed every 3 days until resolved per monthly orders signed 4/6/13 by the physician. A telephone order dated 4/11/2013 from the physician indicated a change in the treatment, to apply Foam Island dressing to left leg and change twice weekly and as needed. The treatment administration record (TAR) dated for April indicates the change of order for 4/11/2013 was done per physician order [REDACTED]. This treatment, to change the Foam Island dressing weekly instead of twice a week, remained in effect for May although the orders dated and signed by the physician on 5/12/2013 indicated treatment dressing to be changed every 3 days. In June the monthly orders continue to read change every 3 days and the Unit Manager verified that the orders were changed in April and not carried through onto the monthly physiciaian orders. He/she also indicated that the orders were not being followed correctly. 2. Per record review, Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident has a history of pressure ulcers on right and left buttocks in February 2013. Medical record review reveals the resident is incontinent of urine and is unaware when s/he is wet. Per a Braden Scale form, completed 6/4/13, Resident #50 currently has a Stage 2 pressure ulcer on right buttock (discovered on 6/2/13), requires moderate to maximum assistance in moving, and s/he frequently slides down in chair, requiring frequent repositioning with maximum assistance. The Braden Scale also states that the resident's nutrition is "probably inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered..." Per review of the care plan addressing the Alteration in Skin Integrity, staff are directed to reposition with toileting/incontinence care before and after meals, with AM and HS (bed time) care and as needed. A dietary assessment on 4/25/13 documented that the resident's skin was intact at that time. Per continuous observation on 6/5/13 from 8:15 AM to 10:45 AM, the resident was not repositioned during this time, and was sitting in a wheelchair with both legs elevated. At 10:45 PM, staff provided care to the resident after transferring him/her back to bed using a mechanical lift. The surveyor observed the provision of care at this time. The resident's incontinence brief was saturated with urine when it was removed. At the time of the observation, the resident had the stage 2 pressure ulcer on the buttock, which was identified on 6/2/13. Further, a new pressure ulcer was observed during this provision of care, on the coccyx area, with an open area measuring 0.8 centimeters (cm) by 0.2 cm. Per facility policy, residents with pressure ulcers are to be assessed to determine a turning/repositioning schedule to meet the resident's needs. There is no evidence this assessment was completed or a new repositioning schedule was implemented since the discovery of the first pressure ulcer on 6/2/13. Also, per interview with the Registered Dietician on 6/5/13 at 11:30 AM, s/he stated that s/he was not aware of any skin breakdown for Resident #50. During an interview on 6/5/13 at 3:00 PM, the Unit Manager confirmed that the resident should be moved every 2 hours and that the protocol for skin care management has not been followed. 2. Based on record review, observation and staff interview the facility failed to provide treatment and services to promote healing of a pressure ulcer. Per observation on 6/4/13 resident #50 was witnessed in the sun room eating lunch at 12:00 noon, he was taken to his room at 2:45 PM at which time incontinent care was provided and he returned to the sun room at 3:15 PM. On 6/5/13 8:15 AM resident witnessed in the sun room eating breakfast. At 10:20 AM Resident removed from Day Room brought back to his room so that Surveyor could observe wound treatment. The resident is non-weight-bearing and sits in a wheel chair with legs elevated. The Resident was brought to the room but not until 10:45 AM that the Licensed Practical Nurse (LPN) and Unit Manger (UM) with 2 Licensed Nurses Aides's transferred resident via a mechanical lift to bed. After adult brief saturated with urine was removed and a transparent dressing removed, the wound cleansed and measured to be 1.2 cm by .4 cm on the left buttocks. At this time a second pressure ulcer noted on the resident's