Every finding on record at Blaire House of Tewksbury

Based on record review and interview, for one of three sampled residents (Resident #1), whose Plan Of Care indicated he/she required an assist of two for transfers, the Facility failed to ensure staff consistently implemented and followed his/her Care Plan interventions related to transfers, when on 04/20/26 Certified Nurse Aide (CNA #7) transferred Resident #1 by himself, and did not get another staff person to assist with the transfer. Findings include:Review of the Facility Policy and Procedure titled Resident ADL Guide/Kardex, dated 12/2023, indicated its purpose to ensure that Certified Nurse Aides are provided with a complete and updated reference source for resident care needs upon admission and throughout length of stay. The Policy and Procedure indicated ADL Kardex are to be reviewed and updated at Case Management/Care plan meetings.Review of Resident #1's clinical record indicated his/her diagnoses included Hemiplegia and Hemiparesis (severe or complete paralysis/loss of voluntary movement on one side) following Cerebral Infarction affecting right dominant side, repeated falls, and abnormal posture.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/11/26, indicated he/she had severe cognitive impairment, and was dependent on staff for transfers from chair to bed.Review of Resident #1's ADL Care Plan, dated as initiated on 12/14/24 with an estimated goal date of 02/27/26, indicated that he/she required a two person stand pivot assist with all transfers.During a telephone interview on 05/05/26 at 2:20 P.M., CNA #7 said the resident care Kardex (utilized by the CNA's) provides specific information on the care needs of the residents. CNA #7 said according to Resident #1's Kardex on 04/20/26, Resident #1 required a two person assist with transfers. CNA #7 said on 04/20/26 at about 9:30 P.M. he transferred Resident #1 from the wheelchair to the bed without the assistance of a second person. CNA #7 said he stood Resident #1 up, and with the assistance of a walker, pivoted and sat him/her onto the bed without incident. CNA #7 said he did not get a second person to assist him, because he did not feel it was needed. At the time of the Survey the facility was unable to provide a copy of Resident #1's care Kardex that was in effect on 04/20/26, that would have indicated to the CNAs what level of staff assistance he/she required.During a telephone interview on 05/05/26 at 2:08 P.M., Nurse #2 said on 04/20/26 at about 9:30 P.M. CNA #7 called nursing staff into Resident #1's bedroom to report an area of ecchymosis (bruising) to his/her right upper arm. Nurse #2 said it was not known to her, if Resident #1 was transferred by CNA #7 alone or with assistance. During a telephone interview on 05/05/26 at 3:45 P.M., the Administrator said CNAs are expected to review the summary of their resident's care needs through the Kardex (which was based on their Plan of Care) in order to provide care and services as required, and that CNA #7 should have gotten another staff member to assist him with Resident #1's transfer.Review of Resident #1's Plan of Care, updated 04/30/26, indicated he/she had impaired mobility related to history of stroke with right side hemiparalysis. Resident #1's Plan of Care interventions indicated staff were now required to transfer him/her with mechanical lift and two assists. During a conference call telephone interview on 05/06/26 at 1:07 P.M., with the Administrator and the Director of Social Services, the Administrator said that he was unable to generate Resident #1's CNA Kardex that was in effect on 04/20/26. The Administrator emailed a copy of Resident #1's Kardex to the Surveyor (on 05/06/26) that was currently in effect. The Administrator said Resident #1 was being transferred at the time of survey (04/30/26) using the mechanical lift with two staff members as reflected in his/her Plan of Care, but that the CNA's Kardex had not been updated to reflect that a mechanical lift was now required for transfers. The Administrator said the Kardex's were not automatically updated within the electronic medical system when changes are made to the Plan of Care.

Based on record review and interview, for two of three sampled residents (Resident #1 and Resident #2), the facility failed to ensure they reviewed and revised their Comprehensive Care Plans following the completion of their Minimum Data Set assessment.Findings include:Review of the Facility Policy and Procedure titled Care Plan Policy, revised May 2025, indicated the following:-The Care Planning/Interdisciplinary Team develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.- The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS). - Each resident comprehensive care plan is designed to reflect treatment goals, timetables and objectives that are measurable. - The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans when there is a significant change in the resident's condition, the desired outcome is not met, when readmitted to the facility from a hospital stay and at least quarterly.1. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment indicated it had been completed with an Assessment Reference Date (ARD) of 03/11/26. Further review of Resident #1's medical record indicated his/her Care Plan Meeting occurred on 02/19/26 (prior to MDS assessment completion) and that the Care Plan was checked off as having been updated. Review of Resident #1's Comprehensive Care Plans indicated it identified Problems/Strengths, Goals (with an Estimated Date), and Interventions, which included but were not limited to the following concern areas:- Cognitive loss and risk of decline in communication (initiated 12/20/24) - Vision impairment (initiated 12/16/24)- Risk of decline in communication (initiated 01/03/25)- Bladder and bowel incontinence (initiated 12/20/24)- Risk of alterations in mood state (initiated 01/03/25)- Mechanically altered diet (initiated 03/10/25)- Skin breakdown (initiated 12/20/24)- Psychotropic medication (initiated 12/20/24)- Alteration in activities of daily living (initiated 12/14/24)- Hard of hearing (initiated 03/14/25)- Risk of Falls (initiated 12/16/24)Although the Care Plan Meeting on 02/19/26 indicated the Care Plans were updated, Resident #1's Care Plan had an Estimated Date for Goals to be met as 02/27/26. 2. Review of Resident #2's Annual MDS assessment indicated it had been completed with an ARD of 03/27/26. Further review of the medical record indicated Resident #2's Care Plan Meeting occurred on 03/19/26, prior to the MDS assessment completion, and that the Care Plans were checked off as having been updated.Review of Resident #2's Comprehensive Care Plans indicated it identified Problems/Strengths, Goals (with an Estimated Date), and Interventions, which included but were not limited to the following concern areas:- Cognitive loss and risk of decline in communication (initiated 07/08/22)- Hearing deficits (initiated 07/08/22)- Bladder and bowel incontinence (initiated 07/08/22)- Long term placement (initiated 09/15/25)- [NAME] for alterations in mood state (initiated 09/15/25)- History of behaviors (initiated 09/15/25)- Risk for Falls (initiated 08/24/23)- At risk for potential nutrition problem (initiated 07/01/22)- At risk for skin breakdown (initiated 07/08/22)- Alteration to activities of daily living (initiated 07/05/22)Although the Care Plan Meeting on 03/19/26 indicated the Care Plan was updated, Resident #2's Care Plan had an Estimated Date for Goals to be met as 03/19/26. During a telephone interview on 05/08/26 at 3:10 P.M., the MDS Coordinator said the Care Plan Meeting should not occur prior to the completion of the MDS. The MDS Coordinator said the Care Plans are reviewed to ensure they are accurate to the resident, that interventions are appropriate to the resident and that goals are realistic and attainable. The MDS Coordinator said Resident #1's and Resident #2's estimate goal dates should have been noted about 90 days from the Care Plan meeting date and were not.

Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, or interventions to promote healing and prevent new ulcers from developing for two Residents (#111 and #32) out of 30 total sampled residents. Specifically:1a.) For Resident #111, the facility failed to prevent a new coccyx wound from developing and worsening by not ensuring the Resident's air mattress was inflated, notifying the physician of a new wound to obtain treatment orders and implementing a wound treatment without a physician's order.1b.) For Resident #111, the facility failed to prevent an existing heel wound from worsening by not assessing and monitoring the wound, not implementing physician orders for wound treatment and not following through with a referral to the wound Nurse practitioner timely.2a.) For Resident #32, the facility failed to implement the correct wound treatment according to the physician order when a packing strip (sterile gauze strip used to fill deep wounds) was observed in the wound instead of the physician ordered hydrofera blue (an antibacterial foam wound dressing). 2b.) For Resident #32, the facility failed to implement the topical medication flagyl (an antibiotic medication) according to the physician order when it was unavailable for over a week without notifying the provider or pharmacy. Findings include:Review of the facility policy titled, Pressure Injury Policy, dated July 2024, indicated the following: Purpose: To provide guidance on the provision of treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing. The licensed nurse will assess each resident's risk for skin breakdown by completing a Norton Plus Pressure Ulcer Scale form on admission, readmission and monthly. If the assessment identifies the resident is at risk for skin breakdown, the nurse will implement a care plan to include preventative measures. The licensed nurse will conduct a weekly assessment of pressure injuries by completing the Skin Care Treatment Sheet. Care guidelines: Conduct and document assessment of the pressure injury site. Conduct pain assessment. Notify the physician of the pressure injury, of the absence or presence of pain, and of adverse changes (i.e. new onset/increase of signs/symptoms of infection, new onset/increase pain level, increase in stage and or size). The facility utilizes pressure redistribution mattresses for all residents. Apply heal suspension devices, and/or wheelchair pressure registration cushion if appropriate. Develop a plan of care addressing the alteration in the skin integrity. If no improvement is noted after 14 days, notify the physician to request a change of treatment. The licensed nurse is to obtain an order from the attending physician to have a wound physician consult if the wound physician program is in place. Case Management: Weekly, residents with pressure injuries will be reviewed by the case management team. The team will discuss the residents' stop conditions and plan of care including etiology of the pressure injury, current treatment, effectiveness of treatment, need to revise treatment, nutritional needs, and other factors associated with wound failing. Review of the facility policy titled, Preventative Sin Care Protocol, dated January 2021, indicated the following: Purpose: To identify adults at risk and to define early intervention for prevention of pressure injury. Scope – the Director of Nursing is responsible for design, orientation, continuing training, and implementation of the Preventative Skin Protocol. The preventative protocol assumes all patients/residents have the potential for skin breakdown. Weekly, residents with alterations in skin integrity will be reviewed by the case management team and plan of care including current treatment, effectiveness of treatment, need to revise treatment, nutritional needs and other aspects of care potentially affecting wound healing. During daily care, the Certified Nursing Assistant will observe for changes in characteristics of skin. Skin changes will be communicated to nurses. All residents are to be assessed once a week by the Licensed Nurse during skin rounds. The results of this hands-on physical skin check are to be recorded on the resident's record. All noted stage 1 - stage 4 areas are to be recorded on the skin care treatment sheet per the pressure injury policy. 1. Resident #111 was admitted to the facility in March 2023, with diagnoses of dementia and chronic kidney disease. Review of Resident #111's most recent Minimum Data Set (MDS) assessment, dated 10/10/25, indicated the Resident had a score of 0 out of a possible 15 on the Brief Interview for Mental Status exam, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #111 is dependent on staff for all functional daily tasks including bed mobility. a.) On 12/9/25 at 7:48 A.M., 9:37 A.M., 12:38 P.M. and 4:26 P.M., Resident #111 was observed lying in bed on top of an air mattress that was not powered on. The Resident's air mattress was completely deflated, and the metal grates of the bed could be felt by the surveyor's hand. At the time of these observations, Resident #111 was unable to participate in an interview. On 12/10/25 at 7:00 A.M., and 10:50 A.M., Resident #111 was observed lying in bed on top of an air mattress that was not powered on. The Resident's air mattress was completely deflated, and the metal grates of the bed could be felt by the surveyor's hand. At 10:54 A.M., Nurse #1 and the surveyor observed the air mattress together and Nurse #1 said the mattress was not inflated and did not know why. Nurse #1 said a deflated air mattress could cause deterioration of skin. On 12/10/25 at 10:43 A.M., Nurse #1 and the surveyor observed Resident #111's coccyx area. The coccyx had a large, round grapefruit sized area with eschar (a dark, leathery, dry layer of dead tissue that forms over deep wounds) with an undated dressing that was only approximately one fourth the size of the area and was saturated with bloody drainage. During an interview at the time of observation, Nurse #1 said she was unaware Resident #111 had a pressure injury to his/her coccyx and that a treatment needed to be completed for this area. Review of Resident #111's nursing notes indicated the following: A wound nurse note dated 12/3/25 that indicated Notified by staff patient found with excoriated, red and inflamed area to buttock. Area gently cleansed, then patted dry. Barrier cream applied to affected area to protect skin from further moisture and skin breakdown.Will continue to monitor skin integrity. A wound nurse note dated 12/4/25 that indicated, Patient appears to be declining, with reports of increased pain and worsening excoriation in the coccyx area. A wound nurse note dated 12/8/25 that indicated, Patient appears to be declining, with reports of increased pain and worsening excoriation in the coccyx area. The patient presents with a stage 2 pressure injury to coccyx. The wound is being managed with wound cleanser and sacrum dressing. Pressure offloading is maintained, patient on air mattress, and frequent repositioning. Area is monitored closely for signs of infection. Wound care follow up with wound NP (Nurse Practitioner) assessment and treatment adjustments. Review of Resident #111's medical record failed to indicate that the physician was notified of the Resident's new coccyx wound. The medical record also failed to indicate that the order completed by the wound nurse on 12/8/25 was ordered by the physician. Further review of the nursing notes failed to indicate any monitoring of the new area by the nursing staff until a note dated 12/12/25, which indicated late entry. Wound on resident's mid buttocks width 11 cm (centimeter) at its longest, length is at 7 cm at its longest. The wound is shaped like a butterfly. Review of Resident #111's care plans failed to indicate a care plan was developed for the new coccyx pressure injury. The Resident's care plans did have skin breakdown care plan for existing wounds to his/her bilateral heels dated 11/21/25, with the following interventions: Provide pressure relieving device(s) air mattress. Provide treatment per physician orders. Monitor for improvement or decline in wound condition to identify need to change treatment in accordance to facility protocols Review of the Norton Pressure Ulcer scale, dated 11/20/25, indicated the Resident had a score of 8 and was very high risk for pressure ulcer development. On 12/12/25 at 8:11 A.M., Resident #111 was able to participate in an interview and said he/she had pain in his/her coccyx area. During an interview on 12/10/25 at 10:49 A.M., Unit Manager #2 said the facility has a wound nurse that works Monday through Friday and completes all skin treatments for all residents in the facility. Unit Manager #2 said the facility also has a wound Nurse Practitioner that rounds weekly, on Tuesdays. Unit Manager #2 said both the wound nurse and Nurse Practitioner were on vacation this week. Unit Manager #2 said the wound nurse noted a new skin impairment on Resident #111's coccyx prior to her leaving for vacation but was unaware if the physician had been notified or if a treatment had been initiated for this new area. Unit Manager #2 said that when the wound nurse is away, the floor nurses are responsible for all wound care. Unit Manager #2 was unable to say why the floor nurses did not monitor and assess this new wound daily or communicate with the medical provider the status of the wound or orders needed for treatment of the wound. Unit Manager #2 said Resident #111 had an order for an air mattress and this mattress should be checked for inflation frequently because the risk of further skin breakdown is high if the mattress is not used correctly. During an interview on 12/11/2025 at 1:17 P.M., Certified Nursing Assistant (CNA) #1 said she has been the primary CNA for Resident #111 since his/her admission to the facility. CNA #1 said that she had not noticed the Resident's are mattress was not inflated and she and all the other staff have the responsibility of making sure the mattress is appropriately inflated. CNA #1 said that approximately a week ago the Resident's bottom has started to deteriorate and she had informed the nursing staff. CNA #1 said she saw the wound while providing care at the start of the week and the skin was open. CNA #1 said that since the wound opened, Resident #111 has complained of pain in his/her bottom and that the nurses have been putting a treatment on the area. During an interview on 12/10/25 at 2:42 P.M., the Director of Nursing (DON) said the facility has a wound nurse that works full time at the facility and a wound Nurse Practitioner that works weekly on Tuesdays. The DON said both the wound nurse and Nurse Practitioner were on vacation this week and it was the responsibility of the floor nurses to cover all wound treatments and skin assessments. The DON said that she expects the wound nurse to communicate any new wound findings to the nurses on the floor, herself and the medical provider. The DON said she was notified by the wound nurse that Resident #111's coccyx was excoriated, however, said she was unaware that prior to her going on vacation, the wound nurse had assessed Resident #111 to have a new stage 2 coccyx pressure injury and had initiated a treatment. The DON said she needed to know this information to ensure daily monitoring of the wound occurred and that the physician was notified for appropriate wound treatment. The DON said she was also unaware that the wound nurse self-initiated a treatment order without consulting the physician and a nurse cannot complete a medical order without the order from the physician. The DON said that she herself had not seen the wound but discussed the wound with Nurse #1 and said the wound had definitely worsened since the wound nurse documented on 12/8/25 and the wound had grown well beyond the treatment area the wound nurse had treated on 12/8/25. The DON said Resident #111 has fragile skin and has care plan interventions in place to prevent skin breakdown and new pressure injuries. The DON said one of these interventions is an air mattress and the nursing staff should be checking the mattress to ensure it is functioning properly at all times. The DON said a deflated air mattress would put Resident #111 at risk for pressure ulcer development. During an interview on 12/15/25 at 10:37 A.M., the Wound Nurse said she was never notified of Resident #111's excoriated skin on his/her coccyx but just happened to be in the room while the staff were providing care to the Resident and she observed it herself. The Wound Nurse said barrier cream was initiated as a treatment that day, and she began to monitor the Resident's coccyx area. The Wound Nurse said that on 12/8/25, the coccyx area was opened, was assessed as a new stage 2 pressure injury, and she notified the Wound Nurse Practitioner by text message that she would have to assess the wound, however, never heard back from the wound Nurse Practitioner. The Wound Nurse said she was unaware the wound Nurse Practitioner was away on vacation that week. The Wound Nurse said that she never notified the physician of the new pressure injury and she self-initiated a treatment. The Wound Nurse said she should not have started a treatment without an order. The Wound Nurse said Resident #111 is on an air mattress because he/she has fragile skin and if the air mattress is not working properly/inflates, the Resident is at risk for skin deterioration and new pressure ulcer development. The Wound Nurse said she feels like a lot of resident skin issues fall through the cracks at the facility. During an interview on 12/12/25 at 10:20 A.M., Nurse Practitioner #1 said she was unaware Resident #111 had developed a new pressure injury to his/her coccyx. Nurse Practitioner #1 said no treatments should be initiated by the nursing staff, as either she or the physician is responsible for writing orders. Nurse Practitioner #1 said the risk of lying on an air mattress without it being inflated is skin deterioration. During an interview on 12/12/25 at 1:01 P.M., Physician #1, who is also the facility Medical Director, said he relies on the nursing staff and wound care nurses to provide the needed care and to notify him is a resident's status changes so he can put appropriate orders and interventions into place. Physician #1 said nursing should not initiate any medical treatments without him being involved as he oversees the medical care. Physician #1 said he was unaware Resident #111 developed a new pressure injury to the coccyx and he did not order the treatment that was provided by the wound nurse on 12/8/25. Physician #1 said that without knowing about the wound or what treatment was started it was unclear if this was an appropriate treatment. Physician #1 said Resident #111 has fragile skin and has an order for an air mattress and there would be a risk of skin deterioration if the mattress was not being used properly. During a telephone interview on 12/17/25 at 1:42 P.M., the Wound Nurse Practitioner said the wound nurse had informed her that Resident #111 had a new area on his/her coccyx, however, since she had not worked in the building since the wound opened, she had not yet assessed the new wound or recommended a treatment for it. The Wound Nurse Practitioner said nursing should never initiate a treatment without the recommendation from her or another medical provider. The Wound Nurse Practitioner said Resident #111 is on an air mattress to protect skin integrity and that if an air mattress is not working properly the risk for skin impairment increases. 1b.) Review of Resident #111's medical record indicated the Resident had a stage 3 wound to his/her left heel. On 12/10/2025 at 10:55 A.M., the surveyor observed the wound dressing changes for Resident #111's left heel wound with Nurse #1. The Resident's left heel had a dressing dated 12/8/25, two days prior. At the time of this observation, Nurse #1 said she is unsure of what the treatment orders are for the left heel. Nurse #1 said she also worked yesterday, and did not complete the ordered wound treatments. Nurse #1 said the facility has a wound nurse and she was told the wound nurse completes all wound treatments. Nurse #1 was unaware the wound nurse did not complete the wound treatment on 12/9/25. Review of Resident #111's July 2025 physician orders indicated an order, initiated on 7/6/25, for the following: Apply skin prep twice a day to left outer foot area twice a day at 10am and 6pm, apply booties to both feet. Review of the July 2025 Treatment Administration Record (TAR) indicated the following nursing notes: 7/8/25: Skin prep applied to outer left foot area, area dark in color no drainage noted. Booties applied to bilat (bilateral) feet a/o (as ordered). 7/9/25 left outer foot area hard surface, skin prep applied, booties a/o. 7/16/25: left outer foot area dry, scabbed, skin prep applied, surrounding tissue clear, no redness. 7/17/25: left foot outer area area (sic), no drainage, no opening, hard and darked, skin prep applied a/o. 7/24/25: Left outer foot area appearance is peeling and hard, color after shower appeared yellowish, surrounding tissue is pink. Skin prep and booties applied. 7/30/25: Left outer foot yellow eschar (a dark, leathery, dry layer of dead tissue that forms over deep wounds). 7/31/25: Skin prep 2 left outer foot a/o. Area is worsening, center yellow area is painful to touch. Review of the July 2025 skin checks dated 7/3/25, 7/13/25, 7/21/25, 7/24/25, and 7/31/25 all failed to indicate any skin impairments noted on the TAR. There were also no nursing notes for the entire month of July 2025 with no assessment or measurement of the left foot wound. Review of Resident #111's medical record failed to indicate the physician was notified of the change in skin condition so a treatment modification could be made if indicated. Review of Resident #111's August 2025 physician orders indicated the following: Apply skin prep twice a day to left outer foot area twice a day at 10am and 6om, apply booties to both feet, discontinued on 8/5/25. Weekly skin check document and nurses note and UDA (User Defined Assessment) on day shift. Document in UDA and nurses note, initiated on 8/4/25 and discontinued on 8/14/25. Twice a day at 10 AM and 6:00 PM cleanse area to outer left foot area twice a day 7-3 and 3-11 with vashe (a brand of sterile, saline-based wound cleanser containing hypochlorous acid), pat dry, apply skin prep, then mupirocin (a prescription-only topical antibiotic used to treat bacterial skin infections), cover with border gauze. Apply booties to both feet, discontinued on 8/31/25. Weekly skin check document and nurses note and UDA on day shift. Document in UDA and nurses note, initiated on 8/14/25. Outer left foot wound 2x/day on days and evenings cleanse with vashe, pat dry, apply mupirocin and cover with border gauze. Change BID (twice a day) and PRN (as needed) for soilage/accidental removal. Apply booties to both feet, initiated 8/31/25. Review of the August 2025 TAR indicated the following nurses' notes: 8/3/25: Left outer foot area open, protective dressing applied, booties on as ordered, will be seeing the wound MD, heels offloaded. 8/7/25: Area 2 left outer foot open with slough (a soft, yellowish/whitish, stringy, or patchy dead tissue acting as a barrier to healing by trapping bacteria and preventing healthy tissue growth present) no drainage noted, outer edges soft and white in color. On 8/11/25, 8/13/25, 8/16/25, and 8/30/25, the above wound order was marked as missed on the day shift and the antibiotic ointment of mupirocin was not applied to the Resident's heel for a total of 4 times. Review of the August nursing notes failed to indicate nursing implemented the physician order to document weekly on the Resident's wound. Review of the August weekly skin checks dated 8/7/25, 8/18/25 and 8/25/25, failed to indicate the nursing staff was measuring the wound to monitor for improvement or worsening of the wound. Review of Resident #111's medical record failed to indicate the Resident was referred to the wound physician as requested by nursing on 8/3/25. Review of Resident #111's September physician orders indicated the following: Weekly skin check document and nurses note and UDA on day shift. Document in UDA and nurses note, initiated on 8/14/25. Outer left foot wound 2x/day on days and evenings cleanse with vashe, pat dry, apply mupirocin and cover with border gauze. Change BID (twice a day) and PRN (as needed) for soilage/accidental removal. Apply booties to both feet, initiated 8/31/25. Review of the September 2025 TAR indicated the following: On 9/24/25, 9/25/25, 9/28/25 and 9/30/25, the above treatment to cleanse with vashe, apply mupirocin and cover with border gauze two times a day was not completed during the morning shift. There were no nursing notes to indicate why the treatments were missed. Review of the September nursing notes failed to indicate nursing implemented the physician order to document weekly on the Resident's wound. Review of the September weekly skin checks dated 9/1/25, 9/8/25, 9/15/25, 9/22/25, and 9/29/25, failed to indicate the nursing staff was measuring the wound to monitor for improvement or worsening of the wound. Review of Resident #111's October 2025 physician orders indicated the following: Weekly skin check document and nurses note and UDA on day shift. Document in UDA and nurses note, initiated on 8/14/25. Outer left foot wound 2x/day on days and evenings cleanse with vashe, pat dry, apply mupirocin and cover with border gauze. Change BID (twice a day) and PRN (as needed) for soilage/accidental removal. Apply booties to both feet, initiated 8/31/25. Outer left foot wound every day on day shift cleanse with vashe, apply calcium alginate to wound bed cover with bordered foam. Change BID and PRN for soilage accidental removal. Applied booties to both feet, initiated 10/29/25. Review of the October 2025 TAR indicated the following: On 10/4/25, 10/7/25, 10/11/25, 10/12/25, 10/19/25, 10/23/25, 10/26/25, and 10/28/25 the above treatment to cleanse with vashe, apply mupirocin and cover with border gauze two times a day was not completed. There were no nursing notes to indicate why the treatments were missed. Review of the October nursing notes failed to indicate nursing implemented the physician order to document weekly on the Resident's wound. Review of the October weekly skin checks dated 10/6/25, 10/13/25, 10/20/25, and 10/27/25, failed to indicate the nursing staff was measuring the wound to monitor for improvement or worsening of the wound. Review of the nursing note dated 10/27/25 indicated Open area to the back of the outer left foot. Wound appears with deep red granulation tissue present, surrounded by hard white skin. No signs of infection or odor observed at this time period we'll have area evaluated by wound NP during wound rounds tomorrow for further evaluation and treatment plan. Review of the nursing note dated 10/28/25 indicated Stage 3 open area to the back of the left outer foot. Wound appears with deep red granulation tissue present, surrounded by macerated hard white skin. Wound NP assessed wound today and new order to cleanse area, apply calcium alginate to wound bed and wrap with caused daily/PRN. Review of the wound Nurse Practitioner's note dated 10/28/25, indicated the Wound Nurse Practitioner had started following Resident #111 on this date, over 2 months after the 8/3/25 note from nursing to refer the Resident to the wound doctor. The note indicated Patient was seen for pressure injury. On exam, the left heel has full thickness wound with granulation tissue present, consistent with stage 3 pressure injury. Review of Resident #111's November 2025 physician orders indicated the following: Weekly skin check document and nurses note and UDA on day shift. Document in UDA and nurses note, initiated on 8/14/25. Outer left foot wound every day on day shift cleanse with vashe, apply calcium alginate to wound bed cover with bordered foam. Change BID and PRN for soilage accidental removal. Applied booties to both feet, initiated 10/29/25 and discontinued 11/12/25. L (left) heel stage 3 wound, every day on day shift, cleanse area on L heel wit vashe, apply iodsorb (wound treatment), apply ABD pad (sterile dressing) and wrap with gauze daily, PRN for soiling, saturation and accidental removal, initiated on 11/12/25. R (right) heel every day on day shift cleanse right heel with normal saline, pat dry, apply skin prep to deep tissue injury, initiated 11/13/25. Review of the wound Nurse Practitioner note dated 11/11/25, indicated the wound Nurse Practitioner recommended obtaining an x-ray of the left heel to evaluate for possible underlying bony involvement or osteomyelitis. Review of the nursing note dated 11/13/25 indicated Resident started on Doxy (Doxycycline - an oral antibiotic) twice daily indefinitely until the results of the MRI are in. Review of Resident #111's medical record indicated that the x-ray obtained on 11/12/25 with the conclusion Findings suspicious for calcaneal osteomyelitis, recommend MRI. The Resident was sent for an MRI on 11/28/25 and the MRI was terminated early secondary to the Resident's inability to handle the test. Review of the physician note dated 11/25/25 indicated (Resident #111) will require initiation of IV (intravenous) antibiotic management. During an interview on 12/15/25 at 10:37 A.M., the Wound Nurse said she became involved in Resident #111's care when his/her heel wound became a stage 3. The Wound Nurse said she believed the wound had been worsening for some time, and the treatment of mupirocin had probably been used for too long of a period, making it ineffective. The Wound Nurse said that communication regarding skin impairments and wound status is poor in the building and she was hired specifically to fix this problem. The Wound Nurse said she was unaware of the nursing note to refer the Resident to the wound physician and said if she had, she would have done that much sooner than 10/28/25. During interviews on 12/10/25 at 2:42 P.M., and 12/11/25 at 9:02 A.M., the Director of Nursing (DON) DON said all residents should have skin checks completed weekly and all skin impairments should be documented on the skin check. The DON said nurses should also be documenting the status of wounds in the daily or weekly nursing notes. The DON said that the skin documentation should include shape, condition and measurements of the wound for the nursing staff and physician to be able to determine if the wound is improving, worsening or if a change of treatment plan is needed. The DON said the facility also has a full-time wound nurse and a consulting wound nurse practitioner once a week on Tuesdays. The DON said both of these staff members were not available this week and on vacation and in their absence, the nurses on the floor should take over all wound treatments and care. The surveyor reviewed the missing wound treatments from the days of survey as well as the previous months and the DON said there is never a reason to miss a treatment as that could result in a worsening wound. During a follow-up interview on 12/16/25 at 10:05 A.M., the DON discussed the origin of Resident #111's left heel wound and its progression. The DON said she was unaware of the wound being present in July and worsening in July, as she only can see orders for treatment beyond skin prep in August. The DON said the July skin checks were inaccurate as the wound was not documented and she would have expected the nurses to document and be specific in their documentation. The DON said that if a scab or slough was present, both wound indicate the worsening of a wound and the need for a change in treatment. The DON said she was also unaware of the note from nursing to refer the Resident to the wound doctor on 8/3/25 and it was a significant delay in treatment to not have the Resident seen until October 28, 2025. The DON said that if the wound Nurse Practitioner had started treating Resident #111 earlier, the wound could have possibly not progressed to this point. During a third follow-up interview on 12/17/25 at 10:37 A.M., the DON said any resident with a wound is discussed in the at-risk meeting to ensure an interdisciplinary approach and that the treatments in place are effective The DON provided the surveyor with all at-risk meeting notes taken on Resident #111. Review of the notes indicated the at-risk interdisciplinary team did not start following the Resident for his/her left heel wound until 10/29/25, when it had become a stage 3 wound. When asked why the team did not follow the Resident until this date, the DON said it was probably because that was when she was first made aware of Resident #111's heel wound. During an interview on 12/16/2025 at 12:10 P.M. Nurse Practitioner #1 said she was not aware of the 8/3/25 nursing note to refer Resident #111 to the wound physician. Nurse Practitioner #1 said not being seen until 10/28/25 was a delay in care and that could possibly cause worsening of the wound. During an interview on 12/17/25 at 1:22 P.M., the Physician, who is also the Medical Director of the facility, said that if he was aware of the worsening wound on Resident #111's left heel he would have documented that in his notes. When the surveyor said she could not see anything in his July notes regarding the wound, the Physician said that he must not have been made aware of the worsening wound until later, possibly August. The Physician said he was not aware of the note from nursing to refer the Resident to the wound physician at the beginning of August. During a telephone interview on 12/17/25 at 1:42 P.M., the Wound Nurse Practitioner said she began working in the facility in March 2025 and is notified of any resident's new skin impairment or worsening of wound and becomes involved in their treatment. The Wound Nurse Practitioner said she does not have access to the facility's electronic health record and said this would be helpful so she could be fully informed of a resident's status. The Wound Nurse Practitioner said she was never notified of the nursing note for a wound consultation written on 8/3/25 and only began working with Resident #111 at the end of October. The Wound Nurse Practitioner said she can't comment on the worsening of Resident #111's heel and can only say that at the end of October when she first assessed the right heel she had concerns of possible infection due to the longevity of the wound, the look of the wound and the Resident's pain level when wound care was provided. 2.) Resident #32 was admitted to the facility in September 2018 with diagnoses including dementia and malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/26/25, indicated Resident #32 had severe cognitive impairment as e

