Every finding on record at Bethel Health Care Center

Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident #8, 60 and 117) reviewed for dignity, the facility failed to ensure signs that included personal and health information, were not posted and visible in the residents' room. The findings include:1. Resident #8 was admitted to the facility in January 2022 with diagnoses that included metabolic encephalopathy, dysphagia, and muscle weakness. A dysphagia evaluation report dated 11/14/24 identified Resident #8 was being evaluated for life limiting or threatening dysphagia with feeding difficulties and coughing with the purpose of the evaluation to determine the least restrictive diet and appropriate swallowing maneuvers and strategies. Further Resident #8 was unable to feed him/herself and was fully dependent due to physical limitations. The report identified Resident #8 should not use straws, be positioned upright and take small bites/sips. Staff should monitor oral intake rate and cue multiple swallows. The report also directed that strategies were dependent on caregiver assistance and that Resident #8 required supervised oral feeding due to aspiration precautions.The quarterly MDS dated [DATE] identified Resident #8 had severely impaired cognition, required with moderate assistance with eating, substantial assistance with bathing, and was dependent on staff to assist with toileting. The care plan dated 3/5/25 identified Resident #8 had an ADL self-care performance deficit. Interventions included providing one staff member to assist with eating/feeding.A physician's order dated 3/5/25 directed to elevate the head of the bed or use multiple pillows for aspiration precautions. A physician's order dated 3/7/25 directed a regular diet with regular texture and mildly thick (nectar) consistency for liquids.A speech therapy note dated 3/21/25 identified Resident #8 had documented silent aspiration with thin liquids and required total assistance with all meals and appropriate body position to decrease risk of aspiration. 2. Resident #60 was admitted to the facility in July 2022 with diagnoses that included hemiplegia of the left non dominant side following a stroke, dysphagia, and weakness.Review of the clinical record identified Resident #60 was hospitalized from [DATE] - 9/17/24 for right sided weakness.The 5-day MDS dated [DATE] identified Resident # 60 had severely impaired cognition, was frequently incontinent of bowel and bladder, required substantial assistance with eating and was dependent on staff to assist with toileting and transfers.Review of the clinical record identified Resident #60 was sent to the hospital for evaluation on 9/30/24 due to hypotension and bradycardia.An APRN note dated 10/11/24 identified Resident #60 had a history of becoming hypotensive easily and was to have the head of the bed elevated at all times with some decline at bedtime.A physician's order dated 10/11/24 directed to keep the head of bed elevated at all times and may decline some at bedtime.Review of the care plan failed to identify interventions to address the hypotensive episodes with a need to always remain upright in bed.Observation on 7/15/25 at 12:45 PM identified Resident #8 and Resident #60 resided in the same room.Observation of Resident #8 identified multiple signs placed above his/her bed and on the bathroom door directly in front of his/her bed. Resident #8 was observed being provided feeding assistance by a staff member. Observation identified Resident #60 was seated in a wheelchair inside the room near the entryway. There was a sign placed above Resident #60's bed. Further observation identified the sign was visible prior to entering the room. Observation on 7/16/25 at 2:15 PM identified that the signs placed above the bed and on the bathroom door for Resident #8, and the sign above Resident #60's head of bed were still in place. Observation of the signs above Resident #8's head of bed identified the following:NO STRAWS (repeated 5 times).NO! Water Pitcher.Patient is total assist with all meals.Please keep head of the bed elevated.Please make sure the phone is on hook and ringer is on. During this observation, 2 additional signs were identified posted on the bathroom door directly in front of Resident #8's bed with the following:Safe Swallowing Strategies.Diet Level: Regular.Liquids: Mild Thick Liquids.Positioning: Upright at 90 degrees-Place pillow under left shoulder to avoid leaning.Supervision: 1:1 assistance during meals.Give small bites.Feed slowly.Have patient clear throat and swallow after each bite, alternate between solids and liquids.NO STRAWS ALLOWED. Ice Chip ProtocolSit upright in bed at 90 , pillow under left arm to avoid leaning.Assist patient with mouth care before giving any ice chips.Patient allowed to have ice chips between meals when given by staff one at a time.Patient not to be left alone with ice chips.Patient not allowed to drink water melted from the ice chips.Patient to remain upright for 30 minutes following ice chips. This observation also identified a sign located above Resident #60's head of bed which read Please keep head of bed ELEVATED. Resident #60 was observed lying completely flat in the bed with a sheet covering him/her. Observation and interview with the DNS on 7/21/25 at 2:11 PM identified that Resident #8 and Resident #60 should not have signs above their beds related to care or treatment. Interview with the Speech Therapists (SP #1 and SP #2) on 7/21/25 at 2:47 PM identified they had placed the signs in and around Resident #8's room as prompts to remind staff of Resident #8's needs regarding oral intake and they posted them as an extra measure to ensure staff were providing Resident #8 assistance due to his/her high risk for aspiration. SP #1 and SP #2 were unable to identify if they had placed any signs above Resident #60's bed. Subsequent to surveyor inquiry, observation on 7/22/25 at 11:14 AM identified the signs for Resident #8 and Resident #60 previously observed had been removed. The facility policy on resident rights directed that residents of the facility had the right to privacy and confidentiality regarding all personal and health information. The policy also directed that residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality. 3. Resident #117 was admitted to the facility in April 2024 with diagnoses that included hemiplegia and hemiparesis following stroke affecting left side and neurological neglect syndrome. The care plan dated 4/23/25 identified Resident #117 has self-care deficits due to a stroke. Interventions included nursing to apply a left-hand splint. Apply the left elbow splint and remove it at bedtime. Additionally, perform skin checks when applying and removing the hand and elbow splints. The quarterly MDS dated [DATE] identified Resident #117 had moderately impaired cognition and required maximum assistance with dressing and personal hygiene. A physician's order dated 6/28/25 (original order date 10/21/24) directed nursing to apply a left elbow splint every day and evening shift and remove at bedtime. Apply the left-hand splint at bedtime. Perform skin checks before applying and removing splint, if redness is noted, discontinue use and notify rehab. Observation on 7/15/25 at 10:25 AM identified Resident #117 was lying in bed with a sign posted above his/her headboard that read hand roll splint on at night and elbow splint on in morning. Resident #117 was wearing the left elbow splint. Resident #117 is in bed by the doorway.The sign was visible from the hallway. Observation on 7/16/25 at 10:52 AM identified Resident #117 was lying in bed. The sign was still posted above Resident #117's headboard visible from the hallway. The care card, undated, identified for the nurse aide to assist with orthotic devices. Apply elbow splint in the morning and remove at bedtime. Apply the hand splint at bedtime and remove in the morning. Skin checks when placing and removing the elbow and hand splints. Splints to the left elbow and left hand are for contracture management. Interview with Person #1 on 7/16/25 at 10:53 AM indicated he/she visits Resident #117 frequently. Person #1 indicated that the facility staff had posted the sign months ago because the staff were forgetting to put the elbow splint on every day. Person #1 indicated the facility staff did not discuss placing the sign about the splints on the wall above Resident #117's head of the bed. Person #1 indicated that he/she thought it was the facilities rule because they just posted the sign to remind the staff to put the splints on even though they still forget at times. Person #1 indicated that he/she would prefer if they put the sign inside Resident #117's closet door for Resident #117's privacy. Observation on 7/21/25 at 11:15 AMidentified Resident #117 was sitting in the wheelchair next to the bed and the splinting schedule sign was still posted above the bed. Interview with the DNS on 7/21/25 at 12:17 PM indicated that she does not know why there is a sign posted on the wall in Resident #117's room regarding the splints. The DNS indicated her expectation was there would be no signs posted in a resident's room unless it was to remind the resident to do something. The DNS indicated that there shouldn't be any signs posted to remind staff. The DNS indicated that the staff are to follow the physician's orders. The DNS indicated the nurse aides are responsible to read the resident care cards. The DNS indicated that she would have the sign removed today and have the sign placed in Resident #117's closet door. The DNS indicated the sign was to remind staff to apply the splints so it should not be posted as to protect Resident #117's privacy. Although requested, a facility policy for posting of signs was not provided.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 resident (Resident #8) who were dependent on staff for feeding assistance, the facility failed to ensure that a resident was provided feeding assistance for a meal. The findings include:Resident #8 was admitted to the facility in January 2022 with diagnoses that included metabolic encephalopathy, dysphagia, and muscle weakness. A dysphagia evaluation dated 11/14/24 identified Resident #8 was being evaluated for life limiting or threatening dysphagia with feeding difficulties and coughing with the purpose of the evaluation to determine the least restrictive diet and appropriate swallowing maneuvers and strategies. Further, Resident #8 was unable to feed him/herself and was fully dependent due to physical limitations. The report identified Resident #8 should not use straws, be positioned upright, take small bites/sips, and staff should monitor oral intake rate, and cue multiple swallows. The report also directed that strategies were dependent on caregiver assistance and that Resident #8 required supervised oral feeding due to aspiration precautions.The quarterly MDS dated [DATE] identified Resident # 8 had severely impaired cognition, required moderate assistance with eating, substantial assistance with bathing, and was dependent on staff to assist with toileting. The care plan dated 3/5/25 identified Resident #8 had an ADL self-care performance deficit. Interventions included providing one staff member to assist with eating/feeding. A physician's order dated 3/5/25 directed to elevate the head of the bed or use multiple pillows for aspiration precautions. A physician's order dated 3/7/25 directed to provide a regular diet with regular texture and mildly thick (nectar) consistency for liquids. A speech therapy note dated 3/21/25 identified Resident #8 had documented silent aspiration with thin liquids and required total assistance with all meals with appropriate body position to decrease risk of aspiration. The nurse aide care card for Resident #8 identified nurse aide staff were to provide total assistance at meal time and that Resident #8 was dependent on staff for all meals. Constant observation on 7/21/25 from 1:50 PM to 2:10 PM identified the resident's untouched meal tray was on the bedside table located approximately 4 feet directly to the right of Resident #8's bed. During this observation, Resident #8 was observed sleeping with a large towel placed over his/her chest area tucked into his/her gown, and the towel appeared clean with no food or debris observed. The meal tray had utensils including a spoon, butter knife, and fork which appeared clean and not used. During this observation, 5 signs were observed to be attached directly behind and above Resident #8's bed. The signs included the following:NO STRAWS (repeated 5 times). NO! Water Pitcher. Patient is total assist with all meals.Please keep head of the bed elevated.Please make sure the phone is on hook and ringer is on. An additional sign was also observed posted on the bathroom room directed in front of Resident #8's bed with the following: Safe Swallowing Strategies.Diet Level: Regular.Liquids: Mild Thick Liquids.Positioning: Upright at 90 degrees.Place pillow under left shoulder to avoid leaning.Supervision: 1:1 assistance during meals.Give small bites.Feed slowly.Have patient clear throat and swallow after each bite, alternate between solids and liquids.NO STRAWS ALLOWED. Observation and interview with NA #7 on 7/21/25 at 2:07 PM identified she was the nurse aide assigned to care for Resident #8 and had brought in the residents lunch tray at 1:00 PM and attempted to wake Resident #8 in order to feed him/her lunch. NA #7 identified Resident #8 declined to eat and continued sleeping. NA #7 was unable to identify how many attempts she made but at 1:30 PM, she left the unit to go on her lunch break and left Resident #8's meal tray on bedside table. NA #7 identified she planned to return after her lunch to offer Resident #8 the same meal tray. NA #7 identified that she did not report off to any other nursing staff that she had left the meal tray in the room or that Resident #8 had not been feed lunch yet since she was planning to address it once her break was over. Observation and interview with the DNS of Resident #8's meal tray on 7/21/25 at 2:11 PM identified that the meal trays should not have been left in Resident #8's room unattended and that Resident #8 requires total assistance with feeding due to aspiration risk. During this observation, the DNS identified Resident #8 was unable to reach the tray due to the need for staff to assist with repositioning and transfers. Interview with Speech Therapists (SP #1 and 2) on 7/21/25 at 2:47 PM identified Resident #8 was a high risk for aspiration and had confirmed silent aspiration with thin liquids when testing was completed on 11/14/24. SP #2 identified Resident #8 would be unable to access a meal tray positioned out of reach and would need staff assistance to sit up and transfer and typically required a hoyer lift to be out of bed. SP #1 identified that Resident #8 was unable to feed hand to mouth and required staff to provide direct supervision and prompts and identified that Resident #8 also had issues with impulsivity with meals, often taking large bites and eating quickly, which also increased his/her risk to aspirate. SP #2 identified that Resident #8 had chronic dysphagia and would always be a risk to aspirate and identified that staff needed to provide 1:1 feeding assistance for all meals. Although attempted, a follow up interview with NA #7 was not obtained. The facility policy on activities of daily living directed that the purpose of the policy was to provide the level of care required by each individual resident. The policy further directed that staff was to provide assistance to complete activities of daily living further resident centered evaluation and care plan and activities included eating/swallowing and feeding including the setting up, arranging, and bringing food to the mouth. The facility policy on resident rights directed that residents of the facility had the right to be treated with consideration, respect, and full recognition of their dignity and individuality.The facility policy on dysphasia management directed that residents who have swallowing difficulties or dysphasia would have treatment interventions to promote adequate nutrition and hydration. The facility assessment directed that the facility would provide person centered directed care which included identifying hazards and risks to residents. The assessment also directed that the facility would provide management of medical conditions that would include assessment, early detection of problems, management of medical conditions, and address individualized dietary requirements. The assessment further directed that the facility would provide care related to activities of daily living including supporting with needs related to eating.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #17) reviewed for comfort measures/hospice, the facility failed to ensure that the comprehensive care plan was reviewed and revised to include interventions related to comfort measures only. The findings include.Resident #17 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), hypertensive heart disease with heart failure, and chronic pain.Facility documentation dated 5/24/24 identified Resident #17 was placed on hospice care due to heart failure and chronic pain.The quarterly MDS dated [DATE] identified Resident #17 had intact cognition, was frequently incontinent of bowel and bladder and required substantial assistance with toileting, bathing, and dressing. The clinical record dated 1/28/25 identified hospice care was discontinued.A physician's order dated 2/12/25 directed comfort measures only. Review of the clinical record failed to identify a care plan with interventions related to comfort measures. Interview with Resident #17 on 7/15/25 at 2:00 PM identified he/she was aware of the order for comfort measures and that it was in place to ensure he/she was comfortable. Resident #17 identified he/she was not sure what specific treatments were in place related to keeping him/her comfortable. Interview and review of the care plans for Resident #17 with the MDS director on 7/22/25 at 11:41 AM identified she was responsible to review and revise the resident's care plans with scheduled resident assessment dates to coincide with the resident's MDS review schedule. The MDS director identified that for Resident #17, the social worker was responsible to review and revise the care plan related to hospice services initially, and then subsequent order for comfort measures. The MDS director identified that the facility social work staff should have added a terminal diagnosis care plan in 2/2025 and amended it to reflect the order for comfort measures, but that it did not appear there was a care plan in place related to comfort measures.The facility policy on comprehensive person-centered care planning directed that the person-centered care plan was developed to include information necessary to properly care for the resident and would address the resident's preferences, goals, desired outcomes, and plan for discharge. The policy further directed that the comprehensive person-centered care plan would be reviewed and revised following a significant change in status and episodically as the plan of care changed for the resident. The policy further directed that the comprehensive person-centered care plan would be kept current by all disciplines on an ongoing basis and that disciplines would be responsible for updating the care plan when there was a new problem that required that discipline to intervene. The policy also directed that the interdisciplinary team would periodically review and revise the comprehensive care plan upon any change in status including when a problem, goal, or intervention was changed. The policy also directed that all clinical department heads were responsible to ensure there was a system for monitoring implementation of the resident care plans and that corrective action would be carried out when problems with implementation of care plans had been modified.

