Every finding on record at Bear Hill Healthcare and Rehabilitation Center

Based on observation, record review, and interview, the facility failed to provide quality of care in accordance with professional standards for four Residents (#154, #40, #118, and #58) out of a total sample of 31 residents. Specifically,1. For Resident #154, the facility failed to document and assess the alteration of the skin on his/her lower extremities to determine if the areas were healing or worsening and failed to report the condition of Resident 154's lower extremities to the medical provider. 2. For Resident #40, the facility failed to implement an order for a diuretic after a significant weight gain for Resident #40, who has congestive heart failure and edema.3. For Resident #118, the facility failed to label wound dressings after changing Resident #118's dressing.4. For Resident #58, the facility failed to complete weekly skin checks as ordered. Findings include:1.Resident #154 was admitted to the facility in December 2024 with diagnoses including multiple sclerosis, severe protein calorie malnutrition and chronic venous hypertension with ulcers of the right lower extremity. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/10/25, indicated Resident #154 had moderate cognitive impairment as evidence by a Brief Interview for Mental Status (BIMS) score of 12 out of a possible score of 15. The MDS further indicated that the Resident required substantial/maximal assistance for daily care. During an observation and interview on 1/13/26 at 9:05 A.M., Resident #154 expressed concerns regarding wounds to both of his/her lower legs. Resident #154 said that he/she felt nothing was being done to treat his/her lower extremity wounds and that the wounds seemed to not be getting better. Resident #154's legs were observed to have partial dry/crusted areas of skin that were peeling and draining fluid. There were also dried fluid stains on Resident # 154's sheets. The wounds have areas that were covered with old skin that were moist and yellow/blackish in color. Review of Resident 154's Norton Assessment (a clinical tool used to assess a resident's risk of developing pressure ulcers) dated 1/4/26, concluded that Resident #154 scored a 9 indicating he/she was at a high risk for skin breakdown. Review of Resident 154's Skin Assessment (a clinical tool used to measure moisture, color, or elasticity helping healthcare professionals monitor skin health, predict issues, and personalize care) dated 1/8/26, indicated that the Resident had multiple closed scabs to both legs. Review of Resident 154's plan of care indicated the following: -Focus: high risk for skin breakdown related to decreased functional mobility, Disease process, multiple sclerosis, severe malnutrition, adult failure to thrive, incontinent of bowel, history of vascular ulcers to BLE's, dated 12/17/24. -Intervention: assess skin condition with ADL care daily; report abnormalities. -Focus: history of actual skin breakdown related to right and left leg chronic open areas r/t Dermatitis. Recurrent occurrence. Scab now, dated 12/20/24. -Interventions: review treatments and change if not effective as needed and notify MD (medical doctor) of lack of progress in healing or deterioration. Review of Resident 154's January 2026 treatment administration record indicated that the Resident's right shin was intact with no drainage noted from dates 1/1/26 through 1/14/26. The January 2026 treatment administration record failed to indicate a wound assessment for Resident #154's left shin. Review of the medical record failed to indicate that the medical provider had been notified regarding Resident 154's change in leg wounds from dates 1/1/26 through 1/14/26. Review of Resident 154's active physician orders indicated the following: - Hibiclens External Solution 4 % (Chlorhexidine Gluconate) (an antibacterial antiseptic skin cleanser that kills germs on contact and provides sustained protection against bacteria): Apply to Bilateral legs topically every day shift every Mon, Wed, Fri for preventive Wash bilateral legs with hibiclens three times weekly, dated 1/24/25. - Right and left shin- clean with normal saline pat dry, apply moisturizer and leave open to air, every day and evening shift for dry skin, dated 11/26/25. - Wound assessment to be completed with each treatment application/dressing change. Right shin, dated 9/11/25. During an interview on 1/14/26 at 9:21 A.M., Resident #154 said that the nurse had been in before breakfast to clean both of his/her legs. Resident 154 stated that prior to this day, it had been quite some time since anyone had tried to clean his/her legs. During an interview on 1/14/26 at 9:33 A.M., Nurse #1 said she washed Resident #154's legs with normal saline (a sterile, saltwater solution) then she applied cream to both legs. Nurse #1 said Resident #154's leg wounds were not open despite the dried drainage noted on the Resident's sheets and that the Resident was followed by the wound Doctor. Nurse #1 said she did not wash the Resident's legs with the skin cleanser but washed the Resident's legs with normal saline. Review of the Medication Administration Recorded dated 1/14/26 indicated that Nurse #1 documented that she had applied the hibiclens skin cleanser to both of Resident #154's legs. Review of the medical record failed to indicate that Resident #154 was being followed by the wound Doctor but had indicated that the Resident had been discharged from the wound Doctor's services on 2/25/25. During an interview on 1/14/26 at 11:46 A.M., the Nurse Practitioner (NP) said the Resident has chronic leg wounds that come and go and he/she has bad skin. The NP said the Resident is followed by the wound Doctor. The NP said she does not always assess his/her legs and expects nursing to tell the wound Doctor and herself if the wounds are open. The NP said if there are open wounds on his/her legs nursing should reach out to the wound Doctor, then update the NP. The NP said she was not aware of any open areas within the past week. During an interview on 1/14/26 at 11:57 A.M., Unit Manager #1 said Resident 154's legs were at baseline in appearance and that there was a lot of dead skin on top of the wound. She said that if the excess skin were to be removed then the area would be open. Unit Manager #1 said that there was drainage noted and she would expect nurses to update the NP when wounds are draining so she could have the Resident referred to the wound Doctor and get treatment orders. During an interview on 1/14/26 at 1:53 P.M., the Staff Development Educator (SDC) said Resident #154's left leg was dry, but the right leg was soft and mushy and when the Resident moves around it peels off skin leaving the area with moist open skin, revealing small open areas. The SDC said she would expect the nurses to update the NP when drainage is involved and receive treatment orders. During an interview on 1/15/26 at 12:02 P.M., the Director of Nurses (DON) said nurses should be updating the NP when changes to a resident's skin is noted and request treatment orders if needed. 2. Review of the facility policy titled Heart Failure - Clinical Protocol, undated, indicated the following: The physician will identify individuals who are receiving medications, or medication combinations, associated with the treatment for HF (heart failure); for example, diuretics, ACE inhibitors, and vasodilators. The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, digoxin level, etc.) to monitor, when to report findings to the physician, etc. The physician will address related medical issues; for example, adjust or stop medications that may be precipitating heart failure, modify doses of diuretics, determine whether oxygen is needed, etc. The physician will help monitor the progress of individuals with HF, including ongoing evaluation and documentation of signs, symptoms, and condition changes. Resident #40 was admitted in November 2025 with diagnoses including congestive heart failure. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #40 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of Resident #40's care plan indicated the following: Focus: The resident has fluid volume deficit related to diuretic use (initiated 11/19/25) Interventions: Monitor weight Q (every) week (undated) Review of the weight summary for Resident #40 indicated the following weights: 11/24/25 - 126.3 pounds 12/2/25- 133 pounds 1/14/26 - 137.6 pounds Review of the medical record failed to indicate that weights were being done weekly to monitor weight changes, per the care plan, related to Resident #40's congestive heart failure. Review of the physician note, dated 12/1/25, indicated the following decreased Lasix (a diuretic used to reduce fluid volume) to 40 mg (milligrams) in the am and 20 mg at 2pm; was taking 40 mg po twice daily: Review of the nursing progress note, dated 12/2/25, indicated Resident #40 had a 6.7 pound weight gain noted and a new order was initiated for increased Lasix, to have and extra dose of 20 mg every afternoon. Review of physician orders indicated that Resident #40 was prescribed Lasix 40 mg one time a day and 20 mg once in the afternoon. Both orders were initiated on 11/11/25. Review of the medical record failed to indicate that an additional Lasix order was initiated after Resident #40 had a 6.7 pound weight gain from 11/24/25 to 12/2/25 and that no new orders for Lasix were initiated after 11/11/25. During an interview on 1/14/26 at 3:35 P.M., the Director of Nursing said that the unit managers update the care plan and should be following the care plan regarding the weekly weights. The Director of Nursing could not speak to why the additional Lasix order never got implemented and reached out to the physician. The physician implemented new orders to increase the Lasix, ordered a chest x-ray, and implemented a new order to weigh the Resident daily. 3. Review of the facility policy titled Wound Care, dated as revised January 2025, indicated the following: Documentation: The following information should be recorded in the residents' medical record: The type of wound care given. The date and time the wound care was given. The name and title of the individual performing wound care. All assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound. If the resident refused the treatment and reason why. The signature and title of the person recording the data. Resident #118 was admitted in November 2025 with diagnoses including unspecified symptoms and signs involving cognitive functions and awareness Review of the Minimum Data Set (MDS) assessment, dated 12/16/25, indicated Resident #118 scored a 6 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. On 1/13/26 at 8:50 A.M., the surveyor observed Resident #118 with bandages on his/her left forehead and on his/her left hand. The bandages were undated. On 1/13/26 at 1:48 P.M., the surveyor observed Resident #118 with bandages on his/her left forehead and his/her left hand. The bandages were undated. On 1/14/26 at 7:24 A.M., the surveyor observed Resident #118 with a bandage on his/her left forehead. The bandage was undated. On 1/14/26 at 8:20 A.M., the surveyor observed Resident #118 with a bandage on his/her right hand. The bandage was undated. On 1/15/26 at 6:33 A.M., the surveyor observed Resident #118 with a bandage on his/her right and his/her left hand. The bandages were undated. Review of Resident #118's care plan for high-risk skin breakdown, revised on 1/9/26 indicated the following: Focus: readmitted on [DATE] skin tear on left anterior arm. Interventions: treatment as ordered. Review of Resident #118's active physician's orders indicated: -Left arm skin tears: wash with normal saline or wound cleanser, apply xero-form gauze and cover with dry protective dressing (DPD) daily everyday shift. Date started 1/13/26. -Left hand skin tear: wash with normal saline or wound cleanser, [NAME] xero-form and cover with DPD daily everyday shift. Date started 1/13/26. -Left should skin tear: wash with normal saline or wound cleanser, [NAME] xero-form and cover with DPD daily everyday shift. Date started 1/13/26. -Head laceration: normal saline cleanse to area daily, apply clean dry dressing. Date started 1/12/25. During an interview on 1/15/26 at 7:33 A.M., Unit Manager #3 said wound dressings should be dated when changed. During an interview on 1/15/26 at 12:00 P.M., the Director of Nursing said that dating wound dressings is the best policy and the gold standard. She said if nurses did not date their wound dressing, then it wouldn't be clear when the dressing had last been changed. 4. Review of the facility policy titled Weekly skin assessment, dated as revised 6/8/22, indicated the following: All residents will have a full body assessment on day of admission and weekly thereafter. The nurse will document on weekly skin assessment in the electronic health record. Resident #58 was admitted in December 2025 with diagnoses including right knee osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 12/22/25, indicated Resident #58 scored a 6 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. Review of Resident #58's care plan for high-risk skin breakdown, revised on 12/15/25 indicated the following: Interventions: Weekly skin assessment. Review of Resident #58's active physician's orders indicated: -Weekly skin evaluation every evening shift on every Monday. Proceed to assessments and complete a skin evaluation. Date started 12/22/25. Review of Resident #58's Treatment Administration Record indicated: -Weekly skin evaluation every evening shift on every Monday. Proceed to assessment and complete a skin evaluation. Review of Resident #58's Skin evaluations scheduled for weekly on 12/1/25, 12/8/25, 12/15/25, 12/22/25, 12/29/25, 1/5/26, 1/12/26 indicated they were completed on 12/3/25 and 12/22/25. The skin evaluations for Resident #58 were completed two times out of a scheduled seven during the months of December and January. During an interview on 1/15/26 at 8:03 A.M., Unit Manager #2 said nurses know when skin checks are due by looking at their Treatment Administration Record and there is also a scheduled taped on the treatment cart. She said when a skin check is due the nurse must complete and document the skin evaluation under assessments in the electronic medical record. During an interview on 1/15/26 at 12:00 P.M., the Director of Nursing and Regional Nurse Consultant said skin evaluation should be done weekly and documented in the electronic medical record.

Based on record review and interview, the facility failed to accurately document in the electronic medical record for two Residents (#12 and #84), out of a total sample of 31 residents. Specifically, 1. For Resident #12, nursing staff documented a right arm sling as being provided when it was not. 2. For Resident #84, the facility failed to accurately record the Resident's oxygen saturation percentages in the medication administration record. Findings include: 1.Resident #12 was admitted to the facility in October 2025 with diagnoses that included but not limited to Alzheimer's Disease and a displaced fracture of the upper end of the right humerus. Review of the most recent Minimum Data Set assessment, dated 10/24/25, indicated Resident #12 scored 6 out of 15 on the Brief Interview for Mental Status exam, indicating he/she had severely impaired cognition, had an upper extremity impairment on one side, and was dependent on staff for upper and lower body dressing. On 1/13/26 at 8:30 A.M., Resident #12 was observed in a recliner near the nursing desk. Resident #12 could not be interviewed. Review of Resident #12's physician's orders indicated the following: R (Right) Arm: Ensure sling in place at all times. Monitor CSM (circulation, sensation and movement). May remove for hygiene, adl (activities of daily living) and skin assessment every shift, active date 10/20/25. On 1/13/26 at 2:14 P.M., Resident #12 was observed in a geri-recliner and being wheeled by a nurse and placed near the front of the nursing desk. Resident #12's right arm was held to his/her side and not in a right arm sling. On 1/14/26 at 4:17 P.M., Resident #12 was observed in a geri-recliner in front of the nursing desk. Resident #12's right arm was not in a sling. On 1/15/25 at 10:10 A.M., Resident #12 was observed in a geri-recliner, and his/her right arm was not in a sling. Review of the Treatment Administration Record (TAR) dated 1/2026 indicated the right arm sling was administered 1/1/26 through 1/14/25. On 1/15/26 at 10:14 A.M., Nurse #4 said Resident #12 used to have a sling and now that the pain has receded, he/she is not using the sling. Nurse #4 said he/she has not put on the sling for a while now. Nurse #4 reviewed the orders and said the order was still in place. Nurse #4 said if there is an order it should be followed unless it is discontinued. Nurse #4 went to Resident #12's room and found a sling in the bottom drawer. During an interview on 1/15/26 at 10:18 A.M., Unit Manager #4 said she has been employed at the facility for one month, and that she had not seen Resident #12 wearing a right arm sling recently. Unit Manager #4 said the Resident may have had the sling when he/she first came up to the unit, and that she believed the order for Resident #12's right sling may have been discontinued. Unit Manger #4 reviewed the orders and said the order for the sling was in place and that the nurses should not be documenting on the TAR that the right arm sling was provided when it was not. 2. Resident #84 was admitted in October 2024 with diagnoses including dementia and hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #84 scored a 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of the MDS indicated Resident #84 does receive oxygen therapy. Review of the current physician's orders for Resident #84 indicate an order to provide 2 L (liters) of oxygen when the Resident's oxygen saturation is less than 92%. Review of the oxygen saturation vitals for Resident #84 indicated the following oxygen saturation percentages: 1/13/26: 18% 11/26/25: 7% Review of the progress notes failed to indicate any follow up or review of the vitals that were out of the oxygen saturation parameters, per the physician orders. During an interview on 1/14/26 at 3:54 P.M., the Director of Nursing said that staff should be entering vitals correctly and it is an issue she has identified and is working on.