Based on observations, record reviews and interviews, the facility failed to keep two Residents (#12 and #82) free from accidents out of a total sample of 30 residents. Specifically, the facility failed to:1) Ensure Resident #12 was supervised during waking hours resulting in a fall with major injury.2) Ensure a fall intervention for alarm when in bed was implemented for Resident #82 after he/she had recently sustained a fall. Findings include:Review of the facility policy titled, Quality Assurance & Performance Improvement Falls Policy and Procedure, dated as revised 9/2025, indicated the following: The interdisciplinary team shall review potential contributing/causative factors associated with the fall and implement individualized interventions accordingly. 1. Resident #12 was admitted to the facility in January 2024 with diagnoses including dementia. Review of Resident #12's most recent Minimum Data Set (MDS) assessment, dated 11/21/25, indicated the Resident scored a 4 out of a possible 15 on the Brief Interview for Mental Status exam which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #12 was dependent on staff for all mobility tasks. On 12/9/25 at 7:59 A.M., Resident #12 was observed lying in bed. His/her bed was in the lowest position and there was a mattress on either side of the bed. The Resident was unable to participate in an interview about his/her fall history. Review of an incident report dated 10/16/25, indicated the following: Alarm sounded, resident (a different resident of the facility) witnessed (Resident #12) falling onto the floor. The incident report included two staff interviews that indicated neither were in the dining room at the time of the fall to witness the fall occurring. Review of the nursing progress notes failed to indicate a note was written on 10/16/25 with details regarding Resident #12's fall. A nursing note dated 10/18/25 indicated, pt (patient) x-ray showed an acute appearing left sub capital femoral (thigh bone) fracture, NP (nurse practitioner) on call recommended pt be sent to the ER (emergency room), (he/she) was sent out at 0615am, family notified. Review of the acute hospital Discharge summary dated [DATE], indicated Resident #12 was admitted to the hospital status post fall and was diagnosed with a left femoral neck fracture. Review of Resident #12's fall prevention care plan indicated the following intervention that was current at the time of the Resident's fall on 10/16/25: Bring to nurse's station while awake s/p (status post) fall on 1/15/24. Review of Resident #12's medical record failed to indicate a falls assessment was completed or the falls care plan was reviewed and updated after the Resident's fall on 10/16/25. During an interview on 12/10/25 at 1:33 P.M., the Director of Nursing (DON) said she was not working at the time of the fall as she was out on leave. The Director of Nursing said although the intervention to be supervised at the nurse's station may have been old, it was still an active fall intervention, and she expects all interventions to be followed as written. The DON said she also would have expected a falls assessment to be completed as well as a review of the Resident's care plans and a new intervention added if appropriate. The DON said the medical record indicates these two things did not happen after Resident #12's fall on 10/16/25. During an interview on 12/15/25 at 9:02 A.M., Certified Nursing Assistant (CNA) #1 said all staff should be aware of the residents' care plan interventions by either going on the computer and reviewing or the staff reporting the interventions verbally. CNA #1 said she is very familiar with Resident #12 and often provides care to him/her. CNA #1 said Resident #12 would often attempt to stand on his/her own and become agitated, requiring supervision from staff to ensure safety. CNA #1 said Resident #12 often sits in his/her wheelchair in the dining room when out of bed and should always have supervision while in the dining room. CNA #1 said she was unaware the Resident had a care plan intervention to be by the nurse's station when awake. During a follow-up interview on 12/15/25 at 1:17 P.M., the DON said all nursing staff should be aware of each resident's care plan interventions and if not, look them up in the medical record. The surveyor reviewed the schedule for October 16, 2025 and interviewed all staff who was working on that unit at the time of Resident #12's fall. During an interview on 12/15/25 at 9:15 A.M., Unit Manager #2 said she is Resident #12's primary nurse and she was working the day the Resident fell. Unit Manager #2 said she was unaware the Resident had a care plan intervention to be at the nurse's station while awake and said the nurses would typically be passing out medication in different rooms so that would not be an effective intervention anyways. Unit manager #2 said she was not in the dining room when Resident #12 fell and is unaware if any staff were supervising the Resident. During an interview on 12/15/25 at 1:04 P.M., Nurse #17 said she was working the day Resident #12 fell and she was not in the dining room supervising the Resident and did not witness the fall. Nurse #17 was unaware of the care plan intervention to have Resident #12 supervised at the nursing station while awake and could not remember if any staff were supervising the Resident at the time of the fall. Nurse #17 said Resident #12 does become agitated and attempt to stand on his/her own and it would be important for him/her to have supervision. Nurse #17 said there is always supposed to be a staff member in the dining room to provide supervision as needed. Nurse #17 said she was the nurse who completed the fall incident report and did not have any staff who witnessed the fall to get witness statements from. During an interview on 12/16/2025 11:43 A.M., CNA #15 said she worked the day Resident #12 fell and was not in the dining room to witness the fall. CNA #15 said she is unaware if any staff were in the room providing supervision. During an interview on 12/16/2025 3:01 P.M., CNA #18 said he worked the day Resident #12 fell and was not in the dining room to witness the fall. CNA #15 said he is unaware if any staff were in the room providing supervision. During an interview on 12/17/2025 7:02 A.M., CNA #5 said she worked the day Resident #12 fell and was not in the dining room to witness the fall. CNA #5 said she is unaware if any staff were in the room providing supervision. During an interview on 12/17/2025 7:18 A.M., CNA #3 said she worked the day Resident #12 fell and was not in the dining room to witness the fall. CNA #3 said she is unaware if any staff were in the room providing supervision. During an interview on 12/16/25 at 11:43 A.M., CNA #15 said she worked the day Resident #12 fell and was not in the dining room to witness the fall. CNA #15 said she is unaware if any staff were in the room providing supervision. During an interview on 12/17/25 at 9:28 A.M., the 2 East Activity Director said the activity staff are typically on the floor until 5:00 P.M. The Activity Director said she does not remember Resident #12 falling, however if any activity staff were in the room and witnessed a fall, they would have written a witness statement. The Activity Director said since no activity staff wrote a witness statement, no staff were in the room providing supervision and witnessed the Resident falling. 2.) Resident #82 was admitted to the facility in October 2024 with diagnoses including Parkinson's disease and orthostatic hypotension (a drop in blood pressure which causes dizziness upon standing). Review of the most recent Minimum Data Set (MDS) assessment, dated 9/26/25, indicated Resident #82 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 12 out of 15. This MDS also indicated Resident #82 required supervision or touching assistance to walk 150 feet. Review of Resident #82's nursing progress notes indicated: -12/1/25: Resident frequently had to be reminded to use walker at all times. -12/2/25: Resident had an unwitnessed fall. Review of Resident #82's plan of care related to falls, revised 12/2/25, indicated a new intervention for the following: -Tab alarm when in bed, initiated 12/2/25. On 12/9/25 at 8:56 A.M., the surveyor observed Resident #82 walking out of the bathroom wearing sneakers which were only halfway on. The backs of the sneakers were folded over and crooked, leaving the Resident's heels not inside the sneaker. Resident #82 was walking in an unsteady, shuffled gait using his/her walker incorrectly by pushing the side of the walker. Resident #82 said he/she did not need any help with going to the bathroom. Resident #82 continued to walk back to his/her bed with shoes on incorrectly in an unsteady gait and got into bed. The surveyor observed no alarm on his/her bed and heard no alarms during this observation. On 12/9/25 at 2:03 P.M., the surveyor observed Resident #82 get out of bed and put on his/her jacket. No alarm sounded when Resident #82 self-transferred out of bed and the surveyor observed no alarms on his/her bed. On 12/10/25 at 6:56 A.M., the surveyor observed Resident #82 in bed without any alarms on his/her bed. On 12/10/25 at 8:32 A.M., the surveyor observed Resident #82 in bed without any alarms on his/her bed. Resident #82 said he/she had fallen recently. Resident #82 said he/she doesn't have any alarms on the bed. The Resident's roommate said Resident #82 often gets out of bed in the middle of the night and is afraid he/she's going to fall again. The Resident's roommate said Resident #82 used to have alarms but hasn't heard them in a while. During an interview on 12/11/25 at 6:54 A.M., Certified Nurse Assistant (CNA) #12 and CNA #13 said they work the night shift and care for Resident #82. CNA #12 and CNA #13 said Resident #82 does not have any alarms on his/her bed. CNA #13 said Resident #82 fell within the last month. CNA #12 and CNA #13 said they do not have access to the care plan or any type of form that would provide resident care instructions, but gets that type of information, such as if alarms are required, through nurse report. CNA #12 and CNA #13 said they were unaware Resident #82 required alarms when in bed. During a follow-up observation on 12/11/25 at 7:03 A.M., the surveyor observed Resident #82 in bed without any alarms on his/her bed. During an interview on 12/11/25 at 7:04 A.M, CNA #14 said Resident #82 is compliant with care and doesn't think he/she would refuse alarms. CNA #14 said Resident #82 does not have any alarms on his/her bed because he/she is constantly walking. During an interview on 12/11/25 at 7:08 A.M., Nurse #10 said CNAs do not have access to the care plan or any type of form that would provide resident care instructions, but the nurses are expected to communicate fall interventions, such as alarms, to them. Nurse #10 said care plan interventions should be implemented, but they often only check the care plan once a week because it's very busy. Nurse #10 said he was unaware Resident #82 had an intervention for a tab alarm when in bed. During an interview on 12/11/25 at 2:07 P.M., the Director of Nursing (DON) said Resident #82 should have been on alarms when in bed, because it was an intervention on his care plan, but was not.

