Every finding on record at Beatitudes Campus

Based on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations and policy review, the facility failed to ensure food and drinks were palatable and maintained at an appetizing temperature. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the 'danger zone'.Findings include:A review of food temperatures from the last 30 days was conducted and revealed that on August 26, 2025, 4th-floor lunch temperatures at 12:00 PM were as follows:- Beet and Feta Salad: 48.3 degrees F- Honey Glazed Pork Tenderloin: 133.1 degrees F- Pina Colada Cheesecake: 51.1 degrees FHowever, that same review revealed that on August 26, 2025, the 3rd-floor lunch temperatures at 12:00 PM were as follows:- Beet and Feta Salad: 37.6 degrees F- Honey Glazed Pork Tenderloin: 173.8 degrees F- Pina Colada Cheesecake: 41.6 degrees FDuring an initial interview with Resident #69 conducted on September 2, 2025, at 9:01 AM, she stated that they do not get their breakfast and lunch meals hot.During another initial interview with Resident #18 conducted on September 2, 2025, at 9:11 AM, he stated that the food provided by the kitchen has no taste and is not hot.On September 3, 2025, an observation was conducted of the lunch tray assembly.At 11:00 AM, the dietary staff was observed taking initial temperatures of the food that was to be taken to the assigned floor.At this time of the observation, an interview was conducted with the Nutrition Care Manager (Staff #47). Staff #47 advised that each floor receiving long-term care services, floors 3 and 4, will undergo an initial temperature check before being escorted to their assigned floor. Staff #47 also stated that each floor has its own hot box for transport; individual carts that hold cold items, serving utensils, and a disinfecting bucket.At 11:42 AM, the prepared food and the test tray had been transferred to the 4th floor via a hot box to be placed into the 4th floor steam table for plate assembly.At 12:45 PM, all residents on the 4th floor received their plates, and a test tray had been made from the food located in the 4th-floor steam table.At this time, the test tray temperatures were taken. The holding temperatures were as follows:- Pork: 126 degrees F- Vegetables: 133 degrees F- Sandwich Melt: 154 degrees F- Beans: 122 degrees F- Cottage Cheese: 57 degrees F- Watermelon Puree: 56 degrees FDuring this observation, an interview was conducted with Staff #47, who stated that the holding temperatures for hot items are expected to be maintained at 140 degrees F and 41 degrees F for cold items, as stated per facility policy, due to the risk of exposure to food-borne illnesses.However, Staff #47 had also stated that the temperatures taken for the 7 individual lunch items are considered safe and palatable to her standards, despite the facility policy.Another interview was conducted with Resident #33 on August 4, 2025, at 8:46 AM. Resident #33 stated that the food for both lunch and dinner is underwhelming and had been served to him at what they considered a cold-to-the-touch temperature.A facility policy titled 'Food Safety Requirement' revealed that staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained, and to refer to the current FDA (Food and Drug Administration) Food Code andfacility policy for food temperatures.Per the FDA Food Code, holding temperatures for cold foods should be held at 41 degrees F or below, and hot foods should be held at 135 degrees F or above. These are minimum requirements for Time/Temperature Control for Safety (TCS) foods to slow the growth of bacteria and prevent foodborne illness.

Based on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations, and policy review, the facility failed to ensure that prepared food was stored in accordance with professional standards for food safety. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the 'danger zone'. Findings include:On September 2, 2025, an initial observation of the facility kitchen was conducted with the Nutrition Care Manager (Staff #47).At 8:41 AM, a walk-through of Refrigerator #1 revealed no evidence of a label of creation date or a use-by date for a food item that had been identified by Staff #47 as Jell-O.At 8:44 AM, a walk-through of Refrigerator #2 revealed raw meats had no evidence of a label of when it was taken out of the freezer or a use-by date. During this walk-through, an interview was conducted with Staff #47, who advised that staff are expected to review the menu and encouraged to defrost necessary raw meat products three days before their preparation date. Staff #47 also advised that she was unsure when the raw meat products were put into the refrigerator for defrosting, but stated her assumption that the dietary staff had kept track. At 8:47 AM, a walk-through of the Freezer revealed two opened bags of what Staff #47 identified as rolls and biscuits, which had no evidence of a label of when they were opened or a use-by date. This walk-through also revealed that an open bag of what Staff #47 identified as fish filets had no evidence of a label of when it was opened or a use-by date. During this walk-through, Staff #47 also advised that the expectation for staff is to ensure the placement of an open date and use-by date for any opened items placed in the freezer.At 8:51 AM, a walk-through of the dry storage revealed that an open bag of what Staff #47 identified as brown rice had no evidence of a label of when it was opened or a use-by date. Staff #47 also identified that an open bag of white rice had no evidence of a label of when it was opened or a use-by date. Staff #47 also identified that an open box of lasagna pasta had no evidence of a label of when it was opened or a use-by date. During this walk-through, Staff #47 advised that the expectation in the dry storage is that any item that is opened and returned to the storage for further use is to be labeled with the date it was opened and a use-by date. At 8:59 AM, Staff #47 advised that not labeling food items stored within the kitchen is not within the facility's expectations and that the lack of a label can pose the risk of preparing meals with expired food items.On September 3, 2025, a secondary observation of the facility kitchen was conducted with the Nutrition Care Manager (Staff #47).At 9:51 AM, a walk-through of Refrigerators #1 and #2, the Freezer, and the Dry Storage revealed that the fish filets were still located in the Freezer with no evidence of a label of when it was opened or a use-by date. The walk-through also revealed that the Jell-O had no evidence of a label of creation date or a use-by date, and that these were no longer in Refrigerator #1. The walk-through also revealed that the raw meats with no evidence of a label of when it was taken out of the freezer or a use-by date were still located in Refrigerator #2. The walk-through also revealed that the brown rice, the white rice, and the lasagna pasta that had no evidence of a label of when it was opened or a use-by date were no longer located in the Dry Storage.A facility policy titled 'Food Safety Requirement' revealed that practices to maintain safe refrigerated storage included separating raw foods from each other and storing raw meats on shelves below other refrigerated items so that the meat juices do not drip on them; and to label, date and monitor refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen/discarded.

The facility failed to ensure resident assessments for two residents were encoded and transmitted according to regulatory requirements. The deficient practice can impact the facility's ability to monitor changes to residents' health data over time. Based on clinical record review, interviews, facility policy and procedure, the facility failed to ensure Minimum Data Sets (MDS) for two residents (#3 and #12) were encoded and transmitted according to regulatory requirements. The deficient practice can impact the facility's ability to monitor changes to residents' health data over time. Findings Include:-Regarding Resident #3Resident #3 was admitted to the facility on [DATE] with diagnoses that included unspecified injury of the head, and difficulty walking.The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 11, indicating moderate impairment in cognition.The Nursing Home Tracking Item Set MDS, dated [DATE], was completed and attested to on the same date for death reporting. The resident's MDS 3.0 Assessment Summary report, retrieved September 5, 2025 at 9:03 a.m., revealed the June 4, 2025 Death in Facility Tracking report has a status of: In process. Facility documentation did not support that the document was finalized, encoded, or transmitted. The resident's MDS 3.0 Assessment Summary report, retrieved September 5, 2025 at 10:39 a.m., revealed the June 4, 2025 Death in Facility tracking report has a status of: In process. Facility documentation did not support that the document was finalized, encoded, or transmitted. The resident's MDS 3.0 Assessment Summary report, retrieved September 5, 2025 at 1:47 p.m., revealed the June 4, 2025 Death in Facility discharge report has a status of: Finalized. Facility documentation does not support that the document was encoded or transmitted. -Regarding Resident #12Resident # 12 was admitted to the facility on [DATE] with diagnosis that included Chronic Obstructive Pulmonary Disease (COPD), anxiety, and resistant hypertension. The quarterly MDS dated [DATE] revealed the resident had a (BIMS) score of 14, indicating the resident was cognitively intact. The verifying assessment completion Registered Nurse (RN) signed the assessment as complete on August 27, 2025. The resident's MDS 3.0 Assessment Summary report, retrieved September 5, 2025 at 9:16 a.m., revealed the August 3, 2025 quarterly review assessment, has a status of: Finalized. The facility documentation does not support that the assessment was encoded or transmitted. The resident's MDS 3.0 Assessment Summary report, retrieved September 5, 2025 at 1:43 p.m., revealed the August 3, 2025 quarterly review assessment, has a status of Finalized. The facility documentation does not support that the assessment was encoded or transmitted.A panel discussion was conducted with the Director of Nursing (DON/Staff #57 ) and the RN MDS Coordinator (Staff # 39) on September 5, 2025 at 10:30 a.m. The panel revealed a purpose of the completion and submission of the Minimum Data Set (MDS) is to assess the resident for risk that the resident may have, so it can be addressed in the resident's Plan of Care. The panel refers to the Resident Assessment Instrument (RAI) manual as their reference to aid in the completion of MDS documentation. The DON ensures that all parties that are participants in the MDS assessment process have the knowledge to complete an accurate and thorough assessment. The DON described knowledge and competency is obtained through training and huddle meetings, but stressed communication is key. The panel described one unique function of the RN in the is to verify the overall completeness of the MDS and then attest once completeness was verified. The panel agreed that the deadline for MDS submission is 14 days but that the facility is aware that the Center for Medicare Services (CMS) does provide a grace period for facilities. The panel shared that the facility has been in transition for a MDS nurse coordinator, and that the current coordinator has almost been active at the facility for two weeks. The DON also shared the facility was also undergoing transition with their electronic health record system upgrade. While dealing with the transitions, the DON reported that the facility conducted an inhouse audit of the Assessment Reference Dates last week, and then notified the Interdisciplinary Team (IDT) of the findings. The panel defined ARD as the last day of that period of time, that the MDS assessment covers for that particular assessment. The DON revealed other ways the facility has been proactive in improving the facility's MDS assessment process also included the discussion of the issue in Quality Assurance Performance Improvement (QAPI) meetings around June/July 2025. The DON reviewed the clinical record for resident #3, and revealed the submission of the documentation failed to meet facility expectation. The DON identified that the documentation was still in active status. The DON voiced being unable to give a definitive rationale for the former coordinator failure to transmit the documentation. The DON speculated that it may have possibly been a technical issue, due to the facility undergoing training in the new electronic record system. After review of resident # 12 clinical record, the DON revealed that the documentation was not submitted in a timely manner, and identified part of the cause was being without a MDS coordinator for a few weeks. While the facility was in-between MDS coordinators, the DON also identified that there was an issue in gaining access in order to transmit the assessments. The DON explained that the electronic record system provides the staff alerts and reminders for MDS documentation submission time tables. The DON voiced the benefit of the alert system, is that it assists the staff in ensuring MDS documentation is submitted on time. The DON revealed being the backup system for MDS submission, and performing audits to ensure compliance. As to why their alert system and safeguards failed for these two residents, the panel was unable to speculate, but does intend to use the experience to help improve the process. The panel agreed that the facility was out of the grace period for transmittal for the two identified residents, but intends on immediately rectifying the discoveries as soon as the panel discussion concludes. An interview was conducted with the Executive Director (ED/Staff #65) on September 5, 2025 at 12:25 p.m. The Executive Director revealed that the facility already had a Performance Improvement Plan (PIP) in place for the submission of MDS documentation. The ED revealed challenges that caused the facility to require a PIP plan for MDS included: the overhaul and upgrading of the electronic health record system, the resignation of the RN MDS coordinator, and the failure to connect with the facility's assigned RAI coordinator. The ED revealed having saved email documentation of RAI correspondence attempts, all of which went unanswered. The ED expressed feelings of hope back then that assistance from the RAI coordinator could have been a valuable resource to provide aid and guidance through their transitions. The ED explained that the facility has been very proactive in trying to fix transitional glitches in the MDS system process. The ED identified those proactive measures included: the hiring of a Director of Nursing with MDS Coordination experience, a recent new-hire of a full time RN MDS coordinator, electronic record audits of the complete facility, and addressing the issue during QAPI. The facility's Comprehensive Care Plans Policy, copyright 2023), revealed that the care plan will be developed within 7 days after completion of the comprehensive MDS assessments. The facility's MDS 3.0 Completion Policy, copyright 2024, revealed that quarterly assessments are completed using an ARD no greater than 92 days from the most recent assessment (counting ARD to ARD). The Death Tracking Record, according to policy does not require a RN Coordinator's signature. In addition, the tracking record is expected to completed no later than the discharge date plus 7 calendar days. The policy mandates the facility to ensure that all assessments are to be transmitted to the designated CMS system within 14 days of completion.