Based on observation, review of facility documentation, facility policy and interview the facility failed to date Insulin pens when opened and ensure medications were within their expiration. The findings include. Observation on [DATE] at 1:50 PM in the medication storage room on the first floor with LPN #3 identified the following. Ipratropium and Bromide and Albuterol, 1 box, 6 pouches, expired 6/2025. IV 5% dextrose 1000ml, outside of the manufacturer plastic cover, label states use by [DATE]. Lansoprazole syrup 3mg/ml, 2 bottles, 1 bottle expired [DATE], 1 bottle expired [DATE]. Observation on [DATE] at 2:00 PM of the [NAME] Medication Cart with LPN #3 identified the following. Humalog Kwikpen, opened 6/11. Lantus Solostar Insulin pen, 100u/ml, opened, no resident name on pen, no date opened. Per LPN #3 she believes the Lantus Insulin pen belongs to Resident #147 because he/she is the only resident on Insulin on that medication cart. Interview with the DNS on [DATE] at 9:30 AM identified that for the IV Dextrose 1000 ml, when the pharmacy sends IV supplies for specific residents, they are sent out of the manufacturers bag and labeled with an expiration date which is 28 days after they remove it from the manufacturer bag. After that date it should be discarded. The DNS indicated the pharmacy does a monthly review to check for expiration of medications and the nurses should also be checking, however, the DNS was unable to identify which nurse/shift would complete that task or how often it should be done.Review of medication storage policy identified that open dose vials of Insulin shall be maintained no longer than the duration indicated on the manufacturer storage and handling instructions or the manufacturer list expiration date on the vial, whichever is shorter. Lantus Insulin shall be maintained no longer than 28 days or the manufacturer list expiration date on the vial, whichever is shorter.

Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 8 residents (Resident #84), reviewed for accidents, the facility failed to ensure that two staff transferred the resident via a sit to stand lift per physician's orders and professional standards of practice, and for 3 of 6 residents (Resident #51, 71 and 95) reviewed for smoking, the facility failed to ensure that residents who had a history of smoking and/or had been found smoking and/or verbalized to staff that they currently smoked, adhered to the smoking policy and did not smoke on the facility grounds to ensure a hazard free environment, and for 1 of 4 residents (Resident #8) reviewed for dignity, the facility failed to ensure the environment was free of hazards for a resident assessed at risk to aspirate, and for 1 of 8 residents (Resident #138) reviewed for accidents, the facility failed to provide adequate supervision to prevent a fall. The findings include:1.Resident #84 was admitted to the facility in May 2022 with diagnoses that included hemiplegia and hemiparesis of the left side following a stroke and muscle weakness. The quarterly MDS dated [DATE] identified Resident #84 had intact cognition, impairment of the upper and lower extremity on one side, used a wheelchair, and was dependent on staff for transfers. The care plan dated 5/7/25 identified Resident #84 had limited physical mobility and required the assistance of two staff via a mechanical lift. Interview with Resident #84 on 7/15/25 at 11:30 AM identified that approximately 2 weeks ago, NA #9 transferred him/her via the sit to stand mechanical lift alone without the benefit of a second staff member. Further, Resident #84 indicated that during the transfer one of the straps popped off. Review of facility documentation identified the DNS interviewed NA #9 on 7/16/25. NA #9 indicated he was transferring Resident #84 from the toilet via the sit to stand lift and the resident became impatient waiting for a second staff member. NA #9 identified he began to transfer the resident without a second staff member and as the resident was lifted, one of the straps popped off. NA #9 indicated he lowered the resident onto the toilet, reattached the strap and transferred the resident with the lift. NA #9 indicated the resident did not fall. A written warning dated 7/16/25 identified NA #9 performed a sit to stand transfer without a second staff member. Corrective action identified NA #9 will always have a second staff member to assist with lift transfers. Further, a sit to stand lift competency was conducted with NA #9. Review of the manufacturer safety summary for the sit to stand lift identified the stand up lift may be operated by 1 healthcare professional with a cooperative, weigh-bearing individual able to support the majority of his/her own weight. However, since medical conditions vary, the recommendations include that the healthcare professional evaluate the need for assistance and determine whether more than 1 healthcare professional is appropriate in each case to safely perform the transfer. Review of the facility sit to stand lift competency identified 2 staff members are required. Review of the ADL policy identified ADLs are the essential tasks that each person needs to perform, on a regular basis, to sustain basic survival and well-being. The term ADL helps healthcare professionals quickly communicate the level of assistance an individual might need or how their health is impacting their day-to-day life. Staff provide assistance to complete ADLs per the person-centered evaluation care plan including functional mobility. 2. Resident #138 was admitted to the facility in February 2025 with diagnoses that included a fall with multiple rib fractures, repeated falls, and dementia. The admission assessment dated [DATE] at 10:21 PM identified Resident #138 was at high risk for falls due to a fall in past 6 months, confusion at times, the need for assistance with elimination and mobility, the need to use a walker, the inability of the resident to indicate if he/she feels unsteady when walking or is afraid of falling when walking. Further, Resident #138 has an unsteady gait and balance. The APRN note dated 2/10/25 identified Resident #138 has dementia and was in the hospital due to falling while smoking a cigarette. The resident sustained moderately displaced left anterior second and third rib fractures and nondisplaced left anterior lateral fourth through seventh rib fractures. The admission MDS dated [DATE] identified Resident #138 had severely impaired cognition, was occasionally incontinent of bowel and bladder, required moderate assistance with toileting, toilet transfers, wheelchair to and from bed transfers, sit to stand, and maximum assistance with dressing. The care plan dated 2/20/25 identified Resident #138 had impaired mobility and rib fractures. Interventions included providing maximum assistance with dressing and personal hygiene. Resident #138 requires a 2 wheeled walker and touching assistance for toileting by 1 staff person. Additionally Resident #138 has the potential for falls. Intervention included to ensure the resident is wearing appropriate footwear when ambulating or mobilizing in a wheelchair. Review of the activities of daily living flowsheet dated 4/1/25 to 5/2/25, which the nurse aides are required to sign off as having been completed every shift identified Resident #138 was a high fall risk, ask resident if he/she needs to use the bathroom, ensure the resident’s belongings were within reach. The APRN note dated 5/2/25 at 8:00 AM identified staff requested evaluation of the resident due to pain on urination. Recommendations included to encourage fluids and monitor for a urinary tract infection for 3 days. If symptoms persist or worsen, a urine culture will be needed. Additionally, a psychiatric evaluation referral was placed for gradual dose reduction due to increased lethargy. A reportable event form dated 5/2/25 at 7:05 PM indicated Resident #138 was in the bathroom and had an unwitnessed fall. Resident #138 complained of back of head and back pain and was transferred to the emergency room. The nurses note dated 5/2/25 at 7:05 PM identified the nurse aide came to this writer stating Resident #138 had fallen. This writer went to see Resident #138 who was sitting on the toilet. Resident #138 indicated he/she hit his/her head and complained of low back pain. The Resident Representative requested the resident be sent to emergency room. The APRN was notified and ordered the resident to be transferred to the emergency room for evaluation. Resident #138 was transferred to at 8:10 PM. A written statement by NA #3 dated 5/2/25 indicated she had assisted Resident #138 to the bathroom at approximately 6:50 PM with a walker. NA #3 indicated she wanted to give Resident #138 some privacy and informed Resident #138 to pull the string when finished. Resident #138 did not pull the string, and a few minutes later she heard Resident #138 yelling. NA #3 indicated at that time she went to Resident #138’s room and Resident #138 was on the floor, so she left the room to get the nurse. NA #3 indicated when she returned to Resident #138’s bathroom there were 2 EMT’s there, and Resident #138 was sitting on the toilet. NA #3 indicated while Resident #138 was on toilet the RN Supervisor came. The hospital Discharge summary dated [DATE] identified Resident #138 was admitted on [DATE] due to an unwitnessed fall and was diagnosed with a urinary tract infection and a T12 compression fracture. Resident #138 was discharged with a back brace to be worn when ambulating and follow up with orthopedics in one week. A physician’s order dated 5/7/25 directed an orthopedic consultation as needed and thoracic lumbar sacral orthosis (horizon brace) should be on when Resident #138 is out of bed and off while lying in bed daily for back support. Interview with NA #3 on 7/21/25 at 9:57 AM indicated Resident #138 was on her assignment on 5/2/25 and she did not think Resident #138 was a fall risk, so she told Resident #138 to pull the call light string when he/she was done and left Resident #138 alone in the bathroom. NA #3 indicated that she left the room to assist another resident, and while she was assisting the other resident, she heard Resident #138 screaming. NA #3 indicated Resident #138 did not put the call light and when she entered the bathroom Resident #138 was on the floor. NA #3 indicated she left Resident #138 alone in the bathroom and went to the nurse’s station to find the nurse. NA #3 indicated the charge nurse called for the supervisor and then they both came to assess Resident #138. NA #3 indicated while she was getting the nurse, 2 EMT’s had gotten Resident #138 off the floor and put the resident back on the toilet. NA #3 indicated when she was heading back to Resident #138’s room she saw the 2 EMT’s leaving the room. NA #3 indicated Resident #138 was complaining of back pain and dizziness from hitting his/her head against the wall. NA #3 indicated Resident #138 could not stand on his/her own at that time. Interview with OTR #1 (covering for Director of Rehab) on 7/21/25 at 10:49 AM identified that based on therapy notes Resident #138 required partial to moderate assistance with 1 staff for transfers to and from the toilet. OTR #1 indicated Resident #138 was forgetful and had a diagnosis of dementia and should not be left alone in the bathroom. OTR #1 indicated based on the therapy fall risk assessment Resident #138 was at risk for falls. OTR #1 indicated therapy will tell the charge nurse if a resident should not be left alone in the bathroom and it is up to the charge nurse to communicate that information with the nursing staff. OTR #1 indicated Resident #138 was not to be left alone in the bathroom because Resident #138 did not have the recall or awareness of the assistance he/she needed, and he/she was a fall risk. OTR #1 could not identify who in the nursing department was notified that the resident should not be left alone in the bathroom. Interview with the DNS on 7/22/25 at 10:29 AM indicated Resident #138 was admitted with a diagnosis of dementia and is confused at times. The DNS indicated that Resident 138 was a high fall risk and interventions were to make sure the resident wore appropriate footwear and have the resident evaluated by the therapy department. The DNS indicated Resident #138 had a couple of falls prior to the fall on 5/3/25. The DNS indicated NA #3 should have stayed with Resident #138 in the bathroom and not leave the resident alone because of the fall risk and confusion. The DNS indicated that NA #3 was educated on not leaving a confused resident that required the assistance of 1 staff alone in a bathroom. Interview with the DNS on 7/22/25 at 12:10 PM indicated that the nurse and nurse aides should stay with any resident that required the assistance of 1 or 2 staff for ambulation to the bathroom, however, prior to 5/2/25 there was no education provided to nursing staff regarding who could or could not be left alone in the bathroom. The DNS indicated after the fall on 5/2/25 she educated nursing staff that any resident that needed assistance to go to the bathroom could not be left alone. Review of the Fall Prevention Program Policy identified the purpose was to reduce the incidence of falls for residents identified at high risk. All residents will be evaluated for risk for falls on admission, readmission, and with a change in condition. Residents at high risk for falls will have interventions initiated to prevent falls. Interventions may include providing staff supervision for activities of daily living and being on a toileting program. Implementing fall interventions included placing interventions on the nurse aide kardex and assignment. If a fall occurs keep resident immobile until resident is examined and determined to be free from fractures. 3. Resident #8 was admitted to the facility in January 2022 with diagnoses that included metabolic encephalopathy, dysphagia, and muscle weakness. A dysphagia evaluation report dated 11/14/24 identified Resident #8 was being evaluated for life limiting or threatening dysphagia with feeding difficulties and coughing with the purpose of the evaluation to determine the least restrictive diet and appropriate swallowing maneuvers and strategies. Further, the evaluation report identified Resident #8 was unable to feed him/herself and was fully dependent due to physical limitations. The report identified Resident #8 should not use straws, take small bites/sips and be positioned upright. Staff should monitor oral intake rate, and cue multiple swallows. The report also directed that strategies were dependent on caregiver assistance and that Resident #8 required supervised oral feeding due to aspiration precautions. The quarterly MDS dated [DATE] identified Resident #8 had severely impaired cognition, required with moderate assistance with eating, substantial assistance with bathing, and was dependent on staff to assist with toileting. The care plan dated 3/5/25 identified Resident #8 had an ADL self-care performance deficit. Interventions included providing one staff member to assist with eating/feeding. A physician’s order dated 3/5/25 directed to elevate the head of the bed or use multiple pillows for aspiration precautions. A physician’s order dated 3/7/25 directed for a regular diet with regular texture and mildly thick (nectar) consistency for liquids. A speech therapy note dated 3/21/25 identified Resident #8 had documented silent aspiration with thin liquids and required total assistance with all meals and appropriate body position to decrease risk of aspiration. A constant observation on 7/21/25 from 1:50 PM to 2:10 PM identified Resident #8’s untouched meal tray on the bedside table located approximately 4 feet directly to the right of Resident #8’s bed. During this observation, Resident #8 was observed sleeping. Observation and interview with the DNS of the meal tray on 7/21/25 at 2:11 PM identified that the resident’s meal tray should not have been left in Resident #8’s room unattended and that Resident #8 required total assistance with feeding due to aspiration risk. During this observation, the DNS identified Resident #8 was unable to reach the tray due to the need for staff to assist with repositioning and transfers. Interview with Speech Therapist SP #1 and 2 on 7/21/25 at 2:47 PM identified Resident #8 was a high risk for aspiration and had confirmed silent aspiration with thin liquids with testing on 11/14/24. SP #2 identified Resident #8 would be unable to access a meal tray positioned out of reach and would need staff assistance to sit up. SP #1 identified that Resident #8 was unable to feed hand to mouth and required staff to provide direct supervision and prompts and identified that Resident #8 also had issues with impulsivity with meals, often taking large bites and eating quickly, which also increased his/her risk to aspirate. SP #2 identified that Resident #8 had chronic dysphagia and would always be a risk to aspirate. Observation on 7/22/25 at 11:14 AM identified Resident #8 was in his/her room alone, in bed, and the bedside table was positioned directly over the resident’s bed. Three separate cups of liquids were on the table within the residents reach. The liquids included a clear thickened liquid in a clear plastic cup approximately 1/3 full; an orange thickened liquid in a white Styrofoam cup filled completely covered with a white plastic lid; and a dark blue plastic mug with thickened brown liquid, approximately 75% full. Observation and interview on 7/22/25 at 11:24 AM with LPN #3 identified the cups of liquid should not have been placed on Resident #8’s bedside table and instead that staff routinely filled a pitcher with thickened water to put on Resident #8’s bedside table. LPN #3 identified that Resident #8 required feeding assistance and supervision with meals, but she was not aware of any issues related to Resident #8 having access to a pitcher of thickened liquid other than that Resident #8 should not use straws when drinking liquids. LPN #3 was unable to identify if Resident #8 should have access to a pitcher of liquid without supervision, or if Resident #8 had the cognitive ability to call out for assistance when he/she wanted liquid from the pitcher. Interview with the DNS on 7/22/25 at 11:33 AM identified Resident #8 should not have had any fluids at the bedside within his/her reach, in a cup or pitcher, because Resident #8 is high risk to aspirate and needs 1:1 supervision. The DNS identified that she would need to provide additional education to the clinical staff regarding this issue. Interview with SP #1 and SP #2 on 7/22/25 at 12:03 PM identified Resident #8 should not have any fluids at the bedside due to aspiration risk and that staff should be assisting and supervising fluid intake. Interview with APRN #1 and Clinical Lead Director APRN on 7/22/25 at 12:54 PM identified that Resident #8 was at risk for aspiration and any orders related to this were directed by the Speech Therapy department. The facility policy on dysphasia management directed that residents who had swallowing difficulties or dysphasia would have treatment interventions to promote adequate nutrition and hydration. The facility assessment directed that the facility would provide person centered directed care which included identifying hazards and risks to residents. The assessment also directed that the facility would provide management of medical conditions that would include assessment, early detection of problems, management of medical conditions, and address individualized dietary requirements. The assessment further directed that the facility would provide care related to activities of daily living including supporting with needs related to eating. 4. Resident #51 had diagnoses that included low back pain. A review of the admission record identified Resident #51 was self-responsible. The admissions packet dated 6/23/22 identified the facility did not permit smoking on the premises and was signed by Resident #51. An APRN note dated 6/23/22 identified Resident #51 was a former smoker who had quit 2 years previously. The quarterly MDS dated [DATE] identified Resident #51 was cognitively intact, was independent with locomotion on the unit, and supervised off the unit with the use of a wheelchair. The care plan dated 4/27/23 identified Resident #51 had a self-care deficit and required assistance of 1 with a wheelchair and supervision with locomotion. An APRN note dated 4/27/23 at 1:00 AM identified Resident #51 and staff reported he/she and another resident would go outside and smoke together, smoking 1 cigarette a day. Resident #51 requested smoking cessation medication. Orders were prescribed to start Wellbutrin SR 150 mg daily for 3 days then increase to 150 mg twice daily for 12 weeks. The care plan dated 5/2/25 identified Resident #51was noncompliant with the facility nonsmoking policy. Interventions included informing the resident the facility did not permit smoking and praise efforts of policy compliance. A social service note dated 6/27/24 at 12:02 PM identified on 6/26/24 three packs of cigarettes were found by staff in the resident’s possession and brought to the Social Service Department. Social services met with Resident #51 to reinforce that the facility is non-smoking. Resident #51 told the writer he/she did not realize he/she could not have the smoking materials in his/her room, and he/she had no objection to them being kept in the social service office. An APRN note dated 2/7/25 at 8:09 AM identified Resident #51 was a smoker and went outside frequently. Resident #51 was counseled on smoking with a plan to continue to monitor. An interview with Resident #51 on 7/21/25 at 12:22 PM identified he/she smoked in the past. Resident #51 indicated he/she obtained cigarettes from a former roommate who also smoked, or from a visitor known to him/her from the community. Resident #51 identified he/she would walk around grounds smoking unsupervised or smoke near the employee parking lot. Resident #51 was aware of the nonsmoking policy but was not aware at the time that there was no smoking permitted outside on the premises as well. Resident #51 further identified staff never made requests to search his/her living space for smoking materials following smoking violations. Resident #51 recalled that he/she last smoked on New Years while on a LOA visit and never resumed smoking in the facility thereafter as it was a hassle. An interview with the DNS on 7/21/23 1:51 PM identified Resident #51 was noncompliant with smoking in the past but had since quit. The DNS indicated Resident #51 likely obtained smoking materials from a former roommate who also smoked but did not formally analyze the root cause following each smoking violation or implement any additional measures outside of education to reduce the environmental risk of future smoking policy violations adding she was not aware of all the violations. A review of the non-smoking facility policy and agreement directs that the facility does not permit smoking in the facility or on the premises at any time. A review of the facility policy for safe smoking identified residents noncompliant with the smoking policy will be re-evaluated by the interdisciplinary team (IDT). New interventions will ensure the safety of the residents and other residents. 5. Resident #71 has diagnoses that included right side hemiplegia (paralysis) and history of alcohol use. A review of the admission record identified Resident #71 was self-responsible. A nursing smoking safety screen dated 1/31/25 identified Resident #71 currently smoked 1 - 2 cigarettes daily, had no cognitive or dexterity deficits and determined safe to smoke without supervision. The Admissions packet dated 2/4/25 identified the facility did not permit smoking on the premises and was signed by Resident #71. The resident smoking policy dated 2/4/25 identified Resident #71 was informed there were no smoking privileges at the facility, including the use of any smoking devices and was signed by Resident #71. The quarterly MDS dated [DATE] identified Resident #71 was cognitively intact, independent with bed mobility, transfers and required set up assist with transfers supervision/touch assist with locomotion using a wheelchair. The care plan dated 5/29/25 identified Resident #71 had a self-care deficit in functional mobility and coronary artery disease. Interventions included ambulation with supervision/touch assist using of one using a two wheeled walker and observe/evaluate respiratory status including shortness of breath and dyspnea. An APRN note dated 6/13/25 at 11:00 AM identified Resident #71 had a significant history of smoking approximately 1 pack per day for over 20 years and has not smoked since admission. Resident #71 previously used a Nicotine Patch with good results and was experiencing increased cravings, requesting to resume the Nicotine Patch. Resident #71 was started on the Nicotine Patch at lowest dose for three weeks on 5/16/25 and will continue to monitor for effectiveness. An interview with NA #4 on 7/15/25 at 11:30 AM identified there was an area, pointing to the patio of the unit identified as “Plumtrees,” where the residents go to smoke. An observation with the DNS on 7/15/25 at 11:43 AM identified Resident #71 sitting under a covered patio located outside the unit known as “Plumtrees” with a visitor with visible lingering haze and the odor of smoke. Resident #71 was holding a now out cigarette butt, with three additional cigarette butts in front of him/her, a pack of cigarettes (undetermined amount) and a lighter. There were no visible staff, no fire safe cigarette receptacles or fire safety equipment in the area. Resident #71 stated “I was smoking” to the DNS. The visitor indicated he/she was sorry, that it was his/her fault because he/she brought them in for him/her. Resident #71 agreed to give the smoking materials to the DNS who also provided education regarding safety concerns. An interview with Resident #71 on 7/16/25 at 8:32 AM identified he/she never smoked in the facility and only smoked on the Plumtrees patio where there was no signage posted that smoking was prohibited outside. Resident #71 indicated he/she had never been spoken to previously about not being able to smoke outside and was unsure if any staff were aware. An interview with the DNS on 7/16/2025 at12:54 PM identified she was not previously aware Resident #71 had been smoking on grounds which was prohibited. A visitor who was with Resident #71 admitted to bringing in the smoking materials which were removed at the time smoking was observed. The DNS further identified Resident #71 was placed on enhanced monitoring every 15 minutes. However, he/she subsequently went outside with staff and pulled a cigarette and lighter out of his/her undergarments, smoked the cigarette and refused to provide the staff with the lighter. The APRN was notified. Resident #71 was placed on 1:1 supervision following the second smoking observation and verbalized he/she will continue to seek out opportunities to smoke on the grounds. Following the event, as an immediate corrective action, all unit managers were notified of the smoking incident, and efforts were in progress to identify any additional residents who smoked. Staff were interviewed regarding any knowledge they had of residents smoking on the grounds, education was provided about the smoking policy and staff were instructed to report any resident observed smoking or in possession of smoking materials. Additional signage was ordered, electronic communication to residents and family informing them the facility was strictly non-smoking, and residents were not to have smoking/lighting materials in the facility or on the grounds. LOA instructions were provided to staff directing 1:1 supervision for Resident #71 until departure in a vehicle and to resume upon return to the facility with a request for a room search and non invasive search for smoking/vaping materials. Resident #71 was offered to transfer to a smoking facility, has agreed, but has since declined the first offering. Resident #71 subsequently signed a behavioral agreement dated 7/16/25 indicating he/she understands and agrees not to smoke in the facility, on the grounds or possess any smoking materials. A review of the non-smoking facility policy and agreement directs that the facility does not permit smoking in the facility or on the premises at any time. 6. Resident #95 had diagnoses that included nicoti ne dependence on cigarettes. A review of the admission record identified Resident #95 was self-responsible. Original physician orders dated 1/23/25 directed the resident may go on a leave of absence, (LOA), authorized leave, with responsible party. The resident smoking policy dated 2/3/25 identified Resident #95 was informed there were no smoking privileges at the center, including the use of any smoking devices. Resident #95 signed the smoking policy acknowledging and agreeing to abide by those rules. The quarterly MDS dated [DATE] identified Resident #95 was cognitively intact, independent with bed mobility and required supervision with transfers and ambulation. The care plan dated 6/17/25 identified Resident #95 had the potential to be a smoker. Interventions included educating the resident on the smoking policy. An APRN note dated 6/18/25 at 12:45 PM identified Resident #95 smoked cigarettes daily, was seen for smoking cessation request, and was reporting concerns regarding the Nicotine Patch use, stating it was causing nightmares. The resident indicated he/she no longer wished to use the Nicotine Patch. Resident #95 also reported that when leaving the building for LOA, he/she was frequently with people who smoked and he/she smoked with them. Lozenge 4 mg (Nicotine) 1 tablet by mouth was ordered every 4 hours as needed for smoke cessation for 30 days. A nurse’s note dated 7/12/25 at 2:48 PM identified Resident #95 signed out for LOA. Observation on 7/15/25 at 11:22 AM identified a faint smell of lingering smoke as Resident #95 was observed walking in his/her room with no visible signs of smoking. Interview with Resident #95 on 7/15/25 at 11:22 AM identified he/she was currently an active smoker who went outside unsupervised on a covered patio (identified as Plumtrees) to smoke. Resident #95 indicated he/she was aware the facility was nonsmoking, and that signs were posted. According to Resident #95, staff were aware he/she smoked and had told him/her, in the past, they could call the police due to the smoking. Resident #95 further identified he/she did not smoke in the building and secured the smoking materials, which he\she purchased while out on LOA. The unit manager was immediately notified of the possession of smoking materials. An interview with NA #4 on 7/15/25 at 11:30 AM identified that although she had not specifically observed Resident #95 smoking, there was an area (pointing to the patio of the unit identified as “Plumtrees” where residents were known to smoke, and had observed Resident #95 in that area frequently. An interview with the DNS on 7/16/2025 at 12:54 PM identified she was not aware that residents were smoking anywhere on grounds. The DNS indicated Resident #95 wanted to quit and lozenges have been prescribed. Resident #95 has since agreed to keep all smoking materials at a friend’s house to use when on LOA and will no longer store them in his/her bag. As an immediate corrective action, all unit managers were notified of the smoking violation, and efforts were in progress to identify any additional residents who smoked. Staff were interviewed regarding any knowledge they had of residents smoking on the grounds, education was provided about the smoking policy and staff were instructed to report any observed resident smoking, or any resident in possession of smoking materials. Additional signage was ordered, electronic communication was sent to residents and family informing them the campus was strictly non-smoking, and that residents were not to have smoking/lighting materials in the facility or on grounds. A subsequent interview with NA #4 on 7/17/25 at 9:25 AM identified she had observed residents outside smoking in the past. NA #4 last observed residents smoking within the past three weeks but was unable to recall which residents. NA #4 further identified she reported the residents smoking to the nurse or nursing supervisor but was unable to recall who. A review of the non- smoking facility policy and agreement directs that the facility does not permit smoking in the facility or on the premises at any time.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #60) reviewed for dignity, the facility failed to follow the physician's order related to the resident's position in bed. The findings include:Facility documentation identified Resident #60 was hospitalized from [DATE] - 9/17/24 for right sided weakness. The 5-day MDS dated [DATE] identified Resident #60 had severely impaired cognition, required substantial assistance with eating and was dependent on staff to assist with toileting and transfers.Facility documentation identified Resident #60 was sent to the hospital for evaluation on 9/30/24 due to hypotension and bradycardia. An APRN note dated 10/11/24 identified Resident #60 had a history of becoming hypotensive easily and was to have the head of the bed elevated at all times with some decline at bedtime. A physician's order dated 10/11/24 directed to keep the head of bed elevated at all times and may decline some at bedtime.Review of the care plan failed to identify interventions related to hypotensive episodes with a need for the resident to always remain upright in bed. Observation on 7/16/25 at 2:15 PM identified a sign located above Resident #60's head of bed with the following: Please keep head of bed ELEVATED. During this observation Resident #60 was observed lying completely flat in the bed covered by a sheet. Observation and interview on 7/16/25 at 2:27 PM with NA #8 identified she was assigned to care for Resident #60 that shift and indicated Resident #60 had a history of yelling out when the head of the bed was elevated, so the nursing staff on the unit routinely repositioned the resident flat in bed. Observation and interview on 7/16/25 at 2:29 PM with LPN #3 identified she was assigned to Resident #60 regularly, and that every morning that she was assigned to the resident she would reposition the resident with the head of the bed elevated, but Resident #60 would yell out to be lowered and the nurse aide staff on the unit would then lower the resident because of the amount of yelling. LPN #3 was unable to identify why Resident #8 had an order for with the head of the bed elevated, how long the resident had been yelling while his/her bed was elevated, or if the physician had ever been notified. Review of the clinical record failed to identify notification to the physician or APRN regarding Resident #60's inability to be maintained upright in bed per the physician's order. Observation on 7/17/25 at 11:23 AM identified Resident #60 observed lying completely flat in the bed. Observation on 7/21/25 at 12:20 PM identified Resident #60 observed lying completely flat in the bed. Observation on 7/22/25 at 11:14 AM identified Resident #60 observed lying completely flat in bed. Interview on 7/22/25 at 12:54 PM with APRN #1 and Clinical Lead Director APRN identified the resident had issues with orthostatic hypotension since October 2024 and that is why the head of the bed was to remain up. Further, APRN #1 and Clinical Lead Director APRN identified they had not been notified that Resident #60 would yell while upright in bed and staff was not maintaining the residents head of the bed elevated. The Clinical Lead Director APRN identified that Resident #60 had not had any documented issues with hypotension recently and identified she would discontinue the order. Although requested, the facility failed to provide a policy on physician's orders. The facility policy on change of condition notification directed that the facility would inform the resident, resident's healthcare provider, and the resident's family or legal representative when there was a change in condition. The policy further directed that a resident's change of condition should be evaluated and documented appropriately and reported to the residence healthcare provider and family or legal representative. The facility policy on comprehensive person-centered care planning directed that the person-centered care plan was developed to include information necessary to properly care for the resident and would address the resident's preferences, goals, desired outcomes, and plan for discharge. The policy further directed that the comprehensive person-centered care plan would be reviewed and revised following a significant change in status and episodically as the plan of care changed for the resident.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who was a recent admission and reviewed for omission of medication, the facility failed to notify the provider or implement proper procedures to authorize payment for a medication that was not covered by the resident's insurance to prevent the omission of a medication for forty-eight (48) days. The findings include: Resident #1's diagnoses included prostate cancer, quadriplegia, and chronic congestive heart failure. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was alert and oriented to person, place and time, and was dependent on staff for all daily living skills. A physician's order dated 8/2/24 directed to administer the hormonal therapy drug in the treatment of advanced prostate cancer Orgovyx 120 milligrams (mg) one (1) time per day. Review of the nurse's notes from 8/3/24 through 8/26/24 identified the Orgovyx was not available at the facility, on order, waiting for pharmacy delivery, and the nurse's notes failed to identify the reason the medication was not available, there was communication with administration, and the physician or Advanced Practice Registered Nurse (APRN) had been notified. The nurse's note dated 8/26/24 at 11:18 AM identified the APRN was made aware that the Orgovyx was not received by the pharmacy. Upon further review of the nurse's notes from 8/26/24 through 9/19/24 identified multiple entries the Orgovyx was on order or not available and the nurse's notes failed to identify there was communication with administration, and the physician or APRN had been notified. Review of the Medication Administration Records from 8/3/24 to 9/19/24 identified Resident #1 did not receive the Orgovyx. The nurse's note dated 10/7/24 at 4:00 PM identified Resident #1 was re-admitted to the facility on [DATE] after hospitalization from 9/19/24 to 9/30/24 and upon returned Resident #1 received the Orgovyx. A physician's note dated 10/10/24 identified the physician was asked to see Resident #1 due to the omission of the Orgovyx for six (6) weeks. The note identified the omission likely did not cause any adverse reactions, Resident #1 had no new complaints or issues, a follow up with a new oncologist was scheduled and will defer follow up and repeat Prostate Specific Antigen (PSA) test to oncology team. Interview with the Director of Nursing (DON) on 10/29/24 at 11:45 AM identified upon her return to the facility on [DATE] she was informed there had been an issue obtaining the Orgovyx. The DON stated upon investigation she discovered when Resident #1 was admitted to the facility on [DATE], the Orgovyx had been ordered, however the pharmacy never delivered the medication because Medicare did not cover the cost, and they were waiting for a response from the facility to authorize payment. The DON identified she authorizes the payment of non-covered medications and since the resident was on Medicare the facility would have been responsible for coverage. The DON indicated she was not notified directly by the pharmacy or staff that there was an issue with obtaining the Orgovyx, therefore Resident #1 did not receive the Orgovyx medication from 8/3/24 to 9/19/24. Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, on 10/29/24 at 12:10 PM identified she was aware the Orgovyx was not covered by the insurance and the pharmacy had advised her to call the physician for an alternative medication, however the resident did not have an oncologist at the time. RN #1 indicated she did not recall informing the DON that there was any issue regarding the medication. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 10/29/24 at 12:20 PM identified she had called the pharmacy regarding the Orgovyx, and they told her the medication was very expensive and the facility had to decide if they were going to pay for the medication. LPN#1 explained she informed one (1) of the Nursing Supervisors and documented the Orgovyx was not available in the APRN communication book. Interview with the 7AM-3PM charge nurse, LPN #2, on 10/29/24 at 12:25 PM identified she informed the Nursing Supervisor, RN #1, that the Orgovyx was not available. Review of the facility policy Medication Pass identified that medications are to be administered safely and timely per the physician's orders.