coccyx (crack) that was not present on 6/4/13. Measures taken on 6/5/13 to be 0 .8 cm's by 0.2 cm. A four inch diameter circumference to include both buttocks, are noted to be red and non-blanchable. Per facility policy for repositioning the patient should be assessed to determine how often the resident needs repositioning. The facility has developed a Flip-Flop initiative that alerts care staff that the resident in a particular room or device needs to be turned frequently as they are at risk for skin breakdown as well as for comfort. During interview with two LNA staff on 6/5/13 at 3:00 PM they confirm that the flip flop symbol identifies that the patient needs to be reposition every two hours. During an interview with the UM on 6/5/13 at 3:00 PM he/she confirms that the resident should be moved every two hours and that the protocol per skin care management has not been followed. also see F-282

Based on record review and interviews, the facility failed to fully implement the nursing plan of care for risk of fluid volume deficit for one of four residents in the sample (Resident #1). Findings include: 1. Per record review on 5/14/13, Resident #1 was admitted to the facility on [DATE] from hospital for short term rehabilitation after having fallen at home and sustaining a chest injury. S/he had been living at home with home health services and help from family, and had recently had a ramp built onto the home. Per record review on 5/14/13, Resident #1 was admitted to the facility on [DATE] from hospital with [DIAGNOSES REDACTED]. The medical record included a nursing plan of care dated 4/30/13. This admission plan of care included the following section: "Fluid volume deficit related to: azotemia/dementia: assess for dehydration, monitor intake and output, encourage PO (by mouth) fluids, and medications as ordered". The Registered Dietician (RD) conducted an admission nutrition assessment on 5/1/13. This assessment estimated the fluid intake needs of Resident #1 as 1,500 cc to 1,700 cc (1 cc=1 milliliter) per day. Fluid intake records provided by the facility documented the following daily fluid intake totals: 4/30/13 120 cc; 5/1/13 420 cc; 5/2/13 240 cc; 5/3/13 420 cc; 5/4/13 480 cc; 5/5/13 0/no entry. From 4/30/13 to 5/5/13 there were no recorded entries regarding urinary output. On 5/3/13, Resident #1 was noted in day shift nursing progress notes as having difficulty keeping in the mouth the crushed medications taken with pudding and water. On 5/4/13, the day shift nursing progress notes documented that Resident #1 was observed having difficulty swallowing foods and liquid, with frequent coughing. The facility did obtain on 5/2/13 an evaluation by the Speech Language Pathologist (SLP) who recommended treatment and staff assistance with eating and drinking due to slow and laborious swallow efforts and choking. There was evidence that the dietary slip and care plan changed to staff assistance for eating from independent status upon admission. However, on 5/15/13 neither the charge nurse, nor the Director of Nursing (DON), nor the physician's office could provide evidence that the physician had been informed regarding the low oral fluid intake since admission, nor the difficulty with swallowing medication, food and drink on 5/3 and 5/4. On the morning of 5/5/13 at 10:30 AM, per record review, Resident #1 was found by the nurse to be unresponsive. Resident #1 was transported emergently to hospital where the physician documented him/her to "appear extremely dehydrated" and "lab values significant for severely elevated creatinine of 3.8 (high, kidneys not working well), [MEDICAL CONDITION] (high sodium, indicator of dehydration) of 151". Further in the physician's report of 5/5/13, comments include: "Further evaluation also reveals that (s/he) has acute kidney injury on [MEDICAL CONDITION] and [MEDICAL CONDITION] (high sodium in the blood). These are most likely due to dehydration." Hospital records of 5/5/13 also indicate that Resident #1 was admitted to the Intensive Care Unit. During an interview on 5/15/13 at 10:40 AM, the DON confirmed that the facility did not have a system of oversight in place to assure monitoring of daily oral intake values as per the written plan of care for risk of fluid volume deficit.