Based on observations and interviews, the facility 1) failed to provide a dignified existence for one Resident (#89) out of a total sample of 30 residents and 2a.) failed to provide a dignified dining experience for one Resident (#38) out of a total sample of 30 residents and 2b.) on two of three units. Specifically:1. For Resident #89 the facility failed to ensure privacy during incontinent care.2a. For Resident #38 the staff removed his/her utensils and guided him/her to eat syrup covered pancakes with his/her hands.2b. In the unit dining rooms residents waited for long periods to be served after their table mates were served, staff stood while feeding and staff referred to residents as feeders, rather than by their name. Findings include: Review of the facility policy titled, Resident [NAME] of Rights, dated as revised 6/2017, indicated the following: -The resident is treated with consideration, respect and full recognition of his dignity and individuality, including privacy and treatment and care of his personal needs. 1. Resident #89 was admitted to the facility in February 2024 with diagnoses including stroke. Review of Resident #89's most recent Minimum Data Set (MDS) assessment, dated 9/19/25, indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status exam which indicates he/she had severe cognitive impairment. The MDS also indicated Resident #89 was dependent on staff for all self-care and mobility tasks. On 12/9/25 at 12:19 P.M., Resident #89 was taken to the bathroom for incontinence care. The Resident was sitting on a commode in the bathroom with both doors to the bathroom and bedroom open. As Resident #89 was sitting on the commode without pants on, the Resident's roommate was taken into the bedroom to use the bathroom and was placed in front of the open bathroom door and Resident #89 was visible to the roommate. The Certified Nursing Assistant (CNA) continued to provide incontinence care to Resident #89 while he/she was visible to his/her roommate. During an interview on 12/15/25 at 9:02 A.M., CNA #1 said all residents should be given privacy when care was being provided and Resident #89's roommate should not have been able to visualize the Resident during care. CNA #1 said the door should have been closed. During an interview on 12/15/25 at 10:03 A.M., the Director of Nursing said the staff should always respect each resident's privacy in order to maintain their dignity. The Director of Nursing said Resident #89's roommate should have been kept out of the room while waiting for the bathroom. 2a. Resident #38 was admitted to the facility in February 2022 and has diagnoses that include dementia and unspecified protein-calorie malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/21/25, indicated that Resident #38 was unable to participate in the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #38 had no behavior of rejecting care. On 12/09/25 at 8:30 A.M., Resident #38 was observed seated at a table in the unit day room watching his/her table mate eat breakfast for 12 minutes. The surveyor continued to make the following observations: At 8:30 A.M., a staff person delivered breakfast of pancakes and syrup to Resident #38. Between 8:40 A.M., and 8:43 A.M., Resident #38 was sucking on an empty milk container. There were no staff present providing redirection or assist. At 8:55 A.M., Resident #38 picked up a fork and made his/her first attempt to self-feed since being served 37 minutes earlier. Certified Nursing Assistant (CNA) #5 observed Resident #38 struggling to use the fork and walked over to him/her, removed the fork from Resident #38's hand, placed Resident #38's hand directly in the pancakes with syrup and said it is here, eat this. Resident #38 then used his/her hand to place pancakes in his/her mouth, CNA #5 replied good and then walked away to feed another resident. As soon as the CNA walked away Resident #38 took his/her hands out of the syrup covered pancakes and stopped eating. On 12/10/25 at 8:56 A.M., during breakfast a CNA offered Resident #38 a glass of water however Resident #38's hand was shaking, and he/she was struggling to manage the glass. The CNA pushed Resident #38's tray of food further away from him/her and walked away. The surveyor continued to make the following observations: At 9:06 A.M., Resident #38 had finished drinking the water and was sucking on the empty glass. At 9:08 A.M., a CNA seated at the table observed this, went and retrieved a cup of milk for Resident #38 to drink. When the CNA returned to the table, he took a fork that was in Resident #38's pancakes and used it to stir the milk before handing it to Resident #38. At 9:12 A.M., a CNA gave Resident #38 a glass of juice. At 9:19 A.M., another CNA took the juice away from the Resident, saying he/she couldn't have the juice because he/she would spill it. During an interview on 12/11/25 at 1:54 P.M., the Director of Nursing said that if Resident #38 was attempting to eat with a fork staff should not have placed his/her hands in pancakes or encouraged Resident #38 to eat with his/her hands. During an interview on 12/15/25 at 8:48 A.M., CNA #1 said that Resident #38 was able to feed him/herself but needed ongoing cueing through the meals. CNA #1 said that Resident #38 does best with finger foods and should not be encouraged to eat pancakes with syrup on them because he/she does not like the sticky feeling of syrup on his/her hands. 2b. Staff failed to provide a dignified dining experience on two of three resident units. During an observation of breakfast on the Dementia Special Care Unit (DSCU) on 12/9/25 the following was observed: A nurse was overheard asking which residents were feeders. A Certified Nursing Assistant (CNA) was observed standing while assisting a resident with her breakfast while she was lying in bed. The bed was not raised to eye level. Three residents were seated at Table 1: At 8:18 A.M., the first resident was served breakfast. At 8:29 A.M., the third resident was served breakfast, 11 minutes after his/her table mate was served breakfast. Two residents were seated at Table 2: At 8:21 A.M., the first resident was served breakfast. At 8:32 A.M., the second resident at the table was served breakfast, 11 min after his/her table mate was served breakfast. During an observation of breakfast on the Dementia Special Care Unit (DSCU) on 12/10/25 the following was observed: Two residents were seated at Table 1: At 8:09 A.M., the first resident was served breakfast. At 8:25 A.M., the second resident at the table was served breakfast, 16 min after his/her table mate was served breakfast. Five residents were seated at Table 2: At 8:10 A.M., the first resident was served breakfast while the four other residents waited. At 8:51 A.M., the last resident at the table was served, 41 minutes after the first resident at the table was served breakfast. Four residents were seated at Table 3: At 8:15 AM the first resident was served breakfast while the four other residents at the table waited. At 8:36 A.M., the final resident at the table was served, 21 minutes after the first resident at the table was served breakfast. During an observation of Lunch on the DSCU on 12/10/25 the following was observed: Three residents were seated at Table 1: At 12:17 P.M., the first resident was served lunch. At 12:33 P.M., 16 minutes later the second resident was served lunch. A 12:35 P.M., the daughter of the third resident seated at the table stated to the tablemates my father/mother is last again. At 12:37 P.M., the daughter got up and retrieved her father's/mother's tray for him/her, 20 minutes after the first resident at the table was served. Five residents were seated at Table 2: At 12:16 P.M., the first resident was served lunch while the four other residents waited. At 12:41 A.M., the last resident at the table was served, 25 minutes after the first resident at the table was served lunch. Five residents were seated at Table #3: At 12:22 P.M., the first resident was served lunch while the four other residents waited. At 12:34 P.M., the last resident at the table was served, 12 minutes after the first resident at the table was served lunch. During an observation of breakfast on the DSCU on 12/11/25 the following was observed: Five residents seated at Table 2: At 8:14 A.M., the first resident at the table was served breakfast while the other four residents waited. At 8:42 A.M., the last resident at the table was served, 28 minutes after the first resident at the table was served breakfast. Three residents were seated at Table 3. At 8:14 A.M., the first resident at the table was served breakfast while the other two residents waited. At 8:28 A.M., a CNA placed a covered tray at the table for the 3rd resident at the table and walked away. At 8:32 A.M., the CNA returned to the table to feed the 3rd resident, 18 minutes after the first resident at the table was served. On 12/11/25 at 8:06 A.M., on the Two [NAME] unit a nurse yelled from one end of a resident hall to staff at the other end is that for her or is she a feeder . is there any feeders. The nurse then turned to the surveyor and said, the last are feeders. During an interview on 12/11/25 at 1:54 P.M., the Director of Nursing said that her expectation that everyone at the table should be served at the same time and not wait for long periods of time watching the other residents at their table eat. The Director of Nursing said residents should not be referred to by labels such as feeders.

