Every finding on record at Belmont Manor Nursing Home, In

Based on interviews and records reviewed, for one of three sampled Residents (Resident #1), who had a history of wandering, and required the use of a wander guard device for safety, the facility failed to ensure his/her device was consistently checked for function by staff, when on 2/21/26 Resident #1 was able to leave his/her unit, take the elevator to the first floor and exit the building to an outside courtyard, undetected by staff, and without triggering the wander guard alarm system. Resident #1 was outside for around 30 minutes unsupervised, before staff became aware he/she was missing off the unit. Findings include:The Facility Policy, titled, Elopement of a Resident, dated 9/02/08, indicated that all residents are assessed for potential elopement risk on admission, quarterly, annually, and when a resident has a change in condition and a care plan will be implemented for any resident who is at risk along with safety measures to prevent elopement while maintaining the least restrictive environment.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 2/28/26, indicated that on 2/21/26 at 7:00 A.M., Facility staff noted that Resident #1 was not in his/her bed and could not be located on his/her Unit. The Report indicated Resident #1 was last seen in his/her room watching television at approximately 6:30 A.M. The Report further indicated Resident #1 was found on the first floor outside in the courtyard sitting on the ground with his/her walker nearby, he/she was assessed by nursing and no injuries were observed. The Report indicated that staff observed that the wander guard system was not functioning (did not trigger alarm when they brought Resident #1 back inside).Review of Resident #1's Medical Record indicated he/she was admitted in April 2024, diagnoses included Alzheimer's, Dementia, Diabetes, History of falling, Difficulty in walking, and his/her health care proxy was invoked.Review of Resident #1's Physician's orders, dated 12/03/24, indicated he/she had an order for a wander guard bracelet to be placed on his/her walker, and to check function with the universal tester daily on 11:00 P.M. to 7:00 A.M. shift.Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 7 out of 15 (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact).Review of Resident #1's Care Plan Titled Elopement, reviewed and renewed with his/her most recent MDS 12/2025, indicated he/she was at risk for elopement, had a history of wandering, that Resident #1 would remove his/her wander guard if on his/her person and therefore it was attached to his/her walker. The Care Plan indicated a goal was for Resident #1 to wander safely within specific bounderies.Review of the most recent Elopement Risk Assessment, dated 2/19/26, indicated that Resident #1 remained at risk for elopement.Review of the Treatment Administration Record (TAR) for the month of February 2026, indicated that on the 11:00 P.M. to 7:00 A.M. shift on 2/21/26, there was no documentation to support that the wander guard check (with the universal tester) had been completed by the nurse. Review of Certified Nurse Aide (CNA) 1's written Witness Statement (included in the Investigation Report), dated 2/21/26, indicated that Resident #1 was last seen by her in his/her room watching television around 6:30 A.M. The Statement indicated CNA #1 assisted with the search for Resident #1, he/she was found downstairs [in the outside courtyard] and returned to his/her Unit.During a telephone interview on 3/28/26 at 2:13 P.M., Nurse #1 said that when she went to check Resident #1's blood sugar at 7:00 A.M., he/she was not in his/her room or on the unit. Nurse #1 said a search was initiated and he/she was found on the first floor outside in the courtyard area sitting on the ground with his/her walker nearby. Nurse #1 said the wander guard device was attached to Resident #1's walker but was not functioning and had not trigger an alarm. Nurse #1 said because the wander guard device itself was not working, that was how Resident #1 was able to get on the elevator, go down to the first floor, open the door to the courtyard and go outside undetected, because the wander guard system alarm did not sound.Nurse #1 said she was supposed to check the wander guard function during her 11:00 P.M. to 7:00 A.M. shift but did not want to go into Resident #1's room and wake him/her. Nurse #1 said she saw that his/her wander guard device was attached to his/her walker but did not know the wander guard device was not functioning.During an interview on 3/19/26 at 1:03 P.M., Nurse #2 said that she was one of the oncoming nurses for the 7:00 A.M. to 3:00 P.M. shift on 2/21/26 and assisted with the search for Resident #1. Nurse #2 said Resident #1 was found on the first floor outside in the courtyard area sitting on the ground with his/her walker nearby at around 7:00 A.M. and was assessed by nursing. Nurse #2 said Resident #1 had no injuries observed, he/she was placed in a wheelchair and brought back to his/her unit.Nurse #2 said they determined that his/her wander guard device was not functioning. Nurse #2 said the wander guard device should have triggered an alarm when Resident #1 left the unit, should have prevented him/her from accessing the elevator, and then triggered an alarm when he/she tried to go out the exit door to the courtyard.During an interview on 3/19/26 at 12:20 P.M. the Staff Development Nurse said there is a universal tester on each Nursing Unit to check wander guard device function, that facility policy is for wander guard checks to be conducted on the 11:00 P.M. to 7:00 A.M. shift and that the policy is reviewed on orientation and during annual education, with all staff.During an interview on 3/19/26 at 1:12 P.M., the Director of Nursing (DON) said she conducted the investigation into the elopement of Resident #1 and said that Nurse #1 told her she had not checked the functioning of his/her wander guard device on 2/21/26, which resulted in his/her elopement. The DON said nursing staff are expected to follow facility policy and MD orders, and in this case, they had not been done.On 3/19/26, the Facility was found to be in past non-compliance with an effective date of 2/24/26 and provided the Surveyor with a plan of correction which addressed the concern as evidenced by:A. On 2/21/26 Resident #1 was immediately assessed by nursing, no injuries were noted, his/her resident representative and physician were notified, and nursing continued to monitor and support.B. Resident #1 was seen by the Facility Social Worker, and the plan is to move Resident #1 to the secure locked unit as soon as a bed becomes available, and his/her resident representative(family) was in agreement.C. On 2/21/26, the Facility immediately replaced the non-functioning wander guard device with a new one and confirmed the function of the new wander guard.D. On 2/21/26, the Facility immediately tested all wander guard devices, to ensure all residents with devices had functioning ones.E. Resident #1's Care Plan was updated to include additional interventions, such as encourage daytime activities to avoid daytime naps to prevent wandering at night and continue all other orders along with new orders for lab testsF. On 2/23/26, the Facility updated interventions on Resident #1's plan of care to include every 15-minute checks.G. On 2/23/26, re-education of nursing staff was initiated by the Director of Nursing (DON) and Staff Development Coordinator on the Elopement Policy and wander guard testing, placement, and functioning. The Education was completed 2/27/26.H. On 2/23/26, the Facility conducted an ad hoc Quality Assurance Meeting to review the incident and to develop their corrective action plan. I. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on observations, record reviews, and interviews, the facility failed to: 1. ensure respiratory care was provided consistently with professional standards of care for one Resident (#148) out of a sample of 31 residents and 2. failed to maintain respiratory equipment to ensure it was clean and prepared for use.Findings include: Review of the facility policy titled Oxygen Administration, undated, indicated the following: The purpose of this procedure is to provide guidelines for oxygen administration. -Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2-3 Liters per minute. -Adjust the delivery device so that it is comfortable to the resident and the proper flow of oxygen is being administered.-Observe the resident to be sure oxygen is being tolerated. -Check the mask, tank, etc., to be sure they are in good working order and are securely fastened. Resident #148 was admitted to the facility in [DATE] with diagnoses including anemia (low level of red blood cells) urinary tract infection and dementia. Review of Resident #148's medical record indicated the Minimum Data Set assessment, was not completed as Resident #148 was newly admitted . On [DATE] at 8:38 A.M., Charge Nurse #3 told the surveyor that Resident #148 was unresponsive and said 911 emergency services were on the way. On [DATE] at 8:39 A.M., Resident #148 was observed lying in bed wearing an oxygen nasal canula. The oxygen concentrator was set to .5 liters per minute. The concentrator psi gauge (meter used to measure amount of oxygen in the tank), black arrow indicator was pointed to the red section 0 (zero) REFILL. There were no staff members in the room with Resident #148. During an interview and observation on [DATE] at 8:40 A.M., Nurse #6 entered Resident #148's room and placed a pulse oximeter (device used to measure oxygen saturation in blood) on Resident # 148's right index finger. The oxygen saturation level was 88 %. Nurse #6 looked at the oxygen tank gauge and liter flow, (which still indicated the psi gauge black arrow indicator was pointed to the red section 0 (zero) REFILL) and said Resident #148 was having difficulty breathing and not responding so he/she was placed on oxygen. Nurse #6 then walked out of the Resident's room. On [DATE] at 8:42 A.M., Unit Manager #1 entered Resident #148's room and said he/she is having difficulty breathing and does not use oxygen regularly but was in respiratory distress this morning and is being sent to the hospital. The Unit Manager then turned up oxygen to 2 Liters and said his/her oxygen saturation is low and he/she is requiring more oxygen until 911 arrives. The oxygen saturation level was 86 %. The Unit Manager then walked out of the Resident's room. On 12:30/25 at 8:44 A.M., Nurse #6 was observed obtaining Resident #148's blood pressure and adjusted the pulse oximeter to Resident #148's right index finger. The oxygen saturation was 86%. Nurse #6 then walked out of Resident #148's room. The oxygen concentrator was set to 2 Liters per minute. The concentrator psi gauge black arrow indicator was still pointed to the red section 0 (zero) REFILL. During an interview and observation on [DATE] at 8:45 A.M., the surveyor observed Resident #148's oxygen saturation level drop to 83%. The oxygen concentrator was still set to 2 Liters per minute and the psi gauge black arrow indicator was pointed to the red section 0 (zero) REFILL. The surveyor walked to the doorway and asked Unit Manager #1 to visualize Resident #148's oxygen settings and tank gauge. Unit Manager #1 then increased the oxygen to 5 Liters and observed the arrow on the pressure gauge in the red zone and said the oxygen tank is empty. Unit Manager #1 said Resident #148 needs a new tank because this one is not delivering any oxygen, then exited the Residents room to obtain a new oxygen concentrator. On [DATE] at 8:48 A.M., a new oxygen tank was obtained, and Resident #148 was placed on 5 Liters of oxygen via nasal cannula. Resident #148's oxygen saturation fluctuated between 86% to 88%. During an interview on [DATE] at 8:54 A.M., Nurse #6 said she was unaware that the tank was empty and thought he/she was receiving the oxygen through the nasal cannula, but he/she was not as the tank was empty. Nurse #6 said the black arrow on the gauge was pointed to zero and needed to be changed. During an interview on [DATE] at 8:57 A.M., Unit Manager #1 said she obtained the oxygen tank off the emergency code cart this morning around 8:30 A.M., after the Resident was found to be unresponsive by a staff member and placed Resident #148 on oxygen because his/her oxygen saturation was 86% on room air. During an interview on [DATE] at 9:11 A.M., Occupational Therapist (OT) #1 said she observed Resident #148 lying in bed unresponsive, diaphoretic, eyes were shut and his/her color did not look good. OT #1 said Resident #148's oxygen saturation was 86-87% and said this was not the Resident's baseline and said she immediately notified the charge nurse who assessed Resident #148 and said he/she did not respond to a sternal rub done by the charge nurse and a call to 911 was placed. During an interview on [DATE] at 11:13 A.M., Charge Nurse #3 said Resident #148 was unresponsive and having trouble breathing this morning and was placed on oxygen until 911 arrived. Charge Nurse #3 said Resident #148 does not have breathing issues and said this was a change in respiratory status. Charge Nurse #3 said staff need to check the oxygen tank to make sure it is not empty and check to see if the Resident is responding to the oxygen therapy. During an interview on [DATE] at 12:01 P.M., the Director of Nurses (DON) said Resident #148 should have been placed on appropriate oxygen therapy when he/she was first identified as having breathing difficulty. The DON said staff must check the oxygen tank settings prior to administering oxygen and after administration to make sure the equipment is working and said staff must assess the resident's response to oxygen therapy. The DON said not administering oxygen to a resident in respiratory distress could cause the resident to have a decrease in oxygen saturation causing an increase in difficulty breathing leading to worsening respiratory distress. During an interview on [DATE] at 12:15 P.M., the Medical Director said it is his expectation that staff respond appropriately and efficiently to residents requiring oxygenation therapy and said staff must know how to administer oxygen correctly to prevent Residents from experiencing or worsening respiratory distress. The Medical Director said Resident #148 needed oxygen as he/she was in respiratory distress and was not receiving oxygen until a new oxygen tank was applied. The Medical Director said Resident #148 should not have been placed on an oxygen tank that was not functioning appropriately. 2. Review of the facility's policy Cleaning of Respiratory Equipment (undated) indicated for emergency suctioning equipment: -Nursing will rinse and disinfect with the appropriate disinfectant the suction machine every shift. -Nursing will rinse the tubing every shift and replace the tubing every 72 hours. -After the resident no longer requires suctioning, nursing will return the suction machine to the dirty utility room and post a date note: To be disinfected. On [DATE] at 10:34 A.M. the surveyor and Infection Preventionist (IP) observed the Station 3 code cart, located in the utility room. On top of the cart was placed a suctioning machine, a canister, Yankauer tubing, and an Ambu bag. A suction machine is a medical device designed to generate negative pressure to create a vacuum that allows for fluid extraction from the mouth and throat. A cannister on the machine collects these secretions from the patient. A Yankauer is a rigid, curved instrument attached to the suction machine made of clear plastic used to remove secretions such as saliva, mucus, blood or vomit from the mouth and throat. It is used to prevent aspiration and maintain a clear airway. An Ambu bag is a portable, hand-held device designed for emergency ventilation, also known as a manual resuscitator. It is used to provide positive pressure ventilation for patients who are not breathing or are struggling to breathe. The surveyor observed that the suction machine was dirty and the cannister was partially filled with an opaque, yellow, dirty liquid. The Yankauer tubing had been removed from its sterile bag and was faded yellow had light brown substance inside the tubing and was dirty. The Ambu bag had been removed from its sterile bag, and the mouth seal was sticky, yellow and deflated. The IP said the equipment appeared to have been used some time in the past and not cleaned or replaced. The IP said the Ambu bag was not in working condition and would not work if placed on a resident's mouth as the mouthpiece was deflated and sticky. On [DATE] at 10:39 A.M. the surveyor and IP observed the Station 1 code cart. On top of the cart there was a suction machine cannister, one Yankauer tubing, and one Ambu bag. The Yankauer tubing had been removed from its sterile bag. The Ambu bag had been removed from its sterile bag, and the mouth seal was sticky, yellow and deflated. The IP said the equipment appeared to have been used some time in the past and not cleaned or replaced. The IP said the Ambu bag was not in working condition and would not work if placed on a resident's mouth as the mouthpiece was deflated and sticky. On [DATE] at 10:45 A.M., the surveyor and IP observed the Station 2 code cart. On top of the cart there was a suction machine cannister, one Yankauer tubing, and one Ambu bag. The Yankauer tubing had been removed from its sterile bag. The Ambu bag had been removed from its sterile bag and had expired. There was one open bottle of sterile water that was expired and clear liquid was floating in the bag that contained the expired Ambu bag. On [DATE] at 10:52 A.M., the surveyor and IP observed the Station 4 code cart. On top of the cart there was a suction machine cannister, one Yankauer tubing, and two Ambu bags. The Yankauer tubing had been removed from its sterile bag. The IP said the expired Ambu bag was no longer considered sterile and should be discarded and the sterile bottle of water should not be open and stored with the Ambu bag. The IP said the equipment was not in working condition and not available if needed in an emergency. The IP said none of the emergency carts located in the facility are stocked with the necessary items needed to respond to an emergency at this time. During an interview on [DATE] at 11:13 A.M., Unit Manager #1 said emergency equipment must be checked every day and replaced when it is used or expired. Unit Manager #1 said used dirty equipment is contaminated and cannot be used on residents and said without emergency equipment available it could cause a delay in care. Unit Manager #1 said emergency carts must be accessible and available with working equipment that is in clean condition and not expired. Unit Manager #1 said she would expect equipment to be checked daily and replaced and said used dirty equipment should not be left on the emergency cart. The Unit Manager #1 said Ambu bags that are expired, yellow, sticky and deflated are not in working condition and can't be used in an emergency. During an interview on [DATE] at the Director of Nurses (DON) said it is her expectation that all equipment is in good, clean sterile working condition and readily accessible to residents and said she expects the emergency carts to be checked daily and available in an emergency. The DON said not having the emergency equipment ready could cause a delay in treatment if a resident is having an emergency and staff do not have access to it.