Based on record review, interview and observation, the facility failed to ensure physicians orders for the care of pressure ulcers were implemented for one Resident (#86) out of a total sample of 31 residents. Specifically, for Resident #86, the facility failed to ensure that the wound physician's recommendations for treatment to Resident #86's sacrum were followed. Findings include: Review of the facility policy titled Prevention of Pressure Ulcers, undated, indicated the following: It is the policy to prevent pressure ulcers unless clinically unavoidable and to provide care and services to promote the prevention of pressure ulcer development, the healing of pressure ulcers that are present (including of infection to the extent possible) and prevent development of additional pressure ulcers. Resident #86 was admitted to the facility in December 2025 with diagnoses including peripheral vascular disease, unstageable pressure ulcers of sacral region (base of the spine), left heel, left ankle and acquired absence of right leg below knee. Review of Resident #86's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of four out of a possible 15, which indicated Resident #86 had severely impaired cognition. This MDS also indicated that Resident #86 required dependence for mobility and that he/she was admitted with three unstageable (full thickness tissue loss where the wound bed is obscured by dead tissue) pressure ulcers. Review of Resident #86's most recent Norton risk Assessment, dated 12/31/25, indicated the Resident was at high risk for skin breakdown. Review of Resident #86's pressure ulcer care plan dated 12/3/25, indicated:-Unstageable sacrum.-Provide treatment as ordered.-Low air loss mattress set at 80-120.-Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, sign and symptoms of infection, maceration, etc. to MD. Review of Resident #86's weekly wound assessment tool, dated 1/12/26, indicated sacrum Length 4.0 cm, Width 0.5cm. Review of Resident #86's active physician orders indicated the following:-Wound assessment to be completed with each treatment application/dressing change every day shift. Start date 12/4/25.-Weekly Skin Evaluation every night shifts every Thursday for monitoring. Start date 12/3/25.-Sacrum: cleanse with normal saline, pat dry, and apply calcium alginate (highly absorbent material) and cover with bordered foam every day shift. Start date 12/5/25. Review of the wound physician's note dated 1/12/26, indicated Resident #86's wound to the sacrum demonstrates an open wound with a mixture of granulation (new, healthy) tissue and slough obscuring the extent of the wound bed, consistent with an unstageable pressure-related injury. Review of the wound physician's recommendations dated 1/12/26, indicated for Resident #86:-Sacrum: cleanse with wound cleanser, apply santyl and calcium alginate to base of wound, secure with dressing, change daily and as needed. Review of the Nurse Practitioner #2 progress note dated 1/14/26 did not indicate that she was aware of the 1/12/26 wound physician recommendation to change treatment order to Resident #86's sacrum wound. Review of Resident #86's medical record failed to indicate new treatment orders were implemented to the sacrum wound as recommended by the wound physician on 1/12/26. On 1/15/25 at 7:10 A.M., Nurse #2 and surveyor observed Resident #86's sacrum wound. During observation of the sacrum there were two new open areas noted under Resident's scrotum. Nurse #2 said she had done Resident's treatments the day before and those open areas were not there. The sacrum/scrotal wounds were covered in slough. During an interview on 1/15/25 at 7:32 A.M., Unit Manager #3 said she had done rounds with the wound physician on 1/12/25 and the open areas under Resident's scrotum were not there. She said that recommendations that are made by the wound physician need to be approved by the Nurse Practitioner but that they are usually put into place the same day. She said the recommendation to add santyl to Resident #86's sacrum treatment must have been overlooked but she would have expected it to have been initiated the same day. During a phone interview on 1/15/25 at 12:00 P.M., Nurse Practitioner #2 said that she would expect any recommendations by the wound physician to be put in place since they are the experts. On 1/15/26 at 12:01P.M., the Director of Nurses (DON) said the Unit Manager had been on a cart on 1/12/26 and that must be why the recommendations got missed, but they should have been put in place.

Based on observations, record reviews and interviews, the facility failed to ensure for one Resident (#145), out of a total sample of 31 residents, that services were provided to maintain his/her hearing abilities. Specifically, for Resident #145 the facility failed to assist with providing his/her's left hearing aid and ensuring it was working to support the Resident's hearing. Findings include: Review of the facility's policy, titled Hearing Aid, Care of, dated as revised February 2022 indicted the purpose of this procedure is to maintain the resident's hearing at the highest attainable level. The following information should be recorded in the resident's medical record; 1. If the resident refused the procedure, the reason(s) why and the interventions taken, Reporting, Notify the supervisor if hearing aid is damaged, Notify the supervisor if the resident complains of problems related to hearing aid and/or the hearing aid or has a wax build up in the ear.Resident #145 was readmitted to the facility in September 2024 and has diagnoses that include but are not limited to Parkinson's Disease, chronic ischemic heart disease, and unspecified dementia.Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #145 scored 3 out of 15 on the Brief Interview for Mental Status, indicating he/she has severe cognitive impairment, requires substantial/maximal assistance with upper body dressing, had highly impaired hearing, and had hearing aids or other hearing appliance is used.On 1/13/26 at 10:41 A.M., Resident #145 was in his/her room. When speaking to Resident #145 it was apparent when he/she could not respond that he/she had a hearing deficit. When Resident #145 was asked about hearing aids, Resident #145 said his/her right hearing aid recently went missing and he/she was waiting for a new right hearing aid. Resident #145 said his/her other hearing aid (left) is not working, even with the new batteries they gave him/her recently. Resident #145 said he told staff that the left hearing aid was not working.On 1/13/26 at 1:29 P.M., Resident #145 was observed in his/her room. Resident #145 did not have his/her left hearing aid in his/her ear. Resident #145 pulled a plastic container with a cover out of the top drawer of his/her bedside table, opened it, revealing one hearing aid and batteries scattered in the container. Resident #145 said the batteries did not work.On 1/13/26 at 4:31 P.M., Resident #145 was observed sitting up in his/her wheelchair. Resident #145 did not have a hearing aid in his/her left ear resulting in difficult communication.On 1/14/26 at 8:56 A.M., Resident #145 was observed in his/her room. Resident #145 did not have hearing aids in his/her ears. Resident #145 said do you have the new batteries?.Review of Resident #145's care plan dated 8/16/25 indicated Resident #145 is at risk for impaired communication due to hearing deficit, dated 8/16/22. Interventions included but not limited to place both hearing aids on in the morning and remove at bedtime.Review of Resident #145's physician's orders indicated the following:-Place bilateral hearing aids in the morning and remove at bedtime. May store at bedside. Every day and evening shift. Order date 5/24/22.-Size 13 hearing aid batteries used. Order date 5/24/22During an interview on 1/15/26 at 9:56 A.M. Social Worker (SW) #1 said Resident #145's right hearing aid was lost, found in the laundry, was out getting fixed and the Resident has not had the right hearing aid since around the end of December (2025). Social Worker #1 said at the same time she provided Resident #145 with batteries for the left hearing aid and was not aware that the Resident was not wearing the left hearing aid, nor aware that it was not working to support his/her hearing. Social Worker #1 and the surveyor went to Resident #145's room and after the SW put in one of the batteries in the container that she said she provided and placed in Resident #145's ear, Resident #145 said it was not working and he/she wanted to be able to use the hearing aid. Review of the Treatment Administration Record (TAR) dated January 2026 indicated the order to place bilateral hearing aids in the morning and remove at bedtime, may store bedside, was documented as administered 1/1/26 through 1/14/26. This documentation conflicts with the observations made and the fact supported by Social Worker #1 that Resident #145 has been without his/her right hearing aid since the end of December 2025. Review of the TAR indicated Nurse #4 documented that bilateral hearing aids were documented as placed per physician order on 1/13/25 and 1/14/25.Review of the progress notes in Resident #145's medical record from 1/1/26 through 1/14/26 failed to indicate the Resident refused to have the left hearing aid placed.During an interview on 1/15/26 at 10:30 A.M., Nurse #4 said Resident #145's right hearing aid is not available. Nurse #4 said the order is for nursing to place the hearing aids in the Resident's ear. Nurse #4 said the Resident did tell him that the batteries were not working for the left hearing aid.

Based on record review and interview, the facility failed to develop an activities care plan for one Resident (#40) out of a total sample of 31 residents. Findings include: Resident #40 was admitted in November 2025 with diagnoses including adjustment disorder with mixed anxiety and depressed mood. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #40 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During an interview on 1/13/26 at 8:58 A.M., Resident #40 said that he/she would like to attend some activities but has only been to one activity since he/she's been admitted . Resident #40 said that no one comes to get him/her for activities because he/she is at the end of the hall. During an observation on 1/13/26 at 4:02 P.M., Resident #40 was sitting in his/her wheelchair in his/her room. Resident #40 said that he/she hadn't done any activities that day. Resident #40 said that he/she loves music and entertainment but can't always listen because his/her phone is not always charged. Resident #40 said that he/she also enjoys group activities. Review of the activities attendance log for January 2026 indicated that Resident #40 participated in independent activities for the entire month. Review of the care plan for Resident #40 failed to indicate that there was an individualized, person-centered activities care plan developed. During an interview on 1/14/25 at 12:51 P.M., the Activities Director said that every resident should have an activities care plan in place after admission. The Activities Director was unaware that Resident #40's care plan had not been developed.

Based on observation, record review and interview, the facility failed to identify and assess the use of a geri-chair (a high back chair on wheels with the ability to recline) as a potential restraint for one Resident (#118) out of a total of 31 sampled Residents. Findings include: Review of the facility's Use of Restraints policy, undated, indicated the following:Restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully.Restraints shall only be used to treat the residents' medical symptoms and never for discipline or staff convenience, or for the prevention of falls.When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine underlying causes of problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. The order shall include the following: a. The specific reason for the restraint (as it relates to the residents' medical symptoms). b. How the restraint will be used to benefit the residents' medical symptom; and c. The type of restraint, and period of time for the restraint.17. Care Plans for residents in restraints will reflect the interventions that address not only the immediate medical symptoms, but the underlying problems that may be causing the symptoms.18. Care Plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use.19. Documentation regarding the use of the restraint shall include: a. Full documentation of the episode leading to the use of physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode. b. A description of the residents' medical symptoms that warranted the use of the restraints. c. How the restraint benefits the residents by addressing the medical symptom. d. The type of restraint used. e. The length of effectiveness of the restraint time. f. Care provided such as observation, range of motion, repositioning, and toileting. Resident #118 was admitted to the facility in November 2025 with diagnoses including unspecified symptoms and signs involving cognitive functions and awareness, depression, and sepsis. Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #118 is severely cognitively impaired as evidenced by a score of 6 out of apossible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated that Resident #118 requires assistance with bathing, dressing and toileting. The MDS indicated that Resident #118 required partial/moderate assist for ambulation and transfers. The MDS did not indicate the use of any restraints for Resident #118. On 1/13/26 at 1:48 P.M., the surveyor observed Resident #118 behind the nursing station seated in a geri-chair in the reclined position. Resident #118 was agitated and was trying to get up by thrusting self forward and throwing his/her legs over the side of the geri-chair On 1/14/26 at 11:21 A.M., the surveyor observed Resident #118 in the hallway in front of nursing station seated in a geri-chair in the reclined position. Resident #118 was agitated and was trying to get up by throwing his/her legs over the side of the geri-chair. On 1/15/26 at 6:33 A.M., the surveyor observed Resident #118 behind the nursing station seated in a geri-chair in the reclined position. Resident #118 was agitated and was trying to get out of the geri-chair by thrusting his/her body forward and throwing his/her legs over the side of the geri-chair. On 1/15/26 at 8:48 A.M., the surveyor observed Resident #118 in his/her room in a geri-chair in the reclined position. Resident #118 was agitated and was trying out of geri-chair by thrusting his/her body forward. Review of Resident #118's active physicians' orders failed to indicate an order for a geri-chair. Review of Resident #118's fall care plan indicated: Problem start date: 12/9/25: Resident is at high risk for falls related to: decreased mobility, history of recurrent falls, poor safety awareness, weakness, restless and agitated, constantly attempting to self-transfer, needing 1:1 attention. Interventions: geri-chair, sit at nurses' station in geri-chair. Review of Resident #118's rehab notes failed to indicate staff assessed for the use of a geri-chair. Review of Resident #118's medical record in January 2026 failed to indicate any Restraint Assessment for the use of a geri-chair. Review of Resident #118's Nursing progress notes indicated:1/10/25: Returned from emergency room with left temporal head laceration. He/she was medicated with Ativan (anti-anxiety medication) and Zyprexa (anti-psychotic medication) prior to being sent back. Patient is a high fall risk receives 1:1 sitter at all times. The Nurse Practitioner is aware that Resident is confused, very anxious, still attempting to walk unassisted and may fall from time to time. The Nurse Practitioner ordered Trazadone (anti-depressant medication) daily and as needed.1/11/25: New geri-chair provided by physical therapy for fall prevention working positively.1/15/25: This writer (sic) was on Resident's unit and noted him/her to be sitting in a reclining chair and trying to stand/self-transfer. During an interview on 1/15/25 at 6:33 A.M., Certified Nursing Assistant (CNA) #2 said that Resident #118 used to have a standard wheelchair but has been using the geri-chair since he/she got back from the hospital. CNA #2 said that Resident #118 is a fall risk and is now in the geri-chair to prevent him/her from falling. During an interview on 1/15/25 at 6:40 A.M., Nurse #4 said she did not know how long Resident #118 had been using the geri-chair, but that he/she had been up in the geri-chair since 4:00 A.M., very agitated and trying to stand. During an interview on 1/15/25 at 7:33 A.M., Unit Manager #3 said that Resident #118 had been using the geri-chair since he/she returned from the hospital in January 2026. She said that therapy would do the assessment for the geri-chair. During an interview on 1/15/25 at 8:55 A.M. the Rehabilitation Director said Resident #118 is on caseload and he/she was assessed for a device that would provide him/her comfort in the evening hours since he/she climbs out of bed. The geri-chair was recommended for use in the evening hours since his/her last hospitalization. She said the geri-chair was not assessed as a restraint. During an interview on 1/15/25 at 12:10 P.M., the Director of Nursing (DON) said that Resident #118 was not safe in his/her standard wheelchair and was switched to the geri-chair, as recommended by therapy, for his/her comfort and to keep him/her from falling. The DON said Resident #118 is a fall risk and that the geri-chair is a fall intervention. She also said that there should be a physician's order and a consent for the use of the geri-chair. The Regional Nurse Consultant then said that there should be a restraint assessment completed before the use of the geri-chair to assess if it is a restraint.

Based on record review and interviews, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) (a form issued by SNFs to notify Medicare beneficiaries of potential financial liability for certain services) for 2 applicable residents, out of a sample of 3 residents. Specifically, the facility failed to issue SNF ABN notices after skilled services ended. Findings include: A review of two Notices of Medicare Non-coverage issued for the two residents who remained in the facility after skilled services ended on 11/28/25 and 1/9/26 respectively, failed to indicate that SNF ABN notices were issued. During an interview on 1/14/26 at 10:04 A.M., Social Worker #1 said that the expectation for residents who remain in the facility after skilled services ending is to get a SNF ABN notice informing them of potential financial liability for certain services.