Based on a review of clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #6), reviewed for accidents, the facility failed to ensure the resident's wheelchair cushion was secured to the wheelchair and as a result, the resident fell and sustained an injury. The finding includes: Resident #6 had diagnoses that included dementia, atrial fibrillation and heart failure (on blood thinner). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 had severe cognitive impairment and required extensive assistance for locomotion in a wheelchair. The Resident Care Plan (RCP) dated 5/23/2023 identified Resident #6 had limited mobility due to weakness and deconditioning, was non ambulatory and had a history of repeated falls. Interventions in part directed the use of a wheelchair. Review of the facility incident report dated 7/12/2023 at 9:45 A.M. identified staff responded to a noise in the common area and observed Resident #6 on the floor in front of his/her wheelchair. Resident #6 was unable to explain how the fall occurred due to cognitive impairment. A small hematoma (bruise) was noted on the inside corner of the eye and a cut on the underside of Resident #6's right 3rd and 4th toes. The APRN was notified and completed an assessment, and Resident #6 was transferred to the hospital for evaluation. The report further indicated Resident #6 returned to the facility at 11:35 P.M. with 5 sutures noted to repair the toe lacerations. Facility incident summary dated 7/14/2023 identified staff had observed Resident #6 five (5) minutes prior to the fall, and when Resident #6 was observed on the floor, staff identified the wheelchair cushion was not buckled to secure it in place to the wheelchair. The summary identified Resident #6 slid down the cushion, off the seat of the chair, and hit his/her toes on the footrest. Interview and record review on 5/10/2024 at 12:55 P.M with LPN #4 identified she was the charge nurse assigned to Resident #6 on 7/12/2023 when Resident #6 had an unwitnessed fall. LPN #4 stated Resident #6 fell from the wheelchair because the seat cushion was not buckled and secured to the wheelchair. Interview with NA #3 on 5/10/2024 at 12:34 P.M. identified she was assigned to Resident #6 on 7/12/2023 and after she had transferred Resident #6 into the wheelchair, she left Resident #6 in the common area. At around 9:45 AM, she observed Resident #6 on the floor in the common area and called for assistance. NA #6 stated Resident #6 had a seat cushion that was required to be buckled behind the wheelchair, expressed that her usual process was to buckle the cushion in place to secure it, and she could not recall if she had buckled the seat cushion on 7/12/2023 prior to Resident #6's fall. Interview with the ADNS on 5/10/2024 at 1:15 P.M. identified she had conducted the investigation and determined the type of seat cushion used for Resident #6 was required to be buckled in place (buckled behind the wheelchair). The ADNS concluded that the wheelchair cushion was not buckled to secure it to the wheelchair at the time of fall. The ADNS stated the unbuckled seat cushion contributed to Resident #6 sliding out of the wheelchair on 7/12/2023, resulting in a laceration to the 3rd and 4th toes on the right foot when the foot hit the hit the wheelchair footrest. Interview and facility documentation review with the DON on 5/10/2024 at 1:45 P.M. stated the Nurse Aides were responsible to ensure the cushion was buckled in place prior to use and was unable to explain why it was not buckled on 7/12/2023. Although requested, a facility policy/procedure regarding use of the buckled wheelchair cushion was not provided for surveyor review as well as the manufacturer's guideline for use.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to follow the plan of care when obtaining the resident's weight, Resident #1 sustained a foot laceration that required hospitalization as a result. The finding includes: Resident #1 had diagnoses that included type one diabetes mellitus, and end stage renal disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had intact cognition, severely impaired vision, and required assistance with transfers. The care plan dated 3/27/2024 identified Resident #1 had the potential for falls due to impaired vision and impaired mobility with interventions that directed the resident is to remain seated in the wheelchair while being weighed on the scale. Review of the Facility's Accident and Incident form dated 4/4/2024 identified on 4/4/2024 at 11:15 A.M. staff were helping Resident #1 get onto the scale when the left foot came into contact with a metal piece on the scale causing a laceration to the left 2nd toe. A nurse's note dated 4/4/2024 at 12:13 P.M. identified that Resident #1 was being weighed on the scale and when Resident #1 stood up to get on the scale h/her left foot slipped off the left side of the scale. The resident was noted with a laceration to h/her left 2nd toe, the Advanced Practice Registered Nurse (APRN) was called, and Resident #1 was sent to the hospital. An APRN note dated 4/4/2024 at 1:16 P.M. identified Resident #1 was assessed and had a very deep laceration with moderate amount of bleeding to the 2nd toe on left foot. Review of the Hospital Discharge summary dated [DATE] identified Resident #1 was admitted on [DATE] for a left foot laceration. Resident #1 sustained a 4.0-centimeter laceration to the bottom of h/her left foot. Resident #1 received the Tdap vaccine (to prevent tetanus), 7 sutures, and a 7-day course of antibiotics. An APRN note dated 4/6/2024 identified that the resident was re-admitted to the facility with wound care orders and a 7-day course of antibiotics. Interview with NA #1 on 4/29/2024 at 10:30 A.M. identified on 4/4/2024 she and Registered Nurse (RN #1) assisted Resident #1 from h/her wheelchair to a standing position on the scale to obtain Resident #1's weight. NA #1 placed the resident back in the wheelchair and noted Resident #1 was bleeding from h/her left foot. NA #1 indicated she was unsure if Resident #1 should be standing on the scale, she questioned RN #1 who directed her to obtain Resident #1's weight in a standing position. Interview with RN #1 on 4/29/2024 at 11:40 A.M. identified on 4/4/2024 Resident #1 needed to be re-weighed due to a weight discrepancy, although Resident #1's care plan directed to weigh the resident while seated in wheelchair, RN #1 felt a standing weight would be more accurate. As Resident #1 stepped on the scale h/her left foot slipped and hit a metal type handle (used to fold the scale for transport) and the resident sustained a laceration to h/her left foot. Interview and clinical record review with the DNS on 4/29/2024 at 12:25 P.M. identified in October 2023, Resident #1 sustained a foot injury while being weighed in the standing position. The DNS stated the plan of care directed to weigh the resident in the wheelchair and not stand on the scale to prevent further accidents. The DNS identified that on 4/4/2024 Resident #1 should have remained seated in h/her wheelchair while being weighed on the scale. The facility care plan policy identified that the person-centered care plan is developed to include information necessary to properly care for the resident and the interventions will be effective on the date of the care plan.

Based on tour of the kitchen and staff interview, the facility failed to ensure that the Dietary Department was maintained in a manner that food items were consistently labeled and stored to reflect their age or shelf-life. The findings included. Tour of the Dietary Department on [DATE] at 11:02 AM during the initial walk-through of the kitchen with the Dietary Manager (DM) identified the following: a. In the dry storage area, 1 bag of pasta was observed to be in the original packaging, was opened, but did not include a date when opened or an expiration date. b. In the dry storage area, 1 bag of fudge brownie mix was observed to be in the original packaging, was opened, with a date of [DATE], was identified by the DM to be good for 5 days and to be thrown out on [DATE] (1 day past the discard date). c. In the dry storage area, 1 bag of yellow cake mix was observed to be in the original packaging, was opened, with a date of [DATE], was identified by the DM to be good for 5 days and to be thrown out on [DATE] (5 days past the discard date). d. In the freezer, not in original packaging, the DM identified approximately ,d+[DATE] lb of opened lima beans without an open date or expiration date. e. In the reach in refrigerator, not in original packaging, approximately 15 individual portioned sour creams dated [DATE], identified by the DM to be good for 5 days, to be thrown out [DATE] (2 days past the discard date). f. In the reach in refrigerator, not in original packaging, approximately 15 individuals portioned Caesar salad dressings dated [DATE], identified by the DM to be good for 5 days, to be thrown out [DATE] (2 days past the discard date). Interview with the DM at that time indicated that it was the responsibility of himself and the Dietary staff to remove expired or outdated items from the Dietary Department Facility policy for culinary services for storage of food and supplies stated that food products that are opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and used by dates. The policy also stated that food should be discarded that exceeds their use by date or expiration date, is damaged, is spoiled, has the time and temperature danger zone requirement, or incorrectly stored such that it is unsafe, or its safety is uncertain.

Based on review of the clinical record, facility documentation, and staff interview for 1 of 3 residents (Resident #30) reviewed for care planning, the facility failed to maintain an accurate and current Resident Care Plan (RCP). The findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, lupus anticoagulant syndrome, obsessive-compulsive behavior, and hypertensive heart disease with heart failure. The Resident Care Plan dated 3/22/23 identified Resident #30 had an actual nutritional problem and potential for malnutrition with a goal that resident will have further significant weight loss through next review. Interventions included to weigh the resident as ordered by MD/Physician as indicated and note weight fluctuations, to provide and serve diet as ordered and monitor intake and record every meal, and provide and serve supplements as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 had intact cognition and required extensive assistance of 2 for bed mobility, was totally dependent on 2 for transfers, dressing, toilet use and personal hygiene. The MDS further identified Resident #30 was independent with setup help only for eating. Additionally, the MDS did not reflect Resident #30 received peritoneal dialysis. The RCP dated 5/26/23 identified Resident #30 required peritoneal dialysis. Interventions included to monitor intake and output, and to monitor resident for complications of peritoneal dialysis (the physician orders, nursing notes, physician progress notes did not reflect Resident #30 received peritoneal dialysis). A Dietary/Nutrition Quarterly Assessment, completed by the Dietician and dated 6/8/23 indicated Resident #30 experienced a significant weight loss since 5/1/23. Resident #30 had lost 13 pounds (lbs) or 6% of his/her body weight in 30 days. In addition, Resident #30 was noted to consume 50% to 100% of his/her meals plus 100% of his/her supplement. The annual MDS dated [DATE] identified Resident #30 had identified Resident #30 had intact cognition and required extensive assistance of 2 for bed mobility, was totally dependent on 2 for transfers, dressing, toilet use and personal hygiene. The MDS further identified Resident #30 was independent with setup help only for eating. The MDS further identified Resident #30 has had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regimen. A Nutrition Evaluation dated 7/6/2023 identified Resident #30 received Ensure supplements two times a day and fortified pudding on his/her supper tray. Additionally, Resident #30 was identified as having a greater than or equal to 5% weight loss in 30 days. A Physician progress note dated 7/27/23 indicated Resident #30 had poor by mouth (po) intake and he/she ate about 25% of his/her meals. An interview with RN #3 on 8/30/23 at 8:35 AM identified the RCP dated 5/6/23 was incorrect indicating Resident #30 required dialysis because he/she does not require peritoneal dialysis and was documented in error. Additionally, RN #3 indicated the RCP also contained an error indicating Resident #30's goal was having further significant weight loss. Subsequent to surveyor inquiry, Resident #30's care plan was corrected. The problem that identified Resident #30 required peritoneal dialysis was removed from the RCP. The problem that identified Resident #30 had an actual nutritional problem and potential for malnutrition with a goal that resident will have further significant weight loss through next review was updated to indicate that Resident #30 has an actual nutritional problem with a goal that the resident will have no further significant weight loss through the next review.