Based on record review and interview, the facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 4 2025 (July 1 - September 30), in accordance with the schedule specified by CMS.Findings include:Review of the facility's policy titled Payroll Based Journal (PBJ), dated as revised February 2024, indicated but was not limited to:Policy: [NAME] Manor is required to submit staffing hours to CMS every 3 months beginning with the data for July, August, September 2016 (This is called 2016 Q4). This is submitted online via the PB&J Data Submission portal.-All data is either uploaded to CMS as a zip file or manually entered.-Fiscal Quarter 4 for Reporting Period 7/1/25 through 9/30/25, due date 11/14/25.During an interview on 12/30/2025 at 9:06 A.M., Human Resource Staff #1 said he missed the deadline and tried to submit the PB&J report after the deadline, but the reporting system would not accept it. Human Resource Staff #1 said quarterly reports should be submitted timely as required by CMS.

Based on record review, interview and observation, the facility failed to ensure it implemented infection control measures for one of one applicable sampled Resident (#84) with a diagnosis of influenza. Specifically, the facility failed to follow physician orders for droplet precautions and failed to ensure staff utilized appropriate personal protective equipment in Resident #84's room and on the unit.Findings include: Review of the Center for Disease Control guidance titled Interim Guidance for Influenza Outbreak Management in Long-term Care and Post-Acute Care Facilities dated 9/17/24 indicated, but was not limited to, the following: - Implement standard and droplet precautions for all residents with suspected or confirmed influenza. - Wear gloves if hand contact with respiratory secretions or potentially contaminated surfaces is anticipated.- Wear a face mask (e.g., surgical or procedure mask) upon entering the resident's room.- Wear a gown if soiling of clothes with a resident's respiratory secretions is anticipated.- Change gloves and gowns after each resident encounter and performing hand hygiene- Perform hand hygiene before and after touching the resident, after touching the resident's environment, or after touching the resident's respiratory secretions, whether gloves are worn or not.Resident #84 was admitted to the facility in November 2025 and has diagnoses which include Parkinson's disease, renal disease and influenza.Review of Resident #84's Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status examination score of 11, signifying moderate cognitive impairment. The MDS also indicated the Resident ambulated with a walker or wheelchair and required partial to moderate assistance with activities of daily living. Review of the infection control line listing for December 2025 indicated Resident #84 was diagnosed with the influenza virus on 12/31/25 and was prescribed Tamiflu, an antiviral agent. Review of Resident #84's physician orders dated 12/31/25 indicated: Droplet precautions every shift, days, evenings, nights.On 12/31/25 at 7:43 A.M., the surveyor observed the entrance to Resident #84's bed had a sign posted indicating isolation precautions. The sign indicated droplet and standard contact precautions were in effect. The sign indicated that all staff and visitors entering the room should wear gloves, a gown, a surgical mask or N-95 respirator, and eye protection. At the entrance to the room was a small cart containing surgical masks, gloves and gowns, but no eye protection. Inside the room, Resident #84 was lying in bed awake, coughing and not wearing a mask. A staff member transferred Resident #84's roommate from bed to a wheelchair, and then to the bathroom. The curtain between the two resident beds was open and the staff member wore a surgical mask below her nose and a pair of surgical gloves. The staff person did not wear a gown or eye protection. The staff member then exited the bedroom, removed the gloves and washed her hands. On 12/31/25 at 7:46 A.M., the surveyor observed a staff person walking in the unit hallway and not wearing a surgical mask. The reader may not understand why this is bad. Did staff have to wear a mask while on the unit too? Were there signs or are we focused on just this one resident and just his/her room?On 12/31/25 at 7:50 A.M., the surveyor observed Nurse #3 enter Resident #84's room to obtain vital signs and administer medications. Nurse #3 wore gloves and a surgical mask, but not a gown or eye protection. During an interview with Nurse #3 on 12/31/25 at 7:55 A.M., she said Resident #84 was on droplet precautions because of a diagnosis of influenza. Nurse #3 said that when she entered the Resident's bedroom she should have worn a gown. Nurse #3 said the staff person who assisted Resident #84's roommate should have worn the mask over her nose and mouth and worn a gown because Resident #84 was on droplet precautions and these interventions applied to the entire room. Nurse #3 said she had offered Resident #84 and his/her roommate a mask, but they declined. During an interview with Unit Manager #1 on 12/31/25 at 8:00 A.M., she said staff and visitors entering Resident #84's room need to follow the precautions listed on the isolation sign. Unit Manager #1 said staff and visitors entering the room should wear gloves, a gown and either a surgical mask or an N-95 respirator. Unit Manager #1 said that all staff and visitors to the floor, whether they enter Resident #84's room, or not, should wear a mask to help prevent the spread of infection.During an interview with the Infection Preventionist (IP) on 12/31/25 at 11:00 A.M., she said staff should be wearing full personal protective equipment, including a mask, gloves and gown when entering Resident #84's room because he/she was on isolation precautions. The IP said that anyone entering Resident #84's unit should wear a surgical mask to prevent the spread of the influenza virus.

Based on record review and interview the facility failed to ensure it offered pneumococcal vaccines to 35 of 71 residents who were eligible for the vaccine. Findings include: Review of the Center for Disease Control (CDC) website indicated to administer PCV15, PCV20 or PCV21 for all adults aged 50 or older who have never received any pneumococcal conjugate vaccine and whose previous vaccination history is unknown.Review of the facility's immunizations records and an audit provided by staff indicated 19 of 35 eligible residents on the 400 unit and 16 of 36 eligible residents on the 300 unit (a total 35 of 71 residents) had not been offered or received the pneumococcal vaccine. Review of the physician's orders of the 71 residents indicated they may have the pneumonia vaccine unless contraindicated. Review of the facility's immunization audit indicated the 35 identified residents were due to receive the pneumococcal vaccine and they did not have a contraindication to receive the vaccine. During an interview with the Infection Preventionist on 12/31/25 at 11:00 A.M., she said there were many residents in the facility who were eligible and due to receive the pneumococcal vaccine and had not declined to receive the vaccine. The Infection Preventionist said the vaccine was available from the pharmacy, but the facility had not yet facilitated payments for these.

Based on interview and record review, the facility failed to ensure invitations to attend care plan meetings were provided to one Resident (#20) out of a total of 31 sampled Residents. Findings include: Resident #20 was admitted to the facility in November 2020 with diagnoses including chronic obstructive pulmonary disease and shortness of breath. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is cognitively intact as evidenced by a score of 15 out a possible 15 on the Brief Interview for Mental Status Exam (BIMS). Review of Resident #20's care plans indicated:Problem: I have an (sic) HCP (Health Care Proxy) that is not activated, 6/20/25.Interventions: Staff will educate me and all surrogate decision makers regarding their roles. During an interview on 12/30/2025 at 7:53 A.M., Resident #20 said that he/she had initially declined attending his/her care plan meetings but wanted to start attending. Resident #20 said that she had told multiple staff and the nurse supervisor, but he/she has still not been invited to attend. Resident #20 said he/she wasn't sure when he/she first told staff he/she wanted to attend, but it was a while ago. During an interview on 12/30/2025 at 9:00 A.M., Social Worker #1 said that the Receptionist is responsible for sending out invitations to residents and their representatives for care plan meetings. Social Worker #1 said that Resident #20 does not attend his/her own care plan meetings. Social Worker #1 said that she was not aware Resident #20 told staff he/she wanted to attend, and he/she should have been invited. During an interview on 12/30/2025 at 9:06 A.M. The Receptionist said she sends out invitations to resident representatives and alert and oriented residents in the building. The Receptionist said she sent out an invitation to Resident #20's activated health care proxy last month (November 2025) to attend the December 2025 care plan meeting. During a follow up interview on 12/30/2025 at 1:16 P.M., Social Worker #2 said that Residents have the right to attend their care plan meetings and Resident #20 does not have an activated healthcare proxy. Social Worker #2 said she was not aware the Receptionist was sending invitations to Resident #20's family member and Resident #20 should have been invited.