Based on interviews, review of clinical record, and facility records, policy, and procedures, the facility failed to protect the rights of one resident (#60) to be free from verbal abuse by a staff member. The deficient practice could result in psychosocial harm.-Findings include:Resident #60 was admitted to the facility on [DATE], with diagnoses that included enterocolitis due to clostridium difficile, urinary tract infection, type 2 diabetes mellitus with foot ulcer, pressure ulcer of sacral region, and muscle weakness.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #60 had a brief interview for mental status (BIMS) score of 15, indicating intact cognition.A facility self-report received by the state agency on April 28, 2024, at 9:56 P.M. revealed that at 9:30 P.M. on the same date, that a certified nursing assistant (CNA / Staff #106) called the Director of Nursing (DON / Staff #90) and stated that a nurse (Staff #99) was yelling at Resident #60 and waving her middle finger in his face. Additionally, that Staff #99 was suspended immediately.A time punch report for Staff #99 revealed that on April 28, 2024, that Staff #99 clocked in at 6:49 P.M. and clocked out at 10:30 P.M.Review of the clinical record revealed no evidence of a progress note or assessment dated [DATE], describing an incident between a staff member and Resident #60.A facility investigation report dated April 28, 2024, revealed that on April 28, 2024, that Staff #106 reported that a Licensed Practical Nurse (LPN / Staff #99) was verbally abusive to Resident #60. Staff #106 reported that Staff #99 waived her middle finger in the resident's face and called him a motherfucker. Staff #99 was suspended immediately. The investigation report revealed that on April 30, 2024, facility staff conducted an interview with Resident #60 that revealed that Resident #60 had called the nurses station because he wanted medication, and the CNA was in the room changing Resident #60. The resident stated that the nurse came in talking all crazy, and the resident asked the nurse why are you saying all this. Resident #60 reported that the nurse said you just want us to wash your ass and that the nurse gave Resident #60 the middle finger and then the nurse picked up a hand weight. The facility investigation revealed that facility staff interviewed the CNA (Staff #106) who stated that she went into Resident #60's room, and the nurse (Staff #99) told Staff #106 that Resident #60 wanted medication and wanted to be cleaned up, and that Staff #99 then entered Resident #60's room and stated to Resident #60 that he needs to get his shitty ass up and get in the shower, and that Staff #99 was cursing at Resident #60 and gave Resident #60 the middle finger. Staff #106 stated that she was motioning to Staff #99 to leave the room, and then pushed Staff #99 towards the door to get her out of the resident's room. Staff #106 stated that when Staff #106 and Staff #99 were in the hallway, Staff #99 got in Staff #106's face and that then Staff #106 told Staff #99 she needed to leave. Staff #106 stated that Staff #99 picked up a hand weight, and Resident #60 picked up the other hand weight and asked Staff #99 if she was going to hit him with that.The facility investigation report revealed that Staff #99 denied using the middle finger but does admit to pointing at the resident and that her behavior was unprofessional. Additionally, the facility investigation concluded that the allegation of verbal abuse was substantiated.An interdisciplinary note dated May 1, 2024, revealed that Resident #60's family member had called and was upset that she was not contacted regarding an incident this week.A provider note dated May 4, 2024, revealed that Resident #60 stated his mood was a little down because he had an incident with a night nurse earlier in the week. The resident continued to state that his anxiety was high and now worse since the incident, and that he was thinking about moving to another facility.A Human Resources Change Request Form dated and effective May 8, 2024, revealed that Staff #99 was involuntarily terminated due to a resident complaint substantiated.A telephonic interview was attempted with Staff #106 on September 3, 2025, at 1:59 P.M., however both of the staff's phone numbers were out of services.A telephonic interview was attempted with Staff #99 on September 3, 2025, at 2:00 P.M., and a voicemail was left for a return call. The staff did not return the phone call.A telephonic interview was conducted with an LPN (Staff #8) on September 3, 2025, at 2:22 P.M, Staff #8 stated that she recalled the incident with Staff #99 and Resident #60. Staff #8 stated she was working that shift and that she received a call from the DON to go and take a statement from the involved parties. Staff #8 stated that she took a statement from Resident #60 and that the resident stated that the nurse had threatened him physically and there was verbal abuse, but that she could not remember the exact details. Staff #8 stated that she then talked to Staff #106, and that Staff #106 corroborated the resident's statements of what happened. Staff #8 stated that when the statements were taken and reported to the DON, that the DON gave the directive for Staff #99 to leave the facility and then Staff #99 left.A telephonic interview was conducted with an LPN (Staff #200) on September 4, 2025, at 8:04 A.M. Staff #200 stated that she recalled the incident, and that she was at the opposite end of the hall in the same unit and heard yelling. She stated that she then saw and heard in the hallway Staff #99 yelling at Staff #106 to stay out of her way, and that Staff #106 was removing Staff #99 from the situation. Staff #200 stated that she had worked with Staff #106 in the past and that Staff #106 was always enjoyable to work with and was good with residents so that when Staff #106 came to her with the concern, Staff #200 knew it was serious. Staff #200 stated that Staff #106 approached her and said that Staff #99 was using curse words toward Resident #60, and was being very disrespectful and degrading to the resident. Staff #200 stated that she called the DON, and that the DON stated that Staff #99 needed to leave the facility. Additionally, prior to that incident, Staff #200 stated that she had heard Staff #99 openly voice opinions about Resident #60 at the nurses station, and that Staff #99 stated that Resident #60 was disgusting, and that Staff #200 had to tell Staff #99 not to speak like that about residents. Also, Staff #200 stated that for weeks prior to the incident, Staff #99 had asked Staff #200 to care for Resident #60 and pass his medications even though the resident was on Staff #99's assigned rooms and not on Staff #200's assigned rooms, because Staff #99 did not like Resident #60. Staff #200 stated that Staff #99 was not even supposed to be in Resident #60's room because Staff #200 had taken over the resident's care.A telephonic interview was attempted with Resident #60 on September 4, 2025, at 1:10 P.M. The phone number was not in service.An interview was conducted with the Administrator (Staff #65) on September 5, 2025, at 10:23 A.M. The Administrator stated that abuse could include different types such as physical, verbal, sexual, financial, or emotional. The Administrator stated that if a staff member used derogatory or threatening gestures such as giving the middle finger to a resident, that would be abusive. The Administrator stated that she could not recall the incident between Staff #99 and Resident #60. The Administrator reviewed the facility investigation of the incident, and the interview continued again at 10:54 A.M. The Administrator stated that after reviewing the investigation file, that there was an accusation of a staff cursing and using the middle finger gesture toward a resident and that there were resident and staff interviews conducted as part of the investigation. The Administrator stated that the facility concluded the investigation with substantiating the allegation of verbal abuse.Review of the facility policy titled Abuse, Neglect, and Exploitation, undated, revealed that it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.

Based on interviews, review of clinical record, and facility policy, the facility failed to ensure a thorough investigation was conducted and recorded, and that a resident (#66) was assessed for injury regarding an allegation of abuse. The deficient practice could lead to continued physical and psychosocial harm of a resident, and/or a missed injury and delay of care.-Findings include:Resident #66 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, tremor, type 2 diabetes mellitus, hypertension, peripheral vascular disease, cervicalgia, pain in thoracic spine, and pain in left knee.An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 13, indicating intact cognition.A facility self-report to the state agency received August 3, 2023, at 10:18 A.M. revealed that Resident #66 reported an allegation of abuse from a certified nursing assistant (CNA / Staff #80), while she was getting the resident ready for the day prior to breakfast. The incident occurred on August 3, 2023, at around 8:30 A.M. Per the report, the resident was interviewed and stated that Staff #80 was rough with him and tossed him around and that Staff #80 gave him bruising to the left forearm. The clinical record was reviewed, and there was no evidence of any progress notes or assessments to indicate that the resident had been assessed for injury on August 3, 2023, after an allegation of staff to resident abuse.An admission MDS assessment dated [DATE], revealed that Section M Skin Conditions was completed by a licensed staff on August 14, 2023. Section M revealed that the resident had no unhealed pressure injuries, no venous or arterial ulcers, no foot problems, no surgical wounds, no burns, no skin tears, no moisture associated skin damage, and no open lesions other than ulcers, rashes, or cuts. The assessment did not reveal questions whether the resident had discolored skin, edema, or bruising. A formal request was submitted on September 4, 2025, for the facility to provide any evidence in the clinical record that Resident #66 had any skin assessment completed on August 3, 2025. The Administrator (Staff #65) signed a statement that revealed a skin assessment was conducted as part of the MDS assessment dated [DATE].A telephonic interview was conducted on September 3, 2025, at 12:45 A.M with a CNA (Staff #52), who stated that she recalled the allegation of abuse from Resident #66 regarding Staff #80. Staff #52 stated that Resident #66 liked things done in a very slow and particular way and to be done at eye level, and that she thought the incident was just a misunderstanding. A telephonic interview was attempted with a licensed practical nurse (LPN / Staff #87) on September 3, 2025, at 1:48 P.M. The number provided was the wrong number.An interview was conducted with the Director of Nursing (DON / Staff #57) on September 3, 2025, at 11:50 A.M. The DON stated that in a case of alleged physical abuse, that staff are expected to report the incident immediately, to protect the residents and make sure they are safe by separating the resident from the alleged abuser, and that the facility staff would initiate an investigation. Additionally, the DON stated that in a case of alleged physical abuse, that the nurse would do a skin assessment and ask the resident if they are in pain to assess for possible injury. The clinical record for Resident #66 was reviewed together, and the DON stated that she could not find any evidence that indicated that Resident #66 had a skin assessment completed on August 3, 2023.An interview was conducted with the Administrator (Staff #65) on September 5, 2025, at 10:23 A.M. The Administrator stated that in the instance of alleged abuse, an investigation is completed by staff to determine what happened. The Administrator stated that a thorough investigation is conducted by staff asking good, curious questions, such as asking the resident how they feel, and getting statements from the alleged perpetrator and other possible witnesses. The Administrator stated that if it is a physical abuse allegation, then staff would look at the resident's skin and do an assessment to help determine if something occurred. The Administrator stated that the nurse's assessment for injury of the resident should be in the clinical record. The Administrator reviewed the facility's investigation file regarding the alleged abuse of Resident #66 and stated that she could not remember the incident, but that it looked like the CNA was getting Resident #66 dressed and that Resident #66 felt that the CNA was rough with him. The Administrator stated that Resident #66 stated that the CNA grabbed him by the hand and tossed him around on the bed, put his socks on and yanked them up, and that the CNA pulled on his legs and yanked his hands, and that the resident stated to the CNA don't abuse me like that. The Administrator stated that she could not tell if a skin assessment should have been done for Resident #66 after reviewing the incident.Review of the facility policy titled Abuse, Neglect and Exploitation, undated, revealed that abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Procedures for investigation include: focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation, including examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed.

Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#34) was reported to the State Agency. Findings include: Resident #34 was admitted to the facility on [DATE] with diagnoses that included dementia, epilepsy, and major depressive disorder. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the facility's grievances revealed a grievance filed which indicated that Resident #34 had reported to a nurse on May 14, 2025 that a Certified Nursing Assistant (CNA) had pulled her hair while caring for her. The grievance indicated that Resident #34 did not know why it had happened. This grievance form indicated that an investigation was initiated and that the allegation was reported to the appropriate parties, including the State Agency. This grievance was marked as resolved on May 19, 2025. A nursing progress note dated May 15, 2025 revealed that the resident was provided care with two staff members on this date. The note detailed that no behaviors were noted and no concerns were voiced by the resident. Further review of the progress notes revealed a progress note, dated May 16, 2025, which indicated that an Adult Protective Services (APS) worker was at the facility due to Resident #34's report. There was no evidence found in the progress notes to indicate that any allegations or reports were made on behalf of Resident #34, nor any details about the situation. On May 19, 2025 at approximately 2:15PM, a list of the facility's self-reported incidents within the last ninety days was requested. The Director of Nursing (DON/Staff #11) provided a statement, dated May 19, 2025, which revealed that the facility did not have any self-reports within the last three months. Later, on May 19, 2025 at 4:26PM, the [NAME] President of Health Services (VP/Staff #23) provided a statement which also indicated that the facility did not have any self-reports in the last ninety days. Review of complaints and facility self-reports submitted to the state agency revealed no evidence that the facility had submitted a self-report for Resident #34's allegation of staff-to-resident abuse on or about May 14, 2025. Interview was conducted on May 20, 2025 at 10:18AM with a Social Worker (Staff #7), who stated that if she received a grievance relating to abuse, she would report it to the VP and DON to report and investigate. The Social Worker explained that since the VP was the abuse coordinator, she would take charge but would also delegate to the DON or to the Social Worker to investigate any allegations of abuse. The Social worker stated that typically, an abuse investigation would consist of interviewing the resident who made the allegation, other residents, and staff. When asked about the grievance filed by Resident #34, the social worker explained that the DON had obtained the initial report and filed the grievance for the resident. She further explained that the DON and Social Worker had jointly conducted the interviews to investigate the allegation. She stated that no residents that she interviewed had any concerns with their care or with staff. When asked where the investigation and results were documented, the Social Worker was unsure where the investigation was documented, but suggested that the VP would typically maintain a folder for investigations. Interview was conducted on May 20, 2025 at 10:27AM with the Director of Nursing (DON/Staff #11), who explained that she had submitted a self-report online to the state agency regarding Resident #34. She explained that she had submitted the report online on May 14, 2025 and followed the steps to verify her email, but had not heard back. The DON provided an email from the state agency, dated May 14, 2025 at 2:38PM, which instructed the user to click a link to verify the email address after a request of complaint submission by the facility tto show that the complaint had been received by the state agency. The email stated that once the email address was verified, the complaint would be submitted to the state agency for review. The DON stated that she had clicked the link as instructed. The DON did not provide any further documentation to show that the complaint had been finalized and submitted. Follow-up interview was conducted on May 20, 2025 at 10:38AM with the Director of Nursing (DON/Staff #11), who stated that she would expect any allegations of abuse, which included sexual, physical, emotional, and mental abuse, to be reported to the abuse coordinator right away. She explained that the allegation should then be reported to the state agency, APS, police, the ombudsman, family, and the provider. The DON stated that the morning of May 14, 2025, Resident #34 stated that a CNA had pulled her hair and she did not know why. The DON again explained that she had reported Resident #34's allegation of abuse to the state agency and other required parties on May 14, 2025 at approximately 07:40AM. The DON also stated that an investigation was completed of the allegation. Interview was conducted on May 20, 2025 at 11:05AM with the [NAME] President of Health Services (VP/Staff #23), who stated that all allegations of physical abuse should be reported within two hours to the appropriate agencies. The VP stated that Resident #34's allegation of abuse was reported immediately on May 14, 2025, and the five-day facility investigation was completed on May 19, 2025. The VP stated that the facility was unable to substantiate the allegation of abuse due to lack of evidence. The VP explained that if any hair pulling occurred when staff was changing the resident's clothing, that it would have been accidental. When asked why this investigation was not included when requesting the last ninety days of self-report investigations, the VP stated that it must have been an oversight, as the facility just completed the five-day report on the day that this was requested. Review of the facility policy titled, Abuse, Neglect and Exploitation, revealed that all alleged violations should be reported to the administrator, state agency, adult protective services and to all other required agencies within specified timeframes, which include: immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of 15 sampled staff (#70 and #19) received training on infection control. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: -Regarding the registered nurse (RN/staff #70) Review of personnel file for the RN (staff #70) revealed a hire date of November 07, 2022. The annual training transcript for the RN revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on November 08, 2022. There was no evidence found that the RN had taken any training on infection control after November 8, 2022. -Regarding the housekeeper (staff #19) The personnel file for the housekeeper (staff #19) included a hire date of August 21, 2023. Review of the housekeeper's annual training transcripts revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on August 21, 2023. There was no evidence found that the housekeeper had taken any training on infection control after August 21, 2023. An interview with the human resources assistant (HR assistant/staff #90) was conducted on August 28, 2024 at 9:57 AM. The HR assistant stated that she could not tell specifics regarding which annual training modules are required for all employees, contract staff, and volunteers. In an interview with the Administrator (Staff #59) conducted on August 29, 2024 at 11:15 AM, the administrator reviewed the provided annually required training module transcripts for Staff #70 and Staff #19. The administrator then stated that there were no annual training module transcripts on the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control for the RN (staff #70) and the housekeeper (staff #19). The administrator also stated that annual training meant within the past 365 days. During an interview with the [NAME] President of Human Resources and Risk Management (VP of HR/staff #40) conducted on August 30, 2024 at 08:35 AM, she stated that when COVID hit, the facility did not update their training; and when the Administrator came on board, the administrator was not aware of that. The VP of HR also said that the facility was missing their old policy and was currently writing a new one. The VP of HR also said that their new written policy included what topics of training were required annually. Review of the facility's policy titled New Hire Training and Annual In-Service Policy revealed that orientation training for newly hired staff members and volunteers, as well as annual training for current staff and volunteers is to include training on the topics of nursing care institution policies and procedures, resident rights, infection control, hand washing, linen handling, prevention of communicable diseases, and disaster plans.

Based on observations, staff interviews, and policy review the facility failed to ensure that infection control practices and standards were followed; failed to perform hand hygiene during provision of care; failed to ensure reusable resident equipment was cleaned and disinfected after its use. The deficient practice could result in the spread of disease and infections to residents. The facility census was 52 residents. Findings include: -Regarding wound care observation: During a wound care observation for Resident (#7) conducted on August 28, 2024 at 8:17 AM, the licensed practical nurse (LPN/staff #29) took a multiuse wound wash solution and betadine container from the treatment cart and into the resident's room. During the course of treatment application, the LPN (staff #29) touched the wound wash and betadine container with gloves used to removed soiled dressing; and, following the application of the wound treatment, staff #7 removed her gown and gloves, and returned the betadine and wound wash bottles directly to the wound treatment cart without sanitizing the bottles. An interview was conducted on August 28, 2024 at 8:17 AM with the LPN (staff #29) who stated that supplies used on residents during treatment down, staff would wipe them down with sanitizing/bleach wipes to ensure infection would not spread to other residents. Regarding the wound care observation, the LPN said that she should have sanitized or wiped down the wound wash solution and betadine containers that were brought into resident (#7)'s room before putting them back in the unit's treatment cart. An interview with the Director of Nursing (DON/Staff #12) was conducted on August 29, 2024 at 1:49 PM. The DON stated that any item used on a resident should be cleaned when it leaves the resident's room; and that, it would not meet the facility's protocol if the items were not cleaned prior to putting them back into the treatment cart. The facility policy titled, Wound Care revealed that after wound treatment is completed, reusable supplies are to be wiped with a sanitizing agent as indicated (outsides of containers that were touched by unclean hands, scissors, blades, etc.) prior to returning the supplies to the treatment cart. -Regarding Enhanced Barrier Precautions: During an observation on the 4th floor conducted on August 26, 2024 at approximately 8:45 a.m., there were residents on enhanced barrier precautions (EBP). However, there were no EBP signs posted in the walls of resident rooms in the hallway. On August 26, 2024 at 10:04 AM, the social services director (SSD/staff # 38) walked down the hallway on the 4th floor and placed the enhanced barrier precautions (EBP) signs next to resident's rooms. At 10:11 a.m., multiple staff were placing EBP signs in the hallway next to resident's rooms. An interview was conducted with the Director of Nursing (DON/Staff #12) on August 27, 2024 at 1:01 PM. The DON stated that staff were expected to use gown, gloves, and a face shield (for splashing) when providing care to residents on EBP. She then stated the EBP policy included that staff would use personal protective equipment (PPE) for any resident care. The DON further stated that staff would know that the resident/s was on EBP because there would be a sign on the resident's door and staff had worked on the unit all the time. The DON stated that she saw staff putting EBP signs by the resident's rooms that morning the survey team arrived on the unit. She further stated that not having EBP signage posted was considered an issue and the risk to the residents would include spread of infection. In an interview with a Certified Nursing Assistant (CNA/Staff #87) conducted on August 28, 2024 at 10:15 AM, the CNA stated that she would have to wear a gown and gloves anytime she goes into the room of residents on EBP for any task that needed to be done. The CNA further stated that she would know which residents were on EBP by the EBP signage outside the resident's room or the nurse would let her know. She also stated that the EBP signs were posted in the hallways by the resident's room on her last shift on Friday, August 23, 2024; however, she was not aware the signs had been taken down before the survey team arrived on the unit. The facility's policy titled, Enhanced Barrier Precautions, revealed that the facility would have discretion on how to communicate to staff which residents required the use of EBP, as long as staff were aware of which residents required the use of EBP during high-contact care activities. -Regarding hand hygiene: An observation conducted on the fourth-floor unit on August 26, 2024 at 8:30 AM, revealed that hand sanitizer was not accessible inside or immediately outside of resident's rooms. During a facility observation conducted on August 26, 2024 at 8:47 AM, the Certified Nursing Assistant (CNA/Staff #22) performed hand hygiene and put on gloves before transferring a resident into bed from a wheelchair using a gait belt. After the transfer, the CNA (Staff #22) removed her gloves but did not perform hand hygiene upon leaving resident's room. Hand sanitizer was not observed outside of resident's room. Further observation conducted on August 26, 2024 at 9:36 AM, a CNA (Staff #16) transported resident (#28) back to her room via wheelchair. The CNA (Staff #16) walked over to another resident (#38) and lifted up her blanket. The CNA (Staff #16) then walked back over to resident (#28) and took the resident back out of the room via wheelchair. The CNA (Staff #16) did not perform hand hygiene between resident interactions or when leaving the room. An interview was conducted on August 26, 2024 at 8:30 AM with a Certified Nursing Assistant (CNA/Staff #16), who stated that the hand sanitizer was located on the unit's medication cart and at the nurse's station. She further stated if the staff did not have time to go the nurse's station or medication cart that they would wash their hands going in and out of the resident's room. An interview was conducted on August 28, 2024 at 10:15 AM with a CNA (Staff #87), who stated that hand hygiene would be performed using either soap and water in the resident's room or hand sanitizer. She further stated that hand hygiene would be performed before and after touching residents and upon entering and leaving the resident's rooms. An interview was conducted on August 29, 2024 at 10:24 AM with the Assistant Director of Nursing (ADON/Staff #68), who stated the policy for hand hygiene included the expectation that staff was to wash or use hand sanitizer between resident contact. She further stated that hand sanitizer was located at the nurse's station and on the medication cart. The ADON (Staff #68) was informed of the observations of CNA (Staff #16) from August 29, 2024. The ADON stated that she would speak with CNA (Staff #16) to correct the behavior. An interview was conducted on August 27, 2024 at 1:01 PM with the Director of Nursing (DON/Staff #12), who stated that hand hygiene would be performed before and after contact with a resident, and at meal times. She also stated that the fourth floor was previously a dementia unit so there were no hand sanitizers installed in the hallways. The DON (Staff #12) stated that she expected staff to wash their hands when going in or out of resident rooms. The facility policy titled, Hand Hygiene, revealed that hand hygiene is a general term for cleaning hands by either handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub. The policy indicated that staff would perform hand hygiene when indicated, and that the use of gloves did not replace hand hygiene. If the task required gloves, the staff would perform hand hygiene prior to putting on gloves and immediately after removing gloves. 51103 -Regarding resident equipment During an observation in the dining area conducted on August 28, 2024 at approximately 7:45 a.m., the licensed practical nurse (LPN/Staff #29) attempt wrist BP (blood pressure) check on resident and the wrist cuff reading was unsuccessful. The LPN returned the wrist cuff to the medication cart, obtained a manual arm cuff from cart and used it to get a BP from the same resident. The LPN then returned both the wrist and the arm BP cuffs into the medication cart without disinfecting or wiping them down. An interview with the with LPN (staff #29) was conducted on August 28, 2024 at approximately 7:50 a.m. The LPN said that it was necessary to wipe down equipment before locking it inside the medication cart to avoid spreading any type of infection. However, the LPN stated that she forgot for wipe down or disinfect the wrist and arm cuff she used on one resident before putting it back in the medication cart. An interview with the assistant director of nursing (ADON/staff #68) was conducted on August 28, 2024 at approximately 9:15 a.m. The ADON stated that dirty items should never be placed in the medication cart; and, all resident equipment should be wiped down with approved disinfectant wipes to avoid spreading of infection before and after each resident use. The DON (staff #12) joined the interview and stated that resident equipment such as BP cuffs were usually wiped down with disinfectant wipes; and that, staff were to use the alcohol prep pads located in the medication cart when disinfectant wipes were not available. A review of facility policy entitled Medication Administration included that medication cart/storage should be kept clean, organized, and stocked with adequate supplies in order to break the chain of infection. The facility policy on Cleaning and Disinfection of Resident Care Equipment revealed that blood pressure cuffs were classified as reusable multiple resident non-critical item. Multiple-resident use equipment was to be cleaned and disinfected after each use. The staff should follow established infection control principles for non-critical equipment. 51124 -Regarding Foley catheter bag An observation was conducted on August 28, 2024 at 7:51 AM. The resident (#19) was lying in bed with his indwelling catheter bag laying on the floor beside the resident's bed. Another observation was conducted on August 28, at 11:07 AM and revealed the resident (#19) was in bed with the indwelling catheter bag on the floor beside the resident's bed. In an interview on August 28, 2024, at 11:37 AM, a certified nursing assistant (CNA/staff #11) stated that the catheter bag should not be on the floor in order to stay clean. An interview with another CNA (staff #1) was conducted on August 28, 2024, at 11:42 AM. The CNA (staff #1) stated that the catheter bag should not be on the floor, and if it is on the floor, then there is a risk of infection. An observation of resident #19 was conducted with the CNA (staff #1) during the interview; and, the CNA stated that the resident's indwelling catheter bag was on the floor and it should not be. The CNA said that she would get a bag for it in order to hang it on the side of the bed. During an interview conducted on August 29, 2024, at 12:44 PM, the Director of Nursing (DON/staff #12) stated that a catheter bag should not be on the floor, and that there was risk of infection if it was on the floor. Review of the facility's policy titled Appropriate Use of Indwelling Catheters revealed that indwelling catheters (urethral or suprapubic) will be utilized with current standards of practice, with interventions to prevent complications to the extent possible. Possible complications include but are not limited to: urinary tract infection, blockage of catheter, pain, discomfort, and bleeding.