Based on clinical record review, observations, and interviews for 2 of 3 residents (Residents #44 and #51) reviewed for dining, the facility failed to ensure adequate supervision was provided for a resident who required staff assistance with meals and failed to ensure that the care plan reflected the needs of the resident during meals. The findings included: 1. Resident #44's diagnoses included malnutrition, cerebral infraction with hemiplegia and hemiparesis, dysphagia, seizures, diabetes mellitus, end stage renal disease and dementia. The quarterly MDS assessment dated [DATE] identified the resident was moderately cognitively impaired and required limited one-person physical assistance with eating and personal hygiene. The physician's order dated 6/1/23 directed one to one feed supervision with meals for poor appetite. Instructions for Certified Nursing Aide revised on 6/7/23 directed one to one feed for meal surveillance. The discharge-return anticipated MDS assessment dated [DATE] identified Resident #44 with moderately impaired cognition and required extensive assistance with bed mobility and eating. The residents Care Kardex with readmitted [DATE] directed one-to-one feed for eating. The Occupational Therapy (OT) evaluation dated 7/19/23 identified Resident #44 required supervision or touching assistance with eating. Right upper extremity strength and range of motion were not tested . Further review identified upon evaluation, the resident presented with decreased strength, balance, activity tolerance/endurance, coordination, and motor planning. Staff reported the resident with decline in self-feeding, fluctuating between requiring supervision to extensive assist. The resident verbalized not liking the food on evaluation. The resident would benefit from skilled OT services to assess positioning seated in wheelchair and to determine the need for equipment to increase independence with self-feeding tasks. The Nutritional Evaluation dated 7/20/23 identified Resident #44 was readmitted to facility with significant weight loss and by mouth intake of meals continued to be inadequate, 25%-75% consumed and sometimes less than 25%. Additional supplements were added. The evaluation further identified the resident continued with potential for malnutrition and suspected ongoing weight loss may occur secondary to inadequate by mouth intake of meals. The care plan dated 8/28/23 identified the resident had an actual nutritional problem, required assistance with meals, had potential for malnutrition and a history of significant weight changes. Interventions directed to provide and serve diet as ordered, monitor intake, record every shift, and feed the resident as needed. The care plan further identified Resident #44 had an ADL self-care performance deficit related to weakness and right-side neglect, and was right side dominant. Interventions directed eating with one-to-one feed. Observation on 8/29/23 at 12:40 PM identified Resident #44 sleeping in bed, the head of bed was elevated at approximately 45 degrees and overbed table was positioned in front of the resident. Further observation identified Nurse Aide (NA #3) delivered and placed lunch tray (half a cup of roasted corn, one serving of ice cream, 4 oz of milk and 4 oz of ginger ale) on overbed table without the benefit of removing covers from the food items and one-to one assistance. The resident looked at the tray and then closed her/his eyes again. At 12:51 PM NA #4 woke the resident up and asked her/him to eat. The resident opened her/his eyes, stated too tired today, gently pushed the overbed table away, pulled bed covers higher and closed her/his eyes. At 12:55 PM NA #3 went into the resident's room, asked the resident to eat but the resident stated no, not hungry. At 1:00 PM, NA #3 assisted the resident's roommate with transfer and Resident #44 started to uncover roasted corn that was identified as a side dish on the menu slip. NA #3 assisted the resident with uncovering her/his corn and offered other food alternatives/multiple food choices, but the resident stated, I only want corn, I do not want anything else. The resident started eating the corn with a fork, dropping some of the corn with each bite onto her/his bed sheets and covers. At 1:08 PM the resident was trying to open her/his pepper packet with her/his teeth and was using only one hand, then continued eating her/his corn with a fork and dropping some of it on the bed. At 1:15 PM NA #3 was noted outside the resident's room stating that the resident is still going. At 1:20 PM the resident was observed opening her/his salt packet with her/his teeth while using only one hand, then continued eating corn and continued dropping some of it on her/his covers. At 1:25 PM NA #3 came inside the room and helped the resident pick up some of the corn that fell , NA #3 adjusted the overbed table to lower position and tried to raise the resident's bed to higher position. NA #3 stated I tried to put the bed higher so it will be closer to the table so it will be easier for her/him to eat, but the bed is broken, and the table will not go down anymore, I will put it in the maintenance book to be fixed. In addition, NA #3 stated I cannot even put her/his head of bed higher. I will let them know. At 1:55 PM the resident continued to eat her/his corn with the fork, using only one hand and dropping some of the corn on the bed and had approximately total 2 oz of milk without one-to-one supervision and/or without being offered to be fed. Interview with Registered Nurse (RN #2) on 8/29/23 at 2:05 PM identified the resident had a very poor appetite and was losing weight, had difficulty using one of her/his arms and the order for one-to-one supervision and feed was written so staff would be with the resident for encouragement and assistance to eat and to complete her/his meal. Interview with NA #4 on 8/29/23 at 2:15 PM identified she was not the regular aide on the unit, and she had no chance to review the resident's care Kardex. Interview with NA #3 on 8/29/23 at 2:20 PM identified she did not have the resident on her assignment and was not aware that the resident required one-to-one supervision and/or feeding. Interview with the Director of Nursing Services (DNS) on 8/29/23 at 3:05 PM identified the resident care Kardex directed NAs to provide one to one supervision and/or feed the resident, therefore the NA should have stayed with Resident #44 during the meal to supervise, assist and/or feed as ordered. She also indicated the nursing staff will be educated and directed to follow the resident's care Kardex, physician orders and plan of care. The DNS further identified the resident refused her/his food most of the time and did not need one-to-one supervision with her/his meals, therefore the care plan will be updated, and one-to-order will be discontinued. Interview with Dietician #1 8/31/23 at 12:55 PM identified the resident's recent weight was 95.9 lbs. Nursing staff should open and uncover all food served, which will be included in the resident's plan of care. Further interview identified Dietician #1 did not request one-to-one supervision but sometimes when she stood next to the resident and encouraged her/him to eat, the resident drank her/his supplements and ate but when she/he was done eating she/he stopped. Dietician #1 further stated you cannot make or force her/him to eat, only encourage. She/he will eat only what she/he wants. Follow up interview with Rehabilitation Director OT #2 on 9/5/23 at 10:40 AM identified on 7/19/23 OT assessed the resident's eating ability and found the resident required supervision or touching assistance during meals which meant the nursing staff should stay with the resident during meals to provide assistance and encouragement to eat. Although requested, a facility policy related to assistance with meals was not provided for surveyor review. Review of Baseline/Comprehensive Person-Centered Care Plan identified the Person-Center Care Plan was developed to include information necessary to properly care for the resident and will address the resident's preferences, goals, desired outcomes, and plan for discharge. 2. Resident #51's diagnoses included hemiplegia and hemiparesis following a cerebral infarction, aphasia, dysphagia, and need for assistance with personal care. A physicians' order dated 3/14/2023 directed to provide a regular whole texture diet of thin consistency. The quarterly MDS assessment dated [DATE] identified Resident #51's cognitive status as intact, required supervision of one person with eating and had an impairment of upper and lower body range of motion on one side. A nutrition quarterly assessment -V7 dated 7/5/2023 indicated Resident #51 feeds him/herself. The Care plan dated 7/11/2023 indicated Resident #51 had an Activity of Daily Living deficit due to weakness and pain due to right sided dominant hemiplegia after a Cerebral Vascular Accident (CVA) with aphasia and dysarthria. Interventions included: providing extensive assistance of 1-2 staff members to assist with turning and repositioning in bed and supervision of one staff member for eating. The care plan further indicated Resident #51 had limited physical mobility due to right sided weakness from stroke. Interventions include providing extensive assistance of one staff member for locomotion in the wheelchair as Resident #51 could not walk. The care plan indicated Resident #51 had a CVA that affected the dominant right side of the body. Interventions included in part to monitor the resident's abilities for Activities of Daily Living and to assist as needed. The care plan further indicated Resident #51 had a potential nutritional problem secondary to use of a therapeutic diet after having a CVA. An intervention in part directed to provide and serve the diet as ordered. On 8/28/23 at 12:59 PM an observation of Resident #51 eating lunch in bed on an overbed table identified the resident stabbing at his/her meat with a spoon held in the left-hand while verbalizing they did not cut my meat, I cannot use my right hand, the slip even says they are to cut the meat. Observation of the lunch diet ticket indicated in highlighted type print Please Cut Up Food by Nurse Aide (NA). On 8/28/2023 at 1:01 PM an observation and interview with Registered Nurse (RN #1), unit manager identified the Nurse Aide (NA) should have cut the resident's meat when the tray was given to the resident and further indicated the diet slip indicated the NA should cut up the resident's meat. On 8/28/2023 at 1:03 PM an interview with NA #10 indicated s/he passed meal trays but did not know who gave the lunch tray to Resident #51. On 8/28/2023 at 1:40 PM NA #10 approached surveyor and indicated s/he did give Resident #51 his/her lunch tray and would have gone back to cut up the meat. On 9/5/2023 at 10:45 AM interview with RN #1 indicated the care plan and resident care card did not reflect the need for Resident #51 to have her/his meat cut and she would revise the care plan. Subsequent to inquiry, a physician's order dated 9/5/023 directed to provide a regular whole texture thin consistency diet and to cut up meat to optimize eating independence. 46046

Based on clinical record review, review of facility documentation, facility policy and interviews for 1 of 1 resident (Resident #98) reviewed for parenteral/ Intravenous (IV) fluid, the facility failed to ensure that staff assessed in accordance with facility policy and failed to ensure annual IV therapy education and competencies for licensed staff were completed. The findings included: Resident # 98's diagnosis's included orthopedic aftercare, infection of an amputated lower extremity stump, and need for assistance with personal care. The physicians' orders dated 2/7/2022 directed to monitor the Intravenous (IV), Peripherally Inserted Central Line Catheter (PICC) for redness, swelling, drainage and any signs of infection every shift and as needed. The physicians' orders dated 2/7/2022 directed to provide Piperacillin-Tazobactam in Dextrose intravenous Solution 2-0.25 GM/50 ML and to use 2.25 grams intravenously every 12 hours for wet gangrene for 7 days. The Admission MDS (Minimum Data Set) dated 2/12/2023 indicated Resident #98 had moderate cognitive impairment required extensive assistance of 2 persons for dressing and received Intravenous (IV) medications before and after admission to the facility. The care plan dated 2/14/2023 indicated Resident #98 received IV therapy via a PICC line with interventions that included in part to administer IV medication as ordered and to monitor the site for placement, signs, and symptoms of infection. A progress note dated 2/16/2023 at 8:40 PM indicated the nurse went into Resident #98's room to administer a solution and found the PICC line on Resident #98's bed, informed the Advanced Practice Registered Nurse (APRN) and indicated Resident # 98 did not know how the PICC line came out. On 8/31/2023 at 12:07 PM an interview with the DNS indicated he/she would have expected the staff to assess the resident and document, applied a dressing to the site, checked that the catheter (PICC) tip and entire line was found intact. Interview via telephone on 8/31/2023 at 1:40 PM with RN#5 indicated when he/she entered Resident #98's room on 2/16/2023 he/she found the PICC line in the bed and indicated s/he notified APRN #1 but could not recall what APRN#1 said about the incident and indicated no new orders were obtained. RN #5 indicated the IV line looked the same but he/she was not sure so he/she covered and saved the PICC line in a plastic bag passing the bag on to the next shift to show the APRN the next day as the APRN would know if the PICC line was fully intact. RN#5 further indicated s/he cleansed the PICC line site with normal saline and applied a bandage to the IV site, there was no bleeding and indicated s/he could not recall what documentation was completed. On 8/31/2023 at 1:50 PM an interview and facility record review with RN #6 indicated no IV education or documentation could be found for any nursing staff including RN #4 for 2021 or 2022 but provided evidence of initial IV-line management training. On 9/5/2023 at 10:45 AM interview with the DNS indicated he/she expects the licensed nurse to provide documentation of the IV site and the catheter, if a dressing was required to be applied and documentation of the site for a few days after. On 9/5/2023 at 11:00AM an interview via telephone with APRN #1 indicated he/she did receive a call from the nurse regarding Resident #98's PICC line coming out and the nurse indicated to him/her that the tip of the catheter was intact. APRN #1 further indicated the IV site should have been monitored for bleeding and a dressing applied and indicated s/he would not have provided any new orders. On 9/6/2023 at 12:22 PM an interview with RN # 4 at 12:22 PM indicated he/she found no PICC line orders for Resident # 98 or any documentation that indicated the length of the PICC line on admission or documentation of any measurements during Resident #98's stay. The facility policy and procedure dated 1/2022 labeled Peripherally Inserted Central Catheter Removal indicated in part, after the catheter is removed to hold manual pressure with gauze for at least 30 seconds or until homeostasis is achieved, fold gauze with ointment and place over the exit site and cover with a transparent dressing keeping area covered for at least 24 hours and verification of the catheter length is the same as the initial catheter documented length and has a clean-cut tip. The policy further indicated in the event the catheter tip is not clean cut or appears jagged to apply a tourniquet above the site continue to monitor pulse below the site, prepare for emergency transfer notifying the physician and closely monitoring the resident's condition. The policy notes for documentation, at a minimum documentation should include the date/time, reason for removal, removed catheter length, condition of the tip, the type of dressing applied, the resident's response to removal, a comprehensive site assessment, and any complication encountered with intervention provided along with resident education.

Based on observations, record review, and staff interviews for 1 of 2 residents (Resident #542) reviewed for nutrition, the facility failed to ensure the ordered nutritional supplement was provided. The findings included: Resident #542 was admitted to the facility on [DATE] with diagnoses that included a terminal condition of the bladder, chronic obstructive pulmonary disease (COPD), and reduced mobility. The Resident Care Plan dated 8/28/23 identified Resident #542 as at risk for malnutrition due to a terminal condition and low Body Mass Index (BMI). Interventions included monitoring the resident's food preferences, providing 4 ounces of medical food supplements, and providing 4 ounces of fortified pudding with breakfast, lunch, and supper trays. A Social Service note dated 8/29/23 identified Resident#542 had intact cognition (an Admission Minimum Data Set assessment had not been completed yet). A Nutritional evaluation (completed by the Registered Dietician) dated 8/30/23 indicated Resident #542 was at risk for malnutrition due to a terminal diagnosis, a Body Mass Index (BMI) of 16%, and severe weight loss (40 pounds (lbs) in one year) before arriving at the facility. Resident #542 was on a regular diet, receiving 4 ounces of a house supplement twice daily and 4 ounces of fortified pudding with breakfast, lunch, and supper trays. On 8/31/23 at 11:40 AM, Resident #542 indicated that he/she had received a fortified pudding the day before that was yellow and tasted like banana cream, however, Resident #542 indicated that for breakfast on 8/31/23, he/she did not receive fortified pudding and there had been no fortified pudding on the breakfast tray. On 8/31/23 at 12:45 PM, Resident #542's lunch tray was observed with the Director of Dietary. The meal ticket indicated one serving of fortified pudding; however, no pudding was noted on the resident's tray. An interview with the Director of Dietary at that time indicated that the small cross on the front of the meal ticket next to the fortified pudding meant it was an item automatically placed on the resident's meal tray by a Dietary Aide in the kitchen. The Director of Dietary indicated that the resident not receiving a fortified pudding with the breakfast and lunch trays must have been an oversight. An interview with the Registered Dietician (RD) on 8/31/23 at 1:16 PM indicated that Resident #542 was at risk for malnutrition based on a low BMI of 16%, where 25% would be considered normal. The RD also indicated that each 4-ounce serving of fortified pudding provided 195 calories and 5 grams of protein (which meant Resident #542 was not provided 390 extra calories/10 gms protein). When shown the resident's meal ticket, the RD indicated that the small cross on the meal ticket meant the resident did not have to ask for the fortified pudding since the kitchen would automatically place it on the meal tray.

Based on observation and staff interviews, the facility failed to ensure the [NAME] Wing Treatment Cart remained locked while not in use and unattended. The findings included: Observation on 8/30/23 at 7:30 AM identified the [NAME] Wing treatment cart was unlocked. Observation of the Treatment Cart continued until the ADNS locked the cart at 7:50 AM. Interview with RN #1 on 8/30/23 at 8:20 AM identified that he/she was not aware the Treatment Cart needed to remain locked. Interview with LPN #3 on 8/30/23 at 8:10 AM identified that the Treatment Cart must remain locked when not in use, had not used it since he/she arrived at 7:00 AM and was not aware of who left it unlocked. Interview with the ADNS on 8/30/23 at 10:50 AM identified that he/she did lock the Treatment Cart on 8/30/23 at 7:50 AM but had not used it since he/she arrived for his/her shift on 8/30/23. The ADNS further identified he/she was not aware of who left it unlocked. Observation of the [NAME] Wing Treatment Cart with LPN #5 on 9/1/23 at 9:03 AM identified the following items were stored in the [NAME] Wing treatment cart: Diflucan, Biotene, Nystatin, Amorphous wound dressing, gauzes, Medi-Honey, [NAME], antifungal cream, nail clippers and razors. LPN #5 further identified being aware the Treatment Cart must remain locked at all times when not in use. Interview with the DNS on 9/5/23 at 10:45 identified that Treatment Carts must remain locked at all times when not in use. The DNS also indicated that she had not been able to locate a policy regarding the Treatment Cart but that it was the expectation of staff to keep the cart locked when not in use. A Treatment Cart policy was requested but the facility was not able to provide a policy.