Based on a resident group meeting, interviews, and record reviews, the facility failed to ensure concerns from the Resident Council were thoroughly documented to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.Findings include:Review of the facility's policy titled Grievance Policy, undated, indicated but was not limited to the following:-It is the policy of [NAME] Manor Nursing Center to assist residents, their representative, other interested family members or advocates in filing grievance or complaints when such request are made. -The Grievance Policy refers to documenting an acting on specific complaints or concerns voiced by residents, staff, and families. Listening to concrete needs, addressing them with appropriate team members(s) and resolving them are the principal components and nature of this policy.-The Record of Resident and Family Concerns will be the only form utilized to document grievance and/or recommendations through an orderly and timely process. -The Record of Resident and Family Concerns will be readily available in all nursing units and in other departments as appropriate. -The Record of Resident and Family Concerns will be completed by the person receiving the grievances and/or recommendation and its disposition will be coordinated by the Social Services Department. Review of Resident Council minutes, dated October 2025, indicated the following: -Missing long winter coat.Review of the Resident Council minutes, dated November 2025, contained no additional follow-up notes.Resident group was held on 12/30/25 at 2:00 P.M., with the following concerns reported: -Three out of 10 participating residents reported missing clothing that has been reported to staff and not followed up on or reimbursed. Reporting this as an ongoing issue that is discussed during every meeting but not resolved.-Five out of 10 participating residents said when issues are reported they are not documented or resolved. Residents reported the same issues discussed month after month and they feel the facility does not respond to grievances brought up in the group meeting. Review of the Grievance logs for 2024 and 2025 failed to indicate any grievances had been filed for the issues reported in resident council meetings. September 2025: no documented grievances.October 2025: no documented grievances.November 2025: no documented grievances.December 2025: no documented grievances. During an interview on 12/31/25 at 7:52 A.M., the Social Worker who is also the Facility Grievance Officer, said grievance forms are not currently located on the nursing units and said he would expect the forms to be accessible on all units so residents, visitors and staff can report issues to be followed up on. The Social Worker said he was not aware of any grievances since he started at the facility about seven weeks ago and said he could not find any grievance forms from August through December 2025. The Social Worker said he would expect staff to complete the grievance forms and submit them for review and follow up and said the facility must track concerns and respond to them timely. During an interview on 12/31/25 at 11:16 A.M., the Administrator said he expects the facility to follow up on grievances as they come up and said the forms are available if needed and said residents, and visitors can ask staff to fill out a form if they have a concern. The Administrator said staff take care of issues reported during resident council meetings and do not need to fill out grievance forms for every issue.

Based on interview, and record review, the facility failed to ensure residents had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance. Specifically, 1. For Resident #16, the facility failed to follow the grievance process after Resident #16 reported he/she was missing sneakers.2. Failed to ensure residents had access to grievance/concern forms to submit grievances anonymously, should they choose not to alert a staff member to their concern.Findings include:Review of the facility's policy titled Grievance Policy, undated, indicated but was not limited to the following:-It is the policy of [NAME] Manor Nursing Center to assist residents, their representative, other interested family members or advocates in filing grievance or complaints when such request are made. -The Grievance Policy refers to documenting an acting on specific complaints or concerns voiced by residents, staff, and families. Listening to concrete needs, addressing them with appropriate team members(s) and resolving them are the principal components and nature of this policy.-The Record of Resident and Family Concerns will be the only form utilized to document grievance and/or recommendations through an orderly and timely process. -The Record of Resident and Family Concerns will be readily available in all nursing units and in other departments as appropriate. -The Record of Resident and Family Concerns will be completed by the person receiving the grievances and/or recommendation and its disposition will be coordinated by the Social Services Department. 1. Resident #16 was admitted to the facility in April 20245 with diagnoses including unspecified dementia, muscle weakness and depression.Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #16 is cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam.Review of grievance binder indicated the following grievance form for Resident #16 dated 12/2/25: Documentation of Concern: HCP called asking where Resident #16's shoes were. Advised that staff will look for shoes. Notified: Social Services, Other; Laundry. Facility Action and Follow-up: Staff conference 12/19/25 DNS (Director of Nursing Services), SS (Social Services, Administrator.Social Work Intervention: Social Worker reached out to HCP to enquire about cost of shoes. $49.99. Amount given to Administrator& DNS.During an interview on 12/31/25 at 9:31 A.M., Resident #16 said he/she had shoes in her room, but they went missing and they (the facility) never replaced them and said she told the staff about the missing sneakers.During an interview on 12/31/25 at 8:02 A.M., Certified Nursing Assistant (CNA) #2 he was not aware of any missing sneakers for Resident #16.During an interview on 12/31/25 at 8:15 A.M., Charge Nurse #3 said she does not recall a grievance form being completed on Resident #16 and was not aware of missing sneakers. During an interview on 12/31/25 at 8:58 A.M., Social Worker #2 said she notified the Administrator and Director of Nurses about the missing shoes and said she would expect the Administrator to follow up to reimburse the resident but did not know if that had been done. During an interview on 12/31/25 at 11:16 A.M., the Administrator said he expects the facility to follow up on grievances as they come up and said he would reimburse the resident for the $49.99 if he/she could submit proof of the cost of the missing shoes and said he was not aware of the status of the missing shoes. 2. During a tour of the facility on 12/30/25 at 8:00 A.M., the surveyor was unable to find any information regarding the grievance process posted in resident care areas. The surveyor observed information regarding how to file grievance near the Social Services office which was not accessible to all residents.Review of the facility grievance binder on 12/30/25 at 8:25 A.M., contained no documented grievances during the months of September 2025, October 2025 and November 2025.During an interview on 12/31/25 at 8:01 A.M., Certified Nursing Assistant (CNA) #2 said he will tell the nurses if residents have issues or are reporting missing items and said he is not aware of any forms on the unit.During an interview on 12/31/25 at 8:07 A.M., Nurse #3 said she is not aware of any grievance forms and said if a resident reports a concern or is missing items she would tell the charge nurse.During an interview on 12/31/25 at 8:14 A.M., Charge Nurse #3 said grievance forms in a drawer behind nurse's station that are filled out if there is an issue and said concerns should go to the unit manager for follow up. During an interview on 12/31/25 at 8:57 A.M., Social Worker #1 said if residents report concerns to staff, then staff are expected to fill out a grievance form and submit it for review by the management team and said she emails concerns to the Director of Nurses, Administrator and new Social Worker for follow up. SW #1 said forms are only located by the social services office and are filled out by staff if issues are reported and said she was not sure why the forms were not being filled out during the month of August to December and said staff would tell the Director of Nurses if there were any resident issues. During an interview on 12/31/25 at 10:52 A.M., the Social Worker #2 who is also the Facility Grievance Officer, said grievance forms are not currently located on the nursing units and said he would expect the forms to be accessible on all units so residents, visitors and staff can report issues to be followed up on. The Social Worker #1said he was not aware of any grievances since he started at the facility about seven weeks ago and said he could not find any grievance forms from August through December 2025. Social Worker #1 said he would expect staff to complete the grievance forms and submit them for review and follow up and said the facility must track concerns and respond to them timely. Social Worker #1 said he was not aware of the issues reported during resident council and said he was not aware of the two December grievances that had not been followed up on. During an interview on 12/31/25 at 11:16 A.M., the Administrator said he expects the facility to follow up on grievances as they come up and said the forms are available if needed and said residents, and visitors can ask staff to fill out a form if they have a concern. The Administrator said staff take care of issues reported during resident council meetings and do not need to fill out grievance forms for every issue.

Based on observation, record review and interview, the facility failed to implement interventions related to fall care plans for one Resident (#62) out of a total of 31 sampled Residents. Findings include: Resident #62 was admitted to the facility in September 2019 with diagnosis including non-traumatic brain dysfunction, dementia and history of falls. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #62 was unable to participate in the Brief Interview for Mental Status Exam and staff assessed him/her as having severely impaired cognitive skills. The MDS also indicated Resident #62 required assistance with transfers, bathing, dressing and toileting. Review of Resident #62 Fall Risk assessment dated [DATE] indicated he/she was identified as being at high risk for falls. Review of Resident #62's Risk for falling care plan dated 3/24/24 indicated the following intervention: Place call don't fall signs in room and bathroom, 6/12/25. On 12/29/25 at 11:13 A.M., the surveyors observed Resident #62 attempting to toilet himself/herself in the bathroom. There was no sign in place indicating call don't fall per the plan of care.On 12/29/25 at 5:07 P.M., the surveyors observed Resident #62 lying in bed. There were no signs in the room indicating call don't fall per the plan of care. On 12/30/25 at 7:34 A.M., the surveyor observed Resident #62's room. There were no signs in the room indicating call don't fall per the plan of care.During an interview on 12/30/25 at 2:10 P.M., Unit Manager #1 said that Resident #62 is a fall risk and has had multiple falls in the past. Unit Manager #1 said that after a resident has a fall the care plan is updated with new interventions, but she was unsure how to access the care plans. Unit Manager said that interventions utilized in the past related to falls included testing for a urinary tract infection, rehab consults and placing call don't fall signs in his/her room because the resident does not remember to call for assistance. Unit Manager #1 said the signs should have been in place since it was implemented and she was not aware the signs were not in the room. Unit Manager #1 said interventions on resident care plans should be in place. During an interview on 12/30/25 at 2:20 P.M., Certified Nurses Aid (CNA) #3 said she had been caring for Resident #62 for a year and a half. CNA #3 said that Resident #62 is a fall risk and has had some falls in the past. CNA #3 did not respond to questions related to the placement of the call don't fall sign as an intervention.

Based on observation, record review, and interview, the facility failed to implement treatment recommendations related to pressure ulcers for one Resident (#48), out of a total of 31 sampled Residents. Specifically, the facility failed to implement a). heel booties (a device utilized to reduce pressure on the heels) as indicated by the Nurse Practitioner and b). failed to implement the use of skin prep timely to a deep tissue injury (DTI; a skin injury caused by pressure) as indicated by the Wound Physician. Findings include:Resident #48 was admitted to the facility in September 2021 with diagnoses including unspecified dementia and osteoarthritis. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #48 is severely cognitively impaired as evidenced by a score of two out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). Additional review of the MDS indicated Resident #48 is at risk for the development of pressure ulcers. Review of Resident #48's care plans indicated: Problem: Resident has increased risks of complications r/t (related to) left foot wound, initiated 10/31/25. Interventions: Treatment to area per MD orders, 10/31/25. a. Review of the Nurse Practitioner Note dated 10/22/25 indicated: since BLE (bilateral lower extremities) are rigid and his/her left foot presses into Right foot, informed nursing he/she should be wearing heel booties to off load pressure at all times, avoid tight fitting shoes (slippers were fitting ok tonight). Nursing aware to order heel booties to off load pressure. Review of the physician orders and care plans failed to indicate the booties were implemented. On 12/29/2025 at 8:30 A.M., the surveyor observed Resident #48 in bed. Resident #48 was unable to participate in the interview process. Resident #48 appeared thin and frail and was resting on an air mattress (a specialty mattress utilized to reduce pressure.) There were no heel booties in place. The Nurse Practitioner no longer practiced at the facility and was unavailable for interview. During an interview on 12/31/25 at 11:59 A.M., Nurse #2 said that Resident #48 had developed wounds, but she could not recall if he/she utilized booties. Nurse #2 then reviewed the clinical record and said heel booties were not ordered. On 12/31/25 at 12:02 P.M., Resident #48 was observed in a reclining wheelchair. He/she was not wearing heel booties. During an interview on 12/31/25 at 12:03 P.M., Certified Nursing Aid (CNA) #1 said she takes care of Resident #48 and he/she has never had heel booties. During an interview on 12/31/2025 at 9:00 A.M Nurse #1 said she had been covering Resident #48's unit while Unit Manager #2 was out on medical leave. Nurse #1 and the surveyor reviewed the Nurse Practitioner note and said that nursing should have implemented the use of heel booties for Resident #48. During an interview on 12/31/2025 at 9:22 A.M., the Director of Nursing said that the Nurse Practitioner should have put in an order for the use of heel booties. b. Review of the Wound Physician note dated 10/23/25, indicated: Unstageable DTI of the left distal medial foot, undetermined thickness. DTI with intact skin. 1 CM (centimeter) X .08. Treatment: skin prep, apply once daily and as needed. Review of the physician orders failed to indicate the skin prep was implemented until 10/29/25; six days after the Wound Physician made his recommendation. During an interview on 12/31/25 at 12:03 P.M., Certified Nursing Aid (CNA) #1 said she takes care of Resident #48 and he/she has never had heel booties. During an interview on 12/31/2025 at 8:52 A.M., The Wound Physician said that he rounds the facility weekly with nursing staff who then input his treatment recommendations as orders. The Wound Physician said he was not aware of a delay in the use of skin prep. During an interview on 12/31/2025 at 9:00 A.M. Nurse #1 said she had been covering Resident #48's unit while Unit Manager #2 was out on medical leave. Nurse #1 said that the Wound Physician rounds with the nursing staff and then faxes over his recommendations which are then put into the record as orders. Nurse #1 said that she was not aware of a delay in implementing skin prep to Resident #48's wound. During an interview on 12/31/2025 at 9:22 A.M., the Director of Nursing said that Unit Managers input the treatment recommendations made by the Wound Physician as orders into the clinical record and she was not aware of a delay in implementing skin prep for Resident #48.