Based on record review and interview, the facility failed to accurately document in the clinical record for 4 Residents (#18, #43, #241 and #110) out of a total sample of 30 residents. Specifically: 1. for Resident #18 the facility failed to accurately document the changing of the oxygen tubing. 2. For Resident #43 the facility failed to accurately document the sex of the Resident. 3. For Resident #241 the facility failed to accurately document the Activities of Daily Living (ADL) care provided. 4. For Resident #110, the facility failed to ensure staff accurately documented the completion of wound treatments provided. Findings include: Review of the facility policy titled 'Charting and Documentation', dated revised July 2017 indicated that Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. 1. Resident #18 was admitted to the facility in January 2023 with diagnoses including chronic obstructive pulmonary disease, dementia and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #18 scored a 7 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicated that Resident #18 is dependent on staff for activities of daily living. Further review indicated that Resident #18 received oxygen therapy while a resident. On 12/17/24, at 8:35 A.M., and 11:59 A.M., and on 12/18/24 at approximately 11:00 A.M., the surveyor observed Resident #18 receiving oxygen via a nasal cannula. The surveyor also observed that the oxygen tubing and the oxygen humidifier bottle were dated 12/9/24. Review of the physician's orders dated December 2024 indicated an order to change oxygen tubing every week on Sunday 11 P.M.-7 A.M. Review of the Treatment Administration Record (TAR) dated December 2024 indicated that the oxygen tubing was documented as changed on 12/15/24. During an interview on 12/18/24, at approximately 11:00 A.M., MDS Nurse #1 said that the tubing and humidification bottle are supposed to be changed every seven days to prevent infection. She then said that the medical record should indicate only what has been done. 2. Resident #43 was admitted to the facility in June 2024 with diagnoses including depression with psychotic features, suicidal ideations and dementia. Review of the psychiatry notes dated 10/4/24, 11/6/24, 12/13/24, indicated that the sex of Resident #43 is not accurate. 3. Resident #241 was admitted to the facility in December 2024 with diagnoses including multiple sclerosis, malnutrition and dysphagia (difficulty swallowing). Further review failed to indicate a diagnosis of cognitive impairment. Review of the facility documents titled Documentation Survey Report V2, dated December 2024, (where the Certified Nurse's Aides (CNA) document on the care provided each shift to residents), indicated that Resident #241 was provided incontinent care on 12/15/24 on the 7 A.M.-3 P.M., 3 P.M.-11 P.M. and 11 P.M.-7 A.M. shifts. Further review indicated that on the 3 P.M.-11 P.M. shift Resident #241 was provided incontinent care. During an interview on 12/17/24, at 8:25 A.M. Resident #241 said that he/she was very upset because he/she had not been provided incontinent care nor had staff provided morning or evening care since 3-11 shift on 12/15/24. Resident #241 then said that a CNA had come into the room in the morning of 12/16/24, said that she needed two CNAs to provide Resident #241 care, then left the room and never came back. Resident #241 then said that another CNA came in at around 8 P.M. on 12/16/24 to empty the urinary catheter bag and another CNA came in sometime on the 11 P.M.-7 A.M. shift to empty the urinary catheter bag but could not be sure of the exact time. During an interview on 12/18/24 11:09 A.M., the Director of Nursing said that the facility should accurately document in the medical record. 36876 4. Resident #110 was admitted to the facility in September 2024 with diagnoses including Alzheimer's Disease and diabetes. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #110 was moderately cognitively impaired evidenced by a score of 11 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #110 required assistance with bathing, dressing and toileting and was at risk for the development of pressure ulcers. Review of the physician's orders dated 12/11/24 indicated: *Pressure injury to Right hip. Wash area with normal saline. Pat dry. Apply triad cream, cover with border foam dressing. Change daily and PRN (as needed) *Stage 1 to Right buttocks. Wash area with soap and water. Pat dry. cover with border foam dressing. Change every other day and PRN. *Wound assessment to be completed with each treatment application/dressing change. (Specify: stage 1 pressure are Right buttocks) every day shift for wound evaluation document the following: odor, pain, drainage amount, peri-wound, drainage type and wound bed. *Wound assessment to be completed with each treatment application/dressing change. (Specify: stage 2 pressure area to Right hip) every day shift for wound evaluation document the following: odor, pain, drainage amount, peri-wound, drainage type and wound bed. During an interview on 12/18/24 at approximately 9:50 A.M., the surveyor requested to observe Resident #110's dressing changes. Unit Manager #1 said she had already completed the dressing changes. Review of the Treatment Administration Record on 12/18/24 at 1:00 P.M., indicated Resident #110's treatment to his/her right hip and wound assessment was documented as completed by Nurse #1, not Unit Manager #1. During an interview on 12/18/24 at 1:10 P.M. Nurse #1 said he came in later this morning and had not done the treatments yet for Resident #110 and wanted to do them after the lunch meal. When asked if he had documented the treatments were completed, Nurse #1 repeated he was hoping to do the treatments after the lunch meal. Nurse #1 said he shouldn't sign off on treatments that had not been completed yet. During an interview on 12/18/24 at 1:18 P.M., Unit Manager #1 said that she had completed the treatment, and that Nurse #1 had not.

Based on observations, record review, and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for two Residents (#61 and #241) out of a total sample of 30 residents. specifically 1. For Resident #61 the facility failed to provide supervision with meals. 2. For Resident #241 the facility failed to provide incontinent care or hygiene care. Findings Include: Review of the facility policy titled Activities of Daily Living (ADL's), Supporting, undated, indicated the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation 1(c). The refusal and information are documented in the resident's clinical record. 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: d. Dining (meals and snacks). 1. Resident #241 was admitted to the facility in December 2024 with diagnoses including multiple sclerosis (MS), malnutrition and ulcer of the right lower extremity. Review of the care plan dated 12/4/24, indicated a focus for decreased ability to perform ADL (activities of daily living) due to MS, FTT (failure to thrive), dysphagia, anxiety, and reflux uropathy. Further review indicated interventions for toileting assistance, and incontinent of bowel with maximum staff assistance for toilet hygiene. Review of the care plan dated 12/4/24, with a focus for falls, indicated an intervention for a call light in place at all times. Review of the care plan dated 12/4/24, with a focus for bowel incontinence indicated interventions to check Resident every 2 hours and assist with toileting as needed and provide pericare after each incontinent episode. Review of the care plan dated 12/4/24 failed to indicate a care plan with a focus/goal/interventions for refusal of care had been developed. During an interview on 12/17/24 at 8:25 A.M., Resident #241 said that he/she was very upset because staff had not provided incontinence care, or morning and evening care, since the 7:00 A.M. to 3:00 P.M. shift on 12/15/24. Resident #241 said that a Certified Nurse Aide (CNA) came into the room on the morning of 12/16/24, then left without providing any care, and never came back. Resident #241 then said that another CNA came into the room at around 8:00 P.M. on 12/16/24 to empty the urinary catheter bag and another CNA came into the room sometime on the 11:00 P.M. to 7:00 A.M. shift, but neither provided care. Resident #241 said that he/she would have asked staff to provide care, but he/she could not find the call light. Resident #241 said he/she had recently left another nursing facility because staff had not provided adequate care and was now afraid that the same was happening at this facility. On 12/17/24 at 8:25 A.M., the surveyor observed the call light on floor. During an interview on 12/17/24 at 8:30 A.M., Unit Manager #2 observed the call light on the floor and said that call lights should be accessible to the residents at all times. Resident #241 then told Unit Manager #2 that staff had not provided care to him/her since the morning of 12/15/24. Unit Manager #2 said that she would inform the CNA responsible for Resident #241's assignment. On 12/17/24, between 8:30 A.M., and 11:12 A.M. the surveyor observed Resident #241 lying in bed without morning care having been provided. On 12/17/24 at 11:12 A.M., the surveyor informed Unit Manager #2 that Resident #241 still had not been provided morning/incontinent care. During an interview on 12/17/24 at 11:12 A.M., CNA #1 said that a CNA on the schedule had left the unit, and they were now short-staffed. CNA #1 said that she had to get her residents, as well as the residents assigned to the other CNA, fed or out of bed for safety reasons. CNA #1 said that Resident #241 can eat safely in bed and that is why she had not provided care to him/her yet. At 11:20 A.M., Unit Manager #2 and CNA #1 entered Resident #241's room and began to provide incontinence care. The surveyor observed CNA #1 and Unit Manager #2 assisting Resident #241 with incontinent care. Resident #241 had been incontinent of bowel. CNA #1 attempted to clean Resident #241 with incontinent wipes only to discover that the feces had dried on and below Resident #241's genitalia. While attempting to remove the dried feces Resident #241 yelled out in pain several times. CNA #1 then obtained a towel with soap and water and continued to clean the dried feces from the genitalia. Resident #241 said several times that it hurt. Unit Manager #2 apologized to Resident #241 and explained to him/her that the feces had dried, and CNA #1 had to rub hard to remove it. After CNA #1 completed incontinence care the surveyor observed Resident #241's genitalia to be red and excoriated. Review of Resident #241's facility document titled Documentation Survey Report V2 dated December 2024, indicated that on 12/16/24 the 7:00 A.M. to 3:00 P.M. and the 11:00 P.M.-7A.M. shifts all activities of daily living tasks were left blank, indicating care was not provided, including incontinence care. Review of the facility document titled Behavior Monitoring and Interventions indicated that Resident #241 had not refused care on 12/15/24 or 12/16/24. Review of the progress notes for December 2024 failed to indicate Resident #241 refused care. Review of CNA #2's written statement (undated) indicated that on 12/16/24 Resident #241 told CNA #2 that he/she wanted to be changed. CNA #2 told Resident #241 that she could not provide the care because Resident #241 required two people to provide all care. CNA #2 indicated that she had requested staff to help her with Resident #241's care and everyone refused to help. CNA #2 said she told the nurse on the unit who then told her that the Unit Manager #2 will handle the issue after lunch. CNA #2 indicated that care had not been provided by the time her shift ended at 3:00 P.M., and she left the facility. During an interview on 12/17/24 at 12:56 P.M., the Director of Nursing (DON) said she heard about the care issues regarding (Resident #241) at about noon from Unit Manager #2. The DON then said that Unit Manager #2 told her that Resident #241 didn't get care yesterday but that the situation was resolved. The DON then said that CNA #2 told her that Resident #241 had refused care yesterday. The DON said that the CNA or nurse is supposed to document all refusals of care. 45343 2. Resident #61 was admitted to the facility in September 2024 with diagnoses that included cerebral infarction, altered mental status and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/26/24, indicated the Resident was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #61 requires substantial to maximal assistance for all self-care activities. On 12/17/24 at 9:26 A.M., Resident #61 was observed sitting alone in his/her room with his/her breakfast tray. Resident #61 said he/she was having difficulty reaching his/her fork and was observed to have oatmeal on his/her right cheek. On 12/17/24 at 12:56 P.M., Resident #61 was observed eating lunch in his/her room. There was no staff observed providing supervision or assistance with self-feeding. On 12/18/24 at 8:53 A.M., 8:59 A.M., 9:05 A.M.,12:50 P.M., and 12:58 P.M., Resident #61 was observed eating his/her meals in his/her room. There was no staff observed providing supervision or assistance with self-feeding. On 12/19/24 at 9:15 A.M., Resident #61 was observed sitting alone with his/her breakfast tray. Resident #61 was observed sleeping holding a fork in his/her right hand. There was no staff providing supervision or assistance with self-feeding. Review of Resident #61's care plans indicated the following: Eating: Resident requires supervision to assistance, requires food to be cut up. Effective date 10/3/24. Nutrition: Monitor for s/sx (signs/symptoms) of dysphagia (difficulty swallowing): Pocketing, choking, coughing, drooling, several attempts at swallowing. Effective date 9/25/24. Further review of Resident #61''s Kardex (a form indicating level of assistance a resident requires) dated as of 12/17/24 indicated the following: - Eating: Resident requires supervision to assistance, requires food to be cut up. Needs help cutting food. Review of Resident #61's medical record failed to indicate Resident #61 refused assistance with meals. During an interview on 12/19/24 at 9:06 A.M., Unit Manager #3 said staff setup Resident #677's meal and he/she can eat on his/her own. Unit Manager #3 said staff will assist if he/she is having difficulties eating. During an interview on 12/19/24 at 9:20 A.M., the Administrator said she would expect Resident #61 would be provided the level of assistance indicated on his/her care plan for self-feeding.

Based on observation, record review and interviews, the facility failed to provide respiratory care services in accordance with professional standards of practice for one Resident (#18) out of a total sample of 30 residents. Findings include: Review of the facility policy titled Oxygen therapy, not dated, indicated that humidifiers and nasal cannulas, mask and tubing are changed every 7 days. Resident #18 was admitted to the facility in January 2023 with diagnoses including chronic obstructive pulmonary disease, dementia and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #18 scored a 7 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicated that Resident #18 is dependent on staff for activities of daily living. Further review indicated that Resident #18 received oxygen therapy while a resident. On 12/17/24, at 8:35 A.M., and 11:59 A.M. 12/18/24 at approximately 11:00 A.M. the surveyor observed Resident #18 receiving oxygen via nasal cannula. The surveyor also observed that the oxygen tubing and the oxygen humidifier bottle were dated 12/9/24. Review of the doctor's orders dated December 2024 indicated an order to change oxygen tubing every week on Sunday 11 P.M. to 7 A.M. Review of the Treatment Administration Record (TAR) dated December 2024 indicated that the oxygen tubing was documented as changed on 12/15/24. During an interview on 12/18/24, at approximately 11:00 A.M. MDS Nurse #1 said that the tubing and humidification bottle are supposed to be changed every seven days to prevent infection.

Based on record review and interview the facility failed to develop a plan of care for two Residents (#43 and #241) out of a total sample of 30 residents. Specifically; 1. For Resident #43 the facility failed to develop a plan of care for suicidal ideation's. 2. For Resident #241 the facility failed to ensure a call light was accessible. Findings include: Review of the facility policy titled Suicide Threats, dated December 2007 indicated that staff will monitor the resident's mood and behavior and update the care plans accordingly until a physician has determined that a risk of suicide does not appear to be present. 1. Resident #43 was admitted to the facility in June 2024 with diagnoses including suicidal ideation, depression with psychotic features, and dementia. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #43 is severely cognitively impaired and scored a 5 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #43 requires substantial/maximal assist with activities of daily living. Review of the psychiatry note dated 12/13/24, indicated that Resident #43 has a history of suicidal ideation's and to continue to monitor for symptoms. Review of the care plan failed to indicate a focus, goal or interventions for the history of suicidal ideation's or to continue to monitor for symptoms. During an interview on 12/17/24 at 1:35 P.M., the Director of Nursing said that a suicidal ideation's care plan should have been developed for Resident #43. 2. Resident #241 was admitted to the facility in December 2024 with diagnoses including multiple sclerosis, malnutrition, and ulcer of the right lower extremity. On 12/17/24 at 8:25 A.M., the surveyor observed the Resident's call light on floor. During an interview on 12/17/24 at 8:25 A.M., Resident #241 said that he/she was very upset because staff had not provided incontinence care, or morning and evening care, since the 7:00 A.M. to 3:00 P.M. shift on 12/15/24. Resident #241 said that a Certified Nurse Aide (CNA) came into the room on the morning of 12/16/24, then left without providing any care, and never came back. Resident #241 then said that another CNA came into the room at around 8:00 P.M. on 12/16/24 to empty the urinary catheter bag and another CNA came into the room sometime on the 11:00 P.M. to 7:00 A.M. shift, but neither provided care. Resident #241 said that he/she would have asked staff to provide care, but he/she could not find the call light. During an interview on 12/17/24 at 8:30 A.M., Unit Manager #2 observed the call light on the floor and said that call lights should be accessible to the residents at all times.