Based on clinical record review, observations, and interview for 1of 3 residents (Resident #63) reviewed for Position/Mobility, the facility failed to ensure a splint was applied as ordered and the resident's skin was properly cleansed. The finding include: Resident # 63's diagnoses included Hemiplegia (paralysis) and Hemiparesis (weakness on one side of the body) post Cerebral Infarction (stroke), chronic kidney disease, and Depression. A physician's order dated 4/19/23, directed left resting hand splint on AM care/off PM care, perform skin checks, if redness noted, discontinue use, and notify rehab, two times a day on in am, off in pm. A Resident Care Plan revised on 6/2/23, indicated resident had an ADL (Activities of Daily Living) self-care deficit related to past medical history of CVA (Cardiovascular Accident/stroke) with paralysis and weakness on left side and a goal for resident to maintain current level of function in ADLs. Interventions included orthosis (brace), staff to assist with Left hand split, apply in morning, off in evening and dependence in bathing (bed bath). A quarterly MDS assessment dated [DATE] identified Resident #63 as cognitively intact, and required total dependence of two for transfers, extensive assistance of two for bed mobility, dressing, toilet use, personal hygiene and independent with setup for meals. A 24-Hour Positioning Plan dated 6/7/23, located in Resident #63's room on the inner side of resident's closet as care guidance for nurse aides identified the resident had a custom wheelchair device, utilized a pressure relieving cushion, transfers via Hoyer lift, out of bed as tolerated, to tilt level of chair for comfort, leg rests, and head rest, but failed to indicate application of left hand brace. A Nurse Progress note dated 8/22/23 at 10:13 PM, indicated weekly skin check was completed, resident has no new wounds. A Physician Wound Evaluation and Management Summary dated and signed on 8/28/23 at 8:47 AM for a lower leg wound, identified the use of support surfaces on bed, chair gel cushion, and a pillow for feet, but did not indicate Left hand brace/splint or assessment of Left hand. A Physician Wound Evaluation and Management Summary dated and signed on 8/28/23 at 8:47 AM for a lower leg wound, indicated the use of support surfaces on bed, chair gel cushion, and a pillow for feet, indicated left upper extremity as normal, but did not indicate hand brace/splint observation/assessment. Observation and interview with Resident #63 on 8/28/23 at 1:10 PM by a surveyor identified resident was not wearing blue wrist brace but further observations identified the brace/ splint device was located on bedside table. The resident indicated, it's been off for a couple of days, they leave it off when my skin is dry on the inside of hand. Observation and interview with Resident #63 on 8/29/23 at 9:50 AM identified the resident was not wearing left hand blue brace, the brace was noted on the bedside table, the resident pointed to the sign above the head of bed (picture of hand in blue brace, sign indicated on AM off afternoon). The resident also verbalized s/he was okay with this sign being on wall above his bed. Observation and interview on 8/31/23 at 10:20 AM with LPN #1 of the resident's left hand, indicated the resident did not have splint on, she indicated that it is off at night, after care per sign above the bed and physician order. LPN # 1 further indicated staff should check after or during medication pass for the brace and indicated that she had been pulled out of room by the nurse aide on several occasions. She identified that the brace/splint was on the dresser, confirmed an odor coming from within the left hand could be attributed to dry, flaky, skin and indicated the color was tan/brownish. The resident identified it as crude at this time and it was observed by surveyor to be a moderate amount of moist odorous clumped tan/brownish material. Subsequent to inquiry, LPN #1 attempted to clean the resident's hand, located (NA #1) provided re-education and both returned to the resident's room. At 10:35 AM NA #1 soaked resident's hand in wash basin and was able to remove tan/brownish material, dried resident's hand and arm, the nurse aide, surveyor, and LPN #1 observed that the left-hand skin was now dry, clean, and intact, LPN # 1 then applied left hand brace at 10:53 AM. Interview, observation, and review of 24-Hour Positioning Plan (located in Resident #63's room closet/cabinet) on 8/31/23 at 10:54 AM with Occupational Therapist (OT #1) indicated if a resident did not want to wear his/her splint because it was bothering them the nursing staff could place a rolled washcloth in hand and to ensure the hand was well cleaned and dry. She further indicated that while therapy documents in another system, they do place orders in the facility's resident care software system for nursing to confirm and follow. Additionally, OT #1 indicated that if a resident was not wearing a splint/brace the nursing should send a screen to the therapy department to reassess splint, and the screen typically occurs within a day. OT #1 further indicated that if a resident did not wear the brace/splint further hand contracture could occur, impacting skin integrity and this can lead to skin breakdown. Observation of the resident on 8/31/23 at 11:00 AM indicated Resident # 63 was wearing a brace to the left hand.

Based on clinical record review, observation, and interview for 1 of 6 residents (Resident #40) reviewed for Pressure Ulcers/Injury, the facility failed to follow physician's orders regarding wound treatment as prescribed to promote wound healing. The finding included: Resident # 40's diagnoses included: Pressure Ulcer of Sacral Region, Stage 4, Necrotizing Fasciitis, Diabetes Mellitus Type 1, severe sepsis, and Acute Kidney Failure. An Admission MDS assessment dated [DATE] identified Resident #40 as alert and cognitively intact, and required extensive assistance of two for bed mobility, transfers, dressing, toilet use, and extensive assistance of one for personal hygiene and eating. The MDS further indicated the resident has several pressure ulcers. A Resident Care Plan dated 8/2/23 identified the resident has several pressure ulcers related to immobility, incontinence, compromised nutritional status, diabetes disease process, and a history of ulcers. Interventions directed for the nursing staff to monitor compliance with turning and positioning, if dressing falls off, nurse to replace, low air loss mattress, pressure relieving chair cushion, directed monitoring for signs and symptoms of infection, and treatment as ordered. Resident Care Plan dated 8/14/23, revised 8/17/23 identified the resident was on antibiotic therapy related to suspected sacral wound infection. Interventions included administering antibiotics as ordered, monitoring for adverse reactions and secondary infections related to antibiotic therapy, and reporting pertinent laboratory results to physician. A Physician Wound Evaluation and Management Summary dated 8/28/23 identified a Stage 4 Pressure Wound to Sacrum Full Thickness, wound measurements 19.9 Centimeter (CM) x 18.5 x 5.9 CM (Centimeters) or (7.8 x 7.28 x 2.3 inches) with undermining (erosion underneath visible skin surface) at 4 o'clock of 6.9 CM or (2.72 inches) and indicated wound progress as not improved. An Advanced Practice Registered Nurse (APRN) wound care order dated 8/30/23, directed to cleanse coccyx and sacral wound with 60 cc normal saline with a syringe, pat dry then pack with 2 kerlix wraps soaked in Dakins 1/4 strength, cover with dry pressure dressing, change two times per day and as needed every day and evening shift for stage 4 ulcer. The Medication Administration Record (MAR) dated 8/30/23 and the Treatment Administration Record (TAR) dated 8/30/23 identified the 3:00 to 11:00 PM nurse documented wound care as directed to cleanse coccyx and sacral wound with 60 cc normal saline with a syringe, pat dry then pack with 2 kerlix wraps soaked in Dakins 1/4 strength, cover with dry pressure dressing, change two times per day and as needed every day and evening shift for stage 4 ulcer. Observation, interview, and clinical record review on 8/31/23 at 11:00 AM with Licensed Practical Nurse (LPN #2) of wound treatment to Resident # 40's sacral pressure ulcer identified the nurse failed to follow wound care treatment as ordered. LPN #2 removed the soiled dressing and packing but failed to remove dirty gloves and perform hand hygiene prior to proceeding to cleaning the wound with a normal saline soaked gauze, packed wound with 1 kerlix and then trimmed 1 kerlix Dakin's solution-soaked gauze dressing roll. The wound care treatment order directed to cleanse with 60cc normal saline with a syringe, pat dry, then pack with 2 Kerlix Dakin's solution-soaked gauze, followed by dry pressure dressing. Upon wound care completion LPN #2 identified she followed the Treatment Administration Record which indicated a prior order dated 8/9/23 to cleanse sacral wound with normal saline, pat dry, pack with kerlix Dakin's solution wet to dry apply protective dressing daily on the day shift for wound management. Additionally, she reviewed the wound care order dated 8/30/23 upon surveyor inquiry, and LPN #2 further indicated she used 1 large Kerlix only because it was a large kerlix, when asked what was the small kerlix she pulled out a package of gauze cling wrap and when asked to read the package label, she identified gauze cling wrap, and she was unable to produce a small kerlix gauze wrap package. Interview and clinical record review on 8/31/23 at 12:02 PM with DNS and Director of Clinical Operations who were both wound certified, the DNS confirmed order for 2 kerlix for wound packing for coccyx/sacral wound. The DNS additionally identified that it is appropriate after removing a dirty/soiled dressing to take off dirty gloves, perform wound hygiene and then apply clean gloves prior to continuing with clean wound care, and she further indicated the facility would research why a dry adhesive to secure the outer dressing was not in use. Interview on 8/31/23 at 12:15 PM with Director of Clinical Operations indicated after she assessed the sacral/coccyx wound and identified that more kerlix would be appropriate for this resident's wound packing. She further identified the resident does not tolerate tape for this wound area and the facility would investigate alternative options to secure outer dressing when resident is rolling in bed or up out of bed. Interview on 8/31/23 at 12:47 PM with DNS indicated it was important for the dressing to fill the wound fully to promote healing.

Based on clinical record review, observation, facility documentation, facility policy and interviews for 1 of 1 sampled resident (Resident #88) reviewed for alteration in skin integrity, the facility failed to ensure a skin evaluation was comprehensive after a fall and failed to ensure a skin assessment was conducted by a Registered Nurse. The findings included: Resident #88 was admitted to the facility on [DATE] with diagnosis that included pulmonary embolism, chronic obstructive pulmonary disease, and orthostatic hypotension. A physician order dated 2/6/23 directed skin integrity checks be completed by nursing weekly. The physician order further directed staff must document skin checks in the electronic record and wound-total body assessment. A physician order dated 5/2/23 directed Rivaroxaban (Xarelto) (a medication to thin the blood, anticoagulation therapy) 20 milligrams (mg), give 1 tablet by mouth at bedtime for a history of pulmonary embolism. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #88 had intact cognition and required set up and assist of 1 for bed mobility, transfers, dressing, personal hygiene. Additionally, the MDS identified Resident #88 required 2 person assistance for toilet use, required set up only for eating, and also identified Resident #88 had skin tears. The Resident Care Plan (RCP) dated 8/6/23 identified a problem with increased potential for skin breakdown and injuries related to decreased mobility, poor safety awareness, and skin fragility with purpura. Interventions included to educate resident to call for assistance, Geri-sleeves as tolerated and weekly skin evaluations. The RCP further identified a potential for untoward effects due to anticoagulation therapy (Xarelto) with interventions to monitor/document/report adverse reactions of anticoagulant therapy, bruising, blurred vision and to report side effects. A nursing note dated 8/26/23 at 5:07 PM identified Resident #88 was found on the floor at the foot of the bed. Resident #88 stated he/she tripped on a towel on the floor, was able to move all extremities, and sustained a large skin tear to the right elbow, denied pain, and was assisted to his/her feet. An APRN progress note dated 8/26/23 identified Resident #88 had a fall and sustained a right elbow abrasion. A Nursing Skin and Wound Evaluation dated 8/26/23 identified Resident #88 had a wound area measurement of 13.1 centimeters (cm) by 5.7 cm in length by 3.3 cm in width but failed to complete all questions of the evaluation (omitted the type of wound, location, acquired, how long has the wound been present, date, wound bed, evidence of infection, exudate, peri wound, pain, orders, treatment and notification to practitioner). An APRN progress note dated 8/27/23 noted a skin tear to Resident #88's right elbow, no erythema, and a Xeroform dressing was in place. A document titled Skin and Wound Total Body Skin Assessment was completed by an LPN on 8/28/23 (and not a Registered Nurse). Observation on 9/1/23 at 1:30 PM with the Clinical Director of Operations noted Resident #88's right elbow had a dressing in place and discoloration was observed to Resident #88's bilateral hands (Purpura). Review of the Total Body Weekly assessment dated [DATE] on 9/1/23 at 1:30 PM with the Clinical Director of Operations identified the weekly Total Body Assessment noted the assessment was not completed in entirety (omitted the type of wound, location, acquired, how long has the wound been present, date, wound bed, evidence of infection, exudate, peri wound, pain, orders, treatment and notification to practitioner). A document titled Skin and Wound Total Body Skin Assessment was completed by an LPN on 8/28/23 (and not a Registered Nurse). Additionally, the clinical record (nursing notes and skin assessments) failed to reflect any documentation of Resident #88's purpura to the bilateral hands. Additionally, the Director of Clinical Operations on 9/1/23 at 1:30 PM identified a skin evaluation can be done by a LPN or RN. The Director of Clinical Operations also stated that an LPN can perform a wound evaluation not an assessment (the document completed by the LPN was titled Total Body Skin Assessment). The facility policy was reviewed with the Director of Clinical Operations which stated, The Licensed nurse will document a skin evaluation weekly on the weekly skin check evaluation and/or Total Body Skin Evaluation.

Based on clinical review, observations, and staff interviews for 1 of 3 residents (Resident # 51) who required assistance with eating, the facility failed to ensure that staff assisted the resident for the lunch meal. The findings included: Resident #51's diagnoses included hemiplegia and hemiparesis following a cerebral infarction, aphasia, dysphagia, and need for assistance with personal care. A physicians' order dated 3/14/2023 directed to provide a regular whole texture diet of thin consistency. The quarterly MDS assessment dated [DATE] identified Resident #51's cognitive status as intact, required supervision of one person with eating and had an impairment of upper and lower body range of motion on one side. The Care plan dated 7/11/2023 indicated Resident #51 had an Activity of Daily Living deficit due to weakness and pain due to right sided dominant hemiplegia after a stroke with aphasia and dysarthria. The interventions included: to provide extensive assistance of 1-2 staff members to assist with turning and reposition in bed and supervision of one staff member for eating. The care plan further indicated Resident #51 had limited physical mobility due to right sided weakness from stroke. Interventions include providing extensive assistance of one staff member for locomotion in the wheelchair as Resident #51 could not walk. The care plan indicated that Resident #51 had a cerebral vascular accident that affected the dominant right side of the body. The interventions included in part to monitor the resident's abilities for Activities of Daily Living and to assist as needed. The care plan further indicated Resident #51 had a potential nutritional problem secondary to use of a therapeutic diet after having a Cerebral Vascular Accident (C VA) intervention including in part to provide and serve the diet as ordered. A nutrition quarterly assessment -V7 dated 7/5/2023 indicated Resident #51 feeds him/herself. On 8/28/23 at 12:59 PM an observation of Resident #51 eating lunch in bed on an overbed table was noted to be stabbing at his/her meat with a spoon held in the left-hand while verbalizing they did not cut my meat, I can't use my right hand, the slip even says they are to cut the meat. Observation of the lunch diet ticket indicated in highlighted type print Please Cut Up Food by Nurse Aide (NA). On 8/28/2023 at 1:01 PM an observation and interview with RN #1, unit manager identified the NA should have cut the resident's meat when the tray was given to the resident and further indicated the diet slip indicated the NA should cut up the resident's meat. On 8/28/2023 at 1:03 PM an interview with NA #10 indicated he/she passes the meal trays but did not know who gave the lunch tray to Resident #51. On 8/28/2023 at 1:40 PM NA #10 approached surveyor and indicated that he/she did give Resident #51 his/her lunch tray and would have gone back to cut up the meat. On 9/5/2023 at 10:45 AM interview with RN #1 indicated the care plan and resident care card did not reflect the need for Resident #51 to have meat cut and she would revise the care plan. Subsequent to inquiry, a physician's order dated 9/5/023 directed to provide a regular whole texture thin consistency diet and to cut up meat to optimize eating independence.