Based on observation, record review and interview the facility failed to provide a dignified existence for two Residents (#222 and #23) out of a total sample of 24 residents, and for residents on three of four units. Specifically: 1.) For Resident #222, the facility failed to maintain his/her urinary catheter bag in a privacy bag; 2.) For Resident #23, the facility failed to provide a dignified dining experience; and 3.) The facility failed to provide a dignified dining experience on Station 2 unit for residents dependent on staff for eating. 4.) The facility failed to ensure a dignified dining experience on Station 4 unit, when staff was observed using their cell phone during the lunch meal while assisting residents during the meal. Findings include: The facility policy titled 'Dignity', dated as revised 3/28/19, indicated it is the policy of [NAME] Manor Nursing Center to provide care in a dignified manner and to promote a lifestyle that is dignified and respectful to the resident. The facility policy titled 'Indwelling Foley Catheter Care', not dated, indicated that to ensure resident dignity, place catheter drainage bag into a dignity bag. 1.) Resident #222 was admitted to the facility in December 2024 with diagnoses including bladder cancer, pelvic fracture and heart disease. Review of the most recent Minimum Data Set assessment, dated 3/16/24, indicated Resident #222 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. On 12/3/24 at 8:08 A.M., the surveyor observed Resident #222 in bed and his/her urinary catheter bag was visible from the hallway. The urinary catheter bag was not in a privacy bag. During an interview on 12/3/24 at 8:08 A.M., Resident #222 said he/she has a urostomy (a means by which urine drains directly from the kidney circumventing the bladder). Resident #222 said he/she prefers to keep things private and that the urinary catheter bag be covered. Resident #222 said he/she was embarrassed by the exposed urinary catheter bag. On 12/4/24 at 7:20 A.M., the surveyor observed Resident #222 in his/her room and the urinary catheter bag was exposed and visible from the hallway. During an interview on 12/4/24 10:35 A.M., Charge Nurse #1 said that it is the Certified Nurse's Aides and the nurse's responsibility to place catheter bags inside of the privacy bags. 41105 2.) Resident #23 was admitted to the facility in October 2018 and had diagnoses that include Alzheimer's dementia, left eye blindness and unspecified cataract. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/22/24, indicated Resident #23 was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #23 had no behavior of rejecting care. Review of the current Activities of Daily Living (ADL) care plan, last revised 11/26/24, indicated Resident #23 required partial to moderate assistance for eating. Review of the POC (point of care) documentation for 11/28/24 through 12/4/24 indicated that Resident #23 varied between requiring substantial/maximal assistance with eating to dependent. Review of the most recent dietitian progress note, dated 11/21/24, indicated Resident #23 is no longer able to feed him/herself at meals and requires moderate physical assist to complete his/her meals. Review of the most recent Nurse Practitioner note, dated 9/26/24, indicated Resident #23 is dependent for all his/her care/ADLs. On 12/3/24 at 8:39 A.M., Resident #23 was observed seated in the unit dining room with a plate of food in front of him/her. Resident #23 watched his/her table mate eating. At 8:45 A.M., 6 minutes later, a nurse sat down beside Resident #23 to assist with feeding. On 12/3/24 between 12:39 P.M., and 12:50 P.M., Resident #23 was observed seated in the unit dining room. Resident #23's plate of food was out of reach and Resident #23 watched his/her tablemate being fed by staff and periodically looked over at his/her plate of food. On 12/4/24 at 8:37 A.M., a staff person served Resident #23 in the unit dining room. The staff person placed the breakfast in front of Resident #23, then without offering assistance, walked away and continued passing meals out to other residents. The surveyor continued to make the following observations: - At 8:39 A.M., Resident #23 stuck his/her hand into the syrup on the plate and a moment later wiped the hand on his/her neck. - At 8:43 A.M., a staff person walked over to Resident #23's table, stood beside him/her and while looking down at Resident #23 placed a spoonful of food in his/her mouth, then turned around and walked away to feed another resident. - At 8:46 A.M., the staff returned to Resident #23, stood beside him/her and without speaking a word, placed a spoonful of food in Resident #23's mouth then walked away. During an interview on 12/5/24 at 8:16 A.M., Nurse Unit Manager #2 said that staff should not be standing while feeding residents but rather seated at eye level interacting with the resident as they feed them. As well, she said that residents that require feeding assistance should not be served until staff are ready to provide the assistance. During an interview on 12/5/24 at 8:28 A.M., the Director of Nursing (DON) said staff should be seated at eye level when feeding and should not leave food sitting in front of dependent residents until they are ready to feed them. 3.) During an observation on the Station 2 unit during the breakfast meal on 12/4/24 the surveyor made the following observations: - Between 8:43 A.M., and 8:50 A.M., a staff person walked around the dining room from resident to resident, standing over each resident, placing a spoonful of food in their mouth then walking away. The staff member repeated the same action with each additional resident. During an observation on the Station 2 unit during the lunch meal on 12/4/24, the surveyor made the following observations beginning at 12:41 P.M.: - Two residents were seated at a table (#1) with plates of food in front of them waiting to be fed by staff; and - Two residents were seated at a table (#2). One of the residents was waiting to be fed by staff while watching the tablemate being fed. - At 12:47 P.M., a Certified Nursing Assistant (CNA) sat down at table #1 and began feeding one of the two residents at the table. - 10 minutes after the initial observation, at 12:51 P.M., the second residents at table #1 and table #2 continued to sit with the plate of food in front of them watching their tablemates be fed. During an interview on 12/5/24 at 8:16 A.M., Nurse Unit Manager #2 said that staff should not be standing while feeding residents but rather seated at eye level interacting with the resident as they feed them. As well, she said that residents that require feeding assistance should not be served until staff are ready to provide the assistance. During an interview on 12/5/24 at 8:28 A.M., the Director of Nursing (DON) said staff should be seated at eye level when feeding residents and should not leave food sitting in front of dependent residents until they are ready to sit down beside the resident and feed them. 36431 4.) During an observation of the lunch meal at Station 4, and interview on 12/4/24 at 12:40 P.M., the surveyor observed a Certified Nursing Assistant (CNA) sitting at a table with four residents using her phone. The CNA said she was assisting one of the resident with his/her meal and should not have been on her phone. During an interview on 12/4/24 at 1:16 P.M., Nurse Unit Manager #3 said staff should not be using their cell phones in resident care areas.

Based on record review and interview, the facility failed to ensure staff developed and implemented a baseline care plan for four Residents (#103, #41, #25, and #69), out of a total sample of 24 residents. Specifically, the facility failed to develop a baseline care plan within 48 hours of the Resident's admissions, which included the instructions needed to provide effective and person-centered care to the Residents with Dementia which meet professional standards of quality care. Findings include: Review of the facility policy titled 'Baseline Care Plans', dated revised November 2017, indicated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. 1.) Resident #103 was admitted to the facility in January 2024 with diagnoses including dementia and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/13/24, indicated that Resident #103 had severe cognitive impairment as evidenced by a staff assessment for Brief Interview for Mental Status (BIMS). Review of the medical record failed to indicate that a baseline care plan for dementia was developed within the required 48 hours of admission. Review of the comprehensive care plan failed to indicate that the facility developed individualized interventions related to Resident #103's dementia and rate of progression. Further review of the comprehensive care plan failed to indicate that Resident #103 had dementia. During an interview on 12/4/24 at 1:07 P.M., Nurse Unit Manager #3 said that nursing staff should have developed a baseline care plan for Resident #103 within 48 hours of admission to the facility. 2.) Resident #41 was admitted to the facility in September 2024 with diagnoses including dementia and bipolar disorder. Review of the most recent MDS assessment, dated 9/17/24, indicated that Resident #41 had severe cognitive impairment as evidenced by a BIMS score of 6 out of 15. Review of the medical record failed to indicate a baseline care plan was developed within 48 hours of admission to the facility. During an interview on 12/4/24 at 1:07 P.M., Nurse Unit Manager #3 said that nursing staff should have developed a baseline care plan for Resident #41 within 48 hours of admission to the facility. 3.) Resident #25 was admitted to the facility in March 2024 with diagnoses including dementia, depression, and anxiety. Review of the most recent MDS assessment, dated 9/13/24 indicated that Resident #25 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15. Review of the medical record failed to indicate a baseline care plan was developed within 48 hours of admission to the facility. During an interview on 12/4/24 at 1:07 P.M., Nurse Unit Manager #3 said that nursing staff should have developed a baseline care plan for Resident #25 within 48 hours of admission to the facility. 36797 4.) Resident #69 was readmitted to the facility in August 2024 with diagnoses including dementia, metabolic encephalopathy and acute kidney injury. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #69 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam and was severely cognitively impaired. Review of the medical record failed to indicate that a baseline care plan for dementia was developed within the required 48 hours of admission. Review of the comprehensive care plan failed to indicate that the facility developed individualized interventions related to Resident #69's dementia and rate of progression. Further review failed to indicate that Resident #69 had dementia. During an interview on 12/4/24 at 11:49 A.M., Nurse Unit Manager #1 said that any resident with a diagnosis of dementia should have a specific baseline care plan for dementia initiated upon admission and then revised as there are changes in cognition. Nurse Unit Manager #1 then said that if a resident is readmitted to the facility after being hospitalized for a number of days then a new baseline care plan should be developed and the comprehensive care plan revised as needed.