Based on observations, interviews and record review, the facility failed to notify the physician of a significant change in the resident's skin condition and/or obtain wound treatment orders for four Residents (#111, #89, #32 and #3) out of a total sample of 30 residents. Specifically:1.) For Resident #111, the facility failed to notify both the physician and the Resident's healthcare proxy of the development of a new: a) stage 2 coccyx wound. b) stage 3 heel wound.2.) For Resident #89, the facility failed to notify the physician of a significant weight loss. 3.) For Resident #32, the facility failed to ensure nursing notified the physician that a topical medication (flagyl) was not being administered due to unavailability and instead discontinued the order without any physician order to do so.4.) For Resident #3, the facility failed to ensure nursing notified the physician of the development of a new pressure wound. Findings include:Review of the facility policy titled, Resident Change in Condition Policy, revised February 2024, indicated the following: Prior to contacting the physician, the nurse will conduct clinical assessment and collect pertinent information to report to the physician, for example, history of present illness and recent and previous test results for comparison. The resident's physician, legal representative and/or responsible party is to be notified. Nursing administration is to be notified of all resident changes in condition. A change in condition will be documented in the nurses' notes, shift report book, and other areas of the medical record as required. 1. Resident #111 was admitted to the facility in March 2023, with diagnoses of dementia and chronic kidney disease. Review of Resident #111's most recent Minimum Data Set (MDS) assessment, dated 10/10/25, indicated the Resident had a score of 0 out of a possible 15 on the Brief Interview for Mental Status exam, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #111 is dependent on staff for all functional daily tasks including bed mobility. 1a.) Review of Resident #111's nursing notes indicated the following: A wound nurse note dated 12/3/25 that indicated Notified by staff patient found with excoriated, red and inflamed area to buttock. Area gently cleansed, then patted dry. Barrier cream applied to affected area to protect skin from further moisture and skin breakdown.Will continue to monitor skin integrity. A wound nurse note dated 12/4/25 that indicated, Patient appears to be declining, with reports of increased pain and worsening excoriation in the coccyx area. A wound nurse note dated 12/8/25 that indicated, Patient appears to be declining, with reports of increased pain and worsening excoriation in the coccyx area. The patient presents with a stage 2 pressure injury to coccyx. The wound is being managed with wound cleanser and sacrum dressing. Pressure offloading is maintained, patient on air mattress, and frequent repositioning. Area is monitored closely for signs of infection. Wound care follow up with wound NP (Nurse Practitioner) assessment and treatment adjustments. Review of Resident #111's physician notes and orders failed to indicate the physician or wound Nurse Practitioner were notified of the new pressure injury and treatment initiated by the wound nurse on 12/8/25. On 12/10/25 at 10:43 A.M., Nurse #1 and the surveyor observed Resident #111's coccyx area. The coccyx had a large grapefruit sized area with eschar (a dark, leathery, dry layer of dead tissue that forms over deep wounds) with an undated dressing that was only approximately one fourth the size of the area and was saturated with bloody drainage. Further review of the nursing note dated 12/12/25, indicated late entry. Wound on resident's mid buttocks width 11 cm (centimeter) at its longest, length is at 7 cm at its longest. The wound is shaped like a butterfly. During an interview on 12/10/25 at 10:49 A.M., Unit Manager #2 said the facility has a wound nurse that works Monday through Friday and completes all skin treatments for all residents in the facility as well as a wound Nurse Practitioner that rounds weekly, on Tuesdays. Unit Manager #2 said the wound nurse was on vacation this week starting on 12/9/25 and the Wound Nurse Practitioner was also on vacation this week. Unit Manager #2 said the wound nurse noted a new skin impairment on Resident #111's coccyx on 12/8/25 but was unaware if the physician had been notified or if a treatment had been initiated for this new area. Unit Manager #2 was unable to say why the floor nurses did not communicate with the medical provider the status of the wound or orders needed for treatment of the wound. During an interview on 12/10/25 at 2:42 P.M., the Director of Nursing (DON) said that she expects the wound nurse to communicate any new wound findings to the nurses on the floor, herself and the medical provider. The DON said she was notified by the wound nurse that Resident #111's coccyx was excoriated, however, said she was unaware that on 12/8/25 the wound nurse had assessed Resident #111 to have a new stage 2 coccyx pressure injury and had initiated a treatment for new wound. The DON said that she herself had not seen the wound but discussed the wound with Nurse #1 and said the wound had worsened since the wound nurse documented on 12/8/25 and the wound had grown well beyond the treatment area the wound nurse had treated on 12/8/25. The DON said it is important to notify the physician immediately so the appropriate wound treatment can be started. The DON said not notifying the physician can lead to a delay in treatment that ultimately leads to a worsening wound. During an interview on 12/15/25 at 10:37 A.M., the Wound Nurse said that on 12/8/25, the coccyx area was opened, was assessed as a new stage 2 pressure injury, and she notified the Wound Nurse Practitioner by text message that she would have to assess the wound, however, never heard back from the wound Nurse Practitioner. The Wound Nurse said she was unaware the wound Nurse Practitioner was away on vacation that week. The Wound Nurse showed the text message without a response to the surveyor during this interview. The Wound Nurse said that she never notified the physician of the new pressure injury and she self-initiated a treatment without first speaking to a member of the medical team. During an interview on 12/12/25 at 10:20 A.M., Nurse Practitioner #1 said she was unaware Resident #111 had developed a new pressure injury to his/her coccyx until 12/10/25. Nurse Practitioner #1 said she or the physician should be notified immediately of the change in status of a residents, such as a new wound. During an interview on 12/12/25 at 1:01 P.M., Physician #1, who is also the facility Medical Director, said he relies on the nursing staff and wound care nurse to provide the needed care and to notify him is a resident's status changes so he can put appropriate orders and interventions into place. Physician #1 said he was unaware Resident #111 developed a new pressure injury to the coccyx until the facility informed him on 12/10/25. Physician #1 said he would want to be notified of a change in condition immediately so the appropriate treatment can be put into place and a delay in treatment did not occur. During an interview on 12/16/25 at 10:02 A.M., Resident #111's son said he only found out last night (12/16/25) that the Resident had a new wound on his/her coccyx. Resident #111's son said he is the Resident's healthcare proxy, and as the proxy feels it is important to be kept up to date with the clinical concerns of his parent. Resident #111's son said he feels the communication between he and the facility is poor. 1b.) Review of Resident #111's medical record indicated the Resident has a stage 3 wound to his/her left heel. Review of the July 2025 Treatment Administration Record (TAR) indicated the following nursing notes: 7/8/25: Skin prep applied to outer left foot area, area dark in color no drainage noted. Booties applied to bilat (bilateral) feet a/o (as ordered). 7/9/25 left outer foot area hard surface, skin prep applied, booties a/o. 7/16/25: left outer foot area dry, scabbed, skin prep applied, surrounding tissue clear, no redness. 7/17/25: left foot outer area area (sic), no drainage, no opening, hard and darked, skin prep applied a/o. 7/24/25: Left outer foot area appearance is peeling and hard, color after shower appeared yellowish, surrounding tissue is pink. Skin prep and booties applied. 7/30/25: Left outer foot yellow eschar (a dark, leathery, dry layer of dead tissue that forms over deep wounds). 7/31/25: Skin prep 2 left outer foot a/o. Area is worsening, center yellow area is painful to touch. Review of Resident #111's medical record failed to indicate the physician was notified of the change in skin condition to the Resident's left heel throughout the month of July. Review of the August 2025 TAR indicated the following nurses' notes: 8/3/25: Left outer foot area open, protective dressing applied, booties on as ordered, will be seeing the wound MD, heels offloaded. Review of the August nursing notes failed to indicate the nursing staff notified the physician of the need to be seen by the wound doctor and the Resident was not seen by the consulting wound nurse practitioner. Review of the wound Nurse Practitioner's note dated 10/28/25, indicated the Wound Nurse Practitioner had started following Resident #111 on this date, over 2 months after the 8/3/25 note from nursing to refer the Resident to the wound doctor. The note indicated Patient was seen for pressure injury. On exam, the left heel has full thickness wound with granulation tissue present, consistent with stage 3 pressure injury. During an interview on 12/16/25 at 10:05 A.M., the Director of Nursing (DON) discussed the origin of Resident #111's left heel wound and its progression. The DON said she expects to be notified of all resident changes in status, especially wounds. The DON said she was never notified of the left heel opening and worsening in July. The DON said she was also not notified of the note from nursing to refer the Resident to the wound doctor on 8/3/25 and it was a significant delay in treatment to not have the Resident seen until October 28, 2005. The DON said that if the wound Nurse Practitioner had started treating Resident #111 earlier, the wound could have possibly not progressed to this point. During a follow-up interview on 12/17/25 at 10:37 A.M., the DON said any resident with a wound is discussed in the at-risk meeting to ensure an interdisciplinary approach and that the treatments in place are effective The DON provided the surveyor with all at-risk meeting notes taken on Resident #111. Review of the notes indicated the at-risk interdisciplinary team did not start following the Resident for his/her left heel wound until 10/29/25, when it had become a stage 3 wound. When asked why the team did not follow the Resident until this date, the DON said it was probably because that was when she was first made aware of Resident #111's heel wound. During an interview on 12/16/2025 at 12:10 P.M. Nurse Practitioner #1 said she was not aware of the 8/3/25 nursing note to refer Resident #111 to the wound physician. Nurse Practitioner #1 said not being seen until 10/28/25 was a delay in care and that could possibly cause worsening of the wound. During an interview on 12/17/25 at 1:22 P.M., the Physician, who is also the Medical Director of the facility, said that if he was notified of the worsening wound on Resident #111's left heel he would have documented that in his notes. When the surveyor said she could not see anything in his July notes regarding the wound, the Physician said that he must not have been made aware of the worsening wound until later, possibly August. The Physician said he was not notified of the note from nursing to refer the Resident to the wound physician at the beginning of August. During a telephone interview on 12/17/25 at 1:42 P.M., the Wound Nurse Practitioner said she began working in the facility in March 2025 and is notified of any resident's new skin impairment or worsening of wound and becomes involved in their treatment. The Wound Nurse Practitioner said she does not have access to the facility's electronic health record and said this would be helpful so she could be fully informed of a resident's status. The Wound Nurse Practitioner said she was never notified of the nursing note for a wound consultation written on 8/3/25 and only began working with Resident #111 at the end of October when the wound nurse suggested she evaluate Resident #111. During an interview on 12/16/25 at 10:02 A.M., Resident #111's son said that about a month ago he noticed his parent had a decline and was constantly in bed. The Resident's son said he had also noticed the Resident had begun to wear blue booties on his/her feet and he was never told why. He said he had asked the nursing staff and they told him the Resident had poor circulation and failed to notify him that his parent had wound on his/her left heel. Resident #111's son said the staff have poor communication skills and fail to keep him notified of changes with the Resident's status. 2. Resident #89 was admitted to the facility in February 2024 with diagnoses including stroke. Review of Resident #89's most recent Minimum Data Set (MDS) assessment, dated 9/19/25, indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status exam which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #89 was dependent on staff for self-feeding and toileting and section H of the MDS indicated the Resident was frequently incontinent of both bladder and urine. Review of Resident #89's weight report indicated the Resident was identified as having a significant weight loss as of 12/12/25. Review of Resident #89's nutritional care plan, last revised 1/6/25, indicated the following interventions: -Notify physician of significant weight change. Review of Resident #89's paper and electronic medical record failed to indicate the physician was notified of the Resident's significant weight loss. The Registered Dietitian wrote recommendations on 12/12/25, however on 12/17/25, the Registered Dietitian's recommendations were still flagged (raised to alert the nursing staff) in the chart and had not yet been communicated to the physician. During an interview on 12/16/25 at 7:42 A.M., the Director of Nursing (DON) said the physician needs to be notified of all significant changes in weight so an intervention should be initiated immediately. During an interview on 12/15/25 at 1:42 P.M., the Registered Dietitian (RD) said she monitors for all significant weight changes in the building and if a significant weight loss is confirmed she immediately makes recommendations for weight loss interventions. The RD said when a significant weight loss occurs, the physician needs to be notified so that he can review her recommendations, and they can be made into an order if he is in agreement. The RD said Resident #89 did have a significant weight loss identified by the RD on 12/12/25. The RD said she had made recommendations for nutritional interventions at this time, however, did not say she notified the physician. During a follow-up interview on 12/16/25 at approximately 1:00 PM., the DON said the physician was never informed by the nursing staff or RD of Resident #89's significant weight loss and because of this, the interventions recommended by the RD on 12/12/25 had not yet been implemented. During an interview on 12/16/25 at 12:10 P.M., Nurse Practitioner #1 said she was never notified of Resident #89's significant weight loss. During an interview on 12/17/25 at 1:22 P.M., Resident #89's physician said he was never notified about Resident #89's significant weight loss or the interventions recommended by the RD. The Physician said he would expect to be notified of a significant weight change immediately so that interventions can be put into place as soon as possible. 3.) Resident #32 was admitted to the facility in September 2018 with diagnoses including dementia and malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/26/25, indicated Resident #32 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. This MDS also indicated Resident #32 had an unstageable pressure ulcer. On 12/15/25 at 9:33 A.M., the surveyor observed the Wound Nurse complete the wound dressing change for Resident #32's coccyx pressure ulcer. After the Wound Nurse gathered dressing supplies, the surveyor observed her approach Unit Manager #2 requesting the flagyl that was indicated to be used in the active physician's order. Unit Manager #2 told the Wound Nurse the flagyl had been discontinued the day prior, but she forgot to put the new order into the electronic medical record. The surveyor then observed the Wound Nurse complete Resident #32's wound dressing change without flagyl. During a follow-up interview on 12/15/25 at 10:07 A.M., Unit Manager #2 said the Weekend Supervisor told her to discontinue the order yesterday, but she forgot to put it in the electronic medical record. Unit Manager #2 said she did not implement flagyl in Resident #32's coccyx wound the day before (12/14/25). Unit Manager #2 said she never personally notified the physician prior to changing the order but assumed the Weekend Supervisor had since a physician is required to order any treatment changes. During an interview on 12/15/25 at 10:43 A.M., the Weekend Supervisor said he asked Unit Manager #2 to follow-up regarding Resident #32's flagyl order because it was input incorrectly in the electronic record, resulting in it not being sent by the pharmacy. The Weekend Supervisor said he was told by the nurses that there was no flagyl available for Resident #32's wound treatment and that the Resident was not receiving the flagyl as ordered by the physician. The Weekend Supervisor said he never personally contacted the pharmacy or a physician to clarify the order or notify them that they flagyl was unavailable, but Unit Manager #2 was supposed to. Review of Resident #32's physician's orders indicated: Cleanse wound to coccyx with vashe, cleanse soak with vashe for 10 minutes apply hydrofera blue to the wound secure with SAD (super absorbent dressing), change daily, initiated 12/15/25. Cleanse wound to coccyx with vashe cleanse soak with vashe for 10 minutes applying crushed flagyl, hydrofera blue to the wound secure with SAD, initiated 12/2/25 and discontinued 12/15/25. Review of Resident #32's treatment administration record, dated 12/9/25 to 12/14/25, indicated the treatment to Cleanse wound to coccyx with vashe, cleanse soak with vashe for 10 minutes applying crushed flagyl, hydrofera blue to the wound secure with SAD (super absorbent dressing), Change daily and PRN was documented as implemented as ordered: 12/9/25 by Nurse #7 12/10/25 by Unit Manager #2 12/11/25 by Unit Manager #2 12/12/25 by Unit Manager #2 12/13/25 by a nurse unable to be interviewed 12/14/25 by Unit Manager #2 During an interview on 12/15/25 at 11:43 A.M., Unit Manager #2 said she implemented Resident #32's coccyx wound dressing treatment on 12/10/25, 12/11/25, 12/12/25, and 12/14/25 but did not administer the flagyl because it was unavailable. Unit Manager #2 said she never notified the provider but that she probably should have since it had not been implemented since at least 12/10/25. Unit Manager #2 further said she never notified the physician before discontinuing the flagyl because she didn't feel the Resident needed it at all anyways. During an interview on 12/15/25 at 11:55 A.M., Nurse #7 said she implemented Resident #32's coccyx wound dressing treatment on 12/9/25. Nurse #7 said she did not implement flagyl, even though it was a part of the physician's order, because it was not available. Nurse #7 said she passed along that it was unavailable in report, but she didn't personally notify the pharmacy or notify the physician because she did not have time. Review of Resident #32's medical record failed to indicate that flagyl was not implemented during the wound treatment, the flagyl was unavailable or unable to be administered, or that a provider was notified regarding any flagyl concerns. During an interview on 12/15/25 at 12:31 P.M., the Director of Nursing (DON) said Resident #32 should have had flagyl implemented in the wound daily. The DON said she contacted the Nurse Practitioner who said the flagyl should have been implemented since 12/2/25 and should not have been discontinued on 12/15/25. The DON said the Wound Nurse Practitioner had been on vacation since 12/9/25, and in her absence she would expect all nurses to contact the house Nurse Practitioner for wound concerns. During an interview on 12/16/25 at 11:58 A.M., the Nurse Practitioner said wound dressings should always be implemented following the physician's order. The Nurse Practitioner said she would expect to be notified if a medication was being stopped or unavailable. The Nurse Practitioner said she was never notified that the flagyl was unavailable, not being administered, or of any concerns regarding its administration and thought the flagyl order had been in place since it was first ordered. The Nurse Practitioner said the facility contacted her yesterday (12/15/25) regarding the flagyl, after the surveyor had brought the concern to the attention of the facility, and she ordered that it be continued because it never should have been discontinued. During an interview on 12/17/25 at 1:42 P.M., the Wound Nurse Practitioner said a nurse should never have discontinued the flagyl order without notifying the physician and obtaining and order. During an interview on 12/17/25 at 2:22 P.M., the Medical Director said a nurse should never have discontinued the flagyl order without notifying the physician and obtaining and order. 4.) Resident #3 was admitted to the facility in July 2025 with diagnoses including immunodeficiency and neurogenic bladder. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/19/25, indicated Resident #3 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. This MDS also indicated Resident #3 had two stage two pressure ulcers at that time. During an interview on 12/9/25 at 10:28 A.M., Resident #3 said he/she had a wound on their bottom that was getting worse. Review of Resident #3's physician's order, initiated 10/24/25, indicated: Cleanse area to coccyx with wound cleanser, let dry, apply barrier cream every shift for preventative of skin breakdown [sic], every shift. Review of Resident #3's assessment titled Weekly Skin Assessment, dated 12/7/25, indicated the coccyx was pink and blanchable. This assessment failed to indicate Resident #3 had any open wounds. During an interview on 12/10/25 at 11:43 A.M., Certified Nurse Assistant (CNA) #9 and CNA #10 said they have recently provided incontinence care to Resident #3 and had not observed any wounds on his/her coccyx. During an interview and observation on 12/10/25 at 11:43 A.M., Nurse #12 said she consistently cares for Resident #3 and that she was not aware of Resident #3 having any wounds. The surveyor observed Resident #3's coccyx with Nurse #12 which had a dime sized open wound. Nurse #12 said that she thought it was a pressure wound but had not seen or heard about it prior. Nurse #12 said she was unaware of the facility process of what to do when a new wound is identified because the Wound Nurse was responsible for all wound care. During an interview on 12/10/25 at 11:53 A.M., Nurse #3 said she consistently is assigned to care for Resident #3 and took care of him/her the day prior on 12/9/25. Nurse #3 said she was unaware of any current wound on Resident #3's coccyx. Nurse #3 said Resident #3 used to have a pressure wound on his/her coccyx in September that developed during a hospital stay, but that it had resolved a while back. Nurse #3 said she knew the Wound Nurse monitored the coccyx breakdown, but that it currently was intact. Review of Resident #3's plan of care related to stage two pressure ulcer on coccyx, dated 9/14/25, indicated: Stage two pressure ulcer was noted on readmission from hospital. Monitor for improvement or decline in wound condition to identify need to change treatment in accordance with facility protocols. Review of Resident #3's nursing progress note, dated 12/10/25 to 12/15/25, failed to indicate any mention of open area on his/her coccyx or notification to provider of change in skin condition. During an interview on 12/15/25 at 9:06 P.M., the Director of Nursing (DON) said she was unaware the Resident #3 had a wound on his/her coccyx. The DON said she was never notified of an open area after Nurse #12 observed that wound with the surveyor present but should have been. The DON said the Wound Nurse and the Wound Nurse Practitioner had been on vacation since 12/9/25, but that the Wound Nurse had returned today. During an interview on 12/15/25 at 9:30 A.M., the Wound Nurse said she had been on vacation since 12/9/25. The Wound Nurse said she kept a close eye on Resident #3's coccyx because it was at high risk for breaking down and often opened and closed. The Wound Nurse said she saw Resident #3 the week prior to her vacation and the skin was intact. The Wound Nurse said that Nurse #12 should have notified a physician regarding the change in Resident #3's skin since she was on vacation. During a follow-up interview on 12/15/25 at 9:45 A.M., the Wound Nurse said she had concerns about communication of wounds within the facility and even when not on vacation she often wasn't notified that wounds have developed. During an interview on 12/16/25 at 11:58 A.M., the Nurse Practitioner reviewed communication between the facility and her provider group and said they were never notified of the development of a new wound for Resident #3 but should have been since the Wound Nurse Practitioner was on vacation. During a follow-up interview on 12/17/25 at 11:30 A.M., Nurse #12 said she did not notify the provider after she observed a new pressure wound on Resident #3's coccyx with the surveyor. Nurse #12 said she didn't know what the process was because she thought the Wound Nurse was responsible. Nurse #12 said she wished the facility offered more training regarding wounds because she was responsible for providing wound care on weekends.

Based on observations, record review and interviews, the facility failed to provide a homelike environment for the residents in the facility. Specifically, the facility failed to maintain bedrooms and furniture in good condition on 3 out of 3 resident units. Findings include:The following was observed on the 2 East unit on 9/16/25 at 6:30 A.M.:-The dining room wainscoting had chipping paint and scuff marks throughout the room.-In room [ROOM NUMBER], there were gouges in the wall behind both A and B beds. Opposite the bathroom door were two small homes in the upper wall next to the armoire.-In room [ROOM NUMBER], there were gouges in the wall behind the A bed with wallpaper missing from the wall. The dresser for the B bed had a broken drawer.-In room [ROOM NUMBER], there were significant gouges in the wall behind the A bed with wallpaper missing. There were significant gouges in the wall behind the B bed with wallpaper missing. Between the beds, the call light box was hanging from the wall with wires exposed.-In room [ROOM NUMBER], there were gauges behind the B bed with wallpaper missing. The side table next to the B bed had a broken cabinet door. Opposite the A bed an electrical cover for cable plug was coming apart from the wall and next to that a section of the wall was missing wallpaper exposing the underneath drywall.-In room [ROOM NUMBER], there was a hole in the wall behind the door handle when entering the room. There is a ceiling tile above the B bed with extensive staining.-In room [ROOM NUMBER], the chair rail on top of the wainscoting behind both beds was missing, exposing plaster grout and glue. In this area there was also wallpaper that had loosened from the wall and was peeling.-In room [ROOM NUMBER] the chair rail above the wainscoting behind both the A and B beds was broken in several places with holes in the wainscoting. There were significant scuff marks in the wall with paint completely removed behind the B bed and across from the a bed an electrical socket was loose from the wall.-In room [ROOM NUMBER], the wall to the left when first entering the room had drip stains and scuff marks the length of the wall.-In room [ROOM NUMBER], there was a hole in the wall between the beds where wires were exposed. Across from the B bed, there was a hole in the wall with an electrical wire extending from it.-In room [ROOM NUMBER], wallpaper was significantly ripped and peeling from the wall behind the B bed.-In room [ROOM NUMBER], there was a hole in the wall across from the television with a wire going through the wall without an electrical socket cover.-In room [ROOM NUMBER], the light in the bathroom did not turn on with multiple attempts. Plaster was exposed on the wall to the right of the toilet, and the toilet paper holder was broken and not able to hold the toilet paper.-In room [ROOM NUMBER], there was a significant large rectangular gouge on the wall with half of it being a full hole behind the A bed. There was also wallpaper peeling away from the wall.-In room [ROOM NUMBER], a section of the wallpaper was missing to the right of the bathroom door with this wall also significantly stained. Opposite the B bed, there was a hole in the wall with wires protruding and a face cloth stuffed into the hole. Next to the A bed, the baseboard was coming apart from the wall.-In room [ROOM NUMBER], two Electrical outlets opposite both beds did not have a cover and wires were protruding from the holes.-In room [ROOM NUMBER], wallpaper was peeling apart from the wall across from the B bed above the television.-In room [ROOM NUMBER], wallpaper was significantly peeling apart from the wall above the B bed.-In room [ROOM NUMBER], behind the B bed wallpaper was peeling apart from the wall.-In room [ROOM NUMBER], there were gouges in the baseboard across from both beds and behind the A bed. The light switch did not turn on the bathroom light, and the bathroom light could only be turned on from the adjoining room.-In room [ROOM NUMBER], there were gouges in the wallpaper behind both the A and B bed. When first entering the room, the wallpaper to the left of the bathroom door was peeling away from the wall. The following was observed on 2 [NAME] on 12/16/25 at 9:00 A.M.:-In room [ROOM NUMBER], there is a large area of peeling wallpaper underneath the window.-In room [ROOM NUMBER], there was peeling and chipped paint around the entirety of the window pane. Behind the A bed, there was peeling wallpaper to the bottom right of the bed which appeared to be reattached to the wall with push pins. -in room [ROOM NUMBER], the wood trim was missing behind both beds with old, dried glue visible. In the bathroom, wallpaper was peeling the cover of the electrical outlet was missing a screw with the electrical socket coming off from the wall and the baseboard was peeling behind and around the toilet.-In room [ROOM NUMBER], above the B bed a large ceiling tile was warped downward, and the wood trim was missing behind the bed. Between the beds, the call light box was hanging from the wall with wires exposed. As you entered the room there were stains on the ceiling tiles above the entrance to the room. The ceiling vent had significant dust and a dark substance on the vent. Oh-In room [ROOM NUMBER], behind the door, the wallpaper was peeling vertically away from the wall. The wood trim behind the bed was missing with chipped paint, and behind the B bed a cable outlet was loosened from the wall. A second outlet next to the dresser was detached from the wall.-In room [ROOM NUMBER], the wallpaper near the baseboard on the right side of the bathroom door was peeling away from the wall. In the bathroom, the vent was coming off the wall the walls had brown stains, the wall was ripped in the middle, and the external center of the ceiling then had a dark substance. Behind the B bed, there was a gauge in the wallpaper leaving drywall exposed. There were multiple stains on the wallpaper underneath the window area with yellow discoloration.-In room [ROOM NUMBER], there were multiple areas with scuff [NAME] and chip paint on the wall behind the door expanding the entire left side of the wall. There was missing wood trim behind both beds with peeling wallpaper.-In room [ROOM NUMBER], the ceiling vent had significant visible dust. Behind the B bed there were two holes in the wall.-In room [ROOM NUMBER], the vent on the left side of the door was loose at the top. There was broken trim on the wall behind both beds and the resident in the room said the facility was supposed to fix this weeks ago. Behind the B bed, the electrical cable outlet was loose from the wall. In the bathroom, the ceiling vent was significantly dusty, and there were approximately 19 to 20 patched holes in the wall with inconsistent wallpaper color and texture and there was a large square hole in the tile where the plumbing enters the wall.-In room [ROOM NUMBER], there was a broken doorstep behind the door. There were two large stains on the ceiling. The resident in the room at this time said the ceiling tiles have to be replaced because they are often stained. Between both beds the call light box was hanging from the wall with exposed wires.-In room [ROOM NUMBER], the door stopped behind the door was broken.-In room [ROOM NUMBER], the baseboard to the right of the bathroom door was cracked and discolored. Behind the bed was significant gouges in the paint in a large area of peeling wallpaper above the bed. In the bathroom, there was a large crack on the flooring spanning the length of the wall. There were brown stains resembling rust on the wall against the right side of the toilet.-In room [ROOM NUMBER], a water stain was visible in the corner above the B bed. Between the beds, the call light boxes hanging from the wall with exposed wires. Above the A bed, the wood trim was detached from the walls with nails exposed. Above the A bed, a wire was hanging from the ceiling.-In room [ROOM NUMBER], between both beds the call light box was hanging from the wall with wires exposed. The wood trim behind both beds was broken and splintered.-In room [ROOM NUMBER], there was peeling paper behind the door, ripped wallpaper around the cable outlet, and unfinished wood trim with nails exposed behind both beds.-In room [ROOM NUMBER], there was a large area of wallpaper ripped by the A bed with a loose outlet cover by the A bed. There was a ceiling tile above the bed with a stain on it. In the bathroom, there was a large dark gray scuff mark spanning the entire wall across from the toilet, the ceiling vent was significantly dusty, and there was a broken wall outlet on the bottom of the wall.-Above the nursing station there was a cluster of stains on the ceiling.-In the dining room, the right corner of the ceiling had stains, the left side of the air conditioner was detached from the wall with a nail protruding. And the baseboards and walls had significant scuff marks.-In room [ROOM NUMBER], the air conditioner was missing the vent cover, and the bathroom had a large section of wallpaper missing behind the grab bar.-Outside of room [ROOM NUMBER] there was a stain on the ceiling tile.-In room [ROOM NUMBER], a piece of printer paper was taped horizontally on the left side of the air conditioner, and the air conditioner cover was falling off to the left side. There was a warped ceiling grid above the a bed. In the bathroom the vent was detached from the wall with sharp edges, the baseboard was peeling off the wall leaving a gap on the right side of the toilet. There was significant dust in the ceiling fan. The resident in this room said the vent falling off the bathroom floor is bothersome.-In room [ROOM NUMBER], the base board was warped in two areas behind the door and along the left side of the room period a large ventilation hole was above the door uncovered and a large area of dust was on the ceiling tile.-In room [ROOM NUMBER] there was a stain on the ceiling tile next to the light above the B bed. Behind the B bed was a hole in the wall with a missing electrical outlet, and the missing outlet was visible underneath the resident's bed. The wood trim was missing behind the bed, there was a yellow hardened substance on the window curtain, and in the bathroom a large ventilation hole in the ceiling was uncovered with visible dust inside.Above the bed there is a stain on the ceiling tile and the ceiling tile in the corner of the room had a tear in it.-In room [ROOM NUMBER], behind the B bed, an electrical outlet was falling out of the wall. Above this bed, there was 1/4 sized hole in the ceiling and a stain on the ceiling above the armoire in the corner of the room. The back of the bedroom door had two areas of chipped wood on the right side with one area having jagged edges. During an observation of the 1 [NAME] unit on 12/16/25 at 11:27 A.M., the following was observed: -In room [ROOM NUMBER], there was a broken chair rail (molding on the wall) off of half of the circumference of the room's walls.-In room [ROOM NUMBER], there were 2 large circular brown stains on the ceiling tile in the bathroom and 2 rectangular holes in the wall opposite the beds with cable wires coming out of them.-In room [ROOM NUMBER], there was a large circular brown stain covering two ceiling tiles in the bathroom.-In room [ROOM NUMBER], 3 ceiling tiles had several brown circular stains in the bathroom.-In room RM [ROOM NUMBER], there was a broken chair rail running 3/4 the length of the wall behind the resident's beds, and2 ceilings tile with large brown stains in the bathroom.-In room [ROOM NUMBER], there was a quarter dollar sized hole in bathroom ceiling tile.-In room [ROOM NUMBER], there was a 2 inch circumference hole in the wall and peeling wallpaper behind the door and bed. -In room [ROOM NUMBER], there were long gouges in walls throughout the room with missing paint. During an interview on 12/17/25 at 11:34 A.M., the Maintenance Assistant said staff typically tell him if something is broken or they have the ability to put a work order in a system named TELS. The Maintenance Assistant said he also does daily rounds to ensure he has eyes on every room in the facility to see if anything needs to be fixed. The Maintenance director was told of the environmental findings of the surveyors and said he was aware that they call light boxes are often hanging from the walls and this is a constant issue in the building. He also said he was aware the light in room [ROOM NUMBER]'s bathroom has not been working for over a week, and he has not yet ordered the new light fixture. The Maintenance Assistant said he was unaware of the other environmental observations of the surveyors. During an interview on 12/17/25 at 11:51 A.M., the Administrator said staff should know how to use the TELS work order system and they also let maintenance know of broken equipment or things needed to be fixed by word of mouth. The Administrator said she was aware of a couple of rooms that needed the chair rail fixed and some rooms had wallpaper that needed regluing but did not have a full list of rooms or a proposed timeline of when these fixes would be made. The Administrator said the environmental observations made by the surveyors indicated the environment was not homelike for the residents.