Based on record reviews and interviews, the facility failed to provide one of four residents in the sample (Resident #1) with sufficient fluid intake to maintain proper hydration and health. Findings include: 1. Per record review on 5/14/13, Resident #1 was admitted to the facility on [DATE] from hospital for short term rehabilitation after having fallen at home and sustaining a chest injury. S/he had been living at home with home health services and help from family, and had recently had a ramp built onto the home. Upon nursing home admission, [DIAGNOSES REDACTED]. The medical record included a nursing plan of care dated 4/30/13. This admission plan of care included the following section: "Fluid volume deficit related to: azotemia/dementia: assess for dehydration, monitor intake and output, encourage PO (by mouth) fluids, and medications as ordered". The Registered Dietician (RD) conducted an admission nutrition assessment on 5/1/13. This assessment estimated the fluid intake needs of Resident #1 as 1,500 cc to 1,700 cc (1 cc=1 milliliter) per day. Fluid intake records provided by the facility documented the following daily fluid intake totals: 4/30/13 120 cc; 5/1/13 420 cc; 5/2/13 240 cc; 5/3/13 420 cc; 5/4/13 480 cc; 5/5/13 0/no entry. On 5/3/13, Resident #1 was noted in day shift nursing progress notes as having difficulty keeping in the mouth the crushed medications taken with pudding and water. On 5/4/13, the day shift nursing progress notes documented that Resident #1 was observed having difficulty swallowing foods and liquid, with frequent coughing. The facility did obtain on 5/2/13 an evaluation by the Speech Language Pathologist (SLP) who recommended treatment and staff assistance with eating and drinking due to slow and laborious swallow and choking. There was evidence that the dietary slip and care plan changed to staff assistance for eating from independent eating upon admission. However, on 5/15/13 neither the charge nurse, nor the Director of Nursing (DON), nor the physician's office could provide evidence that the physician had been informed regarding the low oral fluid intake since admission, nor the difficulty with swallowing medication, food and drink on 5/3 and 5/4. On the morning of 5/5/13 at 10:30 AM, per record review, Resident #1 was found by the nurse to be unresponsive. Resident #1 was transported emergently to hospital where the physician documented him/her to "appear extremely dehydrated" and "lab values significant for severely elevated creatinine of 3.8 (high, kidneys not working well), [MEDICAL CONDITION] (high sodium, indicator of dehydration) of 151". Further in the physician's report of 5/5/13, comments include: "Further evaluation also reveals that (s/he) has acute kidney injury on [MEDICAL CONDITION] and [MEDICAL CONDITION] (high sodium in the blood). These are most likely due to dehydration." Hospital records of 5/5/13 also indicate that Resident #1 was admitted to the Intensive Care Unit. Further review of the hospital record reveals that after receiving at least 2 liters of Intravenous fluids at the hospital, Resident #1's creatinine at 7:35 AM on 5/6/13 improved (decreased) to 3.3. During an interview on 5/15/13 at 10:40 AM, the DON confirmed that there was not a system in place to assure that daily fluid intake totals were reviewed. Additionally, in an interview at 11:25 AM, the DON confirmed that the facility could not provide evidence that nursing staff had informed the physician of the low oral fluid intake since admission.

Based on record reviews and staff interviews, the facility failed to notify the physician of a need to alter treatment significantly for one of four residents in the sample (Resident #1). Findings include: 1. Per record review on 5/14/13, Resident #1 was admitted to the facility on [DATE] from hospital for short term rehabilitation after having fallen at home and sustaining a chest injury. S/he had been living at home with home health services and help from family, and had recently had a ramp built onto the home. Upon nursing home admission, [DIAGNOSES REDACTED]. The medical record included a nursing plan of care dated 4/30/13. This admission plan of care included the following section: "Fluid volume deficit related to: azotemia/dementia: assess for dehydration, monitor intake and output, encourage PO (by mouth) fluids, and medications as ordered". The Registered Dietician (RD) conducted an admission nutrition assessment on 5/1/13. This assessment estimated the fluid intake needs of Resident #1 as 1,500 cc to 1,700 cc (1 cc=1 milliliter) per day. Fluid intake records provided by the facility documented the following daily fluid intake totals: 4/30/13 120 cc; 5/1/13 420 cc; 5/2/13 240 cc; 5/3/13 420 cc; 5/4/13 480 cc; 5/5/13 0/no entry. On 5/3/13, Resident #1 was noted in day shift nursing progress notes as having difficulty keeping in the mouth the crushed medications taken with pudding and water. On 5/4/13, the day shift nursing progress notes documented that Resident #1 was observed having difficulty swallowing foods and liquid, with frequent coughing. The facility did obtain on 5/2/13 an evaluation by the Speech Language Pathologist (SLP) who recommended treatment and