Based on interview and record review the facility failed to ensure that residents' individualized dementia care needs are met through the assessment, development, and implementation of care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative for five Residents (#21, #103, #41, #25, and #69), out of a total sample of 24 residents. Specifically, for Residents #21, #103, #41, #25, and #69, the facility failed to develop an interdisciplinary dementia care plan to ensure the Resident received appropriate treatment and services specific to his/her needs for dementia care. Findings include: S483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Review of the document titled 'Dementia Special Care Unit (DSCU) Disclosure Form' indicated on 2/28/2024 the facility disclosed they meet the specific state licensure requirements to provide specialized care for resident with dementia. 1.) Resident #21 was admitted to the facility in August 2024 and had a diagnosis of unspecified dementia, severe with agitation. Review of Resident #21's Minimum Data Set (MDS) assessment, dated 11/8/24, indicated he/she scored 2 out of 15 on the Brief Interview for Mental Status exam indicating Resident #21 as having severe cognitive impairment and is dependent on staff for all self-care daily activities. Further, the MDS indicated Resident #21 displayed behaviors of delusions, physical and verbal behaviors, and rejected care. On 12/4/24 at 8:33 A.M., Resident #21 was observed resting in bed. He/she did not respond to the surveyor's greeting. On 12/4/24 review of the Care Area Assessment (CAA) Summary (Part of a comprehensive MDS, to assist in developing the resident care plans) indicated that Resident #21 triggered cognitive loss/dementia. Review of the active care plans failed to indicate a person-centered care plan for dementia with a measurable goal and individualized interventions was developed. During an interview on 12/4/24 at 11:21 A.M., MDS Nurse #2 said the MDS nurse did not develop a care plan for dementia care for Resident #21 and said the CAA referred to Social Services who should have developed a care plan specific to Resident #21's cognitive loss/dementia diagnosis. During an interview on 12/4/24 at 11:47 A.M., Social Worker #1 said Resident #21 is confused related to dementia and requires a great deal of care and supervision from the specialized dementia care unit. Social Worker #1 said she did not develop a specific dementia care plan. During an interview on 12/4/24 at 1:08 P.M., Nurse Unit Manager #3 said a resident with a diagnosis of dementia should have a dementia care plan with individualized interventions. 50338 2.) Resident #103 was admitted to the Facility in May 2024 with diagnoses including dementia and Parkinson's disease. Resident #103 resides on the designated DSCU. Review of the most recent MDS assessment, dated 9/13/24, indicated that Resident #103 had severe cognitive impairment as evidenced by a staff assessment for Brief Interview for Mental Status (BIMS). Review of the clinical record indicated no development of an interdisciplinary dementia care plan. During an interview on 12/4/24 at 1:07 P.M., Nurse Unit Manager #3 said he would expect a dementia care plan to have been developed as the Resident lives on a DSCU (Dementia Special Care Unit) and clearly has dementia. 3.) Resident #41 was admitted to the facility in September 2024 with diagnoses including dementia and bipolar disorder. Resident #41 resides on the designated DSCU. Review of the most recent MDS assessment, dated 9/17/24, indicated that Resident #41 had severe cognitive impairment as evidenced by a BIMS score of 6 out of 15. Review of the clinical record indicated no development of an interdisciplinary dementia care plan. During an interview on 12/4/24 at 1:07 P.M., Nurse Unit Manager #3 said he would expect a dementia care plan to have been developed as the Resident lives on a DSCU (Dementia Special Care Unit) and clearly has dementia. 4.) Resident #25 was admitted to the facility in March 2024 with diagnoses including dementia, depression, and anxiety. Resident #25 resides on the designated DSCU. Review of the most recent MDS assessment, dated 9/13/24 indicated that Resident #25 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15. Review of the clinical record indicated no development of an interdisciplinary dementia care plan. During an interview on 12/4/24 at 1:07 P.M., Nurse Unit Manager #3 said he would expect a dementia care plan to have been developed as the Resident lives on a DSCU (Dementia Special Care Unit) and clearly has dementia. 36797 5.) Resident #69 was readmitted to the facility in August 2024 with diagnoses including dementia, metabolic encephalopathy and acute kidney injury. Review of the Minimum Data Set (MDS) assessment, dated 8/23/24, indicated that Resident #69 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam and was severely cognitively impaired. Review of the medical record failed to indicate that a baseline care plan for dementia was developed. Review of the comprehensive care plan failed to indicate that the facility developed individualized interventions related to Resident #69's dementia and rate of progression. Further review of the comprehensive care plan failed to indicate that Resident #69 had dementia. During an interview on 12/4/24 at 11:49 A.M., Nurse Unit Manager #1 said that any resident with a diagnosis of dementia should have a specific baseline care plan for dementia initiated upon admission and then revised as there are changes in cognition. Nurse Unit Manager #1 then said that if a resident is readmitted to the facility after being hospitalized for a number of days then a new baseline care plan should be developed and the comprehensive care plan developed and revised as needed.

Based on observation, record review and interview the facility failed to accurately document in the medical record for four Residents (#77, #57, #53, and #32) out of a total sample of 24 residents. 1.) For Resident #77 and #57, the facility documented padded side rails were in place when the Residents were in bed, when they were not. 2.) For Resident #53, the facility documented that the Resident's oxygen tubing was changed when it was not. 3.) For Resident #32, the facility documented that a palmar guard (a device for contracture management) had been applied when it was not. Findings include: Review of the undated facility policy titled 'Documentation', dated January 2008, indicated the following: - Documentation should be an accurate written account of the resident's current condition, response to events and to medication, care and treatment. - Documentation should be accurate, current, brief, concise and legible. 1a.) Resident #77 was admitted to the facility in April 2022 and had diagnoses that include Alzheimer's dementia and weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/27/24, indicated that on the Brief Interview for Mental Status exam Resident #77 scored a 5 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #77 had no behaviors. Review of the current physician's orders indicated an order for padded side rails when in bed due to agitation, with a start date of 1/30/24. On 12/3/24 at 8:23 A.M., Resident #77 was observed in bed asleep. Both side rails were up and neither were padded. On 12/4/24 at 8:10 A.M., Resident #77 was observed in bed asleep. Both side rails were up and neither were padded. On 12/4/24 at 8:48 A.M., Resident #77 was observed in bed asleep. Both side rails were up and neither were padded. On 12/4/24 at 11:09 A.M., Resident #77 was observed in bed asleep. Both side rails were up and neither were padded. On 12/5/24 at 7:53 A.M., Resident #77 was observed in bed. Both side rails were up and neither were padded. Review of the December 2024 Treatment Administration Record (TAR) indicated that nursing had documented on 12/3/24 and 12/4/24, all three shifts that the side rails were padded while Resident #77 was in bed and had documented on the 12/5/24 day shift that the padded side rails were in place, contrary to direct observation by the surveyor. During an interview on 12/5/24 at 8:07 A.M., the surveyor shared the three days of observations of Resident #77 in bed without padded siderails with Nurse Unit Manager #2. Nurse Unit Manager #2 and the surveyor reviewed the TAR together and she said that the staff should not be documenting that the side rails are padded when they are not. During an interview on 12/5/24 at 8:26 A.M., the Director of Nursing (DON) said that it is her expectation that if a resident has orders for side rails to be padded when in bed, that the order be followed. As well, it is her expectation that the documentation in the TAR be accurate and that if for some reason a resident refuses or removes padding that nursing document that. 1b.) Resident #57 was admitted to the facility in April 2023 and had diagnoses that include epilepsy, dementia and a history of falling. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/27/24, indicated Resident #57 was assessed by staff to have severely impaired cognition. The MDS further indicated that Resident #57 had no behaviors. Review of the current physician's orders indicated an order, with a start date of 4/4/23, for padded side rails while in bed, every shift. On 12/3/24 at 8:29 A.M., Resident #57 was observed in bed. Both side rails were up. The right side rail was padded and the left side rail was not. On 12/3/24 at 12:52 P.M., Resident #57 was observed in bed asleep. Both side rails were up. The right side rail was padded and the left side rail was not. On 12/4/24 at 8:07 A.M., Resident #57 was observed in bed asleep. Both side rails were up. The right side rail was padded and the left side rail was not. On 12/4/24 at 8:49 A.M., Resident #57 was observed in bed asleep. Both side rails were up. The right side rail was padded and the left side rail was not. On 12/4/24 at 10:49 A.M., Resident #57 was observed in bed asleep. Both side rails were up. The right side rail was padded and the left side rail was not. On 12/5/24 at 7:52 A.M., Resident #57 was observed in bed asleep. Both side rails were up. The right side rail was padded and the left side rail was not. Review of the December 2024 Treatment Administration Record (TAR) indicated that nursing had documented on 12/3/24 and 12/4/24, all three shifts that the side rails were padded while Resident #57 was in bed, contrary to direct observation by the surveyor. During an interview on 12/5/24 at 8:07 A.M., the surveyor shared the three days of observations of Resident #57 in bed without a left siderail padded with Nurse Unit Manager #2. Nurse Unit Manager #2 and the surveyor reviewed the TAR together and she said that the staff should not be documenting that the side rails are padded when they are not. During an interview on 12/5/24 at 8:26 A.M., the Director of Nursing (DON) said that it is her expectation that if a resident has orders for side rails to be padded when in bed, that the order be followed. As well, it is her expectation that the documentation in the TAR be accurate and that if for some reason a resident refuses or removes padding that nursing document that. 45763 2.) Resident #53 was admitted to the facility in November 2020 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the most recent Minimum Data Set (MDS) assessment, dated 10/4/24, indicated that Resident #53 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating the Resident was cognitively intact. Review of Resident #53's care plan indicated that the Resident had impaired gas exchange related to COPD and received supplemental oxygen. Review of Resident #53's current physician's orders indicated the following active order: - Change oxygen tubing weekly on Monday, initiated 12/1/22. On 12/3/24 at 8:33 A.M. and 10:45 A.M., the surveyor observed that Resident #53's nasal canula tubing was dated 10/29/24, indicating the tubing was last changed five weeks ago. Review of Resident #53's Medication Administration Record (MAR) indicated that nursing had documented the the oxygen tubing was changed on 11/1/24, 11/11/24, 11/18/24, and 11/25/24. During an interview on 12/4/24 at 12:29 P.M., the Director of Nursing (DON) said that nurses should not document in the MAR that they had changed the oxygen tubing, if they had not. 36431 3.) Resident #32 was admitted to the facility in October 2020 and had diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting his/her right dominant side. Review of the Minimum Data Set assessment, dated 9/13/24, indicated Resident #32 scored a 9 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderately impaired cognition, displays physical and other behaviors, and does not display behaviors of rejecting care. Further the MDS indicated Resident #32 had functional limitation in range in motion of his/her upper extremity on one side. Review of Resident #32's medical record indicated the following: - A physician's order, dated 2/7/24, [NAME] (put on) right [NAME] guard as tolerated, may remove for skin hygiene, twice a day; 23:00-07:00, 15:00-23:00 (11:00 P.M-7:00 A.M., 3:00 P.M.-11:00 P.M.) On 12/3/24 at 12:57 P.M., Resident #32 was observed with his/her lunch tray, with a Certified Nursing Assistant (CNA) sitting with him/her. Resident #32 had a Geri-sleeve on his/her right forearm. Resident #32's 4th and 5th fingers on his/her right hand were bent towards his/her palm. There was no palmar guard in the residents' vicinity. When asked if he/she wore a splint/brace on his/her right hand Resident #32 shook his/her head as in 'no'. On 12/3/24 at 4:26 P.M., Resident #32 was observed in bed. His/her right hand did not have a palmar guard applied. There was no palmar guard in or around the Resident's room. On 12/4/24 at 3:34 P.M., Resident #32 was observed in bed. His/her right hand did not have a palmar guard applied and no palmar guard was in the Resident's vicinity. On 12/5/24 at 6:50 A.M., Resident #32 was observed in bed. His/her right hand did not have a palmar guard applied and no palmar guard was in the Resident's area. During an interview on 12/5/24 at 6:55 A.M., CNA #4 said he took care of Resident #32 during the 11-7 shift and was not aware of any device that the Resident wears on his/her right hand. During an interview on 12/5/24 at 7:03 A.M., Nurse #6 said the Resident wears a Geri-sleeve on his/her right arm to prevent him/her from scratching. When asked about the palmar guard Nurse #6 said the Resident has behaviors and may not wear it. Nurse #6 said if the Resident refuses to wear it then it should be documented as a refusal and not signed off as being donned on the Treatment Administration Record. Nurse #6 and the surveyor went to Resident #32's room and she had difficulty locating the palmar guard, which was under items in the bottom drawer of the dresser. Review of the progress notes, dated 12/3/24 through 12/5/24, failed to indicate Resident #32 refused to don the palmar guard. Review of the treatment administration record (TAR) on 12/4/24 indicated the palmar guard as signed off as donned on the 3-11 shift on 12/3/24 and 11-7 shift on 12/3/24. During an interview on 12/5/24 at 9:08 A.M., Nurse Unit Manger #3 said Resident #32 has behaviors and does not always permit the palmar guard to be donned. Nurse Unit Manager #3 said the palmar guard is for the Resident's right hand contractures, so it does not worsen. Nurse Unit Manager #3 said the nurses should be donning the palmar guard and should not be documenting on the TAR that it is on when it is not. Nurse Unit Manager #3 said a referral to rehab should be made if a Resident does not use a recommended intervention.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#118) did not self-administer medications out of a total sample of 24 residents. Specifically, Resident #118 was observed with pills left at bedside for self-administration after he/she was assessed to not be able to self-administer medications. Findings include: Review of the facility policy titled 'Medication Administration - Self-Administration by Resident', dated 11/17, indicated: - If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. - The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. Review of the facility policy titled 'Medication Administration - General Guidelines', dated 9/18, indicated: - Medications are to be administered at the time they are prepared. - The person who prepares the dose for administration is the person who administers the dose. - The resident is always observed after administration to ensure the dose was completely ingested. Resident #118 was admitted to the facility in November 2024 with diagnoses including adult failure to thrive and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/12/24, indicated Resident #118 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #118's assessment titled 'New Admission - Self Administration of Medications', dated 11/6/24, indicated: - Due to the resident's cognitive, physical, or visual ability, the Interdisciplinary Team feels this resident is not a candidate for self-administration of medications at this time. On 12/3/24 at 8:27 A.M., the surveyor observed two brown pills in a medication cup on Resident #118's bedside table. Resident #118 was not in the room. During an interview on 12/3/24 at 8:28 A.M., Nurse #2 said Resident #118 went out to an appointment. Nurse #2 entered Resident #118's room and visualized the two brown pills on the bedside table. Nurse #2 said the last nurse must have left them there but should not have. During an interview on 12/3/24 at 2:11 P.M., Resident #118 said last night the nurse left his/her pills on the bedside table for him/her to self-administer later because he/she was sleeping. Resident #118 said he/she took the rest of them but decided not to take the two brown pills so that was why those pills were still on his/her bedside table when he/she left for an appointment. During an interview on 12/4/24 at 11:58 A.M., Charge Nurse #1 reviewed Resident #118's assessment titled 'New Admission - Self Administration of Medications', dated 11/6/24, and said based on this assessment Resident #118 should never self-administer medications. Charge Nurse #1 said Resident #118 was never reassessed for self-administration of medication since that assessment, dated 11/6/24, and the pills should never have been left at her bedside unattended. During an interview on 12/4/24 at 12:30 P.M., the Director of Nursing (DON) said on admission Resident #118 was determined to not be able to self-administer any medication. The DON said Resident #118 should not have had any medications or pills left at bedside for self-administration.