Based on record reviews and interviews, the facility failed to complete quarterly care plan review meetings with an interdisciplinary team and a resident representative for one Resident (#111) out of a total sample of 30 residents. Findings include:Review of the facility policy titled, Care Plan Policy, dated May 2025, indicated the following:Our facilities care planning interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.The resident, the resident's representative or court appointed resident representative or surrogate are encouraged to participate in the development of his or her person-centered plan of care. Including: a. The resident's right to know his or her total health status, including but not limited to his or her medical conditions c. The right to participate in the planning process, and the right to request meetings, d. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care, e. The right to be informed, in advance, of changes to the plan of care.The facility shall inform the resident of the right to participate in his/her treatment and shall support the resident in this right.The care planning interdisciplinary team is responsible for the review and updating of care plans, d. At least quarterly.The resident has the right to refuse to participate in the development of his or her care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies.Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. Resident #111 was admitted to the facility in March 2023, with diagnoses of dementia and chronic kidney disease. Review of Resident #111's most recent Minimum Data Set (MDS) assessment, dated 10/10/25, indicated the Resident had a score of 0 out of a possible 15 on the Brief Interview for Mental Status exam, which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #111 was dependent on staff for all functional daily tasks. During an interview on 12/16/25 at 10:02 A.M., Resident #111's son said he was his parent's health care proxy. The Resident's son said the facility had not kept him informed of Resident #111's medical status, recent decline in status and wound status. Resident #111's son said the facility called him last week to say his parent had to go to the hospital because of an infection in a wound and he said he was not even aware the Resident had a wound, was on antibiotics or was this medically ill. Resident #111's son said he had not been invited to any formal meetings at the facility and the staff have very poor communication with him. Resident #111's son said he would attend a care plan meeting if invited. Review of Resident #111's medical chart indicated the following care plan meeting notes for the past year:Dated 11/13/24. The note failed to indicate the Resident or the Resident's son were invited to the meeting. An invitation to a care plan meeting to take place on 2/12/25, however the medical record and social worker were unable to provide documentation that the meeting occurred. Dated 5/7/25: the note failed to indicate the Resident or Resident's son was invited, just that they were not in attendance. The facility was unable to provide a copy of the invitation that was mailed to the son inviting him to the meeting. Dated 7/24/25: the note failed to indicate if the family attended the meeting or declined to come to the meeting. The note indicated the only staff member present was the social worker and the care plan was not reviewed by the interdisciplinary team. Dated 10/17/25: the note failed to indicate if the family attended the meeting or declined to come to the meeting. The note indicated the only staff member present was the social worker and the care plan was not reviewed by the interdisciplinary team. The facility provided the surveyor with a copy of the invitation to the meeting that was mailed to the son. The invitation listed the date of the meeting on 10/23/25 and failed to indicate the son was informed on the meeting on 10/17/25. The medical record failed to indicate anyone from the facility met with Resident #111's son on 10/23/25. During an interview on 12/16/25 at 1:05 P.M., Social Worker #1 said care plan meetings occur every quarter, following the MDS assessment schedule. Social Worker #1 said all residents and their representatives were invited to the meetings and if they do not attend, she documents the refusal to attend. Social Worker #1 said Resident #111's son was invited but never came to the meetings and she was unable to say why there was no documentation of him declining the invitation. Social Worker #1 said the entire interdisciplinary team should be attending the care plan meetings to ensure all levels of care are reviewed and that it was not a true care plan meeting if she was the only person in attendance. During an interview on 12/16/25 at 2:13 P.M., the Director of Nursing said all care plan meetings occur quarterly following the MDS assessment schedule and the entire interdisciplinary team should attend and give input at the meetings. The Director of Nursing said the care plan meetings for Resident #111 did not occur if only the social worker was present. The Director of Nursing said that Resident #111 had several medical issues during the last three months, including wounds, and his/her care would require an interdisciplinary approach.

Based on observation, record review and interview the facility failed to provide assistance with Activities of Daily Living (ADL) care for six Residents (#14, #38, #77, #78, #89 and #93) out of a total sample of 30 residents. Specifically, the facility failed to provide incontinence care for extended periods of time for all six residents. Findings include: Review of the facility policy titled, Bowel and Bladder Program, revised June 2025, indicated the following: -Purpose: to prevent skin breakdown through routine incontinent care and to enhance dignity and self-esteem. -If there is no discernible pattern, the resident will be checked for incontinence and provided with incontinent care at least every two hours and PRN (as needed). 1.Resident #14 was admitted to the facility and has diagnoses that include Multiple Sclerosis, severe vascular dementia and hypertensive heart with chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/3/25, indicated that on the Brief Interview for Mental Status exam Resident #14 scored a 3 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #14 was frequently incontinent of bowel and bladder. Review if Resident #14's active physician orders include: -Lasix 40 mg (Milligrams) by mouth daily. (Lasix is a diuretic with side effects including increased urination). Review of Resident #14's current care plans included the following care plans: An at risk for skin break down care plan due to urinary incontinence and cognitive deficits. An MS (multiple sclerosis) care plan. Interventions include: Toileting-Resident #14 is incontinent of bowel and bladder at times and needs assist to dependent of one with toileting and incontinent care due to unable to maintain proper personal hygiene. A risk for infection care plan due to getting frequent UTIs. Interventions include: provide incontinence care as needed. An Activities of Daily Living care plan that indicates Resident #14 is incontinent of bowel and bladder and needs assist to dependent with incontinence care. Review of Resident #14's Kardex (resident specific care instructions) indicated: -Resident #14 is incontinent of bowel and bladder. Review of Resident #14's most recent [NAME] +Pressure Ulcer Care, dated 11/30/25, indicated Resident #14 scored an 11 (high risk of developing pressure ulcers). Review of Resident #14's Annual Bladder (incontinent) Functioning Assessment, dated 4/18/25, indicated the Resident was incontinent at all times. Review of Resident #14's Annual Bowel (incontinent) Functioning Assessment, dated 4/18/25, indicated the Resident was incontinent at all times. During an observation on 12/9/25 at 7:45 A.M., Resident #14 was observed seated in the unit day room. The surveyor continued to make the following observations: -By 12:45 P.M., Resident #14 had not yet been offered toileting since the initial observation 5 hours earlier. On 12/11/25 at 7:41 A.M., Resident #14 was wheeled into the unit day room and seated at his/her table. The surveyor continued to make the following observations: -At 11:26 A.M., Resident #14 was offered toileting for the first time since arriving to the day room three hours and 45 minutes earlier. The staff took Resident #14 to his/her room, accompanied by a surveyor, and the smell of feces filled the room as soon as care was started. The two staff stood Resident #14 by the toilet and removed his/her incontinence pad that was soiled with both feces and urine. The feces looked dried and had been there for some time. During an interview on 12/11/25 at 12:54 P.M., Certified Nursing Assistant (CNA) #8 said that she had provided incontinence care that day to Resident #14 at 7:00 A.M., and 11:30 A.M., CNA #8 said that she changed Resident #14 at 11:30 A.M., because she noticed he/she had a bowel movement. CNA #8 could not say how often she should check or change incontinent residents. CNA #8 could not say what a Kardex or care plan was. During an interview on 12/11/25 at 1:08 P.M., Nurse Unit Manager #2 said residents should be checked for incontinence and changed every three hours and as needed. Nurse Unit Manager #2 said not providing incontinence care timely put the resident at risk for skin breakdown. During an interview on 12/11/25 at 1:17 P.M., Certified Nursing Assistant (CNA) #1 said that every resident should get incontinent care in the morning with morning care, after breakfast around 10-10:30 A.M., and then again after lunch. CNA #1 said that the CNAs know the level of care for each resident by looking at the Kardex and that the continence status of each resident was listed on their Kardex. CNA #1 said that each morning she gave the CNAs a verbal report of the resident care needs. CNA #1 said that it was very important to change a resident who was wet or soiled immediately to avoid skin break down and other complications and that Resident #14 should have been changed after breakfast each day but that the challenge was the CNAs need more support and that they consistently need five CNAs which they often don't get. During an interview on 12/11/25 at 1:54 P.M., the Director of Nursing said it was her expectation that staff provided incontinence care at least every two hours and as needed. The Director of Nursing said not providing timely care can put a resident at risk for skin breakdown. 2. Resident #38 was admitted to the facility in February 2022 and has diagnoses that include dementia and unspecified protein-calorie malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/21/25, indicated that Resident #38 was unable to participate in the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #38 was frequently incontinent of bowel and bladder. Review of Resident #38's Kardex (resident specific care instructions) indicated: -Resident #38 was dependent on staff for toileting. -Resident #38 was incontinent of bowel and bladder. Review of Resident #38's most recent [NAME] +Pressure Ulcer Scale, dated 11/15/25, indicated Resident #38 scored an 11 (high risk of developing pressure ulcers). Review of Resident #14's Annual Bladder (incontinent) Functioning Assessment, dated 11/25/25, indicated the Resident was incontinent at all times. Review of Resident #14's Annual Bowel (incontinent) Functioning Assessment, dated 11/25/25, indicated the Resident was incontinent at all times. Review of Resident #38's active care plans indicated the following: -An Activities of Daily Living (ADL) care plan, initiated 2/22/22, with the following interventions: Toileting- Mod physical assist to toilet, start date 11/6/23. -An at risk for skin breakdown related to incontinence care plan, initiated 2/22/22 with the following interventions: Provide incontinent care every two hours and as needed and toilet every two hours and as needed. Review of the most recent skin assessment, dated 12/8/25, indicated, Resident #38 had redness to buttock bil (bilateral) legs and arms dry, right side of face self-inflicted scab (sic). On 12/09/25 at 7:45 A.M., Resident #38 was observed seated in the unit day room. The surveyor continued to make the following observations: -By 12:45 P.M., Resident #38 had not yet been offered toileting since the initial observation five hours earlier. On 12/11/25 at 7:36 A.M., Resident #38 was wheeled into the unit day room. The surveyor continued to make the following observations: -By 1:00 P.M., Resident #38 had not offered toileting since he/she was [NAME] to the day room, five and a half hours earlier. During an interview on 12/11/25 at 1:05 P.M., Hospice CNA #1 and CNA #5 said that residents should be checked for incontinence every two hours and changed at that time. During an interview on 12/11/25 at 1:08 P.M., Nurse Unit Manager #2 said residents should be checked for incontinence and changed every three hours and as needed. Nurse Unit Manager #2 said not providing incontinence care timely put the resident at risk for skin breakdown. During an interview on 12/11/25 at 1:17 P.M., Certified Nursing Assistant (CNA) #1 said that every resident should get incontinent care in the morning with morning care, after breakfast around 10-10:30 A.M., and then again after lunch. CNA #1 said that the CNAs know the level of care for each resident by looking at the Kardex and that the continence status of each resident is listed on their Kardex. CNA #1 said that each morning she gives the CNAs a verbal report of the resident care needs. CNA #1 said that it was very important to change a resident who is wet or soiled immediately to avoid skin break down and other complications and that Resident #38 should have been changed after breakfast each day but that the challenge was the CNAs need more support and that they consistently need five CNAs which they often don't get. During an interview on 12/11/25 at 1:54 P.M., the Director of Nursing said it was her expectation that staff provide incontinence care at least every two hours and as needed. The Director of Nursing said not providing timely care can put a resident at risk for skin breakdown. 3. Resident #77 was admitted to the facility in October 2024 with diagnoses including dementia and diabetes. Review of Resident #77's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 0 out of possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #77 was dependent on staff for toileting and section H of the MDS indicated the Resident was frequently incontinent of bowel and bladder. On 12/9/25 at 7:45 A.M., Resident #77 was observed sitting in the dining room. The surveyors observed the Resident in the dining room from 7:45 A.M. to 12:48 P.M., a total of five hours without any staff checking for incontinence or offering him/her to use the bathroom. On 12/10/25 at 8:06 A.M., Resident #77 was observed sitting in the dining room. The surveyors observed the Resident in the dining room from 7:45 A.M. to 12:34 P.M., a total of just under five hours without any staff checking for incontinence or offering him/her to use the bathroom. On 12/11/25 at 8:00 A.M., Resident #77 was observed sitting in the dining room. At 11:18 A.M., three hours later, Certified Nursing Assistant (CNA) #1 took Resident #77 to his/her room to provide incontinence care. The surveyor followed the Resident to his/her room and could smell a strong odor similar to urine. After the care was provided, the surveyor examined the Resident's incontinence brief which was moderately wet with a yellow liquid resembling urine. CNA #1 said Resident #77 had been incontinent of urine. The surveyor attempted to interview Resident #77, however, he/she was unable to participate in the interview. Review of the assessment titled, Bladder (Incontinent) Functioning Assessment), dated 9/13/25, indicated Resident #77 had total bladder incontinence for more than 12 months. Review of the assessment titled, Bowel (Incontinent) Functioning Assessment), dated 9/13/25, indicated Resident #77 had total bowel incontinence for more than 12 months. Review of Resident #77's incontinence care plan last revised 10/1/25, indicated the following intervention: -toilet every two hours and PRN (as needed) containment program. Review of Resident #77's Kardex (a form indicating the level of assistance a resident required) indicated the Resident was incontinent of both bowel and bladder and he/she was dependent on staff for all toileting needs. Review of Resident #77's Norton Pressure Ulcer assessment dated [DATE], indicated Resident #77 had a pressure ulcer risk score of 7, indicating the Resident is a very high risk for pressure ulcer development. During an interview on 12/11/25 at 1:08 P.M., Nurse Unit Manager #2 said residents should be checked for incontinence and changed every three hours and as needed. Nurse Unit Manager #2 said not providing incontinence care timely put the resident at risk for skin breakdown. During an interview on 12/11/25 at 1:17 P.M., Certified Nursing Assistant (CNA) #1 said that every resident should get incontinent care in the morning with morning care, after breakfast around 10-10:30 A.M., and then again after lunch. CNA #1 said that the CNAs know the level of care for each resident by looking at the Kardex and that the continence status of each resident is listed on their Kardex. CNA #1 said that each morning she gave the CNAs a verbal report of the resident care needs. CNA #1 said that it was very important to change a resident who was wet or soiled immediately to avoid skin breakdown and other complications and that Resident #77 should have been changed after breakfast each day but that the challenge was the CNAs needed more support and that they consistently need five CNAs which they often don't get. During an interview on 12/11/25 at 1:54 P.M., the Director of Nursing said it was her expectation that staff provide incontinence care at least every two hours and as needed. The Director of Nursing said not providing timely care could put a resident at risk for skin breakdown. 4. Resident #78 was admitted to the facility in September 2019 with diagnoses including dementia. Review of Resident #78's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #78 was dependent on staff for all toileting needs and section H of the MDS said the Resident was frequently incontinent of both urine and bowel. On 12/9/25 at 7:45 A.M., Resident #78 was observed sitting in the dining room. The surveyors observed the Resident in the dining room from 7:45 A.M. to 12:15 P.M., a total of four and a half hours without any staff checking for incontinence or offering him/her assistance to the bathroom. At 12:19 P.M., Certified Nursing Assistant (CNA) #4 assisted the Resident to the bathroom. CNA #4 told the surveyor that Resident #78 had been incontinent of urine. He said he could not tell how long the Resident had been sitting on a soiled brief. On 12/10/25 at 8:06 A.M., Resident #78 was observed sitting in the dining room. The surveyors observed the Resident in the dining room from 7:45 A.M. to 12:34 P.M., a total of just under 5 hours without any staff checking for incontinence or offering him/her to use the bathroom. On 12/11/25 at 8:01 A.M., Resident #78 was observed sitting in the dining room. At 10:37 A.M., Resident #78 asked a CNA to take him/her to the bathroom. The CNA said, one second and walked away. Resident #78 was not toileted until 11:39 A.M., an hour later. The surveyor was present when incontinent care was provided and observed the Resident's incontinence brief to be saturated with urine. The surveyor attempted to interview Resident #78, however, he/she was unable to participate in the interview. Review of the assessment titled, Bladder (Incontinent) Functioning Assessment), dated 3/16/25, indicated Resident #78 had total bladder incontinence for more than 12 months. Review of the assessment titled, Bowel (Incontinent) Functioning Assessment), dated 3/16/25, indicated Resident #78 had total bowel incontinence for more than 12 months. Review of Resident #78's incontinence care plan indicated the following intervention: -toilet every two hours and as needed. Review of Resident #78's Kardex (a form indicating the level of assistance a resident required) indicated the Resident was incontinent of both bowel and bladder and he/she was dependent on staff for all toileting needs. Review of Resident #78's Norton Pressure Ulcer assessment dated [DATE], indicated Resident #78 had a pressure ulcer risk score of 8, indicating the Resident was a very high risk for pressure ulcer development. During an interview on 12/11/25 at 1:08 P.M., Nurse Unit Manager #2 said residents should be checked for incontinence and changed every three hours and as needed. Nurse Unit Manager #2 said not providing incontinence care timely put the resident at risk for skin breakdown. During an interview on 12/11/25 at 1:17 P.M., Certified Nursing Assistant (CNA) #1 said that every resident should get incontinent care in the morning with morning care, after breakfast around 10-10:30 A.M., and then again after lunch. CNA #1 said that the CNAs know the level of care for each resident by looking at the Kardex and that the continence status of each resident was listed on their Kardex. CNA #1 said that each morning she gives the CNAs a verbal report of the resident care needs. CNA #1 said that it was very important to change a resident who was wet or soiled immediately to avoid skin breakdown and other complications and that Resident #78 should have been changed after breakfast each day but that the challenge was the CNAs needed more support and that they consistently needed five CNAs which they often don't get. During an interview on 12/11/25 at 1:54 P.M., the Director of Nursing said it is her expectation that staff provided incontinence care at least every two hours and as needed. The Director of Nursing said not providing timely care can put a resident at risk for skin breakdown. 5. Resident #89 was admitted to the facility in February 2024 with diagnoses including stroke. Review of Resident #89's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident score a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #89 was dependent on staff for toileting and section H of the MDS indicated the Resident was frequently incontinent of both bladder and urine. On 12/9/25 at 7:30 A.M., Resident #89 was observed sitting in the dining room. The surveyors observed the Resident in the dining room from 7:30 A.M. to 12:15 P.M., a total of four hours without any staff checking for incontinence or offering him/her assistance to the bathroom. At 12:19 P.M., Certified Nursing Assistant (CNA) #2 assisted the Resident to the bathroom. CNA #2 told the surveyor that Resident #89 had been incontinent of urine. On 12/10/25 at 8:06 A.M., Resident #89 was observed sitting in the dining room. The surveyors observed the Resident in the dining room from 8:06 A.M. to 12:34 P.M., a total of four and a half hours without any staff checking for incontinence or offering him/her to use the bathroom. On 12/11/25 at 7:55 A.M., Resident #89 was observed sitting in the dining room. The Resident sat in the dining room until he/she was [NAME] to the bathroom at 12:37 P.M. The surveyor was present while incontinent care was provided and observed Resident #89's incontinent brief to be soiled with both urine and bowel and his/her groin area was reddened. The surveyor attempted to interview Resident #89, however, he/she was unable to participate in the interview. Review of the assessment titled, Bladder (Incontinent) Functioning Assessment), dated 1/10/25, indicated Resident #89 had total bladder incontinence for more than 12 months. Review of the assessment titled, Bowel (Incontinent) Functioning Assessment), dated 1/10/25, indicated Resident #89 had total bowel incontinence for more than 12 months. Review of Resident #89's incontinence care plan, indicated the following intervention: -provide incontinence care when toileting. Review of Resident #89's Kardex (a form indicating the level of assistance a resident requires) indicated the Resident was incontinent of both bowel and bladder and he/she was dependent on staff for all toileting needs. Review of Resident #89's Norton Pressure Ulcer assessment dated [DATE], indicated Resident #89 had a pressure ulcer risk score of 9, indicating the Resident was a very high risk for pressure ulcer development. During an interview on 12/11/25 at 1:08 P.M., Nurse Unit Manager #2 said residents should be checked for incontinence and changed every three hours and as needed. Nurse Unit Manager #2 said not providing incontinence care timely put the resident at risk for skin breakdown. During an interview on 12/11/25 at 1:17 P.M., Certified Nursing Assistant (CNA) #1 said that every resident should get incontinent care in the morning with morning care, after breakfast around 10-10:30 A.M., and then again after lunch. CNA #1 said that the CNAs know the level of care for each resident by looking at the Kardex and that the continence status of each resident was listed on their Kardex. CNA #1 said that each morning she gave the CNAs a verbal report of the resident care needs. CNA #1 said that it was very important to change a resident who was wet or soiled immediately to avoid skin breakdown and other complications and that Resident #89 should have been changed after breakfast each day but that the challenge was the CNAs needed more support and that they consistently needed five CNAs which they often don't get. During an interview on 12/11/25 at 1:54 P.M., the Director of Nursing said it was her expectation that staff provide incontinence care at least every two hours and as needed. The Director of Nursing said not providing timely care can put a resident at risk for skin breakdown. 6. Resident #93 was admitted to the facility in December 2023 with diagnoses including Alzheimer's Disease. Review of Resident #93's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #93 was dependent on staff for all toileting needs and section H of the MDS said the Resident was frequently incontinent of both urine and bowel. On 12/9/25 at 7:30 A.M., Resident #93 was observed sitting in the dining room. The surveyors observed the Resident in the dining room from 7:30 A.M. to 12:48 P.M., a total of five hours without any staff checking for incontinence or offering him/her assistance to the bathroom. On 12/10/25 at 7:44 A.M., Resident #93 was observed sitting in the dining room. The surveyors observed the Resident in the dining room from 7:45 A.M. to 12:02 P.M., a total of just under four and a half hours without any staff checking for incontinence or offering him/her to use the bathroom. On 12/11/25 at 8:10 A.M., Resident #93 was observed sitting in the dining room. At 1:07 P.M., five hours later, a CNA brought Resident #93 to the bathroom. A surveyor was present while incontinent care was provided and the Resident's incontinence brief was observed to be saturated with urine. The surveyor attempted to interview Resident #93, however, he/she was unable to participate in the interview. Review of the assessment titled, Bladder (Incontinent) Functioning Assessment), dated 10/4/25, indicated Resident #93 had total bladder incontinence for more than 12 months. Review of the assessment titled, Bowel (Incontinent) Functioning Assessment), dated 10/4/25, indicated Resident #93 had total bowel incontinence for more than 12 months. Review of Resident #93's risk for skin breakdown due to incontinence care plan last revised 1/9/25, indicated the following intervention: -provide incontinence care every two hours and as needed. Review of Resident #93's Kardex (a form indicating the level of assistance a resident requires) indicated the Resident was incontinent of both bowel and bladder and he/she is dependent on staff for all toileting needs. Review of Resident #93's Norton Pressure Ulcer assessment dated [DATE], indicated Resident #93 had a pressure ulcer risk score of 10, indicating the Resident is a high risk for pressure ulcer development. During an interview on 12/11/2025 at 1:08 P.M., Nurse Unit Manager #2 said residents should be checked for incontinence and changed every three hours and as needed. Nurse Unit Manager #2 said not providing incontinence care timely put the resident at risk for skin breakdown. During an interview on 12/11/2025 at 1:17 P.M., Certified Nursing Assistant (CNA) #1 said that every resident should get incontinent care in the morning with morning care, after breakfast around 10-10:30 A.M., and then again after lunch. CNA #1 said that the CNAs know the level of care for each resident by looking at the Kardex and that the continence status of each resident is listed on their Kardex. CNA #1 said that each morning she gives the CNAs a verbal report of the resident care needs. CNA #1 said that it was very important to change a resident who was wet or soiled immediately to avoid skin breakdown and other complications and that Resident #93 should have been changed after breakfast each day but that the challenge was the CNAs need more support and that they consistently need five CNAs which they often don't get. During an interview on 12/11/25 at 1:54 P.M., the Director of Nursing said it was her expectation that staff provide incontinence care at least every two hours and as needed. The Director of Nursing said not providing timely care can put a resident at risk for skin breakdown.