Based on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of 15 sampled staff (#70 and #19) received ongoing education on residents rights . The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: -Regarding the registered nurse (RN/staff #70) Review of personnel file for the RN (staff #70) revealed a hire date of November 07, 2022. The annual training transcript for the RN revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on November 08, 2022. There was no evidence found that the RN had taken any training on resident rights after November 8, 2022. -Regarding the housekeeper (staff #19) The personnel file for the housekeeper (staff #19) included a hire date of August 21, 2023. Review of the housekeeper's annual training transcripts revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on August 21, 2023. There was no evidence found that the housekeeper had taken any training on resident rights after August 21, 2023. An interview with the human resources assistant (HR assistant/staff #90) was conducted on August 28, 2024 at 9:57 AM. The HR assistant stated that she could not tell specifics regarding which annual training modules are required for all employees, contract staff, and volunteers. In an interview with the Administrator (Staff #59) conducted on August 29, 2024 at 11:15 AM, the administrator reviewed the provided annually required training module transcripts for Staff #70 and Staff #19. The administrator then stated that there were no annual training module transcripts on the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control for the RN (staff #70) and the housekeeper (staff #19). The administrator also stated that annual training meant within the past 365 days. During an interview with the [NAME] President of Human Resources and Risk Management (VP of HR/staff #40) conducted on August 30, 2024 at 08:35 AM, she stated that when COVID hit, the facility did not update their training; and when the Administrator came on board, the administrator was not aware of that. The VP of HR also said that the facility was missing their old policy and was currently writing a new one. The VP of HR also said that their new written policy included what topics of training were required annually. Review of the facility's policy titled New Hire Training and Annual In-Service Policy revealed that orientation training for newly hired staff members and volunteers, as well as annual training for current staff and volunteers is to include training on the topics of nursing care institution policies and procedures, resident rights, infection control, hand washing, linen handling, prevention of communicable diseases, and disaster plans.

Based on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of 15 sampled staff (#70 and #19) received training on abuse, neglect and exploitation. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: -Regarding the registered nurse (RN/staff #70) Review of personnel file for the RN (staff #70) revealed a hire date of November 07, 2022. The annual training transcript for the RN revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on November 08, 2022. There was no evidence found that the RN had taken any training on abuse, neglect and exploitation after November 8, 2022. -Regarding the housekeeper (staff #19) The personnel file for the housekeeper (staff #19) included a hire date of August 21, 2023. Review of the housekeeper's annual training transcripts revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on August 21, 2023. There was no evidence found that the housekeeper had taken any training on abuse, neglect and exploitation after August 21, 2023. An interview with the human resources assistant (HR assistant/staff #90) was conducted on August 28, 2024 at 9:57 AM. The HR assistant stated that she could not tell specifics regarding which annual training modules are required for all employees, contract staff, and volunteers. In an interview with the Administrator (Staff #59) conducted on August 29, 2024 at 11:15 AM, the administrator reviewed the provided annually required training module transcripts for Staff #70 and Staff #19. The administrator then stated that there were no annual training module transcripts on the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control for the RN (staff #70) and the housekeeper (staff #19). The administrator also stated that annual training meant within the past 365 days. During an interview with the [NAME] President of Human Resources and Risk Management (VP of HR/staff #40) conducted on August 30, 2024 at 08:35 AM, she stated that when COVID hit, the facility did not update their training; and when the Administrator came on board, the administrator was not aware of that. The VP of HR also said that the facility was missing their old policy and was currently writing a new one. The VP of HR also said that their new written policy included what topics of training were required annually. Review of the facility's policy titled New Hire Training and Annual In-Service Policy revealed that orientation training for newly hired staff members and volunteers, as well as annual training for current staff and volunteers is to include training on the topics of nursing care institution policies and procedures, resident rights, infection control, hand washing, linen handling, prevention of communicable diseases, and disaster plans.

Based on personnel file review, staff interviews, and facility policy review, the facility failed to maintain an effective training program for two of 15 sampled staff (#70 and #19). The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: -Regarding the registered nurse (RN/staff #70) Review of personnel file for the RN (staff #70) revealed a hire date of November 07, 2022. The annual training transcript for the RN revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on November 08, 2022. There was no evidence found that the RN had taken any training modules after November 8, 2022. -Regarding the housekeeper (staff #19) The personnel file for the housekeeper (staff #19) included a hire date of August 21, 2023. Review of the housekeeper's annual training transcripts revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on August 21, 2023. There was no evidence found that the housekeeper had taken any training modules after August 21, 2023. An interview with the human resources assistant (HR assistant/staff #90) was conducted on August 28, 2024 at 9:57 AM. The HR assistant stated that she could not tell specifics regarding which annual training modules are required for all employees, contract staff, and volunteers. In an interview with the Administrator (Staff #59) conducted on August 29, 2024 at 11:15 AM, the administrator reviewed the provided annually required training module transcripts for Staff #70 and Staff #19. The administrator then stated that there were no annual training module transcripts on the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control for the RN (staff #70) and the housekeeper (staff #19). The administrator also stated that annual training meant within the past 365 days. During an interview with the [NAME] President of Human Resources and Risk Management (VP of HR/staff #40) conducted on August 30, 2024 at 08:35 AM, she stated that when COVID hit, the facility did not update their training; and when the Administrator came on board, the administrator was not aware of that. The VP of HR also said that the facility was missing their old policy and was currently writing a new one. The VP of HR also said that their new written policy included what topics of training were required annually. Review of the facility's policy titled New Hire Training and Annual In-Service Policy revealed that orientation training for newly hired staff members and volunteers, as well as annual training for current staff and volunteers is to include training on the topics of nursing care institution policies and procedures, resident rights, infection control, hand washing, linen handling, prevention of communicable diseases, and disaster plans.

Based on clinical record review, staff interview, and policies and procedures, the facility failed to ensure that a comprehensive person-centered care plan with interventions related to use of oxygen was developed for one resident (#38) and related to the use of a power wheelchair seatbelt and bed rails/mobility bars for one resident (#44). The deficient practice could result in the resident not receiving the necessary care and services according to their assessed needs. Findings include: Resident #38 was readmitted to facility March 28, 2024 with diagnoses of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure. The physician note dated March 29, 2024 revealed that resident had an oxygen saturation of 90% on room air, had an oxygen flow rate of 2 liters, and a respiratory rate of 18 breaths per minute. The documentation included that resident was oxygen dependent without any shortness of breath or wheezing while on 2 liters of oxygen. Diagnoses included emphysema and chronic hypoxemic respiratory failure. Plan was to continue oxygen at 2 liters for chronic hypoxemic respiratory failure. A physician order dated March 30, 2024 included to change oxygen tubing weekly and to initial and date when the change was done. Another physician order dated March 30, 2024 included for supplemental oxygen at 1-4 liters via nasal cannula in order to keep resident oxygen level above 90%. Review of the Significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated resident had cognitive impairment. The MDS also included that resident experienced shortness of breath while lying flat or with exertion and used oxygen. Review of hospice comprehensive assessment and plan of care dated July 15, 2024 revealed an order to initiate oxygen at 2-4 liters via nasal cannula continuously or as needed as indicated. The pain/palliative care consult notes dated July 24, 2024 revealed the resident was oxygen dependent. The physician visit note dated July 31, 2024 assessment statement stated resident was oxygen dependent due to COPD. Despite documentation that the resident was on oxygen therapy, the care plan related to oxygen use was not developed with interventions until August 28, 2024. The care plan with revision date of August 28, 2024 included the resident was expected to lose weight related to emphysema, angina at rest, paroxysmal atrial fibrillation and chronic hypoxemic respiratory failure. Intervention included to administer oxygen as ordered. An interview was conducted with a licensed practical nurse (LPN/staff #60) on August 26, 2024 at 1:09 p.m. The LPN stated that resident #38 should have the oxygen via nasal cannula on. An interview with Assistant Director of Nursing (ADON/staff #68) conducted on August 27, 2024 at approximately 1:00 p.m. The ADON stated that care plans were created on admission, and updated as needed to meet the needs of the resident. ADON located the administrate oxygen intervention in Beatitudes care plan version. ADON believes the oxygen care planning portion was handled by Hospice of the Valley, and will obtain a copy for the surveyor. An interview with the ADON and the restorative nurse assistant (RNA/staff#78) was conducted on August 29, 2024 at 1:28 p.m. Both the ADON and the RNA said that the resident should have the oxygen on her. In an interview with the ADON conducted on August 30, 2024 at approximately 9:00 a.m., the ADON stated that resident #38 was often encouraged to wear oxygen as ordered on a regular basis to prevent shortness of breath and discomfort. The facility policy on Oxygen Therapy included that care planning for oxygen should include oxygen delivery type, time to administer, equipment settings, monitoring of oxygen saturation levels, and monitoring for complications. Review of the facility policy on Comprehensive Care Plan revealed that the care plan will include measurable objectives and timeframes to meet the resident's needs. The objectives will be utilized to monitor the resident's progress. 51124 -Resident #44 was admitted on [DATE] with diagnoses of included acute transverse myelitis, hemiplegia following cerebral infarction, major depressive disorder, and myocardial infarction. The care plan dated October 13, 2022 indicated that the resident required assist with completion of activities of daily living and with mobility due to transverse myelitis and hemiplegia. Another care plan dated October 13, 2022 revealed the resident had a functional decline related to CVa (cerebrovascular disease). Interventions included assistance with ADLs (activities of daily living) as needed) and use cushion in wheelchair. Further review of the care plan revealed no evidence that use of the power wheelchair seatbelt or bedrails/mobility bars on her bed were addressed with interventions implemented. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had intact cognition. The MDS also included that restraints and alarms, bed rail in bed and trunk restraint used in chair were coded as not used. An observation conducted on August 26, 2024 at 11:57 AM revealed Resident #44 in bed with bed rails/mobility bars present on the sides of her bed; and, a power wheelchair with a seatbelt present positioned in front of the bed against the wall. Resident #44 stated that this was her personal wheelchair. In an interview conducted on August 29, 2024 at 08:06 AM, Resident #44 stated that the mobility bars sometimes get in her way, but that they were there for a reason. Review of the facility's policy on Restraint Free Environment revealed that the care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint.