Based on observation, record review and interview the facility failed to investigate bruises of unknown etiology for one Resident (#4) out of a total sample of 24 residents. Findings include: Review of the facility policy titled 'Incident and Accident Investigating and Reporting', dated as revised 5/22/19, indicated that for a bruise of unknown origin, the facility should obtain caregiver statements from the proceeding 24 hours. Resident #4 was admitted to the facility in December 2016 with diagnoses including Alzheimer's dementia, kidney disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #4 is severely cognitively impaired, rarely/never understood and requires maximum assistance with activities of daily living. On 12/3/24 at 9:28 A.M., the surveyor observed Resident #4. The Resident had dark purple areas, consistent with bruises, on both the right and left hands, in between the forefingers and thumbs and covering the dorsal aspect of each hand. Review of the medical record failed to indicate that Resident #4 had bruises on his/her hands. Review of Resident #4's weekly skin checks, dated 11/6/24, 11/13/24, 11/20/24 and 11/27/24, indicated that there were no new skin conditions and that Resident #4's skin was intact. Review of the progress notes for November and December 2024 failed to indicate Resident #4 had bruised hands. During an interview on 12/3/24 at 1:25 P.M., Nurse #2 said that she noticed the bruises that morning but did not tell the charge nurse and should have, in order to start an investigation. During an interview on 12/3/24 at 1:20 P.M., Charge Nurse #1 said that she had not been made aware of the bruises. Charge Nurse #1 said that an investigation should have been started as a bruise of unknown etiology would need to be reported to the state agency with in the required two hour time frame. Charge Nurse #1 said that the lab would not draw blood from the bruised areas. Review of the facility document titled 'Incident/Accident Report', dated 11/18/24, at 1:00 P.M., indicated that Resident #4 had a bruise on his/her left hand. The document failed to indicate that there was a bruise on the right hand. Review of the facility document titled 'Incident/Accident Statement', dated 11/18/24, indicated that Certified Nurse Assistant (CNA) #1 stated that (Resident #4) was fighting with care. (He/she) hit hand off bedrail. I told the nurse (his/her) hand was red. Further review failed to indicate the CNA was questioned as to when he saw the bruising, before or after the Resident hit the siderail with his/her hand. During an interview on 12/3/24 at 2:38 P.M., CNA #1 said that he saw the bruises before he started providing morning care a few weeks ago and before the Resident hit his/her hand on the bedrail. CNA #1 then said that he should have reported the bruise immediately to the manager but he couldn't find her. He said he is supposed to tell the manager about anything he sees that is different before he leaves for the day. He said he told the unit manager in the afternoon. Review of the medical record failed to indicate any other staff members where questioned in relation to the bruised hands. During an interview on 12/4/24, at 12:40 P.M., the Director of Nursing (DON) said that she was not aware of the bruised hands and had not investigated either hand. The DON then said that the bruises should have been investigated thoroughly and reported to the state agency. During an interview on 12/4/24 at 2:30 P.M., The Staff Development Coordinator (SDC) said that she had not been made aware of the bruised right hand and was only made aware of the bruise on the left hand as documented on the incident report, dated 11/18/24. The SDC said that she didn't report the bruise to administration because she thought it was witnessed.

Based on record review and interview, the facility failed to report bruises of unknown origin to the state agency as required for one Resident (#4) out of a total of 24 sampled residents. Findings include: Review of the facility policy titled 'Incident and Accident Investigating and Reporting', dated as revised 5/22/19, failed to indicate that injuries of unknown origin are to be reported to the state agency within the required two hour time frame. Resident #4 was admitted to the facility in December 2016 with diagnoses including Alzheimer's dementia, kidney disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #4 is severely cognitively impaired, is rarely/never understood and requires maximum assistance with activities of daily living. On 12/3/24 at 9:28 A.M., the surveyor observed Resident #4. The Resident had dark purple areas, consistent with bruises, on both the right and left hands, in between the forefingers and thumbs and covering the dorsal aspect of each hand. Review of the medical record failed to indicate that Resident #4 had bruises on his/her hands. Review of Resident #4's weekly skin checks, dated 11/6/24, 11/13/24, 11/20/24 and 11/27/24, indicated that there were no new skin conditions and that Resident #4's skin was intact. Review of the progress notes for November and December 2024 failed to indicate Resident #4 had bruised hands. During an interview on 12/3/24 at 1:25 P.M., Nurse #2 said that she noticed the bruises on Resident #4 that morning but did not tell the charge nurse and should have, in order to start an investigation. Nurse #2 then said that the lab would not draw blood from the bruised areas. During an interview on 12/3/24 at 1:20 P.M., Charge Nurse #1 said that she had not been made aware of the bruises on Resident #4. Charge Nurse #1 then said that an investigation should have been started as a bruise of unknown etiology should have been reported to the state agency with in the required two hour time frame. Charge Nurse #1 then said that the lab would not draw blood from the bruised areas. Review of the facility document titled 'Incident/Accident Report', dated 11/18/24, at 1:00 P.M., indicated that Resident #4 had a bruise on his/her left hand. The document failed to indicate that there was a bruise on the right hand. Further review indicated that Patient combative with care, seen that (he/she) hit (his/her) hand off the bedrail. Review of the facility document titled 'Incident/Accident statement', dated 11/18/24, indicated that Certified Nurse Assistant (CNA) #1 stated that (Resident #4) was fighting with care. (He/she) hit hand off bedrail. I told the nurse (his/her) hand was red. Further review failed to indicate the CNA was questioned as to when he saw the bruising, before or after the Resident hit the siderail with his/her hand. During an interview on 12/3/24 at 2:38 P.M., CNA #1 said that he saw the bruises before he started providing morning care to Resident #4 a few weeks ago and before the Resident hit his/her hand on the bedrail. CNA #1 then said that he should have reported the bruise immediately to the manager but he couldn't find her. He said he is supposed to tell the manager about anything he sees that is different before he leaves for the day. He said he told the unit manager in the afternoon. Review of the medical record failed to indicate any other staff members where questioned in relation to the bruised hands. During an interview on 12/4/24 at 2:30 P.M., The Staff Development Coordinator (SDC) said that she had not been made aware of the bruised right hand and was only made aware of the bruise on the left hand as documented on the incident report, dated 11/18/24. The SDC said that she didn't report the bruise to administration because she thought it was witnessed. During an interview on 12/04/24 at 12:40 P.M., the Director of Nursing said that all injuries of unknown origin should be reported to the state agency within the required two hour timeframe.

Based on record review and interview, the facility failed to ensure person-centered care plans with measurable goals and individualized interventions were developed and implemented for one Resident (#103), out of 24 sampled residents. Specifically, for Resident #103, the facility failed to develop a plan of care related to activities of daily living (ADL's) and the use of psychotropic medication. Findings include: Review of Facility policy titled 'Care Plans Comprehensive, Resident', dated March 2010, comprehensive care plans are developed by the members of the Interdisciplinary Team (IDT)/healthcare proxy/resident and the comprehensive assessment form (MDS), ancillary assessments, MD orders/progress notes, hospital documentation and resident/family/other interviews are used to develop the individual comprehensive care plan(s) for the resident. According to the Resident Assessment Instrument (RAI), which is a comprehensive assessment tool used in Long-Term Care to identify resident's needs, preferences, and strengths, for each triggered care area, Care Planning Decision is checked to indicate that a new care plan, care plan revision, or continuation of the current care plan is necessary to address the issue(s) identified in the assessment of that care area. Resident #103 was admitted to the facility in January 2024 and had diagnoses that include dementia with psychotic disturbance, Parkinson's disease, and difficulty walking. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/13/24, indicated Resident #103 had a staff assessment for Brief Interview for Mental Status (BIMS) that indicated severe cognitive impairment, was dependent with ADL's, and was taking an antipsychotic medication. Review of the comprehensive MDS, dated [DATE], indicated at section GG that Resident #103 required dependence with ADL's. Review of the Care Area Assessment Summary (CAA's) ADL function/rehabilitation potential r/t (related to) needing dependence with ADLs would be addressed in a care plan. Review of the comprehensive MDS, dated [DATE], indicated at section N that Resident #103 was taking a psychotropic medication. Review of the CAA's Psychotropic drug use r/t taking psychotropic medication would be addressed in care plan. Review of the medical record failed to include individualized interventions related to Resident #103's ADL needs or his/her psychotropic medication monitoring. Review of Resident #103's care plans failed to indicate a care plan for Resident's ADL needs and for the use of psychotropic medication was developed. During an interview on 12/4/24 at 11:21 A.M., MDS Nurse #2 said the MDS nurse did not develop a care plan for ADL and psychotropic mediation care for Resident #103 and said the CAA referred to Nursing who should have developed a care plan specific to Resident #103's needs. During an interview on 12/4/24 at 1:07 P.M., Nurse Unit Manager #3 said he develops a resident's care plan based on things including their diagnoses, their medications and other care needs. He said Resident #103 should have a care plan to address ADL needs and use of psychotropic medication.

Based on observation, record review, and interviews, the facility failed to ensure for one Resident (#32), out of a total sample of 24 residents, that the interdisciplinary team reviewed and revised the plan of care after the quarterly review assessment. Specifically, for Resident #32, the facility failed to review and resolve a care plan for a stage 3 left heel pressure ulcer. Findings include: Resident #32 was admitted to the facility in October 2020 and had diagnoses that include type 2 diabetes mellitus and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of most recent Minimum Data Set (MDS) assessment, dated 9/13/24, indicated Resident #32 scored a 9 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderately impaired cognition, displays physical and other behaviors, and does not display behaviors of rejecting care. Further the MDS indicated that Resident #32 did not have any unhealed pressure ulcers/injuries. Review of the physician's orders did not indicate a treatment order for a pressure ulcer/pressure injury. Review of Resident #32's active care plans on 12/4/24 at 8:00 A.M., included a care plan with a problem start date of 3/4/24, Resident has a pressure ulcer R/T (related to) left heel stage 3 pressure ulcer. On 12/3/24 at 9:13 A.M., Resident #32 was observed resting on his/her back, his/her bed was equipped with an air mattress and a blanket cradle (a device to keep covers directly on the feet). Resident #32 made eye contact but did not respond when asked if he/she had any wounds. During an interview on 12/4/24 at 8:10 A.M., Nurse #5 said Resident #32 had a pressure ulcer on his/her left heel that healed a long time ago. Nurse #5 said Nurse Unit Manager #3 updates the care plans. During an interview on 12/4/24 at 1:09 P.M., Nurse Unit Manager #3 said care plans are reviewed and updated as needed and in conjunction with the MDS schedule. Unit Manger #3 said the care plan for Resident #32's pressure ulcer should have been resolved during the care plan review after the quarterly MDS completed on 9/13/24.