Based on observations, record reviews and interviews, the facility failed to ensure two Residents' (#89 and #77) maintained acceptable parameters of nutritional status out of a total sample of 30 residents. Specifically, 1) For Resident #89, the facility failed to a) ensure the Registered Dietitian's recommendations were implemented after a significant weight loss and b) ensure his/her nutritional supplement was provided during meals.2) For Resident #77, the facility failed to provide the Resident with his/her nutritional supplement during a meal. Findings include:Review of the facility policy titled, Resident Nutritional Policy & Procedure, reviewed 6/2025, indicated the following:Purpose: To promote optimal nutrition and provide mechanism to identify significant weight changes and implement corrective action as well as providing nutritional interventions for residents with pressure ulcers.Scope: To be followed by nursing, the Nutritional Coordinator, the Food Service Supervisor and Dietitian.Weights: the resident is weighed upon admission/re-admission according to the facility's weight monitoring policy.Weight Monitoring: Each resident is to be weighed upon admission, and thereafter, a minimum of once a month, or more frequently as medically necessary or as per physician order, by the Nutritional Coordinator (or other individual as designated by nursing). In order to maintain accurate weights, the resident should be weighed at approximately the same time each month. Weights are recorded directly on an individual in the EHR (electronic health record) or the Weights Sheet Form CN-052, to be used if EHR is unavailable, which are kept in a special weight book at the nurses' station.If a significant weight loss occurs, defined as five percent (5%) in one month, seven and one half percent (7.5%) in three months, or ten percent (10%) in six months, the Nutritional Coordinator (or designee) is to notify the Director of Nursing.Except in cases where the resident is on hospice services/comfort measure only and is contradicted by attending physician, a. The Director of Nursing will:1. Ensure that the attending physician is notified;2. Ensure physician orders are followed;3. Review significant weight changes through Case Management by utilizing electronic dashboard. The resident's care plan will be updated at this time.4. Ensure the family/next of kin/responsible party is notified regarding the significant change. b. The Nutritional Coordinator or designee shall: 1. Weigh residents upon admission and once a month to establish weight pattern. If the resident exhibits significant change, the resident must be re-weighed to assure accuracy. Once weight loss or gain is validated, the Nutritional Coordinator/designee will notify the Director of Nursing, Charge Nurse, MDS Nurse and Dietitian. c. The Dietitian shall: 1. Assess the resident's current nutritional status when a significant change is noted and document intervention. Some interventions may include feeding programs, supplementation of liquid or medication, lab work, consults (speech, psych, etc.,), alternate feeding plan, physician involvement, or any resident specific intervention which would benefit the resident in enhancing his/her nutritional status.Nutritional Assessment & Progress Notes: Nutritional progress notes are written for each resident by the dietitian and as necessary, according to the MDS schedule. The dietitian's notes are documented in the EHR. 1. Resident #89 was admitted to the facility in February 2024 with diagnoses including stroke. Review of Resident #89's most recent Minimum Data Set (MDS) assessment, dated 9/19/25, indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status exam which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #89 was dependent on staff for self-feeding and toileting and section H of the MDS indicates the Resident was frequently incontinent of both bladder and urine. Review of Resident #89's weight log indicated that on 9/17/25, Resident #89 weighed 135 pounds and on 12/12/25 weighed 122 pounds, a weight loss of 9.63%. On 12/9/25 at 1:44 P.M., Resident #89 was observed eating lunch. The meal ticket on his/her lunch tray indicated he/she was supposed to have a magic cup (a nutritional supplement). The Resident was never provided with a magic cup throughout the entirety of the meal. On 12/10/25 at 8:25 A.M., Resident #89 was observed eating breakfast. The meal ticket on his/her breakfast tray indicated he/she was supposed to have a magic cup. The Resident was never provided with a magic cup throughout the entirety of the meal. On 12/10/25 at 12:20 P.M., Resident #89 was observed eating lunch. The meal ticket on his/her lunch tray indicated he/she was supposed to have a magic cup. The Resident was never provided with a magic cup throughout the entirety of the meal. On 12/11/25 at 8:24 A.M., Resident #89 was observed eating breakfast. The meal ticket on his/her breakfast tray indicated he/she was supposed to have a magic cup. The Resident was never provided with a magic cup throughout the entirety of the meal. On 12/11/25 at 12:20 P.M., Resident #89 was observed eating lunch. The meal ticket on his/her lunch tray indicated he/she was supposed to have a magic cup. The Resident was never provided with a magic cup throughout the entirety of the meal. On 12/15/25 at 8:58 A.M., Resident #89 was observed eating breakfast. The meal ticket on his/her breakfast tray indicated he/she was supposed to have a magic cup. The Resident was never provided with a magic cup throughout the entirety of the meal. Review of Resident #89's physician orders indicated the following order:Diet: house no salt shaker breakfast, lunch, supper. Ground texture thin liquids. *lip plate, cup with handles and covers, built up utensils and magic cup at breakfast, lunch and dinner, initiated 6/29/25.Magic cup by mouth breakfast, lunch, supper with all meals, initiated 7/22/25. Review of the nutritional assessment dated [DATE] indicated the following:-Resident #89 had a 9.6% unintended weight loss in the past three months.-New recommendations for daily Ensure (a nutritional supplement), weekly weights, and to add Resident #89 to weekly at-risk meetings. On 12/17/25, the surveyor observed Resident #89's paper chart on the unit with a telephone order sheet flagged (raised up) out the top of the chart. The telephone order indicated an order, not yet signed off, for Ensure 237 ml (milliliters) 1x/day, written on 12/12/25. Review of Resident #89's nutritional care plan, last revised 1/6/25, indicated the following interventions:Provide dietary supplement as ordered.Provide diet as ordered.Notify physician of significant weight change. During an interview on 12/15/25 at 12:42 P.M., Nurse #11 said she was the nurse responsible for checking the meal trays at lunch this day. Nurse #11 said she did not check to ensure Resident #89 received his/her magic cup. Nurse #11 said she would have been the first staff member to realize the Resident needed a magic cup added to his/her tray but all other staff should have noticed as well. During an interview on 12/15/25 at 12:45 P.M., the Registered Dietitian said the kitchenette on the unit should be fully stocked with magic cups and the staff should provide the supplement to all residents who require one. Resident #89 was not able to participate in an interview during survey, and the surveyor attempted to contact the Resident's healthcare proxy without success. During an interview on 12/16/25 at 7:42 A.M., the Director of Nursing (DON) said any resident who is ordered a nutritional supplement with a meal should be provided with that supplement. The DON said nursing should ensure accuracy of all trays and that all ordered items are provided. The DON said if a resident were to lose weight, she would expect the Resident to be assessed by the dietitian immediately with nutritional interventions started as soon as possible to prevent further weight loss. The DON said she was unaware Resident #89 had a significant weight loss. During interviews on 12/15/25 at 1:42 P.M., and 12/17/25 at approximately 10:00 A.M., the Registered Dietitian (RD) said she works at the facility fulltime and is responsible for monitoring the residents' weights and implementing dietary interventions if a significant weight change occurs. The RD said a significant weight change would be a weight change of 2% in 1 week, 5% in 1 month, 7.5% in 3 months, and 10% in 6 months. The RD said when a significant weight loss occurs, she immediately makes recommendations for weight loss interventions and the physician needs to be notified so that he can review her recommendations, and they can be made into an order if he agrees. The RD said she was made aware that Resident #89's intake of meals had decreased and when looking at his/her weights, the RD noticed that Resident had a significant weight loss of over 9% from September 2025 to December 2025. The RD said that on 12/12/25 she wrote a recommendation for an order for an additional nutritional supplement of Ensure due to this weight loss and flagged it in the Resident's medical chart for the nurses to communicate the recommendation to the physician so the recommendation could be made into an active order. The RD said her expectation is that the nurses do this within 24 hours so that the dietary interventions can start immediately. The RD said that as of today, 5 days later, the nurses had not yet communicated her recommendations to the physician, and they have not yet been implemented. During an interview on 12/16/2025 12:10 P.M., Nurse Practitioner #1 said she was not aware of Resident #89's weight loss and would expect to have been notified by the facility. Nurse Practitioner #1 said she also expects all nutritional interventions, such as receiving supplements, to be followed by the nursing staff. During an interview on 12/17/25 at 1:22 P.M., Physician #1 said he was unaware of the recommendation from the Registered Dietitian made on 12/12/25. 2. Resident #77 was admitted to the facility in October 2024 with diagnoses including dementia and malnutrition. Review of Resident #77's most recent Minimum Data Set (MDS) assessment, dated 9/19/25, indicated the Resident scored a 0 out of 15 on the Brief Interview for Mental Status exam which indicated he/she had severe cognitive impairment. The MDS also indicates Resident #77 is dependent on staff for all mobility and self-care tasks. Review of Resident #77's physician orders indicated the following order:-Diet: house breakfast, lunch, supper Ground meat with regular sides. Thin mighty shake all meals. Review of Resident #77's nutritional care plan included the following interventions:-Provide diet as ordered.-Dietary supplement as ordered. Review of Resident #77's meal ticket that arrives on all of his/her meals and checked by the nursing staff for accuracy indicated mighty shake in the section of his/her diet. On 12/9/25 at 1:26 P.M., Resident #77 was given another resident's meal at lunch. The Certified Nursing Assistant (CNA) who provided the meal was observed telling another staff member she knew it was the wrong meal, however, proceeded to provide the meal to the Resident anyways. The lunch tray consisted of a meal and two drinks and nothing else on the tray. At 12:43 P.M., the surveyor asked the Nursing Administrative Assistant that was assisting Resident #77 if the meal belonged to Resident #77 and asked if the Resident had an order for a mighty shake. The Nursing Administrative Assistant said it was not Resident #77's tray and she believed the Resident did receive healthy shakes at meals, however, she was told by the CNA to just give the Resident this meal. Resident #77 finished the meal that was provided to him/her and was never given a mighty shake. During an interview on 12/9/25 at 12:47 P.M., Nurse #1 said Resident #77 should have been provided with her nutritional shake as ordered. During an interview on 12/10/25 at 2:42 P.M., the Director of Nursing (DON) said the nursing staff should be checking all trays to ensure accuracy and supplements are provided as ordered. The DON said that as soon as the nursing staff realized they had given Resident #77 the wrong tray, they should have removed the tray and obtained a new tray with the correct diet and nutritional supplements. The DON said a nurse should have ensured Resident #77 was given his/her nutritional shake to ensure all his/her nutritional needs were met. During an interview on 12/15/23 at 1:42 P.M., the Registered Dietitian (RD) said a risk of a resident getting the wrong tray or a meal without certain items is malnutrition. The RD said she would not want a resident to miss even one supplement if ordered for nutritional purposes.