Based on review of the clinical record, facility documentation, facility policy and interview for 2 of 24 sampled residents (Resident #6 and Resident #30), the facility failed to ensure advance directives in the clinical record matched advanced directives in the electronic health record (EHR). The findings included: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia, severe intellectual disabilities, epilepsy, bipolar II disorder, and borderline personality disorder. The Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had severe cognitive impairment and required extensive assistance of 2 for bed mobility, and was totally dependent on the assistance of two for transfers, dressing, toilet use and personal hygiene. The Resident Care Plan dated [DATE] identified Resident #6 had an established advance directive of full code. Interventions included the resident's code status would be honored as directed by resident or legal surrogate. A review of the clinical record on [DATE] failed to identify any signed documentation related to advance directives or code status signed by Resident #6 or his/her representative. A request was made to the facility on [DATE] at 2:05 PM to provide signed advance directive documentation for Resident #6. LPN #6 identified on [DATE] at 2:10 PM that she was unable to locate any signed advance directive documents completed by Resident #6 at admission or by his/her representative. Interview with the DNS on [DATE] at 10:01 AM identified that all residents of the facility should have a signed advance directive in the clinical record, which should be obtained on admission to the facility. The DNS further identified if the resident had a change in cognition or was unable to sign for him/herself, the resident representative would be asked to review and sign the advance directive, and the advance directive should be reviewed at the quarterly RCP meetings. Additionally, the DNS identified that the advanced directive in the clinical record should match the advanced directive in the resident's EHR. Subsequent to surveyor inquiry, Resident #6's Advanced Directive Consent Form was completed, reviewed with Resident #6's surrogate and indicated that Resident #6 and his/her surrogate's life support choices included full code, would accept artificially provided nutrition, IntraVenous hydration, and transfer to the hospital. 2. Resident #30 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, lupus, and hypertensive heart disease with heart failure. The Resident Care Plan (RCP) dated [DATE] identified Resident #30 had an established advance directive of full code (meaning if a person's heart stopped beating and/or they stopped breathing, resuscitation procedures would be provided to keep them alive) and the resident was a Jehovah's Witness and would not accept blood products. Interventions included the resident's code status was DNR and that the resident's expressed advance directive wishes would be honored (a contradiction to the RCP indicating Resident #30 was a full code). An Advanced Directive Consent Form dated [DATE], which was signed by Resident #30 and located in Resident #30's paper chart, indicated that Resident #30's life support choices included full code, would accept artificially provided nutrition, intravenous (IV) hydration, and transfer to the hospital. An Advanced Directive Consent Form dated [DATE], signed by Resident #30, and located in Resident #30's paper chart indicated that Resident #30's life support choices included full code, would accept artificially provided nutrition, intravenous (IV) hydration, and transfer to the hospital. Physician orders [DATE] indicated Resident #30 was a do not resuscitate (DNR) (DNR means that if a person's heart stopped beating and/or they stopped breathing, no resuscitation procedures will be provided to keep them alive) and do not intubate (DNI). The quarterly MDS assessment dated [DATE] identified Resident #30 had intact cognition and required extensive assistance of two for bed mobility, was totally dependent on two for transfers, dressing, toilet use and personal hygiene. Although Resident #30 signed an Advanced Directive document on [DATE] and [DATE] indicating he/she wished to be a full code, a physician order was obtained on [DATE] directing DNR status, but failed to identify any discussions with Resident #30 to reflect the change in code status. The facility policy on advanced care code status directed that every resident of the facility had the right to accept or decline CPR in the event of a cardiac or respiratory arrest, and the facility would ensure that the resident's wishes were followed.

Based on clinical record review and interviews for one of three sampled residents (Resident #651) at risk for dehydration, the facility failed to ensure that care and services were provided to prevent and/or treat the resident's dehydration. The findings include: Resident #651's [DIAGNOSES REDACTED]. A 5 day Minimum Data Set (MDS) assessment dated [DATE] identified an admission date of [DATE], moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) of 11 and independence with eating with set up. physician's orders [REDACTED]. An interagency Patient Referral Report (W-10) from the hospital dated 1/31/15 identified that the resident had a Blood Urea and Nitrogen (BUN) level of 25 (Normal Range is 9-21) and a creatinine of 1.17 (Normal Range 0.69-1.31) on 1/31/15. A Resident Care Plan (RCP) dated 02/02/15 identified that the resident had the potential for dehydration with interventions that included report signs and symptoms of dehydration, complaints of dizziness, lightheadedness, increased heart rate, low blood pressure and laboratory blood work results to the physician/Advanced Practical Registered Nurse (APRN). A nutrition assessment dated [DATE] identified that the resident's daily fluid needs were 1400 Cubic Centimeter (CC) to 1750 CC. A review of Resident # 651's total intake and output record identified that on 1/31/15 the resident's oral fluid intake was 360CC, on 2/1/15 it was 790CC, on 2/2/15 it was 1340CC and on 2/3/15 it was 1230 CC. The laboratory blood work results dated 02/03/15 identified that the resident had a BUN of 38 mg/dl (13 points higher than the 1/31/15 results) and a creatinine of 1.46 mg/dl. A notation on the resident's laboratory results dated [DATE] identified that the APRN was made aware of the results. The APRN orders dated 02/03/15 directed that [MEDICATION NAME] be held for 48 hours, to note and/or monitor the resident's intake and output and to offer hourly intake. Review of the Intake & Output record identified that on 2/4/15, the resident's intake total of 1000 CC, on 2/5/15 the intake total was 1040 CC and on 2/6/15 the intake totaled 1130CC. A dietary progress note dated 02/06/15 at 5:15 P.M. identified that the resident's family had concerns about the resident's intake. The note further identified that the resident's intake was fair to poor on average and the dietician requested that a 4 ounces magic cup supplement (ice cream) be added daily due to variable suboptimal intake. A laboratory report dated 2/7/15 and timed at 10:26 AM identified that the resident's BUN was 51mg/dL (indicating an additional increase of 13 points from the 2/3/15 results) and the creatinine was 1.40 mg/dL. A note on the laboratory results noted that the APRN was made aware. Orders dated 2/7/15 directed to continue hourly fluid offerings and to repeat the chemistry 6 blood work on 2/10/15, to hold the resident's [MEDICATION NAME] and re-evaluate after the blood work results on 2/10/15. Review of the Total Intake and Output record identified that on 2/7/15 the resident's total intake was 1640 cc and on 2/8/15 the intake was 1620cc. Review of the hourly intake oral offerings record from 2/4/15 through 2/9/15 lacked documented evidence that fluids were consistently offered hourly as outlined in the plan of care. An APRN progress note dated 2/9/15 at 2:14 PM identified that the resident was seen at the request of the nurse due to worsening lethargy and [MEDICAL CONDITION]. It further notes that the resident was very lethargic on 2/8/15 and slept most of the day, but notes that on 2/9/15 Resident # 651 was more fatigued and the resident verbalized that the room was spinning. A nurse's note dated 2/9/15 identified that the resident was sent to the hospital to be evaluated for lethargy, [MEDICAL CONDITION], anorexia and mental status changes. The hospital documentation of Resident # 651's evaluation in the Emergency Department (ED) on 2/9/15 noted that the resident'S BUN was 76 ( 25 points higher than the results on 2/7/15) and the Creatinine was 2.19 ( with a high reading). Additionally noted that the resident received Sodium Chloride 0.9 % at 100 ml/hr from 3:22 PM to 7:10 PM and a second Sodium Chloride 0.9 % at 75 ml/hour for Intravenous Hydration and noted that the resident was diagnosed with [REDACTED]. Additionally, the hospital documentation noted that the resident was found to be clinically dehydrated and noted with acute kidney injury in the setting of volume depletion. Interview and review of the record with the DNS on 8/20/15 at 8:50 AM identified that the resident's hourly intakes were not consistently documented in the clinical record and that she/ could not provide documentation and /or evidence that staff consistently offered the resident fluids from 2/3/15 through 2/8/15 hourly as outlined in the plan of care. Interview with the APRN on 8/20/15 at 11:30 AM identified that although she/he was made aware of the resident's increased BUN and creatinine on 2/7/15, she/he did not want to order anything invasive because she/he could not assess the resident, she/he further noted that she/he felt the resident was stable and that she/he instructed the staff to have the other APRN evaluate the resident on 2/9/15. The APRN during the interview on 8/20/15 did not offer an explanation as to why the resident's plan of care did not change when the resident's BUN and Creatinine continued to increase and the oral intake was inconsistent. The facility's intake and output policy notes that intake and output is monitored to ensure adequate hydration levels off residents who may be at risk for dehydration or in actual hydration deficit. It further noted that all nursing personnel are responsible for measuring, recording and documenting intake and output. b. Review of the clinical record and interview with the DNS on 8/20/15 lacked evidence and /or documentation that the facility conducted a dehydration assessment when Resident # 651 was actively treated for [REDACTED]. The facility's policy and procedure for Signs and Symptoms of Dehydration notes to monitor for dry mucous membranes, dry tongue, [MEDICAL CONDITION], lethargy/low energy level, confusion, decrease urine output, slight fever, [MEDICAL CONDITION] irritability. For advance dehydration notes to monitor for decreased skin turgor, sunken eyes, cheeks and possibly abdomen, muscle twitching / [MEDICAL CONDITION], nausea and vomiting, to notify MD or APRN immediately , to place on intake and output , hourly offerings and to encourage by mouth fluids.

Based on a review of the clinical record and interviews for one of three sampled resident's (Resident #13) reviewed for accidents, the facility failed to ensure that a safe environment was in place to prevent an accident. The findings include: a. Resident #13's [DIAGNOSES REDACTED]. An annual assessment dated [DATE] identified the resident had severe cognitive impairment, required total assistance with all activities of daily living, and no falls within the past 3 months. An entry tracing MDS record identified that the resident was admitted to the facility on [DATE]. A review of the resident's clinical record identified that the resident had a fall assessment dated [DATE] that indicated the resident was at risk for falls with a score of 60 (a score of 50 or above indicates an at risk status). A physician's orders [REDACTED]. Review of the facility's mechanical lift policy identified that mechanical lift pads were left in place under the resident once the resident was placed in the wheelchair. A review of the facility's A& I reports as well as a further review of the resident's clinical record identified that on 05/18/15 at 3:34 PM, the resident slid out of the wheelchair onto the wheelchair foot rests. As a result of the fall the nursing staff requested a tilt & space wheelchair from the rehabilitation department. A fall assessment completed on 05/18/15 noted the resident's score was 75 high risk for falls. A therapy screen identified that a tilt in space wheelchair was issued to the resident on 05/19/15 with adjustments made with the resident in the wheelchair. A continued review of facility documentation and the resident's clinical record identified that 05/25/15 at 11:45 AM, the resident slid out of the wheelchair on to the floor and was subsequently sent to the hospital to be evaluated and sustained a left tibial fracture. The A & I report noted that the slide off of the wheelchair was witnessed by a Recreation Assistant (RA) who attempted to support the resident's trunk during the slide to the floor. She/he further noted that the resident's right leg was extended out in front but that the left leg was bent under the resident's body. Additionally, facility documentation noted that the facility attributed resident's the slide out of the wheelchair was related to the Hoyer pad secondary to the material being slippery. Subsequent to the incident resident's care plan was updated with an intervention to apply a dycem (nonskid material) between the Hoyer pad and the resident. Interview and review of the clinical record on 08/20/15 at 12:30 PM with the DNS, ADNS and the Nursing Supervisor identified that after the first fall they did not consider the hoyer pad as a contributing factor to the resident sliding out of the wheelchair. They further identified that they did not consider that the pad was an issue with the sliding until the second fall and indicated that Resident # 13 could not reposition herself/ himself in the wheelchair. b. In an interview and review of the clinical record on 08/19/15 with the Assistant Physical Therapy supervisor she/he identified that the facility lacked evidence and /or documentation on how staff was educated and /or trained to position Resident # 13 in the tilt space wheelchair and /or the resident's tolerance to the tilt space wheelchair. She/he further identified that when there is a new chair purchased specifically for a resident, there is follow up documentation to note the resident's tolerance and positioning in the chair but when there is a facility owned tilt in space wheelchair issued, they do not follow up in the same manner.

Based on clinical record review and interview for one of three residents in survey sample reviewed for hospitalization (R#598), the facility failed to follow the resident's allergy precautions. The findings included: Resident #598 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nursing assessment dated [DATE] identified that R#598 had allergies [REDACTED]. Physician orders [REDACTED].#598 had allergies [REDACTED]. Nurse's notes dated 08/08/14 at 7 PM identified that R#598 was admitted at 4:00 PM. At 5:35 PM, Person #1 approached and indicated that R#598 received clam chowder with his/her meal and may have consumed some of it. APRN Progress note dated 8/8/14 timed at 6:45 PM identified that R#598 was seen acutely for report of [MEDICATION NAME]. The note identified the patient complained of throat closing, numb lips, swelling tongue and itching of face and chest. It further noted that R#598 was given [MEDICATION NAME] subcutaneously and sent to the hospital for continuing symptoms in spite of [MEDICATION NAME]. Facility documentation including corrective action plan dated 08/08/14 identified that NA# 4 had given R#598 another resident's dinner tray containing clam chowder (shell fish). Interview with NA#4 on 11/5/14 at 3:01 PM indicated that s/he had inadvertently given the wrong tray due to not cross checking R#598 identification with the meal tray ticket.