Based on clinical record review, observations, interviews, and policy review; the facility failed to ensure oxygen was administered as ordered for one resident (#38); and, failed to ensure there was a physician order for the use of oxygen for one resident (#50). The deficient practice could result in resident complication and respiratory distress and hospitalization . Findings include: -Resident #38 was readmitted to facility March 28, 2024 with diagnoses of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure. The physician note dated March 29, 2024 revealed that resident had an oxygen saturation of 90% on room air, had an oxygen flow rate of 2 liters, and a respiratory rate of 18 breaths per minute. The documentation included that resident was oxygen dependent without any shortness of breath or wheezing while on 2 liters of oxygen. Diagnoses included emphysema and chronic hypoxemic respiratory failure. Plan was to continue oxygen at 2 liters for chronic hypoxemic respiratory failure. A physician order dated March 30, 2024 included to change oxygen tubing weekly and to initial and date when the change was done. Another physician order dated March 30, 2024 included for supplemental oxygen at 1-4 liters via nasal cannula in order to keep resident oxygen level above 90%. The pain/palliative care consult notes dated April 26, May 1 and May 16, 2024 revealed the resident was oxygen dependent. Review of the Significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated resident had cognitive impairment. The MDS also included that resident experienced shortness of breath while lying flat or with exertion and used oxygen. The pain/palliative care consult notes dated July 24, 2024 revealed the resident was oxygen dependent. The physician visit note dated July 31, 2024 assessment statement stated resident was oxygen dependent due to COPD. The care plan with revision date of August 28, 2024 included the resident was expected to lose weight related to emphysema, angina at rest, paroxysmal atrial fibrillation and chronic hypoxemic respiratory failure. Intervention included to administer oxygen as ordered. An interview was conducted with a licensed practical nurse (LPN/staff #60) on August 26, 2024 at 1:09 p.m. The LPN stated that the oxygen concentrator was turned on at 1.5 liters but was not on the resident because the resident's nasal cannula was on the floor. She stated that the resident should have the oxygen via nasal cannula on; and that, the LPN encouraged the resident compliance with oxygen use and the importance of keeping the nasal cannula on. Further, the LPN instructed the resident to notify staff if the nasal cannula falls off or causes discomfort. On August 27, 2024 from 8:00 p.m. through 10:00 p.m., the facility had a power outage and was using their emergency power system. An observation was conducted on August 29, 2024 at 1:28 p.m. The resident was lying supine in bed and was pushing the buttons on the bed controls which were not working. The resident laid flat with three pillows on head of bed and tried to reposition herself in bed and attempted to sit up; and, did not have the oxygen via nasal cannula on. The resident attempted to reach the call light but was unable to because it was on the side table by her bed. The resident's wheelchair was close to bottom right of bed, with an oxygen tank attached to back of chair; and, the arrow on the oxygen tank pressure gauge pointed to distal end of red area. There was no nasal cannula or tubing attached to the tank. The oxygen concentrator was uncovered and unplugged to the left of resident's dresser with the nasal cannula wrapped around concentrator handle. The nasal cannula was labeled with date August 26, 2024 only and was uncovered while on concentrator. There was no red wall outlet found in the resident's room. The resident complained of not being able to get comfortable, was having difficulty in breathing and requested to have her oxygen brought over and to help elevate her head. The assistant director of nursing (ADON/staff #68) and the restorative nurse assistant (RNA/staff#78) were called to join in the observation. The ADON elevated the resident head using a pillow, and placed pulse oximeter on the resident's finger. The resident's oxygen saturation reading was 87% at 1:45 p.m. and 86% at 1:59 p.m. Both the ADON and RNA stated that the resident's portable oxygen tank on the wheelchair had a pressure gauge in red zone. Both staffs stated that the resident should have the oxygen on her. The RNA immediately left the resident room and came back with an oxygen tank replacement; and, the resident was transferred from bed to chair and was brought to the medication cart area by dining room. At 2:02 p.m., the resident's oxygen saturation was 89 % at 2 liters via nasal cannula. At 2:07 p.m., oxygen was increased to 4 liters; and at 2:09 p.m., resident's oxygen saturation was 92%. In an interview with the ADON conducted on August 30, 2024 at approximately 9:00 a.m., the ADON stated that resident #38 was often encouraged to wear oxygen as ordered on a regular basis to prevent shortness of breath and discomfort. Review of the facility policy entitled Oxygen Concentrator states to keep the oxygen concentrator set up turned off when not actively in use. Facility policy further instructs to keep oxygen delivery devices covered in a plastic bag when not in use. Policy also includes that it is the nurse responsibility to change oxygen tubing and cannula weekly, and as needed if it becomes soiled or contaminated. Review of the policy entitled Oxygen Therapy states the reason for the administration of oxygen is to treat or prevent the symptoms and manifestations of hypoxia. Policy further dictates that staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. 43863 -Resident #50 was admitted on [DATE] with diagnoses that included metabolic encephalopathy, Type 2 diabetes mellitus, and congestive heart failure. A physician order dated June 11, 2024 revealed an order for oxygen (O2) saturations (sat) every shift for O2 use. Review of the Medical Record Administration (MAR) for June through August 2024 revealed no evidence that oxygen was administered to the resident. The care plan dated June 23, 2024 included that resident was on for oxygen therapy. Interventions included to administer oxygen as ordered by the medical doctor, and safety per protocol. Review of a comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. The assessment also included that the resident was receiving oxygen therapy. An amended provider progress note dated July 11, 2024, revealed no evidence on the medication review list that Resident #50 was receiving oxygen. Per the documentation, the staff increases the oxygen to 5 liters. However, the documentation did not include any oxygen orders such as oxygen liters required and whether or not oxygen was to be administered continuously. A provider progress note dated August 24, 2024 revealed the resident had continued hypoxia and need for oxygen. Assessment of chest and lungs revealed the resident was on 4 liters via nasal cannula, continuous oxygen and a plan to continue oxygen supplementation. The medication review list section did not include the resident was receiving oxygen. Despite documentation that the resident was on oxygen, the clinical record revealed no evidence of a physician orders for administration of oxygen from January 1 through August 29, 2024 revealed An observation conducted on August 27, 2024 at 8:20 a.m. revealed resident #50 was lying in bed with oxygen being administered via a nasal cannula. In another observation conducted on August 28, 2024 at 9:30 a.m., the resident was lying in bed, awake and able to converse, with oxygen administered via nasal cannula. Another observation was conducted on August 29, 2024 at 9:31 a.m. and revealed that the resident was lying in bed with a certified nursing assistant (CNA) assisting him with breakfast. The resident had oxygen on via nasal cannula. An interview was conducted on August 29, 2024 at 9:52 a.m. with a Licensed Practical Nurse (LPN/staff #29), who stated that resident #50 had been on the 4th floor for a couple of months, received oxygen continuously since then, and had been administered oxygen when he was on the other unit. The LPN stated that a physician order for oxygen would be required in order to administer oxygen to a a resident. A review of the clinical record was conducted by the LPN during the interview and the LPN stated that she found no physician order to administer oxygen to the resident; and that, there was also no documentation in the MAR and TAR that oxygen was administered to the resident. She further stated that the only physician order related to oxygen that in the clinical record was the order for oxygen saturations every shift for oxygen use; and this indicated that the resident was on oxygen. The LPN further stated that the clinical record revealed there was no evidence of discontinued or deleted orders for oxygen administration for resident #50. An observation of resident #50 in his room was conducted with the LPN who stated that the resident was receiving 4.5 liters of oxygen via nasal cannula. Further, the LPN said that there should have been a physician order for oxygen use for resident #50; however, there was none and this was an error. The LPN stated that resident #50 was administered oxygen without a physician order and this did not meet the facility policy. An interview with resident #50 was conducted on August 29, 2024 at 10:11 a.m. The resident stated that he had been receiving oxygen for about 3 months. During an interview with the Director of Nursing (DON/Staff #12) was conducted on August 29, 2024 at 10:20 a.m. The DON stated that the expectation was that there was physician order for oxygen use and monitoring of oxygen saturation for residents receiving oxygen. A review of the clinical record was conducted by the DON who stated that there was no evidence of a physician order for oxygen administration; and that, resident #50 was currently receiving oxygen. The DON further stated that this situation did not follow the facility policy, and the risk could result in residents receiving oxygen that they may not require. An interview was conducted with an LPN (staff #76) on August 29, 2024 at 10:31 a.m. The LPN stated that resident #50 was transferred to the unit about a month ago; and, the resident had been administered oxygen since June 2024. Further, the LPN stated that oxygen administration required a physician order. Review of a facility policy titled, Oxygen Administration, revealed that oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician, except in the case of an emergency. Review of a facility policy titled, Medication Orders, revealed that medications should be administered only upon the signed order of a person lawfully authorized to prescribe. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician, on the next visit to the facility.

Based on observations, staff and resident interviews, and the facility's documentation and policies, the facility failed to ensure a safe and comfortable environment for residents. The deficient practice could result resident not having a homelike environment and risk for injury and harm. Findings include: Review of the open work order report generated on July 15, 2024 did not reveal any work order pertaining to any of the issues identified during the walk-through observations. During the initial tour of the 4th floor unit conducted on August 28, 2024 at 12:17 PM., multiple rooms were found to have the following: -Water stains on the ceiling tile; -Door frame had a splatter of a brown substance; and, -Temperature probe above the dining area on the 4th floor had built up substance and appeared to be leaking. An interview with a Licensed Practical Nurse (LPN/ #29) was conducted on August 29, 2024 at 12:58 PM. The LPN (staff #29) stated that there was a work order website to put an order in and that staff can always call into the maintenance department. An interview with the Senior Maintenance Engineer (staff #205) was conducted on August 30, 2024 at 8:04 a.m. Staff #205 stated that he conducts a walkthrough of the facility unit/s at least once a week; and that, the maintenance technician for the building does daily walkthroughs to check in and speak with nursing staff to see if anything needs to be done that was not currently in their work orders. Staff #205 stated that staining on the walls/ceilings would be suspicious and the facility would try to get them changed out to find the source of the problem. Staff #205 stated that the staining could occur due to moisture coming from something. Staff #205 further stated that it may be aesthetically unpleasing and anytime there was a high moisture situation there was the chance of mildew. An interview with the Administrator (staff #110) was conducted on July 17, 2024 at 1:09 p.m. The administrator stated that the expectation was that the living area for residents was clean, free of obstruction, without significant odors and safe from hazards. The administrator said that repairs such as paint and upkeep should be maintained to have a homelike environment; and, this was important since the facility was the home for people living here and they deserve a good quality of life. The administrator also said that it has to be safe so that residents were not put at risk for accidents or injuries. Further, the administrator stated that if the facility was not homelike and not safe, the residents might feel discomfort, might reduce the homelike environment feel until things were repaired and could result in a risk for some type of injury i.e. if legs extend beyond the wheelchair there could be a risk of injury. Review of the facility policy titled Preventive Maintenance Program revised January 11, 2023 and reviewed January 22, 2024 indicated that the facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. The facility policy titled Work Request System revised May 14, 2019 and reviewed January 15, 2024 indicated that the work order request system was designed to provide an established and effective means of requesting, coordinating, and completing maintenance of a corrective nature. A facility policy titled Resident Rights issued June 8, 2020 and reviewed September 25, 2023 indicated that residents have a right to a safe, clean, comfortable, and homelike environment.

Based on clinical record review, interviews, facility documentation and a policy review, the facility failed to ensure that one sampled resident (#37) was notified prior to the room change. The deficient practice could result in residents and their representatives, not provided with the opportunity to exercise autonomy regarding their interests, preferences and desires, in regards to a room change. Findings include: Resident #37 was admitted on [DATE] with diagnoses of vascular dementia, moderate, with other behavioral disturbance; major depressive disorder, recurrent, moderate; and unspecified dementia, severe, with other behavioral disturbance. Review of a quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating resident had severe cognitive impairment. A social service note dated July, 15, 2024, revealed that Power of Attorney (POA) had called the Social Worker (SW/staff #38); and that, the SW re-iterated information regarding the cancelled room change, that had been previously discussed during a scheduled quarterly care plan meeting. The note also revealed the resident enjoyed the 4th floor and the connections made on the 4th floor. Review of the electronic health records (EHR) revealed no evidence that the resident or responsible party were provided a written notice prior to the re-initiation of the room change that occurred approximately between the dates of July 22, 2024 and August 3, 2024. Further review of the EHR revealed that the resident or responsible party did not complete a consent form for a room of change that occurred approximately between July 22, 2024 and August 3, 2024. An interview was conducted on August 26, 2024 at 11:29AM with the resident's POA, who stated that they had a concern with the resident moving rooms. The POA reported that to their knowledge, a room change took place while the social services coordinator was out of office. The POA stated that there had been a discussion previously to complete a room change, however, it was then discussed that the room change was cancelled. The POA reported that they were unaware of the room change, until they made a visit to the facility; and, was advised that the resident was no longer on the 4th floor, but now on the 3rd floor. An interview was conducted on August 29, 2024 at 11:20AM with the SW (staff # 38), who stated the room change process start with reaching out to the POA, and/or representative for the update in treatment; and then, a 30-day notice letter are to be sent out to the resident and/or representative. Regarding resident #37, the SW stated that a room change letter had been sent out in June; and that, the POA should have received it. The SW also said that following the letter, they had reached out to the POA and relayed to the POA that the room change had been cancelled. However, the SW admitted that the room change decision and implementation happened while she was out of town. Staff #38 stated that there was miscommunication regarding that room change for resident #37; and that, the room change happened without the proper room change notification expectations. Review of a facility policy titled, Notification of Room or Roommate Change, revealed that notification of room changes will be documented according to the facility's established practices, and to include completion of a Notification of Room or Roommate Changes form signed by the resident and/or resident's legal representative. The policy included that the resident has the right to notification of room or roommate changes and to agree prior to the change taking place.

Based on observations and staff interviews, the facility failed to ensure daily staff posting was current and posted at the beginning of each shift. The deficient practice could result in the accurate daily staffing information not available to residents and visitors. Findings include: An observation in 4th floor was conducted on August 26, 2024 at 8:36 a.m. The daily staff posting was located on the wall by the elevators and across from the 4th floor nurse's station. The daily staff posting was dated January 3, 2024. On August 26, 2024, at 8:40 AM, an observation in the 3rd floor was conducted; and, the daily staff posting was found on the wall by the elevators and across from the 3rd floor nurse's station. The daily staff posting was dated August 6, 2024. An observation in the 4th floor was conducted on August 27, 2024 at 7:57 AM. There was no daily staff posting found on the 4th floor. An observation in the 4th floor was conducted on August 28, 2024 at 8:00 AM. There was no daily staff posting found on the 4th floor. In an interview with the director of nursing (DON/staff #12) conducted on August 29, 2024 at 12:25 PM, the DON stated that the daily staff posting was located on the 3rd floor by the nurse's station; and that, the residents on the 4th floor and their family can ask for the daily staffing information. The DON provided a copy of the daily staff posting dated August 26, 2024 and stated that this posting was previously posted on the 3rd floor on August 26, 2024. Review of the daily staff posting provided by the DON revealed that the date was altered from what appeared to be 8/06/24 and changed to 8/26/24. An interview with the administrator (staff #59) was conducted August 29, 2024 at approximately 12:27 PM. The Administrator stated that a lot of residents from the 4th floor frequently come to the 3rd floor for activities, resident council, or to meet with the Director of Nursing in her office, and would be able to see the daily staff posting. The administrator said that the residents from the 4th floor who do not participate in activities, resident council, or to meet with the Director of Nursing in her office can be brought to the 3rd floor any time or the resident can go to the 3rd floor themselves if they want. Further, the administrator said that staff had not educated residents and their families on the daily staff posting located on the 3rd floor. In an interview with a registered nurse (RN/staff #49) at the 4th floor conducted on August 30, 2024 at 6:56 AM. The RN stated that there usually was a daily staff posting on the 4th floor. The RN then pointed to the empty space on the wall by the elevator across from the nurse's station where there was a pushpin present in the wall. However, there was no daily staff posting posted on the wall; and, the RN stated that there was a daily staff posting found on the 3rd floor as well.