staff assistance with eating and drinking. There was evidence that the dietary slip and care plan changed to staff assistance from independent eating. However, on 5/15/13 neither the charge nurse, nor the Director of Nursing (DON), nor the physician's office could provide evidence that the physician had been informed regarding the low oral fluid intake since admission, nor the difficulty with swallowing medication, food and drink on 5/3 and 5/4. On the morning of 5/5/13 at 10:30 AM, per record review, Resident #1 was found by the nurse to be unresponsive. Resident #1 was transported emergently to hospital where the physician documented him/her to "appear extremely dehydrated" and "lab values significant for severely elevated creatinine of 3.8 (high, kidneys not working well), [MEDICAL CONDITION] (high sodium, indicator of dehydration) of 151". Further in the physician's report of 5/5/13, comments include: "Further evaluation also reveals that (s/he) has acute kidney injury on [MEDICAL CONDITION] and [MEDICAL CONDITION] (high sodium in the blood). These are most likely due to dehydration." Hospital records of 5/5/13 also indicate that Resident #1 was admitted to the Intensive Care Unit. During an interview on 5/15/13 at 11:25 AM, the DON confirmed that the facility could not provide evidence that nursing staff had informed the physician of the low oral fluid intake since admission to the nursing home facility. Per interview with the physician in charge of Resident #1's care on 5/17/13 at 8:48 AM, the physician confirmed that s/he had no evidence of and also did not recall being notified by facility staff of the inadequate fluid intake. The physician had recorded notes regarding conversations with facility staff, but indicated the conversation on 5/3/13 with the staff was focused around the Resident's restlessness and agitation. The physician specifically stated that the labs that were ordered by him/her were due to the behavioral changes, and not because s/he had been informed that the resident was not taking adequate fluids. The physician indicated that if s/he had been informed on 5/3/13 of the intake totals, s/he would have taken action.

Based on record review and staff interview, the facility failed to assure that residents were free from abuse by a facility employee for one sampled resident (Resident #1). Findings include: Per record review on 4/1/13, Resident #1 has dementia with behaviors that include sometimes being resistant to care. According to documentation by staff, on the evening of 3/17/13 at 8:45 PM, a Licensed Nursing Assistant (LNA#1) was walking by the room of Resident #1 and observed another LNA (#2) attempting to put a nightgown on the resident. The resident was observed pinching LNA#1, and LNA#1 responded by hitting Resident #1 in the head and pushing the resident down onto the bed in a forceful manner. LNA#1, who was providing care, turned around and saw LNA#2 at the door and asked them what they needed. LNA #2 stated that they were looking for a staff person, and went out to tell a supervising nurse about the incident that they observed. LNA #1 left the building shortly after the incident, however telephoned another LNA on duty that evening (LNA #3) at 10:00 PM on 3/17/13 to ask if they would retrieve a personal item left behind. LNA #3 wrote a statement for the facility investigation that stated that LNA#1 told LNA#3 in that phone conversation that Resident #1 had pinched them, and that they struck the resident. The incident was reported to the local police department, and to the state agency within the required timeframe, and a follow-up investigation was conducted which confirmed the abuse of Resident #1.

Based on observation, interview, and record review, the facility failed to assure 1 resident is free from potential physical restraints not required to treat the resident's medical symptoms. (Resident #9) Findings include: Per record review on 01/28/13, Resident #9, had bi-lateral half side rails that restricted safe movement out of bed during the months of December 2012 and January 2013. The resident's [DIAGNOSES REDACTED]. Per a fax to the physician dated 01/25/13 at 0800 states ''at change of shift 0700 patient found, body on floor with (resident's) neck caught in rail, (resident's) upper body was lifted to get the neck from the rail, neck very red, patient moving head.'' A nurse progress note dated 01/25/13 at 2:05 PM stated ''I had been in to see patient about 0645-0650, (s/he) was asking to get out of bed and told (resident) that LNA's would be in shortly, at that time (resident) was lying facing wall with bell in place and tab alarms attached. At 0700 LNA's yelling for help went to room found patient lying on the floor with (her/his) neck chin caught in the bed rail, (s/he) was not yelling out, asked male nurse to come help me, he lifted (resident) by the shoulders and lay (resident) on the floor, the patient started complaining that the floor was cold and moving (his/her) neck, without difficulty. vital signs and neuro checks done within normal limits. Patient's neck red but no complaining of pain and moving it. got resident up into wheelchair...started 15 minute checks and got order to discontinue