Based on observation, record review and interview, the facility failed to ensure an intervention for contracture management was implemented in accordance with the medical plan of care for one Resident (#32), out of a total of 24 residents. Findings include: Review of the facility's policy titled 'Positioning Devices', not dated, indicated: It is the policy of the facility to attain and maintain good body alignment. The addition of positioning devices to attain and maintain good body alignment will be based on the rehab department recommendation and approved by the MD/NP (medical doctor/nurse practitioner). Examples of positioning devices could include but are not limited to: - Hand roll or hand grips - Splints Procedure: 1. Rehab screen, 2. Implementation of appropriate positioning device is recommended to MD/NP, 3. Education provided for staff, 4. Monitoring of device for appropriate applications and resident acceptance. Resident #32 was admitted to the facility in October 2020 and had diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting his/her right dominant side. Review of the Minimum Data Set assessment, dated 9/13/24, indicated Resident #32 scored a 9 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderately impaired cognition, displays physical and other behaviors, and does not display behaviors of rejecting care. Further the MDS indicated Resident #32 had functional limitation in range in motion of his/her upper extremity on one side. Review of Resident #32's medical record indicated the following: - A physician's order, dated 2/7/24, [NAME] (put on) right [NAME] guard as tolerated, may remove for skin hygiene, twice a day; 23:00-07:00, 15:00-23:00 (11:00 P.M-7:00 A.M., 3:00 P.M.-11:00 P.M.) - A Resident Daily Care Plan (used by Certified Nursing Aids to breakdown the plan of care), dated March 9, 2023, Splints R (right) [NAME] guard at HS (hour of sleep) as Tol (tolerated). - A care plan, dated 6/11/24, Resident is limited in range of motion to RUE/RLE (Right upper extremity/right lower extremity) R/T (related to) stroke. Goal Resident's RUE/RLE joint contracture will be free from injury and skin breakdown. Approach: Follow PT (physical therapy) and OT (occupational therapy) recommendations, dated 6/11/24. - An OT- Therapist Progress and Discharge summary, dated and signed by the OT on 5/20/2021, which indicated the recommendation to wear a right hand [NAME] guard overnight for a right 4th/5th digit contracture. On 12/3/24 at 12:57 P.M., Resident #32 was observed with his/her lunch tray, with a Certified Nursing Assistant (CNA) sitting with him/her. Resident #32 had a Geri-sleeve on his/her right forearm. Resident #32's 4th and 5th fingers on his/her right hand were bent towards his/her palm. There was no palmar guard in the residents' vicinity. When asked if he/she wore a splint/brace on his/her right hand Resident #32 shook his/her head as in 'no'. On 12/3/24 at 4:26 P.M., Resident #32 was observed in bed. His/her right hand did not have a palmar guard applied. There was no palmar guard in or around the Resident's room. On 12/4/24 at 3:34 P.M., Resident #32 was observed in bed. His/her right hand did not have a palmar guard applied and no palmar guard was in the Resident's vicinity. On 12/5/24 at 6:50 A.M., Resident #32 was observed in bed. His/her right hand did not have a palmar guard applied and no palmar guard was in the Resident's area. During an interview on 12/5/24 at 6:55 A.M., CNA #4 said he took care of Resident #32 during the 11-7 shift and was not aware of any device that the Resident wears on his/her right hand. During an interview on 12/5/24 at 7:03 A.M., Nurse #6 said the Resident wears a Geri-sleeve on his/her right arm to prevent him/her from scratching. When asked about the palmar guard Nurse #6 said the Resident has behaviors and may not wear it. Nurse #6 said if the Resident refuses to wear it then it should be documented as a refusal and not signed off as being donned on the Treatment Administration Record. Nurse #6 and the surveyor went to Resident #32's room and she had difficulty locating the palmar guard, which was under items in the bottom drawer of the dresser. Review of the progress notes, dated 12/3/24 through 12/5/24, failed to indicate Resident #32 refused to don the palmar guard. Review of the treatment administration record (TAR) on 12/4/24 indicated the palmar guard as signed off as donned on the 3-11 shift on 12/3/24 and 11-7 shift on 12/3/24. During an interview on 12/5/24 at 8:49 A.M., the Director of Rehabilitation said she was the OT that worked with the Resident. The DOR said the right palmar guard should be applied as ordered. The DOR said Resident #32 has a contracture and the palmar guard was used to prevent skin issues and further complications or worsening of the contractures of his/her digits. The DOR said if the Resident is combative and refusing the palmar guard, she would want to reconsulted and had not been made aware that the palmar guard was not being donned. During an interview on 12/5/24 at 9:08 A.M., Nurse Unit Manger #3 said Resident #32 has behaviors and does not always permit the palmar guard to be donned. Nurse Unit Manager #3 said the palmar guard is for the Resident's right hand contractures, so it does not worsen. Nurse Unit Manager #3 said the nurses should be donning the palmar guard and should not be documenting on the TAR that it is on when it is not. Nurse Unit Manager #3 said a referral to rehab should be made if a Resident does not use a recommended intervention.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was cognitively intact, was at high risk for falls, and required extensive physical assistance of two staff members to meet his/her care needs, the Facility failed to ensure he/she was provided nursing care and treatment in accordance with professional standards of practice, when on 06/09/23 during the overnight shift, after finding Resident #1 on the floor in his/her room by Nurse #1 after an unwitnessed fall, he/she was not adequately assessed for potential injuries, Nurse #1 had not documented the incident, and had not informed on coming shift nursing staff of the incident so they could monitor Resident #1 for potential injuries. Resident #1 was not adequately assessed by nursing until approximately 24 hours after his/her fall, when he/she complained of pain to nursing staff and told them about the fall. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation, where he/she was diagnosed with right elbow fracture. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Facility's Policy titled Incident and Accident Investigating and Reporting, dated as revised 05/22/19, indicated the following: -Regardless of how minor an incident may be, including injuries of unknown source, it must be reported to the Nursing Department Supervisor and an Incident Report must be reported on the shift that the incident occurred stating known facts concerning the incident and complete notifications, -The first responder nurse will notify the MD and inform MD of this incident, and -When a fall occurs with a Resident, a Falls Investigation Report is completed in addition to an Incident Report. The Policy indicated Incident Reports would include the following: -Name, date, time and location of incident, -Resident condition before incident, -Bed height, rails, restraints if applicable, and equipment or property involved, -Complete description of incident including what happened, why, and any cause and any injury, -Indicate any injury on diagram and include vital signs, type of injury and level of consciousness, -Name(s) and statement(s) from witness(es), -Name, date, time MD notified and time of response, -Name, date, and time Health Care Proxy/next of kin notified and time of response, -any first aide administered, -disposition of resident, -Preventative measures, and -Signature and date of person completing report. Review of the Falls Investigation Form Instructions, dated 11/06/07, indicated the following: -An immediate investigation after a resident falls is critical to determine the cause of the fall and adding intervention(s) to prevent further falls/injury to the resident, -A Falls Investigation Report must be completed on all residents who were found on the floor or who would have fallen if staff was not there, -Unwitnessed falls must have neuro signs (signs that indicate neurological impairments caused by a head strike, requiring potentially immediate intervention) checked every 30 minutes x two, then every four hours x two, and then every shift x four, -Try to find out what the resident was trying to do (this will help you to come up with an appropriate immediate intervention), -All falls must have an immediate intervention in place, and -All incident reports and fall investigations are review the next morning. Accurate and complete information is critical to determine the most appropriate intervention and to prevent further fall/injury to the resident. Resident #1 was admitted to the Facility in May 2023, diagnoses included fall and urinary tract infection. Review of Resident #1's Fall Risk Assessment, dated 05/17/23, indicated Resident #1 was at high risk for falls. Review of Resident #1's Minimum Data Set (MDS) Admission Assessment, dated 05/23/23, indicated that he/she was cognitively intact and required extensive physical assist of two staff members for transfers. Review of the Report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 06/12/23, indicated that on 06/10/23 during rounds, Resident #1 reported to the Weekend Nursing Supervisor (later identified as Nursing Supervisor #1), that he/she had pain in his/her right arm and had fallen in his/her room on 06/09/23 at approximately 5:00 A.M. The Report indicated that Resident #1 was then assessed and was found to have right elbow swelling and tenderness. The Report indicated that on 06/09/23, during the overnight shift, Nurse #1 assisted Resident #1 off the floor with the assistance of two staff members after she assessed his/her skin and Range of Motion (ROM), and that Resident #1 had not complained of pain. The Facility was unable to provide any documentation to support that after being found on the floor by Nurse #1 on 06/09/23, that she had assessed Resident #1 for potential injuries, that she had documented the incident in a progress note, or incident report. There was no documentation to support Nurse #1 notified the physician, the nursing supervisor, or that she completed the steps outlined in the facility policy related to procedures to be followed by staff after finding a resident after an unwitnessed fall. Review of the Nursing Schedule, dated 06/08/23, indicated Nurse #1, Certified Nurse Aide (CNA #1, and CNA #2 worked on Resident #1's unit during the overnight shift that began on 06/08/23 at 11:00 P.M., and ended on 06/09/23 at 7:00 A.M. During a telephone interview on 07/20/23 at 12:50 P.M., and review of Nurse #1's Written Witness Statement, dated 06/09/23, Nurse #1 said that on 06/09/23 at 6:30 A.M., she found Resident #1 on the floor next to his/her bed. Nurse #1 said she did not see any injuries and said she didn't think Resident #1 hit his/her head when he/she fell . Nurse #1 said she told Unit Manager #1 about the fall, but said could not remember when. Nurse #1 said she had not documented an assessment of Resident #1 but should have. Nurse #1 declined to answer any further questions and she ended the call. Although Nurse #1's Written Witness Statement and Telephone Interview indicated she found Resident #1 on the floor on 06/09/23 at approximately 6:30 A.M., review of Resident #1's Medical Record indicated there was no documentation to support this, and no documentation to support that Nurse #1 had assessed Resident #1 after he/she fell , completed an Incident Report, completed an Falls Investigation Report, initiated neurological checks, notified the Nursing Supervisor or notified Resident #1's physician, per Facility Policy. The Facility provided the Surveyor with a Nurse's Note, dated 07/21/23, written by Nurse #1 as a late entry for 06/09/23, which indicated she (Nurse #1) found Resident #1 sitting on the floor next to his/her bed at 6:30 A.M. The Note indicated Resident #1 had no visible injuries and he/she denied a head strike. However, the Progress Note was written approximately six weeks after the incident, and seems suspect, given that Nurse #1 said during an interview on 7/20/23, the day prior to writing the progress note, that she did not think Resident #1 hit his/her head, and then declined any further interview. Review of the June 2023 Medication Administration Record (MAR), indicated that there was no documentation to support that Nurse #1 assessed Resident #1's pain on 06/09/23 after he/she fell at sometime between 5:00 A.M. and 6:30 A.M. During an interview on 07/20/23 at 1:05 P.M., CNA #2 said she did not assist Nurse #1 in picking Resident #1 up from the floor on 06/09/23 because she was busy at the time, and said Nurse #1 asked CNA #1 to assist her instead. The Surveyor was unable to interview CNA #1 as she did not respond to the Department of Public Health's telephone call or letter request for an interview. Review of the Incident Report, dated 06/10/23, written by Nursing Supervisor #1, indicated that Resident #1 reported to her that he/she fell on [DATE] at approximately 5:00 A.M., and said he/she had right elbow pain. The Report indicated that Nursing Supervisor #1 noted a small bruise on his/her right hip and swelling and tenderness in his/her right elbow. The Report indicated that Nurse Practitioner #1 was notified of the fall on 06/10/23 at 9:24 A.M., (which was more than 24 hours after the fall). Review of Nursing Supervisor #1's Written Witness Statement, dated 06/10/23, indicated that when she began her shift on 06/10/23, she reviewed the green shift book and saw that Nurse #2 noted that he administered Resident #1 Tylenol for right arm pain and a note that said Resident #1 told him he/she fell on [DATE] at 5:00 A.M. The Statement indicated Nursing Supervisor #1 went to see Resident #1 and his/her right elbow was swollen and tender. The Statement indicated that Resident #1 told Nursing Supervisor #1 that he/she fell early yesterday morning (6/09/23), and his/her back and elbow hurt. The Statement indicated that Nursing Supervisor #1 noted a small bruise on Resident #1's right hip and that she notified Physician #1. The Statement indicated that Nurse Practitioner #1 ordered an x-ray of Resident #1's right elbow, back, and right hip and neurological checks were initiated (greater than 24 hours after the fall). The Surveyor was unable to interview Nursing Supervisor #1 as she did not respond to the Department of Public Health's telephone call or letter request for an interview. Review of the Green Shift Book, indicated Nurse #2 wrote the following on 06/10/23 at the end of his overnight shift (06/09/23 at 11:00 P.M. to 06/10/23 at 7:00 A.M.); -Resident #1 complained of right arm soreness, -PRN (as needed) Tylenol at 2:00 A.M. (06/10/23) with good effect, and -Claims he/she fell on Friday morning (06/09/23). The Surveyor was unable to interview Nurse #2 as he did not respond to the Department of Public Health's telephone call or letter request for an interview. Review of a Physician's Order, dated 06/10/23 indicated a telephone order was obtained from Nurse Practitioner #1 for an ice pack to right elbow every shift, and stat (immediately) x-rays of Resident #1's right elbow, right hip, and spine, Review of a Physician's Order, dated 06/10/23 indicated a telephone order was obtained from Nurse Practitioner #1 to send Resident #1 to the Hospital Emergency Department for evaluation and treatment. The Facility was unable to provide documentation to support Physician #1, NP #1, or their on-call service had been notified on 6/09/23 by Nurse #1 after Resident #1's unwitnessed fall early that morning (sometime between 5:00 A.M. and 6:30 A.M., exact time unknown), prior to them being called on 06/10/23, when Nursing Supervisor #1 called to notify them of the incident. Review of an email sent from Unit Manager #1 to the Director of Nurses (DON), dated 06/10/23 at 3:15 P.M., indicated that on 06/10/23, during morning rounds, Resident #1 reported to Nursing Supervisor #1 that he/she had pain in his/her right arm and that he/she had a fall in his/her room on 06/09/23 at approximately 5:00 A.M. The Email indicated that Nursing Supervisor #1 assessed Resident #1 and found that his/her right elbow was swollen and tender. The Email indicated that Nursing Supervisor #1 initiated neurological checks per facility protocol because it was unclear if Resident #1 had bumped his/her head when he/she fell . The Email indicated that an order for x-rays was obtained, but Resident #1 did not want to wait so he/she requested to be transferred to the Hospital ED for treatment and evaluation. The Email indicated that Nurse #1 had helped Resident #1 back to bed at 6:30 A.M. on 06/09/23 after assessing skin and range of motion, and Resident #1 denied pain at that time. Although Unit Manager #1 indicated in the HCFRS report and in an Email report to the DON that Nurse #1 had assessed Resident #1 after his/her fall, the Facility was unable to provide any documentation to support this. Further review of the Email indicated Resident #1 was noted to have a nondisplaced fracture of the right humerus (long arm bone from shoulder to elbow). Review of the Hospital ED Notes and Discharge Summary, dated 06/10/23, indicated Resident #1 reported that he/she suffered an accidental strike to his/her right elbow area and reported 8/10 pain (0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, and 7-10 = severe pain) with swelling and limited range of motion of the right elbow. The ED Discharge Summary indicated Resident #1 suffered a nondisplaced right elbow fracture and should use a sling for comfort. Review of a Nurse's Note, dated 06/10/23 at 9:30 A.M., written by Nursing Supervisor #1, indicated that Resident #1 reported to the night nurse (Nurse #2) that he/she sustained a fall at approximately 5:00 A.M. the previous morning (06/09/23) and his/her right elbow was swollen and tender. The Note indicated Resident #1 had received Acetaminophen with some relief, a small bruise on Resident #1's right hip was noted, and neurological checks had been initiated. The Note indicated that there was a call out to Physician #1's office, and they were waiting for a call back. Review of a Physician's Note, dated 06/12/23, indicated that Physician #1 evaluated Resident #1 due to a recent elbow injury. The Note indicated that the Patient (Resident #1) had reported on 06/10/23 that he/she injured his/her elbow, (later determined to have occurred on 6/09/23 towards the end of overnight shift) and Physician #1's service was contacted. The Note indicated that Resident #1 was sent to the Hospital ED and returned to the Facility with a nondisplaced right elbow fracture. During an interview on 07/20/23 at 1:45 P.M. and 3:28 P.M., Unit Manager #1 said Nurse #1 texted her two days after Resident #1 fell on [DATE]. Unit Manager #1 said Nurse #1 told her she put Resident #1 back to bed after he/she fell , and said Nurse #1 should have assessed Resident #1 and notified Physician #1, but she had not. Unit Manager #1 said there was no way to know the mechanism of the unwitnessed fall and said Resident #1 should have had a physical assessment by nursing but that there was no documentation to support Resident #1 had been assessed by nursing until 06/10/23. The Unit Manager said Resident #1 fell on [DATE] at approximately 6:30 A.M. and was assessed by Nursing Supervisor #1 on 06/10/23 during rounds, which were in the morning, after she began her shift sometime between 7:00 A.M. and 8:00 A.M. Unit Manager #1 said all nurses are educated on the Fall/Accidents Polices and Protocols, and said Nurse #1 had not followed them. During an interview on 07/25/23 at 11:14 A.M., the Staff Development Coordinator (SDC) said Nurse #1 was educated on the Accident Policy upon orientation. The SDC said the Physician should be called regardless of whether or not a resident was injured, and residents should be assessed by nursing immediately after a fall and monitored. During an interview on 07/20/23 at 3:02 P.M., the Administrator said he was not aware of the outcome of the fall investigation regarding Resident #1. The Administrator said he thought Resident #1 reported the fall on 06/10/23 and said he did not know that Nurse #1 had picked Resident #1 up off the floor on 06/09/23. During the Survey Exit on 07/20/23 at 3:57 P.M., the Surveyor asked again if the Facility could provide any documentation to support that Nurse #1 assessed Resident #1 when she found him/her on the floor on 06/09/23 sometime between 5:00 A.M. and 6:30 A.M. The Administrator said even though there was no documentation in Resident #1's Medical Record to support this, he knew that Nurse #1 had done an assessment of Resident #1 after he/she fell , and said they needed to check medical record over flow. The Surveyor paused the Exit and requested that staff check over flow prior to the Surveyor exiting the Facility. After checking overflow, the Administrator said there was no documentation found to support Resident #1 was assessed by Nurse #1 after she found him/her on the floor on 06/09/23.