Based on clinical record reviews, staff interviews, and reviews of facility documentation for two of six residents reviewed for accidents (Resident # 99, 337) the facility failed to provide supervision to a resident in a bathroom and/or failed to follow the plan of care for toileting the resident to prevent falls. The findings include: 1. Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] identified a score of 65 indicating a high risk for falls. An admission MDS dated [DATE] identified the resident with severely impaired cognition, no behaviors exhibited, required extensive assist for transfers, toileting, and personal hygiene. A care plan dated 3/3/14 identified a risk for falls. Interventions included assistive/adaptive equipment as indicated with teaching related to use, explain movement/activity before beginning, and to ensure call light is within reach. Nursing notes dated 4/1/14 at 1:00 AM noted while R #99 was in the bathroom, s/he became agitated. NA #1 turned to call for staff assistance and when he/she turned back, R #99 lost his/her balance and fell to his/her left side hitting the wall and falling to the floor. The Physician was notified and directed to send to the emergency room for evaluation. Reportable Event form dated 4/3/14 at 1:00 AM identified while R#99 was in the bathroom with NA #1, the resident became agitated and attempted to push NA#1. NA #1 went to the doorway to call for assistance leaving the resident unattended and when NA #1 turned back, R #99 was observed losing his/her balance and hitting the wall on his/her left side falling to the floor. The physician was notified and directed to send to the hospital for evaluation. X-ray results dated 4/1/14 identified an impacted, comminuted, angulated and displaced fracture of the left distal radius, a displaced inter and subtrochanteric fracture of the left proximal femur, and a left frontal scalp hematoma. Facility investigation identified that on 4/3/14, NA #1 received a one to one in-service counseling related to not leaving a confused, restless resident alone, and instead, the NA should have utilized the call bell system in the bathroom. Interview and review of the reportable event form and investigation dated 4/1/14 with RN #1 on 11/5/14 at 9:45 AM identified while NA #1 was assisting R #99 in the bathroom on 4/1/14, R #99 became restless/agitated and attempted to push NA #1 away. NA #1 turned towards the door to call for help and when NA #1 turned back, R #99 was observed losing his/her balance hitting the wall and falling to the floor on his/her left side. Additionally RN #1 indicated NA #1 received a one to one counseling after the incident to re-educate him/her to not leave a confused/restless resident alone in the bathroom, and to utilize the call bell system when needing assistance . 2. Resident #337 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident was without cognitive impairment, required extensive assistance from staff for bed mobility, transfers and toileting, limited assistance from staff for ambulating, had unsteady balance with transfers, sitting and walking, functional impairment in ROM to bilateral upper extremities, continent for bowel and bladder status and receives antianxiety and antidepressant medications. The RCP dated 7/1/14 identified a fall risk. Interventions included assess for fall risk factors, assistive/adaptive equipment as indicated with teaching relating to use, call light within reach, observe resident for correct use of equipment, observe/report change in ability to function, change in gait, keep environment clutter free and pathways clear, assess/report increased pain, decreased movement of extremities, providing lighting most useful for resident, place needed items within reach, safety precautions as determined by interdisciplinary team, safety checks per nursing judgment and protocol, reinforce use of call bell for assistance, vision screening as indicated, assist with transfers as needed, and safety checks (every 30 minutes) as indicated. Review of the clinical record identified that the resident sustained [REDACTED]. On 8/5/14, he/she fell and sustained bruises to the right knee and ankle. The care plan updated on 8/25/14 included conducting safety checks every 15 minutes and toileting schedule as indicated. A review of facility documentation and nurse's notes dated 9/9/14 at 7:10 P.M. identified that after hearing a loud noise coming from R #337 ' s room, the resident was found on the floor of the bathroom bleeding around the head. The resident was subsequently transferred to the ER for an evaluation by staff following the fall. On 11/5/14 at 2:41 P.M. and 4:25 P.M. interviews and review of the clinical record and facility documentation with NA#2 and #3 indicated that NA #3 was providing care to one of his/her other residents assigned to him/her for care (R #132) who resided next door to R#337. Both aides heard a loud noise in R #337's room. NA #2 discovered R #337 lying face down on the bathroom floor bleeding around the head and mouth. NA#3 indicated that he/she provided care to R#337 on a regular basis and that the resident's toilet schedule was every two hours and that the last time he/she toileted the resident was around 5:00 P.M. NA #3 noted that he/she last checked on the resident at 7:00 P.M. and found the resident sleeping at which time he/she decided to wake the resident up to inquire if R#337 was in need of toileting. The resident declined but 10 minutes later after hearing a loud noise, the resident was found on the floor of his/her bathroom injured. On 11/5/14 at 4:10 P.M. an interview and review of the clinical record and facility documentation with LPN#3, the charge nurse assigned to the resident at the time of the fall on 9/9/14, indicated that R#337 was on the bathroom floor and initially was bleeding moderately around the lower lip, and had a hematoma to the forehead. LPN#3 indicated that initially the resident was unresponsive but eventually began to cry and was unable to say what had happened. LPN#3 indicated that to his/her knowledge, the resident was on a planned toileting schedule of every two hours. On 11/5/14 and 11/6/14 at 3:14 P.M., 4:30 P.M. and 9:45 A.M., an interview and review of the clinical record and facility documentation with LPN#2 and the care plan coordinator (RN#3) noted that R#337 ' s toileting schedule and/or plan was before and after meals, at bedtime and once during the night as identified on the care card and not every two hours as NA#3 and LPN#3 indicated. Further review failed to provide documentation that the resident was toileted after dinner and before being put to bed.

Based on clinical record reviews, review of facility policies and procedures and interviews with facility personnel for one of three sampled residents (Resident #1), the facility failed to ensure that residents who utilized hot packs were monitored to prevent injury. The findings include: Resident #1's [DIAGNOSES REDACTED]. Review of the admission Mininum Data Set ((MDS) dated [DATE] identified that the resident was alert and oriented and need assistance of one with transfers and mobility. On 7/2/13, Resident #1 was admitted to the facility for rehabilitation therapy subsequent to a total knee replacement. Interview with Licensed Practical Nurse (LPN) #2 identified that she had admitted the resident and placed a cold pack on top of the knee area and a hot pack on the back of the knee. Interview with LPN #2 on 9/25/13 at 1:00 PM indicated that she never removed the hot/cold packs and never reported to the oncoming nurse that the packs were in place. An Interview with LPN #1 on 9/25/13 at 1:30 PM, the licensed staff member working the 3:00 PM - 11:00 PM shift on 7/2/13 indicated that a nurse aide came to tell me to take off the heating pad. Futher review identified that the heating pad was on the patient for multiple hours. Subsequently, the resident sustained [REDACTED]. According to the facility policy the treatment time for the use of a hot pack is identified as 20-30 minutes. Interview on 9/25/13 at 9:00 AM identified the hot pack should have been removed after 10-20 minutes and the nurse put it on at the change of shift and did not communicate to the 3:00 PM - 11:00 PM nurse.

Based on clinical record review and staff interviews for one (R#529) of four sampled residents reviewed for accidents, the facility failed to provide adequate supervision to a resident who was at risk for falls, and/or the facility failed to maintain the environment in a manner that prevents accident hazards. The findings include: 1. Resident #529 was admitted on [DATE] for rehabilitation after a fall resulting in a right hip fracture. R#529's history included an episode of syncope in September 2011 resulting in a subdural hematoma. A fall risk assessment dated [DATE] identified R#529 was at risk for falls. A nursing admission assessment identified R#529 was at risk for falls and interventions included safety checks every 30 minutes and the use of slipper socks when ambulating. An assessment dated [DATE] identified R#529 had some difficulty in making decisions in new situations, deficits in short term memory, an unsteady balance, required extensive assistance with transfers, limited assistance with ambulation and required supervision with bathing. An admission/interim resident care plan (RCP) dated 10/18/11 indicated R#529 had decreased ability to perform activities of daily living (ADL) and decreased mobility. Interventions included staff to assist with ADL's, toileting and transfers as identified by nursing. A physician's progress note dated 10/18/11 identified R#529 had a near syncopal episode in the shower while occupational therapy (OT) was present. An OT assessment dated [DATE] and 10/19/11 indicated that although R#529 required minimum assistance with toileting and transfers, the resident had difficulty with follow through of directions during transfers. A physical therapy (PT) assessment dated [DATE] identified R#529 required moderate assistance when going from a sit to stand position. A nurse's note dated 10/20/11 at 4:00 AM identified that R#529 was observed standing and attempting to walk without assistance. At 8:50 AM, a loud crash had been heard coming from R#529's room and the resident was found lying on the bathroom floor with a laceration to the back of his/her head. R#529 was not able to follow commands, his/her blood pressure was low and R#529 could not identify what had happened. R#529 was sent to the emergency room for evaluation due to the fact he/she was on anticoagulant therapy. R#529 was admitted to Hospital #1 with vasovagal syncope, a laceration to the back of the head requiring 3 staples and bilateral acute on chronic subdural hematoma. During an interview with Assistant Director of Nursing (ADNS) #1 on 12/15/11 at 11:40 AM, ADNS #1 was asked if based on R#529's history of falls, syncopal episodes and his/her attempt to ambulate without assistance, should R#529 have been left unattended in the bathroom, the ADNS indicated he/she should not have been left unattended, but unfortunately NA#1 briefly stepped out of the room when a visitor asked for directions. ADNS #1 indicated that after the incident all staff were educated that if a resident is minimal assist of one for toileting; staff needs to stay with the resident in the bathroom. If the resident requests privacy, staff are to keep the door open slightly to observe the resident and to intervene when the resident makes any attempt to get up. During an interview with NA #1 on 12/15/11 at 12:50 PM, NA#1 indicated he/she responded to R#529's call bell and assisted him/her to the bathroom. He/she then waited outside the closed bathroom door after instructing R#529 to use the call bell when done. NA#1 was asked by a visitor for directions and he/she stepped just outside the room door briefly and then heard a crash from R#529's bathroom. NA#1 identified R#529 required minimal assistance with toileting and he/she thought because R#529 was not on a personal alarm it was not required that he/she stay in the bathroom with him/her. 2. Environmental observations 12/8/11 noted that outside room 320, the beveled corner piece of the handrail was noted wrapped in surgical tape. On touching this section of handrail, it was apparent that the tape was what was holding the handrail in place. The tape was somewhat soiled indicating it had been present for a number of days. Further inspection of the handrails in the area revealed that the beveled corner pieces were problematic with those pieces outside rooms 325, 321 and 323 being loose with gaps between the corner pieces and the straight lengths of handrail. The corner piece outside room 324 was splintered. Interview with the 3rd floor unit manager on 12/7/11 revealed that the section of handrail with the surgical tape was not entered into the maintance log, which would be the expectation for any staff finding a maintance issue. The unit manager further acknowledged that based on the cleanliness of the tape, the situation had existed for at least a few days and was both a safety and infection control issue. 3. During tour of the 2nd floor on 12/7/11 at 1:20 PM with the second floor unit supervisor, the following was identified; a. The hand rail adjacent to room 208 near the fire door was noted detached from the supporting hardware creating a gap and the potential to pinch a resident's hand. b. The hand rail adjacent to room 225 was noted with wood splinters. c. Bedroom doors were identified to be damaged and/or had delaminating wood corners with exposed sharp splinters in rooms 203, 204, 205, 207, 217 and 223. The bathroom door in bedroom 223 had delaminating wood with large splinters and exposed edges.

Based on review of the clinical record, facility policies and procedures and facility documentation and interviews for one of three residents reviewed for rehab therapy (Resident #577), the facility failed to provide appropriate therapy to prevent an injury. The findings include: Resident # 577 (R # 577) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A minimum data assessment dated [DATE] identified the resident was without cognitive or memory impairment, required extensive assistance with bed mobility and transfer, limited assist with walking in the room, and supervision with walking in the hallway. The care plan dated 4/3/11 identified decreased ADL ability and mobility related to status [REDACTED]. Interventions included PT/OT as ordered, report decreased ability/tolerance/change in condition to MD/APRN, weight bearing as tolerated and total hip precautions. A physician order [REDACTED]. A letter dated 4/25/11 signed by R#577 and sent to the facility indicated that he/she received aggressive therapy on 4/4/11 in the afternoon. One of the stretches by the therapist was a quadriceps stretch in which the right leg was bent backwards with the leg hanging off the physical therapy table. A strong pull was felt in the right quad muscle. On 4/5/11, the resident experienced severe pain and swelling in the quad muscle. According to the letter, the injury set his/her recovery back about 7 weeks. The letter included an MRI report dated 4/22/11 that indicated, in part, a low grade myotendinous injury at the more proximal aspect of the vastus lateralis muscle with additional mild muscle strain of the vastus lateralis but not yielding a prominent intramuscular fluid collection. A review of Physical Therapy notes indicated the following: On 4/4/11, the resident with right calf/hamstring tightness. Stretched calf in supine. A subsequent entry dated 4/4/11 in a different ink noted performed gentle hip flexor stretch in supine tolerated well. On 4/6/11, trial TENS to right lateral quad and ITB x 15 minutes. Resident with increased pain and decreased range of motion right hip and knee. Unable to tolerate massage to right quads and ITB today. On 4/7/11, patient has been limited over past 4 days by severe pain and tightness right lateral thigh (quads and ITB). Patient has decreased independence with mobility due to above. On 4/11/11, resident spoke with surgeon and surgeon feels pain in right lateral thigh is related to increased INR causing bleeding into the muscle. Surgeon recommends ice and massage. Review of OT notes indicated that on 4/6/11, the patient had increased [MEDICAL CONDITION] and pain in the right lower extremity today. Massage Therapy notes indicated that on 4/10/11, bruising was present at lateral thigh/post thigh. On 4/11/11, patient states felt more tightness and discomfort at lateral thigh and increased sensitivity. On 4/14/11, patient discouraged today with lack of progress. Remains very tight at ITB/quad. Increased tightness at suprapatellar area. A nurse's note dated 4/5/11 at 11:00 AM indicated a gait that was slow, steady, complaining of tightness right lower extremity. Will notify MD/APRN. A review of the APRN note dated 4/5/11 and interview with the APRN on 12/6/11 at 11:10 AM indicated that when she examined R#577 on 4/5/11 he/she presented with a hematoma and increased thigh muscle tightness. The interior/lateral aspect of the thigh was very tender, positive hematoma and/or rigid muscle. The APRN indicated she felt the resident was experiencing muscle spasms which are not unusual for a post total hip replacement. She indicated she ordered a Doppler study to rule out a [MEDICAL CONDITION]. The doppler ultrasound of the right leg was performed on 4/6/11, and was negative for a blood clot. A portable right hip x-ray report dated 4/8/11 indicted satisfactory post-operative appearances. A physician progress notes [REDACTED]. Patient feels [MEDICAL CONDITION] less and pain well controlled. Postoperative hematoma with [MEDICAL CONDITION]. Stop [MEDICATION NAME] and start aspirin. Follow-up with orthopedic surgeon and continue rehab. A physical therapy discharge summary dated 4/14/11 noted, in part, the resident had severe tightness right ITB and lateral quad secondary to hematoma/bleeding into muscle. Activity limited secondary to increased pain and decreased range of motion. Goals -independent sit to stand transfers with straight cane, independent ambulation with straight cane 200 feet, and supervision up and down 6 inch curb with straight cane unmet secondary to increased pain, tightness and right ITB/quads. An Occupational Therapy discharge note dated 4/16/11 indicated patient with post-op tightness and [MEDICAL CONDITION] in right thigh area. Patient with limited range right knee. To follow-up with surgeon or primary physician for x-ray right knee or MRI. An interview on 12/7/11 at 1:20 PM with PT #1 indicated she treated R # 577 only one time during his/her stay on 4/4/11 in the afternoon. At the time of treatment she noted tightness in the right leg while the resident was ambulating. She indicated and demonstrated a stretch she performed on the resident during that treatment. She noted she supported the right leg during the stretch while having the right leg to the side and off the table. She indicated the resident did not complain of pain and/or demonstrate any non-verbal signs of pain during the stretch. She further indicated the resident stated it was an excellent stretch. An interview on 12/6/11 at 1:15 PM with PT #2 indicated she was the resident's primary physical therapist during the resident's stay. She indicated that on 4/6/11 the resident had more tenderness to the quad and decreased range of motion and the resident had spoken with the surgeon regarding the issues. She indicated the resident may have stated he/she was injured during therapy. She further indicated the stretch technique PT #1 had performed on the resident on 4/4/11 was not a stretching technique she used on R # 577. An interview on 12/8/11 at 9:15 AM with MD #2 indicated the MRI conducted on R#577 on 4/22/11 demonstrated a right quadriceps muscle tear. He indicated it was not a complication of the surgery and that the only way it could have occurred was with force generated on the muscle to cause the tear. He noted the resident's history of a tendon tear and repair in 2005 may have affected his range of motion. If the resident was exercised beyond that range it could have caused a muscle tear. MD #2 indicated the bleed into the muscle and [MEDICAL CONDITION] R # 577 experienced were caused by the muscle tear. He further indicated the resident's recovery was delayed because of the muscle tear. An interview on 12/8/11 at 3:00 PM with the Director of Rehab and PT #1 indicated the 4/4/11 PT note had two different ink types because she (PT #1) added the note "performed gentle hip flexor stretch in supine tolerated well" to the 4/4/11 PT note after the resident had been discharged (4/16/11). She indicated that she added the note when she was reviewing the chart with her supervisor. She thought it was appropriate to add, but noted she should have documented it was an addendum. At that time, the Director of Rehab indicated the chart was being reviewed after the facility received a discharge satisfaction survey from R # 577 that stated he was injured in the facility.