the side rails...Doctor faxed and sent back response to check swallowing, breathing and speech, which had already been checked and monitored....most of redness on neck faded, (s/he) has a 6.5 cm long red mark on (his/her) neck." Per review of the care plan dated 12/21/12 for impaired physical mobility related to left [MEDICAL CONDITION] with repair, history [MEDICAL CONDITION](stroke) and [MEDICAL CONDITION] in bilateral feet, the care plan notes the interventions as maximum assist of 2 staff for bed mobility, encourage/assist with repositioning as needed and continue to monitor and re-educate regarding the need for 2 maximum assist with transfer. Per observation on 01/29/13 Resident #9's bed was a low-type bed that had a scoop mattress, the right side of the bed was against the wall and there was a small mattress was on the floor next to the open (left) side of the bed. Per the significant change assessment dated [DATE], after the resident sustained [REDACTED]. Half rails bilaterally were indicated and 'serve as an enabler to promote independence' and an MD order was in place. Per review of the 01/03/13 (re-admission from a hospital stay) notes, the resident arrived via stretcher with assist of two. In addition, in Section D, 'total assist' is needed for personal hygiene, mobility, transfer, and toilet use. Section E (fall risk) lists level of consciousness/mental status as 'intermittent confusion' and under section H (neurological) as 'lethargic'. Section O (side rail evaluation) notes that the resident has difficulty with balance or poor trunk control and has demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed. Again, half rails bilaterally were indicated and 'serve as an enabler to promote independence' and an MD was order was in place. Per review of the signed physician's orders [REDACTED]. Furthermore, there is no determination if the side rail use was appropriate given the resident's current history of falls, transfer ability and risk factors such as entrapment. There was also no assessment for the use of a scoop mattress. Per interview with physical therapy (PT) staff on 01/29/12 at 11:00 AM, s/he stated that the resident had plateaud with therapy as the resident is unable/unwilling to work on gaining mobility independence. The PT was unable to answer as to why the bed rails were removed on the day of the incident and to why a scoop mattress was put in place if the resident was assessed as using side rails as enablers for bed mobility. Per interview on 01/29/13 at 3:00 p.m. LNA (Licensed Nursing Assistant) staff stated ''(Resident #9's) bottom was on the floor and (her/his) neck was pressed against the bar and because of (her/his) weight (s/he) was unable to move or get up, (s/he) is 50-50 when it comes to moving on (her/his) own but lately we need to do most things for (the resident)''. S/he indicated that the resident frequently tries to "wiggle off the bed down past the side rail''. Per review of the facility's policy for assessing side rails, it notes that the use of side rails requires a complete assessment of the resident's mobility and cognitive functioning to determine the category of use. It further states that side rails used as an enabler for mobility must include the following criteria: a) an evaluation of the ability to move about in bed; b) an evaluation of whether the resident is able to use the side rails(s) in turning; c) a determination that the resident's ability to transfer using the side rail outweighs the risk of falls associated with the use of the side rails. Also, the side rail assessment must include a determination that there is no endangerment or entrapment risk from the gap between side rail and mattress or increased risk of injury from extremities caught in side rails, and states that side rail pads and bolsters are to be used when indicated ensure safety with use of side rails. Per interview on 01/30/13 at 10:57 AM, the DNS confirmed the assessment was not clear to determine if side rails (assistance device) were being used appropriately or if the resident's ability to use side rails outweigh the risk as an accident hazard and that the resident sustained [REDACTED]. Also see F323

Based on record review, observation and staff interview, the facility failed to ensure that the environment was free of accident hazards and that each resident received adequate supervision and assistance devices to prevent accidents for 2 applicable residents. (Resident #9 &10) Findings include: 1. Per record review on 01/28/13 Resident #9, did not have an environment as free of an accident hazard as possible. The resident's [DIAGNOSES REDACTED]. Per a fax to the physician dated 01/25/13 at 0800 states ''at change of shift 0700 patient found, body on floor with (resident's) neck caught in rail, (resident's) upper body was lifted to get the neck from the rail, neck very red, patient moving head.'' A nurse progress note dated 01/25/13 at 2:05 PM stated ''I had been in to see patient about 0645-0650, (s/he) was asking to get out of bed and told (resident) that LNA's would be in shortly, at that time (resident) was lying facing wall with bell in place and tab alarms attached. At 0700 LNA's yelling for help went to