Based on observation, record review and interview, the facility failed to follow the fall plan of care for 1 Resident (#124) out of a total of 36 sampled Residents. Subsequently, Resident #124 sustained a fall requiring hospitalization and was diagnosed with subdural hematoma, (bleeding that occurs within the skull but outside the actual brain tissue). Findings include: Review of the facility's Fall Prevention and Fall Committee Policy and Procedure, dated 6/7/22 indicated: *All residents who on admission, readmission or after an actual fall score at high risk for falls will have immediate interventions implemented for prevention of falls. *Any falls prevention interventions should minimize the resident's risk for falling and maintain functional independence and mobility. Various interventions should be used as appropriate for resident risk *Interventions may include but are not limited to: reinforcing use of the call bell, adjusting the bed to its lowest position, education of resident and family, use of chair and/or bed alarms. Resident #124 was admitted to the facility in October 2022 with diagnoses including dementia and legal blindness. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #124 is severely cognitively impaired and requires assistance with bathing and dressing. On 12/11/23 at 10:23 A.M., the surveyor observed Resident #124 seated in a high-back wheelchair behind the nursing station. Resident #124 was pleasantly confused and a chair alarm visible on the back of his/her chair. Review of Resident #124's fall risk evaluation dated 10/20/23 indicated he/she is at high risk for falls. Review of Resident #124's fall care plan dated as revised 10/20/23 indicated the following interventions: *Bed alarm and chair alarms as ordered, 10/20/23 *Monitor for toileting needs, 10/17/22 *Anticipate resident's needs and ensure room is free of clutter, 5/29/23. *Assist resident getting in and out of bed with Hoyer, 10/17/22. Review of fall incident report dated 10/28/23 indicated that at 7:40 A.M., Nurse #1 heard a loud bang coming from Resident #124's room and observed him/her on the floor with a puddle of blood coming from his/her head. The incident report indicated Resident #124's ordered bed alarm and chair alarm were not in place. The incident report failed to indicate the facility investigated why Resident #124's alarms were not in place at the time of the fall. Review of the nurse progress note dated 10/28/23 indicated: At around 7:30 [A.M.], this writer left another room and heard a loud noise coming from another room. This writer immediately ran to find the source of the noise. Upon entering [Resident #124's room], resident was found laying on his/her right side, in between the bed and the bathroom with blood coming from his/her head. Bed and chair alarm ordered, not in place and not sounding, call light not on. Resident showed signs of altered mental status; appeared unconscious around 20 seconds. 11-7 nurse called immediately for help. Upon awakening, resident was alert, confused at his/her mental baseline status . Resident was found incontinent of urine, floor was dry and free of obstacles. Resident had slipper socks on 911 called. Review of the hospital paperwork dated 10/28/29 indicated Resident #124 was diagnosed as having residual parafalcine subdural hematoma and a right parietal subdural hematoma. During an interview on 12/12/23 at 1:19 P.M., Nurse #1 said she had found Resident #124 on floor of his/her room on 10/28/23 and he/she was bleeding and appeared unconscious. Nurse #1 said she immediately called for assistance. Nurse #1 said Resident #124 was sent to the hospital and she alerted the supervisor that Resident #124's bed and chair alarm were not in place at the time of the fall.

Based on observations, policy review and interviews, the facility failed to 1. ensure medications with short expirations dates were dated when opened, expired medications were not available for administration, failed to ensure medication carts were kept clean and 2. failed to ensure medication and treatment carts were locked when unattended on three out of four units. Findings include: Review of the facility policy titled 'Storage of Medications', revised April 2019, indicated the following but not limited to: *The facility stores all drugs and biologicals in a safe, secure, and orderly manner. *The nursing staff is responsible for maintaining medication storage, and preparation area clean, safe, and sanitary manner. *Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. *Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. *Unlocked medication carts are not left unattended. *Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. 1a. During an inspection of the Arbor unit cart two medication cart on 12/12/23 at 8:14 A.M., the following were observed: -29 loose pills in the medication drawer -One incruse elipta (an inhaler) opened and undated -One flonase 50 mcg (microgram) opened and undated -Four bottles of eye drops opened and undated -One estradiol vaginal cream in with by mouth medications -One tube of ketoconazole cream with mouth medications During an interview on 12/12/23 at 8:30 A.M., Nurse #9 said medications like inhalers, eyedrops and nose drops needs to be dated when opened, topicals should be kept separately in the treatment cart and 11-7 nurses are responsible to make sure the medication carts are cleaned with no loose pills. 1b. During an inspection of the D-unit medication cart 1 on 12/12/23 at 8:52 A.M., the following were observed: -Three boxes of Spiriva inhaler opened and undated -One Advair diskus inhaler opened and undated -One bottle of alphagan eye drop opened and undated During an interview on 12/12/23 at 9:01 A.M., Nurse #5 said inhalers and eye drops should be dated when opened. 1c. During an inspection of the Birch hill unit medication cart 2 on 12/12/23 at 12:28 P.M., the following was observed: -One bottle of latanoprost eye drop with directions keep refrigerated until opened. During an interview on 12/12/23 at 12:36 P.M., Nurse #2 said the directions on the bag should be followed and store the eye drop in the refrigerator until ready to use. 1d. During an inspection of the Birch hill unit medication room on 12/12/23 at 12:38 P.M., the following was observed: -One bottle of tuberculin test solution opened and undated. During an interview on 12/12/23 at 12:44 P.M., Nurse #2 said the solution should be dated when opened. 1e. During an inspection of Cherry hill unit medication cart 2 on 12/12/23 at 12:55 P.M., the following were observed: -26 loose pills in the medication drawer. -One bottle of vitamin B12 100 mcg expired 10/23 -Three Spiriva inhalers opened and were undated. During an interview on 12/12/23 at 1:07 P.M., Nurse #7 said all nurses are responsible for ensuring the medication cart is clean and with no loose pills, he also said expired medications should not be in the medication carts, and inhalers need to be dated when opened. 1f. During an inspection of the Cherry hill medication room on 12/12/23 at 1:09 P.M., the following were observed: -One bottle of magnesium citrate expired 11/2022 -One bottle of vitamin B12 100 mcg expired 10/23 During an interview on 12/12/23 at 1:18 P.M., Nurse #7 said expired medications should be removed from the medication room and destroyed. During an interview on 12/12/23 at 3:15 P.M., the Director of Nursing said all inhalers, nasal sprays and eye drops are to be dated when opened, expired medications should not be in the medications carts or medication room they should be removed and destroyed. She further said it is the responsibility of 11-7 PM nurses to clean the medication carts and back up is the unit managers. 36431 2a. During an observation on 12/11/23 at 7:40 A.M., on the D unit, a medication cart parked in the hallway and unlocked and unattended, resulting in the surveyor having access to the medication cart contents. At 7:44 A.M., a nurse approached the unlocked cart. During an interview at this time, Nurse #5 said the medication cart should be always locked. 2b. During an observation on 12/13/23 at 4:30 P.M., on the Arbor Unit a treatment cart was unlocked and unattended. A nurse exited a room at approximately 4:33 P.M. and during an interview at this time said the treatment cart holds medicated treatments and should be locked when unattended. 2c. On 12/11/23 at 10:26 A.M., the surveyor observed a treatment cart on the Birchill unit unlocked and unattended. The surveyor was able to access the treatments and scissors inside the cart. Upon seeing the surveyor looking at the contents of the cart, a staff person then locked the cart. 3d. On 12/14/23 the surveyor observed a treatment cart unlocked and unattended on the Birchill unit from 8:48 A.M. through 9:17 A.M. Multiple staff walked by during the observation and did not secure the cart.

Based on observation, record review and interview the facility failed to ensure practices to prevent the spread of infection were implemented. Specifically, the facility failed to 1. ensure for two residents (#130 and #134) that staff implemented and adhered to enhanced infection precautions, 2. failed provide urinary catheter care in adherence to infection control standards for two residents (#130 and #102), 3. failed to handle clean linen to prevent possible contamination, 4. failed to ensure infection control practices were adhered to with multi-use medical equipment and 5. failed to ensure hand hygiene was preformed after glove use potentially contaminating the resident's environment and 6. failed to ensure a risk assessment was present as part of the overall water management program to prevent the risk of Legionella and other opportunistic pathogens. Findings include: 1. Review of the facility's policy, entitled Enhanced Barrier Precaution Policy, updated July 12, 2022, indicated the following: *Policy Statement Enhanced Barrier Precautions expand the use of PPE (personal protection equipment) and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO's (multi drug resistant organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. *1. All residents with any of the following will be placed on enhanced barrier precautions: a. an infection or colonization with an MDRO when contact precautions do not apply. b. wounds (non-healing or chronic) and and/or indwelling medical devices (central line, urinary catheter, feeding tube, tracheostomy) regardless of MDRO colonization status. *2. The following are examples of high contact care of a resident on enhanced barrier precautions a. dressing b. bathing/showering c. transferring, d. providing hygiene e. changing linens, f. changing briefs or assisting with toileting. g. device care or use (central line, urinary catheter, feeding tube, tracheostomy) h. wound care (chronic-non-healing). 1a. Resident #130 was admitted to the facility in February 2023 with diagnoses that include by not limited to chronic kidney disease, adult failure to thrive and retention of urine. Review of Resident #130's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #102 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating he/she has moderately intact cognition, is dependent on staff for personal hygiene and has an indwelling catheter. Review of Resident #130's physician's orders indicated the following: -Enhanced barrier precautions due to Foley catheter, every shift dated 6/26/23. During an observation on 12/11/23 at 10:23 A.M., Resident #130 was observed resting in bed, his/her urinary collection bag was resting on the floor, uncovered. A sign on the door indicated Enhanced Barrier Precautions and a cart containing PPE was located outside the door. During an observation on 12/13/23 at approximately 7:50 A.M., Certified Nursing Assistant (CNA #5) was observed providing morning care to Resident #130. CNA #5 was observed to be without PPE, while providing high-contact care. During an interview on 12/13/23 at 8:05 A.M., CNA #5 said she provided a bed bath for Resident #130 and changed his/her catheter to a leg bag and helped him/her get dressed. CNA #5 said she did not use a gown for care and said she was not aware that Resident #130 was on enhanced precautions. During an interview on 12/13/23 at 8:09 A.M. Unit Manager #2 said residents with wounds, or catheters requires enhanced barrier precautions for infection control. Unit Manger #2 was aware that CNA #5 provided care to Resident #130 without wearing a gown. During an observation on 12/14/23 at 7:48 A.M. Resident #130 was observed being provided morning care by a CNA that failed to use a gown during the care. The Enhanced Barrier Precaution sign was located on the Resident's room door along with a cart containing PPE. Nurse #6 who was outside Resident #130's room said enhanced precautions are required for care due to Resident #130 having a Foley catheter. 1b. Resident #134 was admitted to the facility in November 2023 with diagnoses that include but not limited to chronic kidney disease, type 2 diabetes mellitus and heart failure. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #134's has moderate cognition for daily decisions and is on hemodialysis. During an interview on 12/11/23 at 12:27 P.M., Resident #134 said he/she goes out three times a week for dialysis. When asked about the dialysis access site, he/she pulled up his/her shirt which revealed a white gauze dressing. Resident #134 said the nursing staff at the facility do not touch the dressing. Observation on Resident #134's room failed to have an Enhanced Barrier Precaution sign, nor a PPE cart. On 12/12/23 at 3:18 P.M., Resident #134 showed the surveyor his/her right chest access site which revealed a white gauze dressing with approximately three to four inches of an external catheter below the dressing, wrapped in gauze. Review of Resident #134's physician's orders failed to indicate an order for enhanced barrier precautions related to the presence of an implanted medical access device. Observations made on 12/11/23, 12/12/23, and 12/13/23 of Resident #134's room failed to indicate the need for enhanced precautions for a Resident with a known chest external catheter used for dialysis. During an interview on 12/13/23 at 7:39 A.M., Nurse #5 said a resident who has wounds and catheters are on enhanced barrier precautions. During an interview on 12/13/23 at 4:58 P.M. the Infection Preventionist Nurse (IP nurse) said enhanced barrier precautions are in place and to be followed for high contact care. The IP nurse said Resident #134 should have had a physician's order for enhanced barrier precautions and a sign outside his/her door. The IP nurse said she would expect staff to don proper PPE for high contact care. 2. For Resident #130 and Resident #102 the facility failed to ensure urinary collection bags were not on the floor. Review of the facility's policy titled indwelling Catheter Policy, not dated, indicated the following: *It is the intent of the facility to ensure that all residents who require indwelling catheters receive appropriate care and are monitored for infection. 2a. Resident #130 was admitted to the facility in February 2023 with diagnoses that include by not limited to chronic kidney disease, adult failure to thrive and retention of urine. Review of Resident #130's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #102 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating he/she has moderately intact cognition, is dependent on staff for personal hygiene and has an indwelling catheter. Review of Resident #130's physician's orders indicated the following: -Enhanced barrier precautions due to Foley catheter, every shift dated 6/26/23. During an observation on 12/11/23 at 10:23 A.M., Resident #130 was observed resting in bed, his/her urinary collection bag was resting on the floor, uncovered. On 12/13/23 at 7:45 A.M., Resident #130's urinary collection bag was observed uncovered and in contact with the legs of the tray table, which was observed to be unclean. During an interview on 12/13/23 at 10:49 A.M., Unit Manager #2 said the urinary collection bag should be kept clean and not in contact with the floor or other unclean areas. Unit Manager #2 observed Resident #130's tray table and said it needed to be cleaned. 2b. Resident #102 was admitted to the facility in June 2023 with diagnoses that include but not limited to retention of urine and chronic kidney disease. Review of Resident #102's MDS dated [DATE] indicated Resident #103 scored a 13 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition, has indwelling urinary catheter and requires moderate assistance with daily care. During the survey the following observations were made: On 12/12/23 at 7:54 A.M., Resident #102's urinary collection bag was uncovered and resting on the floor. On 12/13/23 at 7:42 A.M. Resident #102 observed resting in bed, his/her urinary collection bag had a collection of urine, and the bag was in contact with the floor. During an interview on 12/13/23 at 7:33 A.M., Nurse #5 said Foley catheters are monitored by nursing staff and orders are followed. Nurse #5 and the surveyor observed Resident #102's urinary collection bag was resting on the floor. Nurse #5 said it should not be in contact with the floor for infection control purposes. 3. The facility failed to handle clean linen and briefs to prevent possible contamination. Review of the facility's policy entitled Laundry and Bedding, soiled dated [DATE] indicated: Transport: clean linens are protected from dust and soiling during transport and storage to ensure cleanliness. 3a. During an observation of the laundry room on 12/13/23 at 3:33 P.M., a laundry staff member was folding sheets, four of the six sheets folded were in contact with the floor. During an interview at 4:42 P.M. the Housekeeping Director said the sheets should not be on the floor during the folding process. 3b. On 12/12/23 at 9:06 A.M., Certified Nursing Assistant (CNA) #6 was observed moving a small linen cart on unit D. The CNA dropped adult briefs on the floor, turned around and picked them up and placed them in the linen cart and continued to use the linen cart. During an interview on 12/12/23 at 9:52 A.M., CNA #6 said he was not supposed to put back into the linen cart the items that had dropped on the floor due to infection issues. 4. The facility failed to ensure infection control prevention was adhered to during a blood glucose check for one resident (#102) and failed to ensure the multi-use medical equipment was maintained and sanitized to prevent contamination. Review of facility's policy titled Cleaning and Disinfecting of Resident- Care items and Equipment' revised 9/2022, indicated the following but not limited to: *Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). *Reusable resident care equipment is decontaminated and/ or sterilized between residents according to manufacturers' instructions. 4a. On 12/11/23 at 8:13 A.M., during an observation of the D unit, Nurse #11 exited a resident room carrying an emesis basin containing a glucometer. Nurse #11 entered Resident #102's room and proceeded to don gloves and check Resident #102 blood sugar. Nurse #11 was unable to get a reading and removed her gloves and without performing hygiene donned gloves and proceeded to obtain Resident #102's blood sugar, by using a lancet to draw blood. After obtaining the blood sugar, Nurse #11 removed her gloves and without hand hygiene exited the room and without disinfecting the glucometer placed the emesis basin on the cart unlocked the cart and placed the contaminated glucometer into the cart. During an interview on 12/14/23 at 8:02 A.M., Nurse #5 said the blood glucometer is cleaned between resident use with a disinfecting wipe. Nurse #5 said the glucometer should not put be back in the medication cart before disinfecting. 4b. During a medication pass observation on 12/12/23 at 9:38 A.M., on the D unit side one. Nurse #8 was observed using blood pressure equipment between two residents without sanitizing. During an interview on 12/12/23 at 3:38 P.M., the Director of Nursing said shared medical equipment is to be disinfected between each resident use. 5. During an observation on the C-unit on 12/11/23 at 3:14 P.M., A housekeeper was observed in the hall wearing gloves on both hands and breaking down cardboard and putting it in the trash bin. The housekeeper moved between one area and another near the nursing medication cart and nursing desk. The housekeeper then used his gloved hands to push the cart in the hall. When a resident was in his way, he used his contaminated gloves to touch the resident's wheelchair and moved the resident out of the way, then proceeded to the elevator. During an interview on 12/14/23 11:33 A.M., the Infection Preventionist said she does rounds to ensure staff are following infection control practices. The Infection Perfectionist was informed of the infection control breach and said she would expect that staff did not wear gloves in the hall and not touch resident's environment and equipment. 6. The facility failed to ensure a risk assessment was present as part of the overall water management program to prevent the risk of Legionella and other opportunistic pathogens. Legionella can cause a serious type of pneumonia in persons at risk. Review of the facility's policy titled, Legionella Water Management Program dated 11/17 indicated: *Facility is committed to the prevention and detection and control of water-borne contaminants, including Legionella. 3. The purposes of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaires' disease. 5. The water management program includes the following elements: A detailed description and diagram of the water system in the facility, including the following: receiving, cold water distribution heating, hot water distribution and waste. Review of the facility's water management binder on 12/14/23 failed to indicate a specific risk assessment or detailed description and diagram of the water system in the facility. During an interview on 12/14/23 at 9:02 A.M., the Maintenance Director said he is aware of the facility risks for Legionella. He said there are no fountains, no roof vents and he checks water temperatures weekly and the facility has a looping system. He said he changed shower heads as part of the program but was unable to provide a facility detailed risk assessment for Legionella or other opportunistic pathogens. During an interview on 12/14/23 at 9:17 A.M., the Administrator said she was not involved in the water management risk assessment and that she would look for it. 46339