Based on observation, record review, interviews, and facility policy review the facility failed to ensure one resident (#44) was assessed and care planned for the use of a power wheelchair seatbelt and bed rails/mobility bars. The deficient practice could lead to a resident experiencing decreased mobility, possible entrapment, and psychosocial and/or physical harm. Findings include: Resident #44 was admitted into the facility on [DATE] with diagnoses that included acute transverse myelitis, hemiplegia following cerebral infarction, major depressive disorder, and myocardial infarction. The care plan dated October 13, 2022 indicated that the resident required assist with completion of activities of daily living and with mobility due to transverse myelitis and hemiplegia. Another care plan dated October 13, 2022 revealed the resident had a functional decline related to CVa (cerebrovascular disease). Interventions included assistance with ADLs (activities of daily living) as needed) and use cushion in wheelchair. Further review of the care plan revealed no evidence that use of the power wheelchair seatbelt or bedrails/mobility bars on her bed were addressed with interventions implemented. Review of the physician orders revealed no evidence of any orders regarding use or assessment of seatbelt on her power wheelchair or bedrails/mobility bars on her bed. Further, there was no evidence in the clinical record that the resident was assessed for seatbelt use on her power wheelchair or bedrails/mobility bars on her bed. Review of the Treatment Administration Record (TAR) for July 2024 revealed no assessment, intervention, or monitoring, for Resident #44's seatbelt on her power wheelchair or bedrails/mobility bars on her bed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had intact cognition. The MDS also included that restraints and alarms, bed rail in bed and trunk restraint used in chair were coded as not used. An observation conducted on August 26, 2024 at 11:57 AM revealed Resident #44 in bed with mobility bars present on the sides of her bed and a power wheelchair with a seatbelt present positioned in front of the bed against the wall. Resident #44 confirmed that this was her personal wheelchair. In an interview conducted on August 29, 2024 at 08:06 AM, Resident #44 stated that the mobility bars sometimes get in her way, but that they were there for a reason. In an interview conducted on August 29, 2024 at approximately 8:10 AM, a licensed practical nurse (LPN/staff #76) stated that he was not aware of any process that the facility had for assessing and monitoring possible restraints. Staff #76 stated that a restraint was considered to be a full side rail on a bed; and, anything that keeps a resident from getting out of bed, chair alarms or straps that restrain a patient. He further stated there were no residents at the facility that had been assessed for possible restraints because the facility does not use restraints. In an interview on August 29, 2024 at 10:07 AM, the Director of Nursing (staff #12) stated that the facility does not restrain anybody; and that, restraints were anything that keeps the resident from getting up from the bed or chair. The DON said that a seatbelt was a restraint if the resident could not self-release; or, siderails were restraints if they cover the whole end of the bed. The DON said that if a resident had a seatbelt on their chair, then the facility conducts an assessment if the resident can self-release the seatbelt and this is documented in the electronic record. During the interview, a review of the clinical record was conducted with the DON who stated that resident #44 did not have any assessment for seatbelt use and bed rail/mobility bars and she could not find any documentation that the resident was assessed for ability to self-release seatbelt and/or use of bedrails/mobility bars. The DON said that if a resident was not assessed for a possible restraint, there was a risk of possible harm such as choking, if resident slide down in the chair, or contractures if they are restrained. Further, the DON said that the expectation was that staff would complete restraint assessment for residents who had a potential restraint and to document it on the TAR as per the facility policy. Review of the facility's policy on Restraint Free Environment revealed that restraints was defined as any physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to: using bed rails that keep the resident from voluntarily getting out of bed and using devices in conjunction with a chair such as trays, bars, or belts, that the resident cannot remove and prevents the resident from rising. Before a resident is restrained, the facility will determine the specific medical symptom that warrants the use of the restraint, the type of direct monitoring and supervision that will be provided during the use of the restraint, how the resident will request staff assistance while the restraint is in place, and how to assist the resident in attaining or maintaining his or her highest practicable level of physical well-being. Finally, the care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint.

Based on observations, staff interview, and policy review, the facility failed to ensure that the third-floor resident nourishment refrigerator food was stored in accordance with professional standards for food service safety. The deficient practice could result in food growing harmful bacteria that is a risk factor to cause foodborne illness. Findings include: During an observation of the third-floor nourishment refrigerator conducted on August 27, 2024 at 12:50 PM, revealed upon the refrigerator shelves, two fruit plates that were undated and partially uncovered. On half of the two paper-plates were green grapes and banana slices, and on the other half of paper plate were red color (strawberry color) liquid puddles with red stain soaked into the paper plate. The section of the plates with red color puddled juices had the clear plastic wrap pulled back leaving both plates partially uncovered with the banana slices and grapes exposed. An interview was conducted on August 27, 2024 at 12:57 PM with the registered dietician (RD/staff #35) near the third-floor secured nourishment refrigerator. Registered Dietician (#35) stated that the two fruit plates located within the nourishment refrigerator were from the night-shift staff, and that staff should have placed a use-by dated sticker on each plate and recovered the plates with saran wrap. The registered dietician opened the third-floor nourishment refrigerator and removed the two un-dated fruit plates and disposed. Review of the facility policy titled, Production, Purchasing, Storage; Food and Supply Storage revealed that the procedures are to cover, label and date unused portions and open packages with a completed orange-color label system. Products are good through the close of business on the date noted on the orange label and to discard food past the use-by or expiration date.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure one resident (#18) or resident representative was informed in advance of the risks and benefits prior to administration of a psychotropic medication. The deficient practice could result in not having the right to choose the option the resident prefers. Findings include: Resident #18 admitted on [DATE] with diagnoses of dementia, depressive disorder, and Parkinson's disease. The care plan initiated on July 5, 2022 revealed the resident was receiving an antidepressant for depression and was at risk for adverse effects. A physician order dated September 23, 2022 included for Mirtazapine (antidepressant) for depression as evidenced by restlessness and low appetite. The MAR (medication administration record) from September 2022 through January 2023 revealed the resident received Mirtazapine as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated resident had severe cognitive impairment. The assessment also included the resident received daily antidepressant use in the assessment time period. However, further review of the clinical record revealed no evidence the resident/representative was informed of the risks and benefits of Mirtazapine prior to administering the medication. An interview was conducted on January 20, 2023 at 8:30 a.m. with the Administrator/Director of Nursing (DON/staff #12) who stated she was unable to find documentation that the risks/benefits of Mirtazapine was discussed and provided to resident #18 or resident representative. Staff #12 also said that the facility failed to obtain informed consent for use of Mirtazapine from the resident #18 or resident representative. In an interview conducted with a Licensed Practical Nurse (LPN/staff # 54) on January 20, 2023 at 9:43 a.m., the LPN stated when staff gets a new medication order for a psychotropic medication, a consent for its use is obtained from and explained to the resident or the resident's Power of Attorney (POA). She stated she would explain to the resident and/or POA what the psychotropic medication would be used for, the dose, the expected benefits, and adverse effects. She stated staff was not supposed to administer a psychotropic medication without obtaining the psychotropic consent. The LPN also stated it was important to make the resident or family aware of the risks because a psychotropic medication use had side effects and could snow people. Further, she stated staff did not follow policy if consent was not obtained prior to the use or administration of a psychotropic medication to the resident. The LPN also said that if there is no documentation found in the clinical record that a consent and risk/benefits for its use, there was no way to show that the consent was obtained. During a second interview with the Administrator/DON (staff #12) conducted on January 20, 2023 at 9:59 a.m., staff #12 stated the informed consent was the documentation for the risk and benefit for psychotropic medication use. She stated staff were expected to obtain the informed consent with the resident/responsible party; and that, the documentation or discussion of informed consent included providing the name and dose of the medication, possible contributing factors for use, diagnosis of why the resident was taking the medication, and adverse effects. Staff #12 also said the nurse and family member were supposed to sign the form and if obtained by phone staff would note it as verbal consent. She stated that if the resident or representative did not give informed consent, there should be a discussion with the resident or representative by the nursing, administrative team, and physician to alleviate concerns and answer questions; and that, if consent was still not obtained, the medication would not be given or will be discontinued. Regarding resident #18, she stated staff did not obtain informed consent for Mirtazapine prior to its administration to the resident. The facility policy on Psychotropic Medication revised on November 2021 revealed that based on each resident's comprehensive assessment, the facility will ensure to provide the resident/resident representative with information on the medication, indication, dose, side effects, adverse consequences and goal of treatment; and, obtain informed consent from the resident and/or resident representative and document education, information regarding the medication indication and directions for use, side effects and potential adverse consequences, risks and benefits of the medication and resident choice. The resident and/or responsible party will be notified regarding dose changes and this will be documented in the nurse notes. Consents and any psychotropic medications will be reviewed quarterly at resident care conference.

Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure care provided met professional standards of care by failing to follow physician orders regarding insulin for one resident (#14). The deficient practice could result in adverse outcomes and/or complications related to diabetes mellitus (DM). Findings include: Resident #14 admitted to the facility on [DATE] with diagnoses that included dysphagia, dementia, and type two diabetes mellitus (DM). The care plan dated January 17, 2019 revealed the resident had DM and was at risk for complications to this disease process, especially if blood sugars were not well controlled. The goal was that the resident's blood sugars would be controlled within normal limits. Intervention included insulin as ordered. The physician order dated March 31, 2021 revealed an order for Novolog Flex pen U-100 insulin Aspart 100 unit/milliliter (ml) subcutaneous 17 units plus sliding scale insulin (SSI) three times a day for DM type 2: -150-199 mg/dl (milligrams/deciliter), give 3 units; -200-249 mg/dl, give 6 units; -250-299 mg/dl give 9 units; -300-349 mg/dl give 12 units; -350-399 mg/dl give 15 units; -400-449 mg/dl give 18 units; -450-499 mg/dl give 21 units; and to notify physician if glucose was over 500 mg/dl. Review of the Medication Administration Record (MAR) for Novolog for November 2022 revealed that on the following dates for the 7:30 a.m. dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin: -November 2 - blood sugar (BS) was 215 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order; -November 6 - BS was 211 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order; -November 13 - BS was 107 mg/dl and no insulin were administered; and that, medication was not administered with no noted reason. However, the resident should have received 17 units of insulin per the physician's order; and, -November 15 - BS was 216 mg/dl and 26 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order. The MAR for December 2022 revealed that on the following dates for the 7:30 a.m. dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin: -December 2 - BS was 221 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order. -December 4 - BS was 327 mg/dl and 32 units of insulin was administered. However, the resident should have received 29 units of insulin per the physician's order. -December 31 - BS was 228 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order. A review of the MAR for January 2023 revealed on the following dates for the 12:00 noon dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin: -January 1 - BS was 109 mg/dl. Zero insulin was administered and the documentation included that the medication was not administered with no noted reason. However, the resident should have received 17 units of insulin per the physician's order; -January 6 - BS was 131 mg/dl and 20 units of insulin was administered. However, the resident should have received 17 units of insulin per the physician's order; -January 14 - BS was 162 mg/dl and 3 units of insulin was administered. However, the resident should have received 20 units of insulin per the physician's order; -January 18 - BS was 219 mg/dl and 13 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order; and, -January 19 - BS was 266 mg/dl and 29 units of insulin was administered. However, the resident should have received 26 units of insulin per the physician's order. Review of the progress notes for November 2022 through January 2023 revealed no documentation why Novolog insulin was not administered according to the physician ordered parameters; and that, the physician was notified. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident's cognition was severely impaired. The assessment included a diagnosis of DM and daily insulin injections. An interview was conducted on January 20, 2023 at 9:04 a.m. with a Registered Nurse (RN/staff #81) who stated staff was expected to follow the physician orders as written, including insulin and sliding scales. He stated the risks for insulin not given as ordered included resident having hyperglycemia, insulin shock; altered mental status, and it could lead to ketoacidosis. The RN said that if the resident was given too much insulin they could become hypoglycemic, sweaty, clammy, drowsy, and could pass out. During the interview, a review of the clinical record was conducted with the RN who stated the insulin orders included that resident #14 was supposed to get 17 units of Novolog insulin plus additional sliding scale insulin whose was dependent on the resident's blood sugar. The RN said that if he thinks the blood sugar was low, he would give the resident food/drink, and hold the medication until he could call the doctor and get direction. The RN said that the January 2023 MAR in the three entries he reviewed, insulin was not administered according to the physician ordered parameter for the sliding scale. During an interview with the Administrator/Director of Nursing (DON/staff #12) conducted on January 20, 2023 at 9:52 a.m., staff #12 stated staff are expected to follow the physician's orders as written, including following the orders for insulin and SSI administration. Staff #12 said that if the resident refuse, staff was still expected to follow the physician's order until they had an updated order from physician. She stated the risk factor if the ordered amount of insulin was not given could be adverse health effects. During the interview, a review of the clinical record was conducted with staff #12 who stated that the January 2023 MAR revealed that staff had not administered the insulin as ordered by the physician. The facility policy on Timely Administration of Insulin reviewed/revised on April 2021 revealed that it was their policy to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. All insulin will be administered in accordance with physician's orders. Review the insulin order to include resident name, medication name, medication dosage, time to be administered, route of administration. Review of a facility policy on Medication Management policy revised on June 2021 revealed that medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. Prior to administration, the medication and dosage schedule on the Medication Administration Record (MAR) is compared with the medication label. Medications are administered in accordance with written orders of the attending physician or physician extender. A review of the facility policy on Physician's Orders updated on April 2021 included that to ensure accuracy, physician orders will be written, noted and carried out as ordered.