room found patient lying on the floor with (her/his) neck chin caught in the bed rail, (s/he) was not yelling out, asked male nurse to come help me, he lifted (resident) by the shoulders and lay (resident) on the floor, the patient started complaining that the floor was cold and moving (his/her) neck, without difficulty. vital signs and neuro checks done within normal limits. Patient's neck red but no complaining of pain and moving it. got resident up into wheelchair...started 15 minute checks and got order to discontinue the side rails...Doctor faxed and sent back response to check swallowing, breathing and speech, which had already been checked and monitored....most of redness on neck faded, (s/he) has a 6.5 cm long red mark on (his/her) neck." Per review of the care plan dated 12/21/12 for impaired physical mobility related to left hip fracture with repair, history of CVA (stroke) and neuropathy in bilateral feet, the care plan notes the interventions as maximum assist of 2 staff for bed mobility, encourage/assist with repositioning as needed and continue to monitor and re-educate regarding the need for 2 maximum assist with transfer. Per observation on 01/29/13 Resident #9's bed was a low-type bed that had a scoop mattress, the right side of the bed was against the wall and there was a small mattress was on the floor next to the open (left) side of the bed. The significant change assessment dated [DATE], after the resident sustained [REDACTED]. Half rails bilaterally were indicated and 'serve as an enabler to promote independence' and an MD order was in place. Per review of the 01/03/13 (re-admission from a hospital stay) notes, the resident arrived via stretcher with assist of two. In addition, in Section D, 'total assist' is needed for personal hygiene, mobility, transfer, and toilet use. Section E (fall risk) lists level of consciousness/mental status as 'intermittent confusion' and under section H (neurological) as 'lethargic'. Section O (side rail evaluation) notes that the resident has difficulty with balance or poor trunk control and has demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed. Again, half rails bilaterally were indicated and 'serve as an enabler to promote independence' and an MD was order was in place. Per review of the signed physician's orders [REDACTED]. Furthermore, there is no determination if the side rail use was appropriate given the resident's current history of falls, transfer ability and risk factors such as entrapment. There was also no assessment for the use of a scoop mattress. Per interview with physical therapy (PT) staff on 01/29/12 at 11:00 AM, s/he stated that the resident had plateaud with therapy as the resident is unable/unwilling to work on gaining mobility independence. The PT was unable to answer as to why the bed rails were removed on the day of the incident and to why a scoop mattress was put in place if the resident was assessed as using side rails as enablers for bed mobility. Per interview on 01/29/13 at 3:00 p.m. LNA (Licensed Nursing Assistant) staff stated ''(Resident #9's) bottom was on the floor and (her/his) neck was pressed against the bar and because of (her/his) weight (s/he) was unable to move or get up, (s/he) is 50-50 when it comes to moving on (her/his) own but lately we need to do most things for (the resident)''. S/he indicated that the resident frequently tries to "wiggle off the bed down past the side rail''. Per review of the facility's policy for assessing side rails, it notes that the use of side rails requires a complete assessment of the resident's mobility and cognitive functioning to determine the category of use. It further states that side rails used as an enabler for mobility must include the following criteria: a) an evaluation of the ability to move about in bed; b) an evaluation of whether the resident is able to use the side rails(s) in turning; c) a determination that the resident's ability to transfer using the side rail outweighs the risk of falls associated with the use of the side rails. Also, the side rail assessment must include a determination that there is no endangerment or entrapment risk from the gap between side rail and mattress or increased risk of injury from extremities caught in side rails, and states that side rail pads and bolsters are to be used when indicated ensure safety with use of side rails. Per review of the side rail assessment dated [DATE] after a hospital admission, notes that the resident has difficulty with balance or poor trunk control and has demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed. Furthermore, there is no determination if the side rail use was appropriate given the resident's current history of falls, transfer ability and risk factors such as entrapment. Per review of the incident report there is no indication as to the mental status or predisposing environmental factors. It erroneously states 'no injuries observed' and the predisposing physiological factors only as history of recent falls, but fails to note co-morbidities, functional impairment or use of assistance devices. Per interview on 01/30/13 at 10:57 AM, the DNS confirmed the assessment was not clear to determine if side rails (assistance device) were being used appropriately or if the resident's ability to use side rails outweigh the risk as an accident hazard and that the resident sustained [REDACTED]. Per interview on 01/29/13 at 1:00 PM, the Administrator stated that the resident was on the floor and the head/neck area was up against the rail. The Administrator confirmed that the resident needed to be assisted off the floor and that the side rails were removed and a scoop mattress was ordered because of the safety issue. 