Based on observations, record reviews and interviews, the facility 1) failed to implement personalized care plans for 3 Residents (#128, #52, and #94) and 2) failed to develop a behavior care plan for 1 Resident (#81) out of a total sample of 36 residents. Findings include: 1a) Resident #128 was admitted to the facility in March 2023 with diagnoses including stroke and hemiplegia. Review of Resident #128's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview of Mental Status (BIMS) score of 0 out of a possible 10, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #128 required extensive assistance from staff for all bed mobility tasks. On 12/11/23 at 7:58 A.M., Resident #128 was observed lying in bed. A floor mat was standing upright, not flat on the floor on the left side of the bed. There was no floor mat on the right side of the bed and no other mat was visible in the room. On 12/14/23 at 7:05 A.M., Resident #128 was observed lying in bed. There was a fall mat on the left side of the bed and no fall mat on the right side of the bed. Throughout survey, there was only 1 fall mat observed in Resident #128's room. Review of Resident #128's medial record indicate the Resident has previously fallen out of bed. A Nursing note dated 6/13/2023 indicated the following: *Around 2:15 am, this writer was called by the CNA that resident was on lying on his/her back on the floor. Upon getting to the resident's room, resident was lying next to her bed. Upon assessment, resident was moving all extremities, no noted injuries. Neuro checks within normal limit. Resident was brought out of his/her room to the nurses' station for supervision. NP was notified and daughter was updated. Review of Resident #128's physician orders indicated the following order: *Ensure floor mat is located next to the resident's both side of bed when occupied. Ensure mat is placed under resident's bed when bed is unoccupied, initiated 6/13/23, after the Resident had fallen out of bed. Review of Resident #128's fall care plan indicated the following intervention: *fall mat on both side as ordered. Review of Resident #128's Kardex (a form indicating the amount of assistance and equipment required) indicated: *fall mat as ordered. During an interview on 12/12/23 at 1:42 P.M., Certified Nursing Assistant (CNA) #3 said Resident #128 has not had any recent falls and does not need fall mats next to his/her bed. During an interview on 12/14/23 at 7:55 A.M., CNA #4 said she had just finished providing care to Resident #128 and he/she had only one fall mat next to his/her bed. During an interview on 12/14/23 at 7:50 A.M., Nurse #4 said Resident #128 has a physician order to have a fall mat on either side of his/her bed and was unaware the Resident only had 1 fall mat. During an interview on 12/14/23 at 7:56 A.M., Unit Manager #1 said Resident #128 should have a fall mat on either side of his/her bed. Unit Manager #1 said each resident has a Kardex and staff are expected to review the Kardex for each resident to ensure the correct assistance and equipment is provided. 1b) Resident #52 was admitted to the facility in August 2023 with diagnoses including stroke and syncope and collapse. Review of Resident #52's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief interview for Mental Status score of 11 out of a possible 15 which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #52 is dependent on staff for transfers. On 12/11/23 at 8:35 A.M., and 12:35 P.M., Resident #52 was observed sitting in his/her wheelchair in the dining room. There was no alarm on the wheelchair. On 12/12/23 at 8:30 A.M., Resident #52 was observed sitting in his/her wheelchair in the dining room. There was no alarm on the wheelchair. On 12/14/23 at 7:54 A.M., Resident #52 was observed sitting in his/her wheelchair in the dining room. There was no alarm on the wheelchair. Review of Resident #52's medical record indicated the Resident has previously fallen out of his/her wheelchair. A Nursing note dated 9/25/2023 indicated the following: *Note Text: Around 3:17 pm, writer heard chair alarm, went to answer with another CNA, patient found lying on the floor by his/her bed. Patient crying and yelling she is not sure of what happened, reported that she wanted to transfer herself from chair to bed. Upon assessment patient was alert and talkative, reported hitting the left side of his/her head,- denied headache or dizziness, able to move upper and lower extremities, no apparent skin injury noted, assisted patient back to w/c with [two extra] CNAs. NP and HCP daughter made aware. Patient is now sitting on the hallway for safety watching TV, he/she denied any discomfort, VSS, ongoing neuro checks in place and stable as of now. Review of Resident #52's physician orders indicated the following: *Chair alarm check for placement and function, every shift for safety, initiated 9/26/23, after the Resident had fallen out of his/her chair. Review of Resident #52's fall care plan indicated the following intervention: *chair alarm as ordered. Review of Resident #52's Kardex (a form indicating the amount of assistance and equipment required) indicated the following: *chair alarm as ordered. During an interview on 12/12/23 at 1:42 P.M., Certified Nursing Assistant (CNA) #3 said Resident #52 fell a couple of months ago and requires a bed alarm but not a chair alarm. During an interview on 12/14/23 at 7:56 A.M., Unit Manager #1 said Resident #52 has an order for a chair alarm. Unit Manager #1 said each resident has a Kardex and staff are expected to review the Kardex for each resident to ensure the correct assistance and equipment is provided. 36876 1c . Resident #94 was admitted to the facility in June 2023 with diagnoses including dementia, arthrosclerosis and dysphagia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #94 scored 4 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) which indicated he/she is severely cognitively impaired. The MDS also indicated he/she requires assistance with bathing, dressing, and transfers. On 12/11/23 at 8:42 A.M., Resident #94 was observed resting in bed on an air mattress (a specialty mattress used to redistribute pressure to the body). Family Member #1 said that Resident #94 had developed a pressure ulcer on his/her back. Review of Resident #94's admission assessment indicated he/she was at high risk for developing pressure ulcers. Review of Resident #94's physicians orders indicated the following: *Skin tear to left lower extremity; cleanse with NS (normal saline) followed by DPD (dry protective dressing) initiated 11/9/23. *Lower back open area, cleanse with NS, Collagen followed by DPD daily, until healed every day shift, 11/30/23. *Apply skin prep to bony prominence on back twice daily every day and evening shift. Apply to lower spine, mid spine, right shoulder blade, 11/1/23. *Left back reddened area; Apply skin prep twice daily every day and evening shift, 10/24/23 *Apply bag balm to bilateral buttocks twice daily every day and evening shift, 11/15/23 *Apply heel boot to left heel at all times, removed during care or to assess skin integrity, every shift for protection, 7/22/23. Review of the Treatment Administration Record for December 2023 indicated the above treatments were not completed as ordered on 12/3/23 and 12/4/23. Review of the document titled Notice/Record of Warning to Employee indicated Nurse #1 did not complete a treatment as ordered on 12/10/23. During an interview on 12/14/23 at 8:56 A.M., the Director of Nursing said he/she was doing rounds on 12/10/23 and noted that Resident #94's skin tear treatment was not completed as ordered as the bandage was dated 12/9/23. 2. Resident #81 was admitted to the facility in May 2023 with diagnoses including dementia and obstructive uropathy. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #81 is severely cognitively impaired and requires assistance with bathing and dressing. On 12/11/23 at 8:33 A.M., Resident #81 was observed asleep in bed with his/her foley catheter visible and attached to the side of the bed. Review of the clinical record indicated the following nurse progress notes: *10/20/23: Patient is alert and [confused]. He/she had a family visit and returned around approximately 7:30 P.M .After awhile patient started being restless and agitated and stating I want to use the bathroom and am in a lot of pain. Upon assessment .patient didn't have Foley. Got patient ready for reinsertion with no success. Other nurse on the floor also tried . Obtained order to send patient out to hospital for insertion. *11/17/23: Resident was demonstrating signs of agitation, screaming out, non compliant with safety, and attempting to tug hat his/her foley. Review of Resident #81's care plans failed to indicate Resident #81 had any behaviors related pulling at or removing his/her catheter, or methods or means for staff to monitor and intervene as needed. During an interview on 12/13/23 at 9:12 A.M. Certified Nursing Assistant (CNA) #1 said Resident #81 does have some behaviors at times of pulling at his/her foley catheter. During interviews on 12/13/23 at 9:36 A.M. and 9:54 A.M., Nurse #1 said that Resident #81 has behaviors at times of pulling on his/her catheter. Nurse #1 said that she would expect these behaviors to be documented Resident #81's care plan. During an interview on 12/13/23 at 9:50 A.M., Social Worker #1 said that Resident #81's behaviors related to pulling on his/her catheter should be indicated in his/her care plan.

Based on observation, record review and interview, the facility failed to alert the physician of changes in condition for 1 Resident (#94) and failed to notify the responsible party of a change in condition for 1 Resident (#40) out of a total of 36 sampled Residents. Specifically, the facility failed to: 1.) Alert the physician of a newly developed gangrenous wound for Resident #94 and, 2.) failed to notify the responsible party of a change in condition, resulting in the needs for medical attention. Review of the facility's policy entitled Change is Resident's Condition, undated, indicated the following: *The facility is required to notify a resident's physician when there is a significant change in the resident's health status. The facility is required to make any pertinent information available and provide it to the resident's physician upon request. *The facility is also required to notify resident's next of kin/responsible party with any and all changes in a resident's condition. 1. Resident #94 was admitted to the facility in June 2023 with diagnoses including dementia, arthrosclerosis and dysphagia. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #94 scored 4 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she is severely cognitively impaired. The MDS also indicated he/she requires assistance with bathing, dressing, and transfers. On 12/12/23 at 8:22 A.M., the surveyor observed Resident #94 in bed resting on an air mattress. Family Member #1 was also present. The surveyor observed Resident #94 had a darkened circular area approximately the size of a quarter on his/her left toe. Family Member #1 said that Resident #94 usually wears socks and did not know when the skin injury began. Review of Resident #94's Wound Physician's note dated 12/5/23 indicated that Resident #94 had a lower stage II ulcer in the midline pressure injuries two stage III on the right buttocks and an unstageable coccyx wound. The note also indicated that Resident #94 had a pressure ulcer on his/her left great toe which had healed weeks prior. Review of the Podiatry note dated 12/5/23, (the same day of the most recent Wound Physician visit) indicated: Dry gangrene on distal tip of left great toe, please keep the area dry and clean, monitor for any sign of infection or converting to wet gangrene, consult wound care team for appropriate treatment. The note did not indicate any measurements of the area. Review of the nurse progress notes, weekly wound checks, physician and nurse practitioner notes, and physician orders failed to indicate Resident #94's physician was alerted to Resident #94's gangrenous toe injury. Review of the weekly skin check dated 12/8/23 failed to indicate Resident #94 had any areas on his/her feet. Review of the nurse progress note dated 12/12/23 indicated: At around 7:49 A.M. [Family Member #1] called this writer to [Resident #94's room] and stated his/her toe is black. Upon entering the room, the resident was in his/her bed with the blankets pulled off of his/her feet. This writer noticed an area, unstageable, with eschar present on his/her left hallux (toe) measuring 3 CM (centimeters) X 2.5 CM. NP (Nurse Practitioner) notified. On 12/12/23 at 11:23 A.M. the surveyor and Nurse Practitioner #1 observed Resident #94's left great toe. Nurse Practitioner #1 said that Resident #94 was seen by podiatry on 12/5/23 and the note indicated that Resident #94 had a gangrenous skin injury on his/her left toe. Nurse Practitioner #1 said staff was not aware and she was alerted that morning by Nurse #1. During an interview on 12/12/23 at 11:45 A.M., Nurse #1 said she was first made aware of Resident #94's skin injury when Family Member #1 alerted her. During an interview on 12/12/23 at 11:16 A.M., Nurse #2 said that if Certified Nursing Aids (CNAs) are providing care to Residents and observe new skin injuries, they are expected to alert nursing staff for an assessment and interventions. Nurse #2 said she had worked on 12/11/23 and no staff alerted her of any new skin injuries for Resident #94. Nurse #2 said she was only made aware this morning that Resident #94 had a gangrenous skin area on his/her toe. During an interview on 12/12/23 at 11:21 A.M., CNA #2 said he took care of Resident #94 earlier in the morning. CNA #2 said Resident #94 had no skin issues on his/her feet. On 12/14/23 at 9:21 A.M. the Wound Physician and the surveyor observed Resident #94's left great toe. The Wound Physician said that that Resident #94's was gangrenous and most likely was related to vascular issues. The Wound Physician said she could not recall if she had examined Resident #94's feet during his/her last visit (12/5/23) and it would have taken one to two weeks for the wound to have developed to its current size. During an interview on 12/14/23 at 11:26 A.M. the Wound Physician said that Resident #94's wound measured 2.3 CM X 2.7 CM with dry gangrene. The Wound Physician said that she initiated orders for betadyine paint and to leave the toe open to air. The Wound Physician said she was made aware of Resident #94's gangrenous area yesterday, 12/13/23. The Wound Physician said she was not aware that the Podiatrist had seen Resident #94 on 12/5/23 and indicated he/she had developed a gangrenous area on his/her toe with recommendations for a wound consult. The Wound Physician said she would expect staff to have notified her of the Podiatrists findings. During an interview on 12/14/23 at 11:18 A.M. the Podiatrist said that on 12/5/23 she observed a very small small circular gangrenous area on Resident #94's left great toe. The Podiatrist said it was about the half the size of a penny and she alerted staff. The Podiatrist said she could not recall the name of the nurse she spoke with but had made recommendations for staff to keep the area clean, monitor for signs of infection and consult the wound team. During an interview on 12/14/23 at 12:00 P.M., the Director of Nursing (DON) said that staff are expected to complete wound assessment, notify the physician and wound physician when there is a new skin injury found on a Resident. The DON said she was not aware that Resident #94 had a gangrenous area on his/her toe until the surveyor brought it to her attention during the interview. The DON said she was not aware of the Podiatrists' findings of a gangrenous area on Resident #94's great toe on 12/5/23. The DON said she completed the skin check on 12/8/23 because she saw it had not been done. The DON said Resident #94 refused to let him/her look at his/her feet during the skin check, but she did not document it and did not return or ask staff to return to complete the skin check. The DON could not say why staff were not aware of the gangrenous area on Resident #94's toe until 12/12/23 when Family Member #1 alerted the staff; seven days after it was identified by the Podiatrist. 36431 2. Resident #40 was admitted to the facility in 12/2022 and has diagnoses that include but not limited to heart failure, gout, hearing loss, seizure disorder and unspecified dementia. Review of Resident #40's most recent MDS, dated [DATE] indicated Resident #40 scored 13 out of 15 on the Brief Interview for Mental Status exam, which indicated intact cognition. Review of Resident #40's care plan with the focus decrease ability to perform ADLS (activities of daily living), dated as revised 10/14/23, indicated walking/ambulation: the Resident uses a walker and one assist with ambulation to destinations outside his/her room. On 12/11/23 at 11:00 A.M., Resident #40 was observed resting in bed. He/she did not respond to the surveyor. Resident #40 was observed to be small and frail in stature. A family member, who was present said this is a change for the Resident. The family member said the Resident is usually up, dressed and will use his/her walker to go to the dining room. The family member said she just went to the nursing desk to find out what was going on with the Resident and was told he/she had a test recently that was negative, and that the Resident is pending blood work and has swelling in his/her left arm. The family member said she visited last Monday, and that she was not notified by staff of the changes until she inquired herself today. Review of Resident #40's medical record indicated the following: -An order dated 12/7/23 ultrasound of hand and apply ice. -A note with the effective date 12/8/23 entered by the Nurse Practitioner. A/P (Assessment and Plan) 1.Gout, increase and restart prednisone taper 2. Cellulitis doxycycline 100 mg p BID x 7 days and probiotic 1 po bid x 14 days, monitor, labs prn. -A nurses note dated 12/8/23 indicating Resident left hand still swollen very red sore to touch move ice applied with little effect encourage to keep elevated in bed on pillow still waiting for ultrasound to be done. (sic) Review of Resident #40's medical record including progress notes from 12/3/23 through 12/11/23 failed to indicate Resident #40 's activated Health Care Proxy(HCP)/Family member was notified and informed of the change in condition that required medication changes, laboratory and ultrasound tests and diagnoses of gout and cellulitis and swelling to his/her left hand/arm. During an interview on 12/13/23 at 10:58 A.M., Certified Nursing Assistant (CNA) #6 said Resident #40 has been not feeling well the past few days, that his/her left hand has swelling, and he/she now needs more assistance with daily care. CNA#6 said Resident #40 would be up daily and would walk to the downstairs dining room for meals but has not gone in about a week. CNA #6 said this is a change in him/her. During an interview on 12/13/23 at 4:02 P.M., the Director of Nursing said the nursing staff should notify and inform a resident's responsible party and/or HCP of any changes including new medications or tests, new diagnoses, and changes in condition. The DON said she was not aware that Resident #40's HCP was not notified.