Based on observations, clinical record reviews and staff interviews, the facility failed to ensure that pressure ulcers were assessed timely and thoroughly, and/or failed to notify the physician timely regarding pressure ulcer development for 2 of 3 sampled residents (#5 and #52). Continued non compliance could place other residents at risk for pressure ulcer development and complications. Findings include: -Resident #5 was admitted on (MONTH) 1, 2010, with [DIAGNOSES REDACTED]. According to a Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 3, 2019, the resident was assessed to be at risk. Review of a wound/pressure ulcer care plan with a start date of (MONTH) 15, (YEAR) revealed the resident was at risk for development of pressure ulcers due to mobility impairment and incontinence. A goal was to manage risk factors to effectively reduce the risk of ulcer development. Approaches included pressure redistributing devices in place at all times, watch for skin condition as care is provided daily as well as during weekly skin assessments, and to notify wound team and provider as needed. The annual MDS (Minimum Data Set) assessment dated (MONTH) 29, 2019 included the resident was severely impaired with cognitive skills for daily decision making. The MDS included the resident was at risk of developing pressure ulcers, but did not have any unhealed pressure ulcers. Regarding the left heel/foot: Review of the clinical record revealed there was no documentation of any pressure redistributing devices/treatments which were in place, such as an air mattress or floating of the heels in (MONTH) 2019. There was also no documentation that the resident had any pressure ulcers or skin breakdown to the left heel/foot from (MONTH) 1, 2019 through (MONTH) 14, 2019. A skin assessment dated (MONTH) 15, 2019 included the resident had three pressure spots located along the left lateral foot. Per the documentation, the spot closest to the heel was dark purple and the other two spots further towards the toes were red. The documentation included that all three areas measured 2-3 cm (centimeters), and the feet were offloaded with pillows and that the wound nurse was informed. A nursing note dated (MONTH) 15, 2019 included the resident had three pressure spots along the side of the left foot: the spot closest to the heel was dark purple and the other two spots further towards the toes were red and all spots measured approximately 2-3 cm. A nursing note dated (MONTH) 16, 2019 included that skin prep was applied to the pressure spots on the left heel and that both heels were offloaded from the mattress. Despite documentation of three pressure spots to the left foot, there was no documentation that the physician was notified on (MONTH) 15 or 16, nor were there any orders for wound treatment. A nursing note dated (MONTH) 17, 2019 revealed that a pressure injury was noted to the outer part of the left foot close to the heel, which was black in color and measured 1.5 cm, and the margins were red and slightly swollen. This note only identified one pressure injury, not three as in the above notes. Another nursing note dated (MONTH) 17, 2019 included the physician assessed the resident's pressure areas on the feet and ordered treatment. A physician's progress note dated (MONTH) 17, 2019 (which was two days after the left foot wounds were first identified) included the resident had a [MEDICAL CONDITION] pressure area on the lateral aspect of the left foot. There was no description of this wound, nor did the note address any other wounds to the left foot. A physician's orders [REDACTED]. The orders included for [MEDICATION NAME] swab to left lateral foot and foam boots bilaterally every shift. Review of the Resident at Risk Review dated (MONTH) 19, 2019, revealed the resident had three new pressure ulcers to the left foot, one was to the left heel, one near toes and a 2nd area near toes, with each wound measuring 2-3 cm. The documentation included that the left heel was dark purple. The resident's overall oral intake was very poor and not sufficient to heal pressure injuries. The goal was for the resident to not have signs and symptoms of infection with the pressure injuries. The documentation included that the wound nurse had not assessed the wounds yet. A skin evaluation was completed by the wound nurse (staff #40) on (MONTH) 20, 2019, which was five days after the wounds had been identified. The documentation included a pressure injury to the lateral aspect of the left heel which measured 1.3 cm x 1.6 cm and was circular shaped. The wound was described as black and dark brown spot with skin intact and surrounding skin was red. The wound documentation also included the tissue type was necrotic/eschar and there was no undermining or drainage present. The evaluation did not address the status of the two pressure spots located on the left lateral foot, as previously identified. A skin assessment dated (MONTH) 28, 2019 which was eight days after the last assessment included a wound to the left heel. However, a description of the wound bed, surrounding skin, and measurements were not documented. No other wounds to the left lateral foot were mentioned. Review of the (MONTH) 2019 TAR (Treatment Administration Record) revealed the orders for [MEDICATION NAME] swab to left lateral foot and foam boots bilaterally every shift. The treatments were provided as ordered. A nursing note dated (MONTH) 1, 2019 revealed the pressure injury to the left outer foot had black eschar, with no redness. Per the note, the area was painted with [MEDICATION NAME] and left open to air. Foam heel protectors in place on both feet. Further review of the clinical record revealed there was no documentation that the physician was notified of the left heel pressure injury, which now had black eschar from (MONTH) 20, 2019 through (MONTH) 3, 2019. There was also no evidence of any thorough assessments of the left heel pressure injury from (MONTH) 21 through (MONTH) 3, 2019. A skin evaluation dated (MONTH) 4, 2019 included a pressure injury to the left heel, which previously was a closed unstageable wound which had opened. The wound measured 1.4 cm x 1.6 cm with necrotic/eschar tissue including slough and that the wound bed was not visible. The drainage was described as brown exudate, and there was bright redness to the periwound. There was no documentation regarding the other two pressure ulcers on the left foot. A physician's orders [REDACTED]. The order also included to float heel on foam boots at bedtime until healed. Review of the (MONTH) 2019 TAR revealed the above order. The documentation included that the treatments were provided as ordered. A skin observation was conducted with a RN (staff #15) and a CNA (staff #130) on (MONTH) 10, 2019 at 11:08 a.m. Staff #15 stated he could not remove the dressing on the left heel, because it may disrupt the [MEDICATION NAME] healing process of the wound. Regarding the pressure ulcer on the right foot bunion area: The skin assessment dated (MONTH) 15, 2019 included the resident had a red pressure spot located on the bunion of the right foot, which was approximately 2-3 cm. The documentation included the feet were offloaded with pillows and the wound nurse was informed. A physician's progress note dated (MONTH) 17, 2019 revealed the resident had a [MEDICAL CONDITION] pressure area on the right feet ball of big toe showing [MEDICAL CONDITION] changes, however, there was no documentation regarding a pressure ulcer on the right foot bunion area. Review of the physician orders [REDACTED]. A physician's orders [REDACTED]. The skin evaluation dated (MONTH) 20, 2019 did not address the pressure spot on the bunion area of the right foot. A nursing note dated (MONTH) 30, 2019 included that [MEDICATION NAME] was the treatment for [REDACTED]. Review of the (MONTH) 2019 TAR revealed for [MEDICATION NAME] swab to the right foot bunion and foam boots bilaterally every shift for wound care. The documentation showed that the treatments were provided as ordered. Continued review of the clinical record revealed there were no further thorough wound assessments of the right toe bunion pressure spot, which included a description of the wound bed and surrounding skin and any measurements from (MONTH) 18 through (MONTH) 9, 2019. There was also no documentation if the area had healed. A skin observation was conducted with a RN (staff #15) and a CNA (staff #130) on (MONTH) 10, 2019 at 11:08 a.m. There was no wound observed to the bunion area of the right foot. Regarding the right buttocks: Review of the clinical record revealed no evidence that the resident had any skin issues to the right buttocks area from (MONTH) 1, through (MONTH) 4, 2019. On (MONTH) 5, 2019, a nursing note stated the resident had a new pressure ulcer on the right butt cheek. There was no further description of the pressure area. Nursing notes dated (MONTH) 6 and 7, 2019 included the resident had a blister with some redness on the right buttock and had a dry dressing in place. A nursing note dated (MONTH) 8, 2019 included that treatment was ongoing for the pressure ulcer on the right buttocks. Despite documentation that the resident had a pressure ulcer to the right buttocks, there was no documentation of a thorough assessment of the right buttocks pressure ulcer from (MONTH) 5-9, 2019, which included any measurements, if the blister had opened up and if so a description of the wound bed, if any drainage or odor was present, and the condition of the surrounding skin. In addition, a nursing note referred to ongoing treatments to the right buttocks pressure ulcer, however, there was no physicians order for any treatment, nor was there documentation that wound care was consistently provided. In an interview with a registered nurse (RN/staff #15) conducted on (MONTH) 9, 2019 at 11:24 a.m., he stated when a resident develops a pressure ulcer, he will assess the wound and notify the wound nurse, who works at the facility on a daily basis. He said that every Friday the wound nurse is scheduled to do wound rounds which includes assessing and measuring the wound, and documenting the assessment in the clinical record. He said the wound nurse and the floor nurses can provide wound treatments and that treatments should be documented on the MAR/TAR. Multiple attempts were made on (MONTH) 8, 9 and 10 to conduct a wound observation with the wound nurse (LPN/staff #40), however, staff #40 was unavailable. A skin observation was conducted with a RN (staff #15) and a CNA (staff #130) on (MONTH) 10, 2019 at 11:08 a.m. There were no open areas on the coccyx/buttocks area, however, there was redness to the coccyx/buttocks area. Staff #15 stated the resident's buttocks had redness from moisture, but there were no open areas. Attempts were made to conduct an interview with the DON (staff #79) on (MONTH) 10, 2019, but were unsuccessful because staff #79 was unavailable. During an interview conducted on (MONTH) 10, 2019 at 3:37 p.m. with the Administrator (RN/staff #102), she stated when a CNA identifies a skin issue such as pressure ulcer, it should be reported to the nurse who will assess the area, contact the physician for orders and notify the wound nurse. She stated the floor nurses can assess, measure and stage pressure ulcers. She said it should include the stage, measurements and description of the wound and should be documented on the skin assessment or IDT note in the clinical record. She stated it is expected that when a wound is identified, the nurses will assess and measure the wound. She said the wound nurse (staff #40) conducts wound rounds every Friday and works a normal shift three other days of the week, so the wound nurse does not have to wait until Friday to do an assessment. She stated for a while the wound nurse (staff #40) was documenting in the electronic record and the paper record, because the facility's software had some issues. However, she said the DON is working with the wound nurse to have all wound assessments documented in the electronic record. She further stated that the DON and staff #40 work together and are involved with the facility's wound program. Regarding the pressure injuries for resident #5, the Administrator stated that she does not have the answers as to why the wounds were not assessed and monitored or why there was a lack of documentation of these wounds. She stated the DON may have answers, but was unavailable at this time. -Resident #52 was admitted to the facility on (MONTH) 28, 2019, with [DIAGNOSES REDACTED]. An admission note dated (MONTH) 28, 2019 included the resident was non weight bearing due to a pressure ulcer on the left heel. The note included skin issues to the left heel and left great toe and that treatment and dressing changes were done by the hospice nurse twice a week and as needed. The note did not include the resident had any skin breakdown to the coccyx/buttocks area. Despite having a pressure ulcer to the left heel, the Braden Scale for predicting pressure sore risk dated (MONTH) 29, 2019 identified that the resident was at mild risk of developing pressure sores. Review of the physician's orders [REDACTED]. -skin assessment weekly -encourage and assist to turn and reposition frequently every shift -encourage and assist to float heels in bed every shift -barrier cream to buttocks and peri area every shift and after episodes of incontinence for skin integrity A physician's note dated (MONTH) 30, 2019 included the resident had multiple sores on the lower extremity and on the left heel, with wound care being done. However, there was no documentation that the resident had any pressure ulcers or skin concerns to the coccyx/buttocks area. A skin integrity care plan dated (MONTH) 30, 2019 included the resident was at risk for further alteration in skin integrity related to generalized weakness, immobility and incontinence. The care plan included the resident had a left heel stage 3 pressure ulcer with [MEDICAL CONDITION] and had an unstageable pressure ulcer to the left great toe. The goal was for the resident's skin to remain free of further skin breakdown through the next review. Interventions included the resident will receive a skin assessment on admission and weekly, provide treatments as ordered, a pressure relieving mattress and a cushion to wheelchair as ordered. A nursing note dated (MONTH) 31, 2019 included that an air mattress was on the resident's bed to protect red buttock and was ordered by hospice. This is the first documentation of a skin issue to the resident's buttocks area. Per the note, the resident spends most of the day in bed watching TV, is encouraged to turn and elevate feet, and barrier cream to buttock. The documentation did not include any further description of the red buttock area or any measurements. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed the order for barrier cream every shift and that it was administered as ordered from (MONTH) 29-31. Nursing notes dated (MONTH) 1 and 2, 2019 included wound on bottom and that the resident was on an air mattress. There were no further descriptors of the wound or any measurements. Review of a weekly skin assessment dated (MONTH) 3, 2019 revealed the resident had skin excoriation to the coccyx area, which was described as shallow excoriated skin with redness. There were no further description of the coccyx area and no measurements to indicate how large of an area which was excoriated. Nursing notes dated (MONTH) 3, 2019 included wound on bottom. The coccyx skin was excoriated with redness, and was cleaned and moisture barrier cream was applied. The resident experienced incontinence and has been using briefs. The resident was encouraged to stay off her back but refused. An admission Minimum Data Set (MDS) assessment dated (MONTH) 4, 2019 included the resident had a brief interview for mental status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS included the resident was at risk for developing pressure ulcers and currently had a stage 3 and an unstageable that were both present upon admission. Further, the assessment included for pressure reducing devices for bed and chair, pressure ulcer care, and applications of ointments or medications. A nursing note dated (MONTH) 5, 2019 included the resident was on an air mattress and it was too difficult for her to turn from side to side, and was up in a recliner chair for meals via mechanical lift. A weekly skin assessment dated (MONTH) 9, 2019 included the resident had a red area to the coccyx/buttocks and that barrier cream was applied with each incontinent episode. A nursing note dated (MONTH) 10, 2019 included the resident's bottom was red and barrier cream was applied. There were no further description of the redden area and no measurements. A nursing note dated (MONTH) 15 and 16, 2019 included the coccyx and bilateral buttocks areas were red, barrier cream was applied, and that the resident was on an air mattress. There was no further description of the coccyx and bilateral buttock areas and there were no measurements. A nursing note dated (MONTH) 17, 2019 included the coccyx and bilateral buttocks areas were red and barrier cream applied. However, a weekly skin assessment dated (MONTH) 17, 2019 revealed there was no mention of any concerns to the coccyx or sacral area. Review of a nursing note dated (MONTH) 26, 2019 revealed the sacral area was slightly red and moisture barrier applied. There was no further description of the sacral area and there were no measurements. Review of the clinical record revealed that from (MONTH) 31, when the resident was first identified to have redness to the coccyx area through (MONTH) 30, 2019, there was no documentation that a thorough assessment of the coccyx and buttocks areas had been completed, which included a description of the wound bed and surrounding skin, and any measurements. Review of the TAR for (MONTH) 2019 revealed barrier cream was administered as ordered from (MONTH) 1- 30, 2019. A weekly skin assessment dated (MONTH) 1, 2019 included the sacral area was slightly red and the top layer of skin was excoriated. There were no measurements of the area. Further review of the skin integrity care plan revealed it was not revised to reflect skin breakdown to the coccyx/buttock area and there were no additional interventions which were implemented to prevent further breakdown. A nursing note dated (MONTH) 1, 2019 included the sacral area remained excoriated due to patient refusing to stay off her back and that moisture barrier cream was applied with incontinent care. There was no further descriptors of the sacral area and no measurements. A nursing note dated (MONTH) 5, 2019 included the resident had a small open area on the coccyx, which was covered with a foam dressing, barrier cream was applied with every incontinent episode and that the wound nurse was informed. There was no description of the wound bed or surrounding skin, or if any drainage or odor was present and there were no measurements of the open area on the coccyx. In addition, there was no clinical record documentation that the wound nurse had assessed the open area to the coccyx on (MONTH) 5 or 6, 2019. There was also no documentation that the physician was notified of the open area. A nursing note dated (MONTH) 6, 2019 included a small open area on the coccyx with a foam dressing in place. This is the second reference to a foam dressing in place, however there were no orders for this. A weekly skin assessment dated (MONTH) 7, 2019 included a pressure ulcer to the coccyx with treatment ongoing. There was no description of the pressure ulcer to the coccyx and no measurements. A nursing note dated (MONTH) 7, 2019 included the resident was very incontinent and prefers sleeping on her back, and did not turn side to side this shift, after it was stressed to her the importance to reduce pressure to buttocks even with the air mattress in place. Another nursing note dated (MONTH) 7, 2019 included the resident was turned every two hours today. Per the note, there was an open area on the coccyx, with a foam dressing in place. Further, the note included a hospice RN came to assess the resident and looked at the new open area on the buttocks and wasn't concerned. There was no documentation of an assessment of the open area to include a description of the wound bed and surrounding skin and any measurements. A nursing note dated (MONTH) 8, 2019 included the resident's open area on the coccyx had a foam dressing in place and treatment was ongoing, toileting and repositioning were done frequently to ease the pressure on the back especially the coccyx area, and that barrier cream was used with incontinent episodes. An observation was conducted on (MONTH) 9, 2019 at 11:08 a.m. of the resident in her room, lying in bed with the head of the bed elevated at approximately 45 degrees. The resident was on a pressure relieving mattress. A nursing note dated (MONTH) 10, 2019 included the sacral area was red and the area was cleaned and moisture barrier was applied. There was no further description of the wound, nor any measurements. Review of the TAR for (MONTH) 2019 revealed barrier cream was administered as ordered from (MONTH) 1-10, 2019. Continued review of the clinical record revealed that from (MONTH) 1-9, 2019, there was no documentation that a thorough assessment of the coccyx and buttock areas were done, nor were there any measurements. There was also no documentation that the physician was notified of the open area on the coccyx. A skin observation of the resident was conducted on (MONTH) 10, 2019 at 10:30 a.m., with a Registered Nurse (staff #15). The resident was observed to be lying in bed and the head of the bed was elevated approximately at a 45 degree angle. He stated that he observes the skin for any areas of concern and then describes them for the weekly skin assessment. Staff #15 stated that he would not be measuring the wound because it is strictly the wound nurse who does the measurements, when she does her weekly skin assessments. At this time, the resident's brief was removed and an open area approximately the size of a quarter was observed on the right upper buttocks. The wound bed was pink with intact wound edges, no drainage and no odor. Staff #15 stated there is an open area to the resident's right gluteal cleft and described the open area as a beefy red wound with no drainage. He said that he will call the provider to get an order and will also let the wound nurse know. He stated it was a pressure wound and the wound nurse does the staging of pressure ulcers. Immediately following this observation, staff #15 checked the electronic record to see if the open area on the resident's bottom had been identified previously. He stated it had been identified and the treatment was barrier cream. He stated the wound nurse would have any assessments or measurements, but she was unavailable today. He stated he would notify the wound nurse just in case she was not aware of this area. A wound treatment observation was conducted on (MONTH) 10, 2019 at 1:15 p.m. with staff #15. He stated that he would be measuring and staging the wound. Staff #15 measured the wound which was 3 x 1.9 x 0.3 cm and staff #15 identified it as a stage 2 pressure ulcer with red granulation tissue and intact edges, no odor, no drainage, no undermining and no tunneling. In an interview with the Administrator (RN/staff #102) on (MONTH) 10, 2019 at 3:54 p.m., she stated the expectation regarding skin assessments is, if a new skin concern is identified, the nurse will be notified and assess the area and contact the physician to get orders. She stated the floor nurse should also make the wound nurse aware of the area of concern. She said the floor nurses can stage and measure the area and determine if it is a pressure ulcer, and they should document their assessment, including size, stage and wound description in a skin assessment or in a nursing note. Staff #102 stated all wound assessments are in the electronic record for continuity, so all nurses can see previous assessments and measurements. Regarding this resident's wound on the coccyx, she stated that she was unable to find any measurements. She stated the expectation is that the floor nurse or whoever identifies the new area should do an assessment and take measurements, then notify the appropriate parties. She stated it doesn't matter if the resident is on hospice, there still should be measurements done at the time the wound is identified. She stated the Director of Nursing oversees the wound nurse. The DON and wound nurse were unavailable for interviews on (MONTH) 10, 2019.