2. Per observation on 01/28/13 at 3:00 PM, the nurse surveyor observed Resident #10's mattress as having a greater than 5 inch gap between the left side rail and the mattress. The right side of the bed was up against the wall. Per further observation on 01/29/13 at 9:00 AM, there remained a gap of about 3 inches between the left side rail and the mattress, while the bottom of the mattress did not reach the foot of the bed, but had a mattress bolster to fill the space. Per interview on 01/29/13 at 12:13 PM, the Clinical Director stated that the side rails are used as enablers and also both rails are raised to 'keep the mattress in place''. Per observation on 01/30/13 at 11:36 AM, the foot of the bed mattress bolster was not secured and a side gap in the mattress remained at 3 inches. In addition, the call light was not near the resident and the resident stated at that time "I can't reach the bell and sometimes I can't find it''. The resident did demonstrate the ability to use the side rail to get on the side of the bed, however the resident's leg got stuck under the rail. Per observation and confirmed by the VP of Clinical Services on 01/30/13 at 11:45 AM, the mattress bolster at the foot of the bed was not secured (as indicated), and a gap between the rail and the mattress remained. At this time a new bed/mattress was obtained to assure resident safety. Also see F221

Based on record reviews and interviews, the nurse failed to assure Resident #1's right to be free from involuntary seclusion when a nurse placed the resident (who is wheelchair-bound and has severe dementia) alone in the shower room with the door closed, lights off, and without access to a call system, for an unspecified length of time during the night shift of 09/23-24/11. Findings include: 1. During an interview at 10:30 AM on 09/30/11, the Administrator provided copies of the signed, written statements and interview notes of 09/28/11, as conducted by the Director of Nursing (DNS) with the charge nurse and two Licensed Nurse Assistants (LNA) who were on duty during the night shift from 09/23/11 into 09/24/11. Per incident record review, LNA A wrote that on the night of 09/23/11, the nurse placed Resident #1 (who had been yelling) in the shower room with the door closed for an unspecified length of time. LNA B wrote that "on Friday night, the nurse put (Resident #1) into the shower room because (s/he) wouldn't settle down". There was no written statement from the charge nurse; however, the DNS (Director of Nursing Services) documented a phone conversation with the nurse on 09/28/11 where the nurse answered " yes " when the DNS asked if s/he had placed Resident #1 in the shower room. Per record review, the nurse also stated having "tried everything else". Per Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. At 0100 (1:00 AM) on 09/24/11, the nurse administered 650 mg [MEDICATION NAME] (an as needed medication for pain) with no effect. At 0200 (2:00 AM) on 09/24/11, the nurse administered 0.5 mg [MEDICATION NAME] (a medication ordered for as needed use to address severe agitation) with no effect. Per review of the behavioral sheets, documentation indicated that Resident #1 had three episodes of agitation and yelling out during the night shift on 09/24/11. On 09/30/11 at 2:00 PM, the nurse unit manager confirmed that the medical record reflected three pharmacological interventions for agitation and yelling during the night shift of 09/24/11. Per review of a signed written statement, LNA C wrote that at 5:15 AM on the morning of 09/24/11, s/he "went into the shower room and found (Resident #1) sitting in the dark. The shower room door was closed". During an interview at 1:15 PM on 09/30/11, LNA C stated that as part of his/her preparation for the 06:00 AM day shift, s/he always goes first into the shower room to check the shower list for the day. LNA C further stated that on the morning of 09/24/11 at 05:15 AM, s/he opened the door and turned on the light and discovered Resident #1 asleep in the wheelchair in the back of the shower room. LNA C indicated that there was no call system available to resident. LNA C also stated that s/he wheeled Resident #1 out to the nurse's station and said to the charge nurse, "Look who I found in the shower room", and that the charge nurse stated, "Oh, I forgot about her being in there". On 09/30/11 at 1:45 PM, LNA C and this surveyor observed the shower room together and stood in the back of the room with the lights off. There was a very small amount of light visible through a slit window in the upper left panel of the door. At that time, LNA C confirmed that this was the environment in which s/he discovered Resident #1 at 5:15 AM on 09/24/11.