Based on observation, record review and interview the facility failed to ensure care and services for the provision for hemodialysis was in accordance with professional standards of practice for one out of one applicable resident (#134), out of a total sample of 36 residents. Specifically, the facility failed to 1.) ensure ongoing appropriate assessment of the resident's hemodialysis access site, and 2.) failed to provide equipment and supplies necessary to manage a medical emergency for those. Review of the facility's policy and procedure dated as revised 2/2019, titled Dialysis indicated the following: *Purpose: to ensure that residents receiving outpatient dialysis will have a comprehensive treatment plan. Policy: communication regarding treatment delivery or problems will be comprehensive and ongoing between the dialysis delivery company and the facility's nursing staff. *Procedure: 1. Each resident receiving dialysis must have an order on their physician order sheet for HD (hemodialysis). 2. Each dialysis resident must also have a dialysis care plan that will include this same information. 3. Each dialysis resident must have their dialysis access site checked per physician orders for sign or symptoms of infection and/or bruit and thrill checks on an arterial/venous graft site. -A bruit is an audible vascular sound associated with turbulent blood flow. -A thrill is a palpable vibratory sensation over a vessel in which a bruit is heard. 1. Resident #134 was admitted in November 2023 with diagnoses that include but not limited to chronic kidney disease, type 2 diabetes mellitus and heart failure. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #134's has moderate cognition for daily decisions and is on hemodialysis. During an interview on 12/11/23 at 12:27 P.M., Resident #134 said he/she goes out three times a week for dialysis. He/she said his/her schedule recently changed to Tuesday, Thursday, Saturdays. When asked about the dialysis access site, he/she pulled up his/her shirt which revealed a white gauze dressing. Resident #134 said the nursing staff at the facility do not touch the dressing. On 12/12/23 at 3:18 P.M., Resident #134 showed the surveyor his/her right chest access site which revealed a white gauze dressing with approximately three to four inches of an external catheter below the dressing, wrapped in gauze. Review of Resident #134's physician's orders indicated the following: -HD (hemodialysis) location Tues, Thursday, Saturday pick up time 5:15 A.M., will need breakfast prior to pick up, dated 12/1/23. -Assess dialysis site to right upper chest for presence of bruit and thrill every shift. If absent, notify the MD (medical doctor), dated 11/15/23. The presence of an external catheter on Resident #134's right chest is not an arterial/venous graft site and therefore cannot be checked for bruit and thrill. Review of the Medication Administration Record dated November 2023 and December 2023 indicated the following: -Assess dialysis access site to right upper chest for presence of bruit and thrill every shift, if absent notify M.D. was signed off as administered from 11/15/23 through 11/29 (dated 11/30 and 11/31, were cut off) and from 12/1/23 through 12/11/23. During an interview on 12/12/23 at 1:02 P.M., Nurse #8 said when Resident #134 returns from dialysis he checks in with him/her. Nurse #8 said he did not know what kind of access site Resident #134 had but that it was up on his/her right chest. Nurse #8 said he was not clear how the bruit and thrill can be checked on the chest catheter, that he was a new nurse and had limited experience with dialysis patients. Nurse #8 said you feel for thrill and demonstrated on his inner wrist. During an interview on 12/12/23 at 1:16 P.M., Unit Manager #2 said she did not know what kind of chest access catheter Resident #134 has for dialysis. Unit Manger #2 said the nurses are to check for bruit and thrill each shift. Unit Manger #2 said she has never done bruit and thrill on an eternal catheter and would need to check into it. During an interview on 12/12/23 at 2:39 P.M., the Director of Nursing (DON) said Resident #134 was admitted on dialysis and currently he/she is the only resident receiving dialysis services and that they have had residents requiring dialysis in the past. The DON said the nursing staff should know what kind of access a resident has for dialysis and acknowledged there are different types of access. The DON said normally you see an A/V (arterial/venous) access. The DON said bruit and thrill cannot be performed on an external catheter and the nursing staff should have known and questioned the order. B. The facility failed to ensure a plan for the provision of emergency care and treatment for an external catheter used for dialysis. During observations and interviews on 12/11/23 at 12:27 P.M., and 12/12/23 at 3:17 P.M., Resident #134's room did not reveal any supplies related to possible emergency treatment. During an interview on 12/12/23 at 3:18 P.M., Nurse #8 said he was not made aware and was not told of any need for supplies related to emergency care for Resident #134. During an interview on 12/12/23 at 1:29 P.M. Unit Manager #2 said if Resident #134 experienced bleeding from the dialysis access site, pressure would be applied, the doctor would be notified and 911 called. During an interview on 12/12/12/23 at 2:39 P.M., DON said if a dialysis access site was bleeding 911 and the MD would be called and she would expect that dressing supplies, including tape and a [NAME] clamp be readily available to staff to apply a pressure dressing.

Based on observations, record reviews and interviews, the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to 1. have physician orders to administer continuous oxygen for one Resident (#98), and 2. failed to ensure oxygen administration was in accordance with the medical plan of care for one resident (#134) out of a total sample of 36 residents. Findings include: Review of facility policy titled 'Oxygen Therapy' undated indicated the following but not limited to: *To administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. 1. Resident #98 was admitted to the facility in September 2023 with diagnoses including acute respiratory failure with hypoxia. Review of Resident #98's Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) score indicating he/she was cognitively intact. On 12/11/23 at 9:31 A.M., the surveyor observed Resident #98 lying in his/her bed wearing oxygen tubing in his/her nostrils, the oxygen concentrator was set as 2 liters/minute. Review of Resident #98's Nursing Admission/ Readmission Evaluation- BH-V3 dated 12/4/23 indicated the Resident was readmitted to the facility on 3 liters/minute of oxygen. Review of a nursing progress note dated 12/4/23 16:06 indicated the following: Resident admitted here at 2 p via ambulance accompanied by 2 EMTS V/S 92% on 3 liters via NC. Alert and oriented and able to express needs and wants. (sic) Further review of medical records failed to indicate a physician order for the continuous use of oxygen therapy. During an interview on 12/12/23 at 11:15 A.M., Nurse #9 said there should be a physician order to administer oxygen. During an interview on 12/12/23 at 2:11 P.M., Charge Nurse #1 said residents on oxygen therapy require a physician order, she further said nurses can apply oxygen under emergency circumstance and then follow up with the physician for further orders and treatment. During an interview on 12/12/23 at 3:23 P.M., the Director of Nursing said Resident #98 should have had oxygen orders in place since his/her readmission on 12/4/23. 36431 2. Resident #134 was admitted in November 2023 with diagnoses that include but not limited to chronic kidney disease, type 2 diabetes mellitus, heart failure and chronic kidney disease. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #134's has moderate cognition for daily decisions and is administered oxygen therapy. On 12/11/23 at 12:27 P.M., Resident #134 was observed resting in bed wearing a nasal cannula administering 2 liters of oxygen. On 12/12/23 at 12:16 A.M., Resident #134 was observed resting in bed with a nasal cannula in his/her nose. The oxygen concentrator was administering 2 liters of oxygen. Review of Resident #134's physician's orders indicated the following: -An order dated 12/14/23, Administer O2 (oxygen) at 1 liter/minute via nc (nasal cannula) During an interview on 12/12/23 at 1:02 P.M., Nurse #8 said Resident #134 returned from dialysis and he assisted in transferring him/her from the portable oxygen to the oxygen concentrator and it is running at 2 liters. Nurse #8 reviewed the orders and said the order is to administer 1 liter of oxygen. Nurse #8 and the surveyor then went to Resident #134's room and Nurse #8 said the oxygen was running at 2 liters. During an interview on 12/12/23 at approximately 1:10 P.M., Unit Manager #2 said Resident #134's order is for 1 liter of oxygen and should be monitored to be on the correct setting.