Based on clinical record review, observation, hospital record review, staff interviews, and review of facility's policies and procedures, the facility failed to ensure one cognitively impaired resident (#1) was adequately supervised to prevent an elopement that resulted in injury. The sample size was three. Findings include: Resident #1 was admitted [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed admission documentation that included the resident had intermittent confusion with poor safety awareness and was ambulatory. The resident was admitted to the facility's secured unit, which is located on the fourth floor of the facility. The unit is designed for residents with dementia. Review of a Wandering Risk assessment dated [DATE], revealed that the resident had a [DIAGNOSES REDACTED]. An admission care plan dated January 30, 2013, documented the resident was at risk for wandering/elopement. Interventions included to allow the resident to wander on the unit with supervision, monitor the resident's whereabouts, and engage in activities away from the elevators. Nursing notes from January 30 through February 1, 2013, revealed documentation of the resident being confused about where he was and how he had gotten to the facility. The notes further revealed that the resident was frequently ambulating in the hallways and activating the alarms on the fire doors and other alarmed doors on the unit. Despite this, there was no documentation of any increased supervision that was provided to resident #1. A nursing note dated February 1, 2013 at 3:00 p.m., documented the resident was found outside the facility on the ground, with blood coming from his mouth, forehead, and nose. The resident was laying on top of his left arm. Paramedics arrived and the resident was transported to the hospital. Hospital documentation dated February 1, 2013, revealed that the resident sustained [REDACTED]. The documentation further included the forehead and finger required sutures. An observation was conducted on May 15, 2013, of the 4th floor secured unit. The elevator to the unit had an activation code that must be used for the elevator to open. On May 15, 2013, interviews were conducted with staff who were identified via staff assignment sheets, to have provided care or who were on the unit with resident #1 on February 1, 2013. Staff #1 (unit clerk) stated she had seen resident #1 during lunch and that the resident was pacing up and down the hallway. She stated there was a new admission brought to the unit around 2:00 p.m. on February 1, via the elevator, but that she did not see the resident get onto the elevator. She further stated that approximately three to five minutes later, a telephone call was received regarding resident #1 being found on the ground outside the building. Staff #1 provided a copy of the unit's daily CNA (certified nursing assistant) schedule for February 1, 2013. The schedule documented that staff were assigned 15 minute watches that were to include watching the elevator and residents during shift change, 2:00 p.m. to 2:15 p.m. The schedule documented that staff #5 was assigned the 2:00 p.m. - 2:15 p.m. task. Staff #5, a CNA stated during a telephone interview, that she was on the unit working on February 1, and remembered the incident where resident #1 was found on the ground outside the building. She stated the resident frequently walked up and down the hallway and would tell staff he wanted to leave. She said that she had been assigned to be in the dining area across from the elevator from 2:00 p.m. to 2:15 p.m., to watch the elevators and make sure residents were safe. Staff #5 further stated that one of her residents needed to use the bathroom, so she left with the resident and did not see resident #1 get on the elevator. During an interview staff #2 (CNA) remembered working on the unit on February 1, when the resident eloped from the unit. Staff #2 stated she was seated in the dining room area across from the elevator around 2:00 p.m. completing paperwork. She said she saw transport staff with a resident on a stretcher getting off the elevator, however, the doors of the elevator closed and she did not see the resident get on the elevator. During an interview with staff #3 (CNA), staff stated she remembered the incident regarding resident #1 on February 1, however, she was busy providing care to her assigned residents and did not see the resident. Staff #4 (CNA) stated that she was at the nurses station at approximately 2:00 p.m. to 2:15 p.m., on February 1, 2013. She said that she had seen resident #1 pacing up and down the hallway, as was his usual behavior. She stated that a new admission was brought to the floor on a stretcher and the transport staff had to remove the ropes in front of the elevator. Staff #4 stated that the transport staff probably didn't put the rope back and that resident #1 must have quickly got on the elevator. She said she did not see the resident get on the elevator, as the elevator is not visible from the nursing station. A telephone interview was conducted with staff #6 (RN). Staff #6 stated that she was coming down the hallway on February 1, 2013 at approximately 2:15 p.m. She stated that she saw resident #1 in the hallway with a newspaper around shift change and there were staff seated at tables in the dining area across from the elevators completing paperwork. She said at this time a new admission was brought to the unit via stretcher. She stated the resident was known to wander and set off the door alarms. Staff #6 stated that it was the responsibility of all the staff to watch residents and watch the elevator, especially at shift change. Staff #6 continued that a staff from the third floor came onto the unit and told her that there was a resident on the ground outside and asked staff #6 if it was someone from the unit. She said she went down to the first floor and out the back door and found resident #1 on the ground to the left of the exit door. Staff #6 stated the resident had blood on his face and hands, and his finger looked broken. During an interview, the Administrator stated staff are trained to be observant of the elevator for others that may not remember to replace the ropes in front of the elevator. The Administrator stated that facility and campus staff have been provided in-service training regarding the fourth floor dementia unit and the elevator code, to prevent elopements. A review of the facility's Dementia Care policy documented that the fourth floor of the facility is designed for the care of resident's with dementia. The policy documented the use of a keypad in the elevator for access to the unit to keep residents from going outdoors and getting hurt. The policy further documented that staff on the fourth floor should watch for residents trying to get on and off the elevator to make sure each resident stays safe.