Based on policy review, record review and interview the facility failed to prevent a decline in range of motion for 1 one Resident (#46) out of a total sample of 29 residents. Findings include: Review of the facility policy titled, Range of Motion, dated June 2017 indicated the following: -It is the policy of [NAME] Manor to provide range of motion during daily care to all residents in need. -Range of motion is performed by CNA (Certified Nursing Assistant) during daily care of the resident. -For those residents who require a specific range of motion program, the rehab department will develop, implement, and educate designated staff members to perform the specialized range of motion program as indicated. Those specialized range of motion programs will be reviewed on a monthly basis by a designated rehab staff member to ensure efficacy. Resident #46 was admitted to the facility in May 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's most recent Minimum Data Set (MDS), dated [DATE], revealed that Resident #46 had a Brief Interview for Mental Status (BIMS) of 12 out of a possible 15, which indicated moderate cognitive impairment. During an interview and observation on 4/13/21 at 1:24 P.M., Resident #46 said that his/her right hand has been feeling tighter, specifically the last two fingers. The surveyor observed Resident #46's right ring finger was bent into his/her palm and he/she was unable to straighten it and his/her pinky finger was half bent and unable to straighten. In addition, all five fingers were bending in the direction of the pinky finger. Resident #46 said that this was impacting his/her ability to grab handlebars during transfers, and he/she was having increased pain in his/her hand. Resident #46 said that someone from the facility came to look at his/her hand, but never followed up with a treatment plan on how to improve the mobility of his/her fingers. Resident #46 also said that staff does not attempt to stretch his/her fingers during care. Resident #46 said that he/she was given something to put in his/her hand but doesn't know where it is, and staff does not help to put it on. Review of section G of the MDS, dated [DATE], indicated no impairment in Resident #46's range of motion. Review of section G of the MDS, dated [DATE], indicated impairment of Resident #46's range of motion to one side of his/her body. Review of Resident #46's medical record indicated the following: -Resident #46 went to a neurologist on 10/19/20. He/she returned with a referral for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -An Occupational Therapy (OT) screen, dated 10/22/20, indicated no skilled OT services needed at this time. -A request for OT screen from nursing, dated 2/23/21, secondary to Resident #46 complaint that his/her right hand is more contracted. -An OT screen, dated 2/24/21, indicated Resident #46 had trigger finger to his/her fourth right finger and was unable to straighten the finger without assistance. The OT screen also indicated that Resident #46 had ulnar drift (bending to towards the pinky) in all five fingers and wrist of right hand. The OT recommended that Resident #46 follow-up with a hand specialist to assess. -An OT screen, dated 3/30/21, indicated Resident #46 continues with right fourth finger trigger finger and is tolerating putty exercises and palmar guard well and no OT treatment indicated. During an interview on 4/15/21 at 8:24 A.M., Certified Nursing Assistant (CNA) #1 said that she was aware of Resident #46's decrease in range of motion. CNA #1 said she was unaware of any range of motion exercises that Resident #46 was supposed to do daily. During an interview on 4/15/21 at 8:28 A.M., and 11:47 A.M., Unit Manager (UM) #1 said that Resident #46 was not admitted with any range of motion issues and that his/her fingers have gotten worse since admission and would classify it as a contracture. UM #1 said that Resident #46 can stretch his/her fingers him/herself and does not need assistance from staff. UM #1 also said that Resident #46 has hand putty that he/she should be using. UM #1 said that Resident #46 had recently gone to the neurologist to address his/her right fingers decreased range of motion. UM #1 acknowledged that occupational therapy had recommended that Resident #46 be seen by a hand specialist and that this recommendation was not completed. During an interview on 4/15/21 at 12:07 P.M., the Director of Rehabilitation (DOR) said that she believes the decrease in range of motion to Resident #46's hand can be contributed to having a trigger finger, but that Resident #46 would have to see a hand specialist to diagnose that. The DOR said that a recommendation was made by OT for Resident #46 to see a hand specialist but that had not yet been done. The DOR also said that the ulnar deviation (bend toward pinky finger) of Resident #46's hand is not typically seen with a trigger finger diagnosis.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of a mechanical lift for all transfers, the Facility failed to ensure staff followed and implemented interventions from his/her Plan of Care, when Certified Nurse Aide #1 (CNA) transferred Resident #1 from his/her wheelchair into bed, without the use of a mechanical lift. Findings Include: The Facility Policy titled Resident Comprehensive Care Plans, dated 11/10, indicated that all resident care providers would follow the comprehensive care plane when providing care for a resident. Resident #1's Face Sheet indicated that his/her medical [DIAGNOSES REDACTED]. Resident #1's Activities of Daily Living plan of care, dated 5/22/19, indicated that Resident #1 required the use of a mechanical lift for transfers in and out of bed. A Nurse Progress Note, dated 6/16/19, indicated the surveyor interviewed CNA #1 at 1:20 P.M. on 7/2/19. CNA #1 said that at approximately 2:00 P.M. on 6/16/19, she manually transferred Resident #1 from his/her wheelchair back into bed. CNA #1 said she did not use a mechanical lift to transfer Resident #1. CNA #1 said she knew Resident #1 required the use of a mechanical lift for transfers and said she made a mistake by not transferring him/her properly. The Surveyor interviewed the Director of Nursing (DON) at 9:15 [NAME]M. on 7/2/19. The DON said CNA #1 initially told her that she had used the mechanical lift to transfer Resident #1 into bed, but said later CNA #1 told her that she had not use a mechanical lift when completing the transfer. The DON said that Resident #1's plan of care indicated that he/she required a mechanical lift for transfers and said that CNA #1 should have transferred Resident #1 with the mechanical lift.