Based on observation, record review and interview, the facility failed to ensure staff provided treatment and care in accordance with professional standards of practice for two Residents (#94, #40) out of a total of 36 sampled Residents. Specifically the facility failed to: 1. Identify and address a newly developed gangrenous (dead tissue) skin injury for Resident #94. 2. Implement an antibiotic treatment for cellulitis and implement monitoring of the diagnosis for Resident #40. 1. Review of the facility's Prevention of Pressure Ulcer policy, undated, indicated: *Any resident who has a pressure or stasis ulcer (an skin ulcer related to poor circulation) as well as residents with weight loss/gain are reviewed weekly. *Residents will additionally be re-assessed minimally quarterly and with any chance in condition thereafter. *Resident's will receive necessary service to promote healing. *All direct care staff are educated on skin care prevention, identification and communication of issues and documentation of risk factors during orientation, annually and more frequently as needed. Resident #94 was admitted to the facility in June 2023 with diagnoses including dementia, arthrosclerosis and dysphagia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #94 scored 4 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she is severely cognitively impaired. The MDS also indicated he/she requires assistance with bathing, dressing, and transfers. Review of Resident #94's Wound Physician's note dated 12/5/23 indicated that Resident #94 had a lower stage II ulcer in the midline pressure injuries two stage III on the right buttocks and an unstageable coccyx wound. The note also indicated that Resident #94 had a pressure ulcer on his/her left great toe which had healed weeks prior. On 12/12/23 at 8:22 A.M., the surveyor observed Resident #94 in bed resting on an air mattress. Family Member #1 was also present. The surveyor observed Resident #94 had a darkened circular area approximately the size of a quarter on his/her left toe. Family Member #1 said that Resident #94 usually wears socks and did not know when the skin injury began. Review of the Podiatry note dated 12/5/23, (the same day of the most recent Wound Physician visit) indicated: Dry gangrene on distal tip of left great toe, please keep the area dry and clean, monitor for any sign of infection or converting to wet gangrene, consult wound care team for appropriate treatment. The note did not indicate any measurements of the area. Review of the nurse progress notes, weekly wound checks, physician and nurse practitioner notes, and physician orders failed to indicate Resident #94 had developed a new skin injury, or implemented interventions to address the skin injury until 12/12/23; when Family Member #1 alerted staff of her observations. Review of the weekly skin check dated 12/8/23 failed to indicate Resident #94 had any areas on his/her feet. Review of the nurse progress note dated 12/12/23 indicated: At around 7:49 A.M. [Family Member #1] called this writer to [Resident #94's room] and stated his/her toe is black. Upon entering the room, the resident was in his/her bed with the blankets pulled off of his/her feet. This writer noticed an area, unstageable, with eschar present on his/her left hallux (toe) measuring 3 CM (centimeters) X 2.5 CM. NP (Nurse Practitioner) notified. On 12/12/23 at 11:23 A.M. the surveyor and the NP #1 observed Resident #94's left great toe. NP #1 said that she had found Resident #94's podiatry note on 12/5/23 and the note indicated that Resident #94 had a gangrenous skin injury on his/her left toe. NP #1 said she was first made aware of the gangrenous area earlier this morning (12/12/23) by Nurse #1. During an interview on 12/12/23 at 11:45 A.M., Nurse #1 said she was first made aware of Resident #94's skin injury when Family Member #1 alerted her. During an interview on 12/12/23 at 11:16 A.M., Nurse #2 said that if Certified Nursing Aids (CNAs) are providing care to Residents and observe new skin injuries, they are expected to alert nursing staff for an assessment and interventions. Nurse #2 said she had worked on 12/11/23 and no staff alerted her of any new skin injuries for Resident #94. Nurse #2 said she was only made aware this morning. During an interview on 12/12/23 at 11:21 A.M., CNA #2 said he took care of Resident #94 earlier in the morning. CNA #2 said Resident #94 had no skin issues on his/her feet. On 12/14/23 at 9:21 A.M. the Wound Physician and the surveyor observed Resident #94's left great toe. The Wound Physician said that that Resident #94's was gangrenous and most likely was related to vascular issues. The Wound Physician said she could not recall if she had examined Resident #94's feet during his/her last visit (12/5/23) and it would have taken one to two weeks for the wound to have developed to its current size. During an interview on 12/14/23 at 11:26 A.M. the Wound Physician said that Resident #94's wound measured 2.3 CM X 2.7 CM with dry gangrene. The Wound Physician said that she initiated orders for betadyine paint and to leave the toe open to air. The Wound Physician said she was made aware of Resident #94's gangrenous area yesterday, 12/13/23. The Wound Physician said she was not aware that the Podiatrist had seen Resident #94 on 12/5/23 and indicated he/she had developed a gangrenous area on his/her toe with recommendations for a wound consult. The Wound Physician said she would expect staff to have notified her of the Podiatrists findings. During an interview on 12/14/23 at 11:18 A.M. the Podiatrist said that on 12/5/23 she observed a very small small circular gangrenous area on Resident #94's left great toe. The Podiatrist said it was about the half the size of a penny and she alerted a nurse. The Podiatrist said she could not recall the name of the nurse she spoke with but had made recommendations for staff to keep the area clean, monitor for signs of infection and consult the wound team. During an interview on 12/14/23 at 12:00 P.M., the Director of Nursing (DON) said that staff are expected to complete wound assessment, notify the physician and wound physician when there is a new skin injury found on a Resident. The DON said she was not aware that Resident #94 had a gangrenous area on his/her toe until the surveyor brought it to her attention during the interview. The DON said she was not aware of the Podiatrists' findings of a gangrenous area on Resident #94's great toe on 12/5/23. The DON said she completed the skin check on 12/8/23 because she saw it had not been done. The DON said Resident #94 refused to let him/her look at his/her feet during the skin check, but she did not document it and did not return or ask staff to return to complete the skin check. The DON could not say why staff were not aware of the gangrenous area on Resident #94's toe until 12/12/23 when Family Member #1 alerted the staff; seven days after it was identified by the Podiatrist and she had informed a staff nurse. 36431 2. Resident #40 was admitted to the facility in 12/2022 and has diagnoses that include but not limited to heart failure, gout, hearing loss, seizure disorder and unspecified dementia. Review of Resident #40's most recent Minimum Data Set assessment dated [DATE] indicated Resident #40 scored 13 out of 15 on the Brief Interview for Mental Status exam, which indicated intact cognition. On 12/11/23 at 11:00 A.M., Resident #40 was observed resting in bed. He/she did not respond to the surveyor. Resident #40 was observed to be small and frail in stature. A family member who was present said the Resident is usually up, dressed and will use his/her walker to go to the dining room. The family member said she went to the nursing desk to find out what was going on with the Resident and was told he/she had a test recently that was negative, and that the Resident is pending blood work and has swelling in his/her left arm. On 12/11/23 at 4:00 P.M., Resident # 40 observed resting in bed, his/her left arm and fingers were puffy/swollen. On 12/13/23 at 10:28 A.M., Resident #40 observed in bed resting on his/her left side. Left arm, elbow puffy, fingers puffy in comparison to his/her right hand. Review of Resident #40's medical record indicated the following: -A Nurse Practitioner Note, dated 12/8/23, left hand, joints with positive swelling/erythema and troph at joints, bil (bilateral) feet with positive swelling and troph, tender with palpation. A/P (Assessment and Plan) 2. Cellulitis-doxycycline (an antibiotic) 100 mg po (by mouth) bid (twice a day) x 14 days, monitor, labs prn (as needed) -A Nurse Practitioner Note, dated 12/11/23 2. Cellulitis-improved-cont. (continue) doxycycline 100 mg po bid x 14 days and probiotic 1 po bid x 14 days, monitor, labs prn. Review of the Medication Administration Record (MAR) failed to indicate Resident #40 was administered doxycycline as indicated in the assessment and plan dated 12/8/23. Further, the medical record failed to indicate nursing staff monitored Resident #40 for the diagnosis of cellulitis. During an interview on 12/13/23 at 11:04 A.M., Nurse #6 said Resident #40 has had a change in his/her daily routine and is being treated with an antibiotic for cellulitis on his/her left hand. Nurse #6 said the antibiotic started yesterday 12/12/23. During an interview on 12/13/23 at 11:13 A.M. Nurse Practitioner #3 said she assessed Resident #40 on 12/8/23, and Resident #40 had a red, swollen painful hand, gout flare up and possible cellulitis. Nurse Practitioner #3 said she intended for the Resident to start the antibiotic doxycycline for seven days. Nurse Practitioner #3 said she wrote many orders for the Resident but missed writing the order for the doxycycline. Nurse Practitioner #3 said she wrote a note on 12/11/23 continue doxycycline because she thought Resident #40 was being administered the antibiotic. Nurse Practitioner #3 acknowledged that Resident #40 missed 5 doses of the antibiotic had it started on 12/8/23 as part of the treatment plan. Further, Nurse Practitioner #3 said she would expect the nursing staff to monitor and assess the Resident for any changes and response to the treatment plan. During an interview on 12/13/23 at 4:02 P.M., the Director of Nursing (DON) said the nurses read report, can review the medical record for residents who are having clinical changes. The DON said the treatment with antibiotics for Resident #40 did not get addressed until 12/12/23. The DON said the nurses should be writing daily notes and have specific monitoring of the cellulitis.

Based on observations, record review and interviews, the facility failed to ensure that services provided met professional standards of quality, for three Residents (#48, #405 and #130) out of a total sample of 36 residents. Specifically, the facility 1. failed to follow physician's orders for maintaining and documenting fluid restriction for Resident #48 and #405 and 2. failed to provide fortified mashed potatoes in accordance with the medical orders. Findings include: Review of facility policy titled 'Fluid Restriction' revised September 2017, indicated the following but not limited to: *The nursing services will be responsible for tracking and documenting the total volume consumed in accordance with facility policy. 1. Resident #48 was admitted to the facility in November 2023 with diagnoses including renal insufficiency, hypo-osmolality, and hyponatremia. Review of Resident #48's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) score indicating he/she was cognitively intact. Review of the physician's order dated August 2023 indicated the following: *Fluid restriction 1120 ml (milliliter) total day shift, 240 ml night shift and 640 ml in the evening shift. Total of 2000 ml/day. Review of the care plan titled potential for fluid imbalance and activity intolerance related to congestive heart failure: Intervention initiated 11/24/23 indicated the following: Fluid restriction as ordered. Review of the Medication Administration Record (MAR) for December 2023 failed to indicate the total amount of fluids the Resident consumed per day. During an interview on 12/13/23 at 8:56 A.M., Nurse #10 said nurses are responsible to ensure the total fluid amount is calculated at the end of the day. She further said without accurate documentation and monitoring the resident could go into fluid overload and other complications. During an interview on 12/13/23 at 9:25 A.M., Charge Nurse #1 said nursing should document at the end of each shift how much the resident has consumed and if over the limit notify the physician. During an interview on 12/13/23 at 3:46 P.M., the Director of Nursing said that 11-7 PM shift nurses are responsible for tallying the fluid intake and if any concerns the day shift nurses would report to the physician. 2. Resident #405 was admitted to the facility in December 2023 with diagnoses including heart failure and acute respiratory failure with hypoxia. Review of the current physician's order dated 12/6/23 indicated the following: *2 liters fluid restriction per day, 1040 ml from nursing and 960 ml from dietary. Review of the care plan titled potential for fluid imbalance and activity intolerance related to congestive heart failure: Intervention initiated 12/1/23 indicated the following: Provide diet (specify) and educate resident about dietary restrictions. Review of the current Medication Administration Record (MAR) failed to indicate the total amount of fluids the Resident consumed per day. During an interview on 12/13/23 at 8:56 A.M., Nurse #10 said nurses are responsible to ensure the total fluid amount is calculated at the end of the day. She further said without accurate documentation and monitoring the resident could go into fluid overload and other complications. During an interview on 12/13/23 at 9:25 A.M., Charge Nurse #1 said nursing should document at the end of each shift how much the resident has consumed and if over the limit notify the physician. During an interview on 12/13/23 at 3:46 P.M., the Director of Nursing said that 11-7 PM shift nurses are responsible for tallying the fluid intake and if any concerns the day shift nurses would report to the physician. 36431 2. For Resident #130 the facility failed to ensure fortified mashed potatoes were provided in accordance with the medical orders. Resident #130 was admitted to the facility in 2/2023 with diagnoses that include by not limited to chronic kidney disease, adult failure to thrive and retention of urine. Review of Resident #130's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #102 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating he/she has moderately intact cognition, is 51 inches in length and weighs 87 pounds. On 12/11/23 at 10:08 A.M., Resident #30 was observed resting in bed. He/she was observed to be frail and small in stature. Review of Resident #130's physician's orders indicated the following: -Fortified mashed potatoes with lunch, one time a day for weight loss, dated 9/15/23. On 12/12/23 at 12:22 P.M., Resident #130 was eating his/her lunch in his/her room. There were no fortified mashed potatoes on his/her plate. Review of the lunch menu for 12/11/23 indicated lunch was chicken pot pie with biscuit, 12/12/23 lunch was sweet and sour meatballs, and 12/13/23 open faced roast pork sandwich, brown gravy, herbed green beans, and mashed potatoes. On 12/13/23 at 12:35 P.M., Resident #130 was observed in the dining room. He/she had the roast pork sandwich and mashed potatoes on his/her plate. On 12/13/23 at 1:01 P.M. the Food Service Director said they have a recipe for fortified mashed potatoes which makes them higher in calories. The Food Service Director said Resident #130 does not have fortified mashed potatoes on her meal ticket. Cook #1 showed the surveyor the two different mashed potatoes and said she has not been serving Resident #130 fortified mashed potatoes. During an interview on 12/13/23 at 1:17 P.M., the Registered Dietician (RD) said the Nurse Practitioner entered the order for the fortified mashed potatoes on 9/15/23 for weight loss. The RD said she did a quarterly assessment on 11/21/23 and recommended the fortified mashed potatoes to continue. The RD said she did not verify that the fortified mashed potatoes were on the meal ticket which resulted in Resident #130 not being served fortified mashed potatoes per the physician order.

Based on observation, record review and interview the facility failed to ensure interventions to prevent the development of a pressure ulcer were developed and implemented for 1 Resident (#82), which resulted in the development of a Stage IV pressure ulcer, out of a total sample of 29 residents. Findings include: Review of the Facility's policy, entitled 'Weekly Skin Assessment' dated as revised 6/8/22, included the following: Purpose: Early identification of alterations in skin integrity and ongoing assessment to intervene and prevent changed in resident skin condition. Policy: All residents will have a full body assessment on day of admission and weekly thereafter. Procedure: The nurse will perform a full body skin assessment on admission and weekly as assigned Special observations of bony prominences, such as elbows, heels, and coccyx areas. The nurse will document on weekly skin assessment in point click care. Codes as follows: *#1 No new skin changes *#2 Pre-existing skin condition as noted on skin assessment for or nursing notes. *#3 New skin condition. The nurse will review current treatment and preventative measure for #1 and #2, if #3 is identified, the nurse will follow procedure of assessing, reporting, recording, and obtaining and implementing appropriate treatment orders and nursing intervention. Review of the Facility policy, entitled Prevention of Pressure Ulcers not dated, included the following: Policy: It is the policy of the facility to prevent pressure ulcers unless clinically unavoidable and to provide care and services to promote: the prevention of pressure ulcer development, the healing of pressure ulcers that are present (including preventions of infection to the extent possible) and prevent development of additional pressure ulcers. Further review of the policy indicated a stage IV pressure ulcer as: Full thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bones or supporting structures (example: tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers. Resident #82 was admitted to the facility in March of 2015 with diagnoses which included type 2 diabetes mellitus, anxiety disorder, acquired absence of right leg below the knee, acquired absence of left leg below the knee and peripheral vascular disease. Review of the quarterly Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #82 scored 15 out of 15 on the Brief Interview for Mental Status Exam, indicating he/she had intact cognition, required supervision for bed mobility, limited assistance with dressing, physical assist for bathing and supervision for hygiene. Further review of the MDS indicated that Resident #82 had impairment in range of motion in both lower extremities, used a wheelchair and limb prosthesis. The MDS indicated that Resident #82 was at risk for developing pressure ulcers, had no current pressure ulcers and was not coded as exhibiting behaviors. Review of the most recent Norton Scale of Predicting Pressure ulcers indicated that Resident #82 had a score of 11, indicating a moderate risk for developing pressure ulcers. During an interview on 10/19/22 at 1:42 P.M., Resident #82 said he/she has a wound on the back of his/her right leg, caused by chaffing from his/her prosthesis. He/she said he/she had a wound before (on his/her right leg) and it had been doing good. Review of Resident #82's medical record indicated the following: -A potential for skin breakdown care plan, dated 6/15/22, with the goal that Resident #82 will have no new skin breakdown in the next 90 days, target date 11/4/22. Interventions dated 9/20/22 included: *Weekly skin assessment on shower days. *Assess skin during activities of daily living care and report changes to medical doctor, registered dietician. *Barrier cream to all bony areas every shift. *Weekly skin checks as ordered. -A care plan with the focus for peripheral vascular disease due to diabetes, heart disease, dated 8/3/22. Interventions, dated 8/3/22, indicated: *Keep skin on extremities well lubricated with lotion in order to prevent dry skin and cracking of the skin. -A care plan, dated 8/3/22, with the focus of insulin dependent diabetes. Interventions dated 8/3/22 indicated: *Assess skin integrity daily with care-report abnormalities. *Conduct a comprehensive skin inspection weekly. -A care plan, dated 10/14/22, with the focus of behaviors, resident refuses care, takes food from others, is verbally abusive, fabricates stories. Interventions dated 10/14/22 indicated: *During care use a calm slow approach, greet by name, introduce yourself and smile. *Explain care step by step before proceeding. *If resident becomes combative or resistive, stop task and /or leave the room, allowing time to calm. *Log incidents of target behaviors in progress notes and notify the social worker and medical doctor of significant increases of behaviors. * Psych eval as needed. *Reassure resident of his/her safety and of your purpose. *Assess for possible contributors (pain, physical unmet need, temperature, need to void, etc.) through simple questioning, gestures and cures and assist with the same. During an interview on 10/19/22 at 5:06 P.M., Resident #82 said he/she was putting a dressing/pad on his/her knee and then put on the right leg prostheses. Resident #82 said he/she ran out of the thick pads and began using thinner pads and that is why the chaffing happened. Resident #82 said they (nursing staff) used to look at his/her knee, but he/she told them it was okay, and they did not look at it anymore. Resident #82 would not say how he/she got the protective covering pads. He/she showed the surveyor the packaged dressings. The surveyor observed the package as Comfort Foam Border, bordered foam wound dressing with soft silicone adhesive, for the management of exuding wounds and Bordered gauze, 6 inches by 6 inches dressing, a roll of dressing gauze was also observed. Resident #82 said he/she obtained the supplies by scrounging around. Review of Resident #82's medical record did not indicate an order for the use of pads (wound supplies) with the use of the right prosthesis. On 10/20/22 at 10:18 A.M., Certified Nursing Assistant (CNA #2) said Resident #82 did a lot of his/her own care and would not always allow staff to assist him/her and would use foul words. CNA #2 said she would help apply cream on his/her back and backside and would notify nursing staff if any new skin areas were present. Review of the physician's orders, dated 10/2022, indicated the following: *Diabetic foot care, dated 9/8/22 (Resident #82 is a person with the absence of both legs). The physician's orders failed to indicate an order in place for weekly skin checks. Further review of Resident #82's medical record Skin Evaluations indicated the following: *8/28/22, Is the resident's skin intact? checked off as 'yes'. *9/4/22, Is the resident's skin intact? checked off as 'yes' *9/11/22, Is the resident's skin intact? checked off as 'yes' Comments skin intact, pt. (patient) refused to eval his/her coccyx area. *9/18/22, Is resident's skin intact? Checked off as 'yes' *9/25/22, Is resident's skin intact? Checked off as 'yes' *10/2/22, Is resident's skin intact? Checked of as 'No' No comments or documentation as to where the Resident's skin was not intact, including location on the body diagram, site, type, length, width, depth, or stage. *10/9/22, Is resident's skin intact? Checked off as 'No'. Does resident have any preexisting area/areas? Checked off as 'yes Site: Right knee below the knee amputation, left knee below the knee amputation. Right knee (front) skin tear. Additional comments: calazime and DPD (dry protective dressing) applied. Wound consult in place. There was no order for calazmine or dpd in the physician's current orders. During an interview on 10/20/22 at 2:17 P.M., Nurse #5 who completed the 10/2/22 'Skin Evaluation on Resident #82, said Resident #82 was wearing a right leg prosthesis. Nurse #5 said she did not evaluate the Resident's skin under the right leg prosthesis. During an interview on 10/20/22 at 8:01 A.M., Nurse #1 said a skin evaluation is a head-to-toe assessment and all areas of a resident's skin should be observed including under dressings or devices used by residents. Nurse #1 said Certified Nurses Aides (CNAs) are to report any skin changes to the nurse as part of daily care. Nurse #1 said she did the skin evaluation on Resident #82 dated 10/9/22 and documented a skin tear on the front of the resident's right knee. Nurse #1 said Resident #82 was a challenge and would not let nursing staff see his/her skin and would say don't worry about it. Nurse #1 said on 10/11/22 Resident #82 complained of pain and she assessed his/her skin and observed an open area on the back of Resident #82's right knee. Nurse #1 said Resident #82 had an area there before and that it must have reopened. Nurse #1 said she got the facility wound nurse to look at the area. Nurse #1 said Resident #82 can put on his/her own right prosthesis and there was no order for the Resident to apply a pad between the knee and the prosthesis. Nurse #1 said Resident #82 does take supplies and gets into things without staff seeing. On 10/11/22 a wound note entered into the medical record two days after the 10/9/22 skin evaluation, indicated the following: Pressure ulcers, Site: right knee, type; pressure, length 4.2, width 5.5, depth 1 (unit of measure in centimeters), stage IV. Wound shape: irregular, undermining. Surrounding tissue: excoriated. Drainage: serosanguinous (drainage composed of serum and blood) minimal/moderate amount. Pain: with movement, with dressing change. Narrative Note/Treatment and Response: Resident (#82) has a history of right knee ulcers caused by prosthesis which healed a few months ago. Resident noted today to have a stage 4 under right knee, Resident admits that the areas started a couple of weeks ago, I was using the bandages in my room and didn't tell anyone Wound has purple edges with exposed muscle and tendon, moderate amount of purulent drainage noted. Treatment will be iodosorb, calcium alginate and dpd (dry protective dressing) daily. The facility wound nurse was not available for interview. During an interview on 10/20/22 at 3:20 P.M., the Director of Nursing (DON) said the expectation is for staff to follow through on weekly skin evaluations to identify any skin changes. The DON said until today she was not aware of the extent of Resident #82's Stage IV pressure ulcer. She said interventions to work to connect with Resident #82 to allow staff to observe his/her skin could have been implemented to prevent the area from becoming Stage IV pressure ulcer.