Based on record reviews, interviews and observations, the facility staff failed to provide care to Resident #1 (who is wheelchair-bound and has severe dementia) in a manner and in an environment that promoted or maintained the resident's dignity when they placed and maintained the resident alone in a dark shower room for an unspecified length of time during the night shift of 09/23-24/11. Findings include: 1. During an interview at 10:30 AM on 09/30/11, the Administrator provided copies of the signed, written statements and interview notes of 09/28/11, as conducted by the Director of Nursing (DNS) with the charge nurse and two LNAs who were on duty during the night shift from 09/23/11 into 09/24/11 on wing 1. Per incident record review, LNA A wrote that on the night of 09/23/11, the nurse placed Resident #1 (who had been yelling) in the shower room with the door closed for an unspecified length of time. LNA B wrote that "on Friday night, the nurse put (Resident #1) into the shower room because (s/he) wouldn't settle down". There was no written statement from the nurse; however, the DNS documented a phone conversation with the nurse on 09/28/11 where the nurse answered "yes" when the DNS asked if s/he had placed Resident #1 in the shower room. Per review of a signed written statement, LNA C wrote that at 5:15 AM on the morning of 09/24/11, s/he "went into the shower room and found (Resident #1) sitting in the dark. The shower room door was closed". During an interview at 1:15 PM on 09/30/11, LNA C stated that as part of his/her preparation for the 06:00 AM day shift, s/he always goes first into the shower room to check the shower list for the day. LNA C further stated that on the morning of 09/24/11 at 05:15 AM, s/he opened the door and turned on the light and discovered Resident #1 asleep in the wheelchair in the back of the shower room. LNA C indicated that there was no call system available to the resident. LNA C also stated that s/he wheeled Resident #1 out to the nurse's station and said to the charge nurse, "Look who I found in the shower room", and that the nurse stated, "Oh, I forgot about her being in there". On 09/30/11 at 1:45 PM, LNA C and this surveyor observed the shower room together and stood in the back of the room with the lights off. There was a very small amount of light visible through a slit window in the upper left panel of the door. At that time, LNA C confirmed that this was the environment in which s/he discovered Resident #1 at 5:15 AM on 09/24/11.

Based on record reviews and interviews, the facility staff failed to correctly implement the written, multidisciplinary plan of care for Resident #1 (who is at high risk for falls, is wheelchair/bed bound, and has severe dementia). Findings include: 1. Per medical record review, the written plan of care for Resident #1 includes specific measures to: "maintain safe environment; reassure of safety if delusional thinking occurs; be sure the resident is within sight of staff when out of bed in wheelchair; maintain safety when behavior escalates and attempt to reapproach; offer non-pharmaceutical approach to sleep assist, back massage, music, reading, tv, etc.". During an interview at 10:30 AM on 09/30/11, the Administrator provided copies of the signed, written statements and interview notes of 09/28/11, as conducted by the Director of Nursing (DNS) with the nurse and two LNAs who were on duty during the night shift from 09/23/11 into 09/24/11. Per incident record review, LNA A wrote that on the night of 09/23/11, the nurse placed Resident #1 (who had been yelling) in the shower room with the door closed for an unspecified length of time. LNA B wrote that "on Friday night, the nurse put (Resident #1) into the shower room because s/he wouldn't settle down". The DNS documented a phone conversation with the nurse on 09/28/11 where the nurse answered "yes" when the DNS asked if s/he had placed Resident #1 in the shower room. Per review of a signed written statement, LNA C wrote that at 5:15 AM on the morning of 09/24/11, s/he "went into the shower room and found (Resident #1) sitting in the dark asleep in the wheelchair. The shower room door was closed and there was no call system " . During an interview at 1:15 PM on 09/30/11, LNA C confirmed that on the morning of 09/24/11 at 05:15 AM, s/he opened the door and turned on the light and discovered Resident #1 asleep in the wheelchair in the back of the shower room. LNA C indicated that there was no call system available to the resident. During an interview on 09/30/11 at 4:00 PM, the nurse unit manager confirmed that on the night shift of 09/24/11, the three staff on duty had not implemented the written plan of care for safety, reassurance, and non-pharmaceutical approaches when they left Resident #1 alone and unsupervised in the dark shower room for an unspecified length of time.