Based on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically,1.) The facility failed to ensure medications with short expiration were dated once opened according to manufacturer's guidelines in three out of three medication carts observed.2.) The facility failed to ensure medication and treatment carts were locked when unattended.Findings include: Review of the policy title 'Storage and Expiration Dating of Medications and Biologicals', dated 6/30/25, indicated the following: -Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. -Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents or visitors. 1. On 12/10/25 at 6:39 A.M., the surveyor and Nurse #10 observed the following in the medication cart on the Two [NAME] Unit. 1 bottle of [NAME] eye drop opened and undated. 1 Flonase 50 (microgram) mcg opened and undated. During an interview on 12/10/25 at 6:45 A.M., Nurse #10 said eye drops and nasal spray should be dated when opened. On 12/10/25 at 6:50 A.M., the surveyor and Nurse #5 observed the following in the medication cart on the Two East Unit. 1 bottle of latanoprost 0.005% eye drop opened and undated. During an interview on 12/10/25 at 6:55 A.M., Nurse #5 said eye drops should be dated when opened. On 12/10/25 at 7:15 A.M., the surveyor and Nurse #6 observed the following in the medication cart on the One [NAME] Unit. 1 bottle of latanoprost 0.005% eye drop opened and undated. During an interview on 12/10/25 at 7:20 A.M., Nurse #6 said eye drops should be dated when opened. During an interview on 12/10/25 at 12:15 P.M., the Director of Nursing said medications with short expiration date like inhalers, nasal sprays and eye drops should be dated once opened. 2.) On 12/9/25 at 2:05 P.M., the surveyor observed that a medication cart on the Two [NAME] unit was unlocked without any staff within view of the medication cart. The surveyor opened the medication cart and observed multiple medications within the drawers. During an interview on 12/9/25 at 2:07 P.M., Nurse # 12 said she should have locked the medication because it was unattended but did not. On 12/10/25 at 2:06 P.M., the surveyor observed that a medication cart on the Two East unit was unlocked without any staff within view of the medication cart. The surveyor opened the medication cart and observed multiple medications within the drawers. There was a resident standing right next to the unlocked medication cart without any staff present. During an interview on 12/10/25 at 2:08 P.M., Unit Manager #2 came down the hallway and said the cart was not hers, but it should have been locked because it was unattended. During an interview on 12/10/25 at 2:12 P.M., Nurse #1 said it was her medication cart and she should have locked it because it was unattended while she was in a room down the hall but did not. On 12/15/15 at 9:55 A.M. to 10:05 A.M., the surveyor observed the Wound Nurse leave the treatment cart on the Two East unit, which the surveyor observed had contained both topical medications and treatment supplies, unlocked and unattended while she completed a dressing change in a resident room with the door closed. During an interview on 12/15/25 at 10:37 A.M., Nurse #1 said she should have locked the treatment cart when she was in the resident room with the door closed because it was unattended but did not. On 12/9/25 AT 2:05 P.M., the surveyor observed that a medication cart on the Two East unit was unlocked without any staff within view of the medication cart. The surveyor opened the medication cart and observed multiple medications within the drawers. During an interview on 12/16/25 at 11:18 A.M., Nurse #16 said he should have locked the medication cart because it wasn't within his view but did not. During an interview on 12/11/25 at 1:54 P.M., the Director of Nursing (DON) said medication and treatment carts should be locked when unattended by the nurse responsible for it.

Based on interviews and test trays, the facility failed to provide meals that were palatable in temperature on three out of three units and texture in one out of one altered texture meal tested. Findings include:Review of the form titled, Daily Food Temperature Charting (Test Tray), undated indicated the following:-Service Standards (once tray arrives to unit) - Temperatures:-Hot entree, starches, vegetables: Goal: >/= (over or equal to) 130 degrees Fahrenheit, Acceptable: 125-129 degrees Fahrenheit, Unacceptable: 120-124 degrees Fahrenheit, unacceptable < (less than) 120 degrees Fahrenheit-Cold food & cold beverages: Goal: </= 45 degrees Fahrenheit, Acceptable: 48-50 degrees Fahrenheit, Unacceptable: 51-54 degrees Fahrenheit, Unacceptable >/= 55 degrees Fahrenheit.-Hot beverages: Goal 130-140 degrees Fahrenheit, Acceptable 120-130 degrees Fahrenheit, Unacceptable, <120 degrees Fahrenheit. A resident group meeting was held on 12/10/25 at 1:30 P.M. During this meeting, 8 out of 11 residents said the food at meals was often cold. The following test tray observation took place on 12/11/25 at 8:08 A.M., on the Two East Unit:The meal truck arrived on the unit at 8:10 A.M. and the last meal was passed out at 8:43 A.M., 33 minutes later.A test tray was conducted 8:43 A.M., with the following temperatures recorded: Eggs covered in cheese were 80 degrees Fahrenheit and tasted rubbery and lukewarm not hot. Bacon was 78 degrees Fahrenheit and tasted chewy and cool not hot. Toast was 74 degrees Fahrenheit and tasted cool. Oatmeal was 94 degrees Fahrenheit and tasted lukewarm not hot. The following test tray observation took place on 12/11/25 at 7:50 A.M., on the Two [NAME] Unit:The meal truck arrived on the floor at 7:55 A.M., and the last tray was passed at 8:08 A.M., 13 minutes later.A test tray was completed at 8:08 A.M., with the following temperatures recorded: Egg with cheese was 92 degrees Fahrenheit and tasted cool not hot.Toast was 93 degrees Fahrenheit and tasted cool. Oatmeal was 90 degrees Fahrenheit and tasted warm not hot.Apple juice was 58 degrees Fahrenheit and tasted warm not cold. A second test tray observation took place on 12/11/25 at 8:13 A.M., on the Two [NAME] Unit. Pureed toast was 130 degrees Fahrenheit and tasted warm, however, was thick and sticky and difficult to swallow. Oatmeal was 118 degrees Fahrenheit and tasted lukewarm not hot. The following test tray observation took place on 12/11/25 at 7:55 A.M., on the One [NAME] Unit:The meal truck arrived on the floor at 8:17 A.M., and the last tray was passed at 8:36 A.M., 19 minutes later.The test tray was completed at 8:36 A.M., with the following temperatures recorded: Egg with cheese was 105 degrees Fahrenheit and tasted cool. Toast was 100 degrees Fahrenheit and tasted cool and bland. Bacon was 97 degrees Fahrenheit and tasted cold. During an interview on 12/11/25 at 9:06 A.M., the Food Service Director said hot foods should temp at above 135 degrees Fahrenheit and cold foods should temp lower than 40 degrees Fahrenheit. The surveyor shared the results of the test tray with the Food Service Director and he said those temperatures were unacceptable and that trays sitting on the units for a delayed amount of time would cause unacceptable temperature ranges of foods when the residents are given their meals.

Based on observation and interview, the facility failed to store and handle food in accordance with professional standards for food service safety. Specifically, the facility failed to:1) Ensure shelves on which food was stored were clean/free of possible contaminants, and that food was stored, labeled and dated properly in the main kitchen and in three of three unit kitchenettes. 2) Ensure staff did not handle ready-to-eat food with contaminated gloves. Findings include: 1. Review of the facility policy titled, Resident Personal Food Storage Policy & Procedure, dates 2/2025, indicated the following:-Resident food and beverage items stored in the unit kitchenettes must be clearly marked with the resident's name and the date the item was placed in the kitchenette. On 12/9/25 at 7:21 A.M. the surveyor made the following observations during the initial walkthrough of the main kitchen:A gray wispy substance present on the shelves in the walk-in refrigerator, there was food stored above and below the gray wispy substance.An undated pan containing yellow liquid in the walk-in refrigerator.An undated pan containing cooked green beans in the walk-in refrigerator.An undated take-out container with left-over macaroni and cheese in the walk-in refrigerator.A container labeled crab salad, dated 12/3/25, in the walk-in refrigerator.An undated pan of food consistent in appearance with tuna salad in the walk-in refrigerator.An undated container of macaroni salad in the walk-in refrigerator, the container was not wrapped or covered.Uncooked bacon open but undated in the walk-in refrigerator.A bag of mozzarella cheese open but undated in the walk-in refrigerator.An undated pan containing a thick yellow liquid consistent in appearance with egg in the walk-in refrigerator.Two open but undated containers of orange juice in the reach-in refrigerator.An open but undated container of nectar-thick juice in the reach-in refrigerator.Sliced ham open but undated in the reach-in refrigerator.Sliced turkey open but undated in the reach-in refrigerator. Two packages of open but undated sliced cheese in the reach-in refrigerator.A container of potato salad dated 12/3 in the reach-in refrigerator.A container of pudding dated 11/29 in the reach-in refrigerator.Dry pasta open but undated in the dry storage area.A package of undated hot dog buns in the dry-storage area.Three cans (mandarins, cranberry sauce and sweet potato) with significant dents stored on the can-rack in the dry storage area. During an interview on 12/9/25 at 7:54 A.M., the kitchen supervisor said that all food should be labeled and discarded after three days, that shelving in the walk-in refrigerator should be washed and that dented cans should be set aside and not placed on the can-rack. On 12/9/25 at 8:03 A.M. the surveyor made the following observations in the One [NAME] unit kitchenette refrigerator:An undated container of food with a Resident's room number and name written on it.An open container of cous-cous with a best-by date of 10/2/25.Four open but undated containers of cranberry juice.One open container of cranberry juice dated 11/24. On 12/9/25 at 8:19 A.M. the surveyor made the following observations in the Two East unit kitchenette:An undated half of a blueberry muffin.Three containers of active food thickener powder with expiration dates of October 2025.Three opened but undated thickened cranberry juices in the refrigerator.Two open but undated containers of cranberry juice in the refrigerator.One open but undated container of apple juice in the refrigerator.An undated creamy food substance wrapped in tinfoil in the refrigerator. On 12/9/25 at approximately 8:30 A.M. the surveyor made the following observations in the Two [NAME] unit kitchenette:An undated and unrefrigerated apple pie.Chocolate cake with a sell-by date of 12/8.An undated and unrefrigerated bacon egg and cheese bagel sandwich.An undated plastic tub containing hardboiled eggs in the refrigerator.An undated container of food consistent in appearance with cooked sweet potatoes in the refrigerator.An undated plastic bag containing leftover food in the refrigerator.French onion dip open but undated in the refrigerator. Two open but undated containers of apple juice in the refrigerator.One open but undated container of cranberry juice in the refrigerator.One container of thickened apple juice with an expiration date of 12/3/25 in the refrigerator. During an interview on 12/9/25 at approximately 8:35 A.M., Nurse #3 said staff must date Resident food and opened juices and that the bacon egg and cheese sandwich should have been refrigerated. During an interview on 12/11/25 at 9:06 A.M., the Food Service Director (FSD) said that the walk in is cleaned weekly and the temperature of the walk-in had been too high, creating the gray substance on the shelves, which he believed was most likely mold. He said that food should not have been stored underneath this substance. The FSD said all food must be labeled when opened and discarded after three days, that dented cans should not be in rotation to be served and that any dented cans should be taken out of rotation. The FSD also said kitchenettes on the units were cleaned by the housekeeping staff but he is in charge of stocking the kitchenettes and maintaining inside of the refrigerators. The FSD said all food in the kitchenette also had to be labeled with a resident's name if it was personal food, and all food must be labeled when opened and discarded after three days. 2. The facility did not provide a policy for food handling to the surveyor. On 12/11/25 at 7:37 A.M., the surveyors observed the food preparation line with the following observations:The cook washed her hands, put on gloves, and touched the lid to the plate holder, the countertop and serving utensils, potentially contaminating her gloves. The cook then began to serve food using the same contaminated gloves and did not use a utensil to serve the toast, touching all pieces of the ready-to-eat toast served throughout meal. Using the same potentially contaminated gloves, the cook touched four pieces of bacon when placing them onto a resident's plate. In the middle of meal service, the cook took off her gloves, washed her hands and put on a new pair of gloves. She then touched the countertop, serving utensils and plates, potentially contaminating her gloves and then continued to use her gloved hands to serve the ready-to-eat toast. During an interview on 12/11/25 at 9:06 A.M., the Food Service Director (FSD) said that once gloves were put on, if the person touches any other surface than food, the gloves were contaminated, and the person should not handle food with those gloves.

Based on observations, record review and interviews, the facility failed to maintain accurate medical records for two Residents (#111 and #32) out of a total sample of 30 residents. Specifically, 1) For Resident #11, the facility failed to accurately document the completion of a left heel wound treatment2) For Resident #32, the nurses documented the topical medication Flagyl (an antibiotic medication) inaccurately, when they documented that it was administered when it was not. Findings include:1. Resident #111 was admitted to the facility in March 2023, with diagnoses of dementia and chronic kidney disease. Review of Resident #111's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a score of 0 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #111 was dependent on staff for all functional daily tasks including bed mobility. Review of Resident #111's physician orders indicated the following order: L (left) heel stage 3 wound EVERY DAY ON DAY SHIFT, cleanse with vashe, apply iodsorb apply ABD pad (a sterile dressing) and wrap with gauze daily, [NAME] (as needed) for soiling, saturation, and accidental removal, initiated 11/12/25. Review of the Treatment Administration Record for December 2025 indicated Nurse #1 had marked the left heel wound treatment as completed on 12/9/25. On 12/10/2025 at 10:55 A.M., the surveyor observed the wound dressing changes for Resident #111's left heel wound with Nurse #1. The Resident's left heel had a dressing dated 12/8/25, two days prior. At the time of this observation, Nurse #1 said she is unsure of what the treatment orders are for the left heel. Nurse #1 said she also worked yesterday on 12/9/25 and took care of Resident #111. Nurse #1 said she did not complete the ordered wound treatments on 12/9/25. Nurse #1 said the facility has a wound nurse and she was told the wound nurse completes all wounds. Nurse #1 was unaware the wound nurse did not complete the wound treatment on 12/9/25. Nurse #1 said she should not have marked the order as completed if she had not actually completed the treatment. During an interview on 12/11/25 at 7:42 A.M., the Director of Nursing said a nurse should never document a treatment order as complete if they had not done the treatment. 2.) Resident #32 was admitted to the facility in September 2018 with diagnoses including dementia and malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/26/25, indicated Resident #32 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 3 out of 15. This MDS also indicated Resident #32 had an unstageable pressure ulcer. On 12/15/25 at 9:33 A.M., the surveyor observed the Wound Nurse complete the wound dressing change for Resident #32's coccyx pressure ulcer. After the Wound Nurse gathered dressing supplies, the surveyor observed her approach Unit Manager #2 requesting the Flagyl that was indicated to be used in active physician's order. Unit Manager #2 told the Wound Nurse the Flagyl had been discontinued the day prior, but she forgot to put the new order into the electronic medical record. The surveyor then observed the Wound Nurse complete Resident #32's wound dressing change without Flagyl. During a follow-up interview on 12/15/25 at 10:07 A.M., Unit Manager #2 said the Weekend Supervisor told her to discontinue the order yesterday, but she forgot to put it in the electronic medical record. Unit Manager #2 said she did not implement Flagyl in Resident #32's coccyx wound the day before (12/14/25), even though she documented that she had. During an interview on 12/15/25 at 10:43 A.M., the Weekend Supervisor said he asked Unit Manager #2 to follow-up regarding Resident #32's Flagyl order because it was input incorrectly in the electronic record, resulting in it not being sent by the pharmacy. The Weekend Supervisor said he was told by the nurses that there was no Flagyl available for Resident #32's wound treatment and that the Resident was not receiving the Flagyl as ordered by the physician. The Weekend Supervisor said he never personally contacted the pharmacy or a physician to clarify to order or notify them that they Flagyl was unavailable, but Unit Manager #2 was supposed to. Review of Resident #32's physician's orders indicated: Cleanse wound to coccyx with vashe (a wound cleanser), cleanse soak with vashe for 10 minutes apply hydrofera blue (an antibacterial foam wound dressing) to the wound secure with SAD (super absorbent dressing), change daily, initiated 12/15/25. Cleanse wound to coccyx with vashe cleanse soak with vashe for 10 minutes applying crushed Flagyl, hydrofera blue to the wound secure with SAD, initiated 12/2/25 and discontinued 12/15/25. Review of Resident #32's treatment administration record, dated 12/9/25 to 12/14/25, indicated the treatment to Cleanse wound to coccyx with vashe, cleanse soak with vashe for 10 minutes applying crushed Flagyl, hydrofera blue to the wound secure with SAD (super absorbent dressing), Change daily and PRN was documented as implemented as ordered: 12/9/25 by Nurse #7 12/10/25 by Unit Manager #2 12/11/25 by Unit Manager #2 12/12/25 by Unit Manager #2 12/13/25 by a nurse unable to be interviewed 12/14/25 by Unit Manager #2 During an interview on 12/15/25 at 11:43 A.M., Unit Manager #2 said she implemented Resident #32's coccyx wound dressing treatment on 12/10/25, 12/11/25, 12/12/25, and 12/14/25 but did not administer the Flagyl because it was unavailable. Unit Manager #2 also said even if there was Flagyl she couldn't have implemented it because the wound was so deep she would have to put Resident #32's leg over his/her head because the Flagyl wouldn't even fit in the wound. Unit Manager #2 said she never notified the provider but that she probably should have since it had not been implemented since at least 12/10/25. Unit Manager #2 further said she should not have documented it as implemented since she did not implement it. During an interview on 12/15/25 at 11:55 A.M., Nurse #7 said she implemented Resident #32's coccyx wound dressing treatment on 12/9/25. Nurse #7 said she did not implement flagyl, even though it was a part of the physicians order, because it was not available. Nurse #7 said she passed along that it was unavailable in report, but she didn't personally notify the pharmacy or notify the physician because she did not have time. Nurse #7 further said she should not have documented it as implemented since she did not implement it. Review of Resident #32's medical record failed to indicate that flagyl was not implemented during the wound treatment, the flagyl was unavailable or unable to be administered, or that a provider was notified regarding any flagyl concerns. During an interview on 12/15/25 at 12:31 P.M., the Director of Nursing (DON) said Resident #32 should have had flagyl implemented in the wound daily. The DON said she contacted the Nurse Practitioner who said the flagyl should have been implemented since 12/2/25 and should not have been discontinued on 12/15/25. The DON said the Wound Nurse Practitioner had been on vacation since 12/9/25, and in her absence she would expect all nurses to contact the house Nurse Practitioner for wound concerns. The DON further said the nurses should not have documented it as implemented when they did not.