Based on interviews and records reviewed, for one of three sampled residents (Resident #3), the Facility failed to ensure Resident #3 was free from a significant medication error. Nurse #1 administered Hemocult developer (used to detect presence of blood in stool) in error to Resident #3's right eye, as a result Resident #3 was transferred to the Hospital Emergency Department and diagnosed with [REDACTED]. Findings include: The Facility Policy titled, Administering Medications, undated, indicated medications would be administered in a safe and timely manner, and as prescribed, and the staff member administering the medication would check the label three times to verify the right resident, right medication, right dosage form, and resident's rights before giving the medication. The Facility protocol, titled Ophthalmic (eye) Drops, undated, indicated nursing staff would verify the medication against the Medication Administration Record [REDACTED]. The policy also stated nursing staff would make certain the medication was labeled for ophthalmic use and would assure sterility and compatibility for use in the eye. The Facility protocol, titled Med Pass Review, undated, indicated that at no time would medication be placed in staff's pockets. The Safety Data Sheet for Seracult (Hemocult) Developer, undated, indicated the solution may cause eye, skin, and respiratory tract irritation, avoid contact with eyes and skin, and if contact occurs to flush area with water. Resident #3 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Facility's Incident Report, dated 9/9/18, indicated Nurse #1 had administered Hemocult developer into Resident #3's right eye, in error. The Report indicated Resident #3 was transferred to the Hospital Emergency Department and returned to the Facility later that night. The Emergency Department Report, dated 9/9/18, indicated Resident #3 was diagnosed with [REDACTED]. The Nursing Home/Hospital Referral Form, dated 9/10/18, indicated Resident #3 was diagnosed a with chemical burn and corneal abrasion of the right eye. The Surveyor interviewed Resident #3 at 1:09 P.M. on 9/19/18. Resident #3 said when Nurse #1 put the drops in his/her right eye, he/she immediately felt pain and burning in his/her eye. Resident #3 said he/she yelled Stop! and told Nurse #1 to check the eye drops. Resident #3 said Nurse #1 left the room for about one to two minutes, and came back to flush his/her eye. Resident #3 said he/she did not want the Facility's staff to do anything to his/her eye, so he/she was sent to the Hospital for treatment. Resident #3 said for the following four or five days, it felt like there was a rock in his/her eye. The Surveyor interviewed Nurse #1 at 1:23 P.M. on 9/19/18. Nurse #1 said on 9/9/18, she had performed a Hemocult test a stool specimen prior to preparing Resident #3's medications, and that is why she had the Hemocult vial with her. Nurse #1 said after performing the test, she placed the vial of Hemocult developer into her pocket, and forgot it was there. Nurse #1 said she then prepared Resident #3's medications, and placed his/her [MEDICATION NAME] eye drop vial in her pocket because she was carrying water and Resident #3's medications in her hands and her hands were full. Nurse #1 said after she administered Resident #3 his/her oral medications, she reached into her pocket to get Resident #3's [MEDICATION NAME] eye drops. Nurse #1 said she did not look at the vial before administering the eye drops into Resident #3's right eye, and said as soon as she instilled the first drop, Resident #3 began complaining of burning to his/her right eye. Nurse #1 said she covered the vial, placed it back in her pocket, and gave Resident #3 a tissue. Nurse #1 said she reached back into her pocket afterwards, and there were two vials in her pocket (the Hemocult developer and the [MEDICATION NAME] eye drops), and said that was when she realized she had administered the Hemocult developer into Resident #3's right eye, in error. The Surveyor interviewed the Director of Nurses (DON) at 8:26 A.M. on 9/19/18. The DON said Nurse #1 should have checked the vial before administering the medication.

Based on interviews and records reviewed, for one of three sampled residents (Resident #3) the Facility failed to ensure nursing services were provided according to acceptable standards of practice and failed to ensure nursing followed policy regarding medication administration when Nurse #1 failed to check the bottle of medication prior to instilling it in Resident #3's right eye. - Nurse #1 administered a caustic substance (Hemocult developer- used to perform a test on stool specimens) into Resident #3's right eye, causing immediate pain, chemical burn, and corneal abrasion. Findings include: The Facility policy titled, Administering Medications, undated, indicated medications would be administered in a safe and timely manner, and as prescribed, and the staff member administering the medication would check the label three times to verify the right resident, right medication, right dosage form, right route, and resident's rights before giving the medication. The Facility protocol, titled Ophthalmic (eye) Drops, undated, indicated nursing staff would verify the medication against the Medication Administration Record [REDACTED]. The policy also stated nursing staff would make certain the medication was labeled for ophthalmic use and would assure sterility and compatibility for use in the eye. The Facility protocol, titled Med Pass Review, undated, indicated that at no time would medication be placed in staff's pockets. The Safety Data Sheet for Seracult (Hemocult) Developer, undated, indicated the solution may cause eye, skin, and respiratory tract irritation, avoid contact with eyes and skin, and if contact occurs to flush area with water. Resident #3 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 7/20/18, indicated Resident #3 was cognitively intact. The physician's orders [REDACTED]. The Facility's Incident Report, dated 9/9/18, indicated Nurse #1 had administered Hemocult developer into Resident #3's right eye, in error. The report indicated Resident #3 was transferred to the Hospital Emergency Department and returned to the Facility later that night. The Emergency Department Report, dated 9/9/18, indicated Resident #3 was diagnosed with [REDACTED]. The Nursing Home/Hospital Referral Form, dated 9/10/18, indicated Resident #3 was diagnosed with [REDACTED]. The Surveyor interviewed Resident #3 at 1:09 P.M. on 9/19/18. Resident #3 said when Nurse #1 put the drops in his/her right eye, he/she immediately felt pain and burning in his/her eye. Resident #3 said he/she yelled Stop! and told Nurse #1 to check the eye drops. Resident #3 said Nurse #1 left the room for about one to two minutes, and came back to flush his/her eye. Resident #1 said he/she did not want Facility's staff to do anything to his/her eye, so he/she was sent to the Hospital for treatment. Resident #3 said for the following four or five days, it felt like there was a rock in his/her eye. The Surveyor interviewed Nurse #1 at 1:23 P.M. on 9/19/18. Nurse #1 said that on 9/9/18, she had performed a Hemocult test on a stool specimen, and that is why she had the Hemocult vial on her. Nurse #1 said after performing the test, she placed the vial of developer in her pocket, and forgot it was there. Nurse #1 said she then prepared Resident #3's medications, and placed his/her [MEDICATION NAME] eye drop vial in her pocket because she was carrying water and Resident #3's medications in her hands and her hands were full. Nurse #1 said she reached into her pocket for Resident #3's [MEDICATION NAME] eye drops, but said she did not look at the vial before administering the eye drops to Resident #3's right eye. Nurse #1 said as soon as she applied the first drop, Resident #3 began complaining of burning to his/her right eye. Nurse #1 said she realized she had administered the Hemocult developer into Resident #3's right eye, in error. The Surveyor interviewed the Director of Nurses (DON) at 8:26 A.M. on 9/19/18. The DON said Nurse #1 should have checked the vial before administering the medication.

Based on interview and record review, for one of three sampled residents (Resident #1), the Facility failed to ensure two staff members immediately and accurately reported their knowledge of Resident #1's fall on 3/2/14, and the etiology of his/her forehead hematoma. As a result, a fracture of Resident #1's right clavicle was not diagnosed and treated for [REDACTED].#1's fall, causing needless delay in Resident #1 receiving medical evaluation and treatment. Findings include: Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment Form, dated 2/6/14, indicated his/her short and long term memory skills were impaired and his/her decision making skills were severely impaired. The MDS indicated Resident #1 was totally dependent on the physical assistance of two staff members with bed mobility and transfer between surfaces. Resident #1's care plan, initiated 12/14/09 and most recently reviewed 2/24/14, indicated that he/she was at risk for falls due to dementia, poor safety awareness and decreased strength and endurance. Resident #1's care plan interventions included repositioning him/her with the assistance of two people and transferring him/her between surfaces with a mechanical lift and the assistance of two staff members. Resident #1 was observed but not interviewed by the Surveyor on 4/1/14 due to Resident #1's impaired communication and cognition. The Surveyor interviewed CNA #1 at 3:20 P.M. on 4/10/14. CNA #1 said that, around 7:30 A.M. on 3/2/14, when CNA #1 repositioned Resident #1 on the edge of his/her bed to prepare to transfer him/her from the bed to a shower chair, Resident #1 fell to the floor. CNA #1 said that she panicked and picked Resident #1 up off of the floor and placed him/her into the shower chair. CNA #1 said Resident #1 sustained a hematoma on his/her right forehead in the fall. CNA #1 said CNA #2 entered Resident #1's room after CNA #1 picked Resident #1 up off the floor and placed him/her into the shower chair. CNA #1 said she told CNA #2 about the fall. The Surveyor interviewed CNA #2 at 9:00 A.M. on 4/10/14. CNA #2 said CNA #1 approached her in the hallway and asked her for assistance getting Resident #1 out of bed. CNA #2 said that, when she entered Resident #1's room a few minutes later, Resident #1 was already in the shower chair and there was a hematoma on his/her right forehead. CNA #2 said CNA #1 told her that Resident #1 fell on the floor and CNA #1 picked him/her up and put him/her in the shower chair. CNA #2 said she did not immediately report the fall or CNA #1's actions to the nurse. CNA #1 said she told Nurse #1 and Nurse Supervisor #1 about the hematoma on Resident #1's right forehead. CNA #1 said when she reported the hematoma, she did not tell Nurse #1 and Nurse Supervisor #1 Resident #1 fell or that she picked Resident #1 up off the floor without assistance. CNA #1 said she told Nurse #1 and Nurse Supervisor #1 that Resident #1 sustained the hematoma during a transfer with the mechanical lift while being assisted by CNA #1 and CNA #2. CNA #2 said she knew CNA #1 spoke to Nurse #1 and the Nurse Supervisor #1 about the hematoma on Resident #1's forehead, but did not know precisely what CNA #1 told them. The Facility's undated Fall Prevention Policy indicated that all residents who experience a fall would have an assessment by the nurse and an injury report completed. The policy indicated it was the purpose of the policy to ensure timely reassessment and re-evaluation of any resident who experienced a fall. The Surveyor interviewed Nurse #1 at 6:00 P.M. on 4/18/14 and Nurse Supervisor #1 at 2:00 P.M. on 4/1/14. Nurse #1 and Nurse Supervisor #1 said CNA #1 told them Resident #1 bumped his/her head on the mechanical lift during a transfer while being assisted by CNA #1 and CNA #2. Nurse #1 and Nurse Supervisor #1 said they asked CNA #1 to re-enact the transfer and the re-enactment plausibly explained CNA #1's report regarding the etiology of the hematoma. Nurse #1 and Nurse Supervisor #1 said CNA #2 observed CNA #1's re-enactment, and nodded her head in agreement. Nurse #1 said she assessed Resident #1 and did not identify any injury other than the hematoma. Nurse #1 and Nurse Supervisor #1 said about 8 hours later, a family member reported they found a bump on the back of Resident #1's head. Nurse Supervisor #1 said she re-interviewed CNA #2, and it was at that time that CNA #2 reported to her that CNA #1 told CNA #2 that Resident #1 fell prior to CNA #2 entering the room to assist with the transfer. Nurse Supervisor #1 said she re-interviewed CNA #1 and CNA #1 told her the hematoma occurred when Resident #1 fell from bed and she had not reported Resident #1's fall. Nurse #1 said based on CNA #1 and CNA #2's report of Resident #1's fall eight hours before, she conducted a second assessment of Resident #1 and she found a bruise on Resident #1's right forearm. Nurse #1 said that the physician was notified of the bruise by telephone, x-rays were ordered, and the radiology results indicated Resident #1 had a fractured right clavicle. CNA #1 and CNA #2's failure to accurately report Resident #1's fall resulted in a needless delay in Resident #1 being evaluated and treated for [REDACTED].