Based on interview and record review, the facility failed to develop, implement and maintain a Quality Assurance and Performance Improvement (QAPI) program which focuses on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to ensure a QAPI plan was implemented and addressed concerns regarding Activities of Daily Living (ADL) care in the facility, when a.) staff identified the inability to provide the frequency of ADL care needed on the Dementia Specialty Care Unit (DSCU) and b.) nursing identified there was a problem with wound care. Findings includeReview of the policy titled Quality Assurance and Performance Improvement Procedure, dated 02/2025, indicated:PURPOSE: The facility will develop, implement and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. Quality Assurance and Performance Improvement is a management process that is ongoing, multi-level, comprehensive and facility wide. It deals with full range care and services offered by the facility, including the full range of departments. It encompasses managerial, administrative, clinical, system of care, quality of life, resident choices and environmental services, as well as the performance of outside (contracted) providers and suppliers of care and services. The purpose is continuous evaluation of facility systems with the objective of:Keeping systems functioning satisfactorily and consistently including maintaining current practice standards.Preventing deviation from care processes arising, to the extent possible.Discerning issues and concerns, if any, with the facility systems and determining if issues/concerns are identified. Correcting inappropriate care processes.Focusing on quality of life and allowing resident choice to extent (sic) possible without compromised outcomes. Adverse event monitoring data review to develop activities to prevent adverse event. Create systematic approach to determine underlying causes of problems, impacting larger problems. On 12/17/25 at 12:40 A.M., the survey team met with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to review the facility's QAPI program. The NHA said that the QAPI team meets quarterly, but should probably meet monthly. The DON said that she presently does not have a QAPI plan for Activities of Daily Living (ADL) care or wound care, but should. The DON said:a.) The lead Certified Nursing Assistant (CNA) #1 on the facility's Dementia Specialty Care Unit is a big resident advocate and that CNA #1 has expressed concern regarding the staff's ability to provide the needed ADL care, such as incontinence care, as often as they should, due to the number of CNAs and high care needs of the unit's residents. The DON said that her hands are tied with the facility's PPD (Patients Per Day=a metric used in nursing homes that measures the average number of patients cared for by staff on any given day. The PPD reflects the average number of patients per staff member). b.) She had a QAPI early in 2025 for skin but that it fell off for no particular reason. The DON said that the communication issues in the building are a big part of the problem and expressed that she feels very frustrated with the nurses because you can educate them till you are blue in the face and the issues persist. The DON indicated that a wound nurse was hired 9/2/25 due to significant concerns regarding wound care in the facility and that at that time that should have triggered her to start a wound QAPI. She said that the wound nurse has been communicating to her that she had concerns within the building regarding to the lack of communication from nurses regarding wounds and regarding staff competency for wound care. The NHA reviewed the active QAPI's and said that the facility had a QAPI between March and June 2025 regarding skin checks not being done. The DON added that a QAPI should have been in place to address these ongoing repeat issues that are not getting resolved with ADL care and wound care

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically,1a.) For Resident #111, the facility failed to implement enhanced barrier precautions.1b.) For Resident #66, the facility failed to implement enhanced barrier precautions.2.) The facility failed to ensure the nurse changed gloves between removing/handing a dirty dressing and applying a clean dressing to a pressure wound.3.) The facility failed to ensure staff performed hand hygiene before applying and after removing gloves during wound care.4.) The facility failed to ensure a nurse did not pour pills directly onto her laptop keyboard. Findings include: 1.) Review of the facility policy titled Enhanced Barrier Precautions, revised December 2024, indicated: Enhanced barrier precautions (EBP) apply when: a resident is NOT known to be infected or colonized with any MDRO (multi-drug-resistant organism), has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or maintained. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing, bathing/showering, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, providing bed mobility, changing linens, wound care. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE (personal protective equipment) required. 1a.) Resident #11 was admitted to the facility in March 2023 with diagnoses including a stage three pressure ulcer and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/10/25, indicated Resident #111 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status exam score of 0 out of 15. This MDS also indicated Resident #111 had a pressure ulcer/injury. Review of Resident #111's Wound Nurse note, dated 10/28/25, indicated: Stage 3 open area to the back of outer left foot. Review of Resident #111's active physician's orders on 12/10/25 failed to indicate use of enhanced barrier precautions. Review of Resident #111's active plan of care on 12/10/25 failed to indicate use of enhanced barrier precautions. On 12/10/25 at 10:42 A.M., the surveyor entered Resident #111's room, there was no sign that indicated the need for any special precautions on or near the doorway. On 12/10/25 at 10:43 A.M., the surveyor observed Nurse #1 and Certified Nurse Assistant (CNA) #3 providing incontinence care to Resident #111. Nurse #1 said Resident #3 had multiple pressure wounds. Nurse #1 and CNA #3 both had gloves on but were not wearing precaution gowns. On 12/10/25 at 2:10 P.M., the surveyor observed Nurse #1 and CNA #3 assisting Resident #111 with bed mobility. Nurse #1 and CNA #3 both had gloves on but were not wearing precaution gowns. During an observation of wound dressing change on 12/10/25 at 2:13 P.M., Nurse #1 gathered wound dressing supplies and then put on a precaution gown and gloves to enter the room. Nurse #1 said she needed to wear a precaution gown because enhanced barrier precautions are required for wound care. Nurse #1 said she didn't know why there was no sign or a physician's order for enhanced barrier precautions, but since other facilities would require it, she knew she should put on the precaution gown on to provide wound care. During an interview on 12/10/25 at 1:08 P.M., the Director of Nursing (DON) said residents with chronic wounds should be on enhanced barrier precautions while providing incontinence care, removing incontinence briefs, and/or repositioning in bed. During a follow-up interview on 12/11/25 at 11:07 A.M., the DON said Resident #111 should have been on enhanced barrier precautions but was not. 1b.) Review of the facility policy titled 'Handwashing/Hand Hygiene', revised October 2023, indicated: Hand hygiene is indicated: after contact with blood, body fluids, or contaminated surfaces, after touching a resident; immediately after glove removal. Resident #66 was admitted to the facility in April 2024 with diagnoses including obstructive and reflux uropathy. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/19/25, indicated Resident #66 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. This MDS also indicated Resident #66 had an indwelling urinary catheter. During an interview on 12/10/25 at 6:59 A.M., Resident #66 was observed in his/her room with the urinary catheter drainage bag hanging from a trash can that was filled with trash. Resident #66 said staff put the catheter on the trash can and sometimes they put it on the floor if urine isn't draining adequately. Resident #66 said staff often does not wear precaution gowns while emptying his/her urinary catheter bag. Review of Resident #66's physician's order, initiated 9/4/24, indicated: Enhanced Barrier Precautions, every shift, for Foley (indwelling urinary) catheter. Review of Resident #66's plan of care related to infection risk r/t (related to) Foley (indwelling urinary) catheter, revised 9/3/25, indicated: Enhanced Barrier Precautions as appropriate to prevent and control transmission of infectious agents during care r/t foley catheter. On 12/9/25 at 9:06 AM, the surveyor observed a staff member kneeling on the floor emptying urine from a urinary catheter drainage bag. This staff member had gloves on but was not wearing a precaution gown. On 12/10/25 at 7:01 A.M., Certified Nurse Assistant (CNA) #11 said she put the urinary catheter drainage bag on the trash can because the urine wasn't draining. CNA #11 was observed handling the urinary catheter bag with bare hands. CNA #11 touched the spout, where urine is drained from, and moved the urinary catheter drainage bag off the trash can and onto the bed frame. CNA #11 was not wearing a precaution gown or gloves. CNA #11 left room and began touching the laundry cart outside without performing any hand hygiene. During an interview on 12/10/25 at 7:16 A.M., Nurse #10 said the urinary catheter drainage bag or tubing should never be stored on the floor or hanging from a trash can because of risk of infection or injury from it pulling. Nurse #10 said the CNA should never put it on the trash can. Nurse #10 said staff should wear a precaution care when providing care to a urinary catheter. Nurse #10 said CNA should not have touched the urinary catheter drainage bag or spout without gloves, and further said she should have performed hand hygiene immediately after touching it and before leaving the Resident's room and touching the laundry cart. During an interview on 12/10/25 at 1:08 P.M., the Director of Nursing (DON) said residents with indwelling urinary catheters should be on enhanced barrier precautions while performing any urinary catheter care. The DON said staff should have been wearing a precaution gown while emptying Resident #66's indwelling urinary catheter drainage bag. The DON said the urinary catheter drainage bag should not have been hanging or touching a trash can. The DON further said the CNA should not have handled the urinary catheter drainage bag with bare hands and should have performed hand hygiene before leaving the Resident's room and touching the laundry cart. 2.) Review of the facility titled 'Dressings, Dry/Clean', revised September 2013, indicated: Steps in the Procedure: 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) by pulling the corners of the exterior wrapping outward, touching only the exterior surface. 10. Label tape or dressing with date, time and initials. Place on clean field. 11. Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). 12. Wash and dry your hands thoroughly. 13. Put on clean gloves. On 12/10/25 at 2:21 P.M., the surveyor observed Nurse #1 perform a dressing change to a stage three pressure wound on a resident's heel. Nurse #1 removed a dressing, which was soiled with brown drainage and cleansed the wound with a wound cleanser using gauze, contaminating her gloves. Nurse #1 did not remove/change her gloves or perform hand hygiene before continuing to apply a new clean dressing. During a follow-up interview on 12/10/25 at 2:25 P.M., Nurse #1 said she should have changed her gloves and performed hand hygiene after removing the dirty dressing and before applying the new, clean dressing. During an interview on 12/11/25 at 11:07 A.M., the Director of Nursing (DON) said Nurse #1 should have changed her gloves and performed hand hygiene after removing the dirty dressing and before applying the new, clean dressing. 3.) Review of the facility policy titled 'Handwashing/Hand Hygiene', revised October 2023, indicated: Hand hygiene is indicated: after contact with blood, body fluids, or contaminated surfaces, after touching a resident; immediately after glove removal. The use of gloves does not replace hand washing/hand hygiene. On 12/15/25 at 9:33 A.M., the surveyor observed the Wound Nurse perform a wound dressing change to an unstageable pressure ulcer on a coccyx. The Wound Nurse unfastened the resident's incontinence brief, which contained loose feces, and removed a dressing and an approximately six-inch-long thin strip of a white fabric-like material from inside the coccyx wound, both of which were soiled with brown drainage, contaminating her gloves. The Wound Nurse then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. The Wound Nurse then cleansed the wound with wound cleanser and gauze. The Wound Nurse then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. The Wound Nurse then rearranged dressing supplies, touched the bed remote control to adjust height of bed, and prepared dressing supplies. The Wound Nurse then again removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. The Wound Nurse then cleansed the wound again and said this was because the feces present in the incontinence brief may have contaminated the wound. The Wound Nurse then removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. The Wound Nurse applied a clean dressing to the wound. The Wound Nurse then again removed gloves and did not perform hand hygiene prior to applying a new pair of gloves. The Wound Nurse then refastened the incontinence brief, which contained loose feces, on the resident. The Wound Nurse then performed hand hygiene and left the room. The Wound Nurse did not perform any hand hygiene after removing gloves and before applying new ones during five glove changes. During a follow-up interview on 12/15/25 at 10:37 A.M., the Wound Nurse said she should have performed hand hygiene in between glove changes but did not. During an interview on 12/15/25 at 12:31 P.M., the Director of Nursing (DON) said the Wound Nurse should have performed hand hygiene before applying and after removing gloves during wound care. 4.) During an observation on 12/16/25 at 8:07 A.M., the surveyor observed Nurse #15 at her medication cart with pills popped onto the laptop keyboard in front of her. During an interview on 12/16/25 at 8:08 A.M., the Nurse #15 said that she should be popping the pills into a cup, not onto her keyboard. During the interview Nurse #15 was observed to use her bare hands to split the pills and empty the contents of the pills into a small plastic cup. During an interview on 12/16/2025 at 8:13 A.M., the Director of Nursing said that it is the expectation that staff pop their pills into a cup, not on top of their computer keyboard due to the risk of contamination and said that it is an infection control issue as the keyboard is not sterile. Further she said that the nurse should be wearing gloves when empty the contents of a pill, not doing this with her bare hands.

Based on observations, record reviews and interviews, the facility failed to ensure one Resident (#36) out of a total sample of 30 residents did not self-administer medication without an assessment or physician's order.Findings include: Review of the facility policy titled Medication Administration/Self Administration policy, revised 7/2012, indicated the following:-Upon admission or upon request, the residents will be advised of their right to self-administer medications. The residents will review the implementation of self-medication and the self-administration of medication form #ADM-G26. Form is to be completed and added to the resident's record. Facility's case management team will determine upon completion of the nursing assessment form. Evaluation of Resident's Ability to Safely Self-Administer Medications. (Form #CN-070) whether the resident is safe in carrying out the self-administration practice.The decision of the case management team will be discussed with the resident and recorded on the self-administration of medications form and placed in the residence medical record. The physician's order will reflect the self-administration approval and practice. If the resident is able to self-medicate, the medications will be placed in a locked compartment at his/her bedside. The residents' care plan will be updated to reflect his/her ability to self-medicate. Resident #36 was admitted to the facility in October 2025 with diagnoses including chronic obstructive pulmonary disease and acute respiratory failure. Review of the Minimum Data Set (MDS) assessment, dated 10/28/25, indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam indicating intact cognition. On 12/9/25 at 8:19 A.M., the surveyor observed an Albuterol sulfate inhaler (used for treating respiratory diseases) on Resident #36's over the bed table. Resident #36 said the nurses knew he/she had the inhaler and that he/she would not give it to the nurses to keep in the medication cart as it is called a rescue inhaler for a reason. On 12/10/25 at 1:38 P.M., the surveyor observed the albuterol sulfate inhaler on Resident #36's over the bed table. On 12/11/25 at 2:08 P.M., the surveyor and Nurse #9 observed the albuterol sulfate inhaler on the over the bed table. Resident #36 told the nurse he/she was going to continue to keep it. Review of the medical record failed to indicate that Resident #36 had been assessed for the ability to self-administer medications. Further review of the medical record failed to indicate a physician order indicating the Resident could self-administer medication and store by bedside. Review of Resident #36's active care plan failed to indicate a plan of care for the self-administration of medications. During an interview on 12/11/25 at 2:10 P.M., Nurse #9 said residents who would like to keep medication by bedside require an assessment. She said she wasn't sure if Resident #36 had an assessment for self-medication administration. During an interview on 12/12/25 at 10:06 A.M., the Director of Nursing said residents who self-administered medications required an assessment and a physician order. During an interview on 12/12/25 at 10:23 A.M., Unit Manager #1 said if a resident wanted to keep medication by bedside for self-administration that an assessment would be done with the observation of return demonstration, a care plan would be initiated, and a physician order would be obtained. She further said she was aware Resident #36 had the albuterol inhaler by bedside and that the Resident gets very upset if anyone tries to take it away from him/her.

Based on record review and interview the facility failed to ensure for one Resident (#3) out of a total sample of 30 residents, that the facility's abuse policy was implemented following an allegation of abuse. Findings include:The facility policy titled Abuse Prevention Policies and Procedures, dated 11/2024, indicates the following:Upon the observation/allegation/formed suspicion of resident abuse, the supervising staff ensure the safety of all residents and then initiates the investigation through recording known information on the Quality Assessment and Assurance Incident Report, and if an injury of unknown origin is identified, the Injury of Unknown Origin Investigation form.During the course of any investigation into allegations of resident abuse, it is the policy of the facility to protect residents from harm during investigations. Review of the policy titled Reporting Resident Neglect/Abuse, dated 2/2025, indicated:1.The Executive Director/Director of Nursing must investigate any suspicion of resident neglect/abuse.2.In the event that any staff member believes that a resident of the facility has been abused, mistreated or neglected, the individual is required to notify their direct supervisor who will notify the Executive Director/Director of Nursing.A. The Executive Director/Director of Nursing must investigate any allegation to determine the validity of the complaint. During this process, the accused individual may be suspended without pay until a formal determination is made. Review of the Quality Assurance and Performance Improvement, Procedural and Investigational Guide: Allegations of Resident/Participant Abuse, Neglect and Mistreatment, dated 2/2025, indicated the following:3. Conduct an interview of the accuser/alleged victim as soon as possible following the allegation. Consider utilizing a clinical staff member, nurse or social worker, with whom the resident has formed a trusting relationship. Document the interview in detail, using direct resident quotes if possible, on form CAD-066. More than one investigation of the resident may be required as the investigation develops.4. Identify staff who require interviews, and from whom statements should be obtained. More than one interview of staff members may be required as the investigation develops. Are all statements signed and dated, and on the Employee Statement Form, CAS-066.7. Create a folder which contains investigation documents:the schedule for the affected time periodcopies of the Nurse Aide Registry and proof of CORI check completed on hire for the accuseda current Nurse Aide Registry check for the accuseda printout of on-line learning system completed courses for the accuse, reviewed to ensure that the accused is current in Abuse Prevention and Reporting Procedures and Resident Rightsall written, signed and dated statements from staff, other witnesses, and/or from resident (s)staff interviews documented by managementFlash Drive (or reference to location of electronic file) of video related to the allegation, if available, and if used in determination of the investigation outcome.copies of emails, text messages, and/or other documents which contain communications and/or information relevant to the accusation, if available and if used in determining investigation outcomemedical record documentation including EHR reports and other documentation used or considered when determining the investigation outcomethe printed report submitted via the online reporting systemcopies of any disciplinary actions directly resulting from the eventcopies of re-in-servicing completed as a result of the event8. Verify that all documents within the folder are signed and dated by the author, and/or are dated for the date in which they were received by management. Resident #3 was admitted to the facility in July 2025 and has diagnoses that includes depression and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/19/25 indicated that on the Brief Interview for Mental Status exam Resident #3 scored an 11 out of a possible 15, indicating moderately impaired cognition. The MDS indicated Resident #3 had no behaviors. During an interview on 12/9/25 at 10:28 A.M. Resident #3 said he/she got slapped by the aide that was taking care of him/her, that the facility staff were aware because he/she had told everybody and that the police were called. During an interview on 12/9/25 at 12:33 P.M. Resident #3's spouse said that a few weeks ago Resident #3 had told the spouse that the staff member feeding him/her had slapped him/her but that Resident #3 could not remember who slapped him/her. Resident #3's spouse said that he/she had told the nurse and social worker right away who then called the police. Review of the Activities of Daily Living care plan, initiated 7/1/25, indicated that for eating Resident #3 requires supervision with cueing to increase PO (by mouth) intakes. Review of the Advanced Directive care plan, initiated 8/1/25, indicates Resident #3 was his/her own responsible party. Further review of the care plan failed to indicate Resident #3 had impaired cognition. As well, the care plan failed to indicate Resident #3 had a behavior care plan in place until 11/19/25, the day after she made an allegation of abuse. At that time the record indicated a care plan for accusatory behavior toward staff was initiated. Review of the clinical record failed to indicate an allegation of abuse was made by Resident #3 on 11/18/25, or that the facility Social Worker was seeing Resident #3 or providing support following the allegation. Review of the facility's investigation regarding an allegation of abuse by Resident #3 included the following statements:A statement from Resident #3's Nurse #15 on 11/18/25. On 11/18/25 Nurse #15 wrote: After breakfast pt (patient) began crying stating CNA (Certified Nursing Assistant) staff member force fed him/her. Pt calmed down after asking him/her what happened. I let him/her know that CNA would not be allowed back into room to feed him/her (sic). During lunch time when husband came in Pt disclosed that CNA from morning feeding had 'slapped me across the face'. I did not hear or see any type of indication in regard to assault, nor was I present during meal time as I was on break during lunch feeding time. I reported the incident immediately to the DON. Pt did not present with any injuries.A statement dated 11/19/25, typed by the DON from the CNA (#17) assigned to Resident #3 on 11/18/25. The statement reads CNA #17 was assigned to care for Resident #3 on the day of the accusation. She fed him/her breakfast and reports that there were no issues during that meal. She stated she went to provide full care after breakfast and removed a small pillow (commemorative of a family member) from the bed so she could wash and dress Resident #3. When CNA #17 moved the pillow Resident #3 began to cry and become very upset. CNA nurse #9 had come into the room to care for the roommate. CNA #9 reported to the nurse that Resident #3 was upset. CNA #17 said that after this crying incident, she was reassigned and did not care for Resident #3 for the rest of the day. She did not provide him/her lunch, not did she have anything else to do with Resident #3 for the rest of the shift. The statement is unsigned.A statement dated 11/18/25, typed by the DON from CNA #9. The statement reads On this date, I conducted a phone interview with CNA #9 regarding the allegations made by Resident #3. Per CNA #9, CNA #17 was assigned to Resident #3 that day and as CAN #9 entered the room to care for the roommate, she noted that Resident #3 was being washed and care for by CNA #17 but that Resident #3 started crying and was upset. CNA #9 was not sure who fed Resident #3 breakfast and stated she herself did not feed her lunch. CNA #9 left early and was unaware of the accusation. The statement was unsigned. Review of the clinical record indicated that CNA #17 documented having provided care to Resident #3 throughout the entire shift on 11/18/25. CNA #17 documented that Resident #3 was dependent for eating that day. Review of CNA #17's timecard indicates that on 11/18/25 she worked from 7:01 A.M., to 3:43 P.M. During an interview on 12/17/25 at 8:04 A.M., the facility Social Worker (SW) said that on 11/18/25 she was informed that Resident #3 reported that he/she was slapped by his/her CNA. The SW said that she went up to speak to Resident #3 and his/her spouse. The SW said that Resident #3 reported someone had slapped him/her during breakfast but couldn't say who it was or give her details and that Resident #3 was very vague and very confused which is his/her baseline. The SW said that she reported what was told to her by Resident #3 to the Director of Nursing (DON) and then was out of the loop for the remainder of the investigation. The SW said that whenever a resident alleges abuse she sees the resident in the days following and documents it in the progress notes. SW cannot say why there were no notes in Resident #3's record but said that she followed up with him/her following the allegation and that she was recently referred to see a psych therapist due to apathy and potential depression. According to the SW Resident #3 had never made an allegation of abuse prior to the report on 11/18/25 and had not made one since.During an interview on 12/17/25 at 8:27 A.M., the DON said that the facility process when there was an allegation of abuse was:The ensure that the resident is safe.The police are notifiedIf there is an accused staff person, they obtain a statement from them, and then immediately suspend the staff person and send them home pending investigation.The SW interviews the resident, staff that are working and other residents She files an initial report within 2 hours of receiving the allegation to DPH The DON investigation she provided was reviewed. The DON cannot say:Why the CNA in question continued to work and provide care to Resident #3.Why other resident's were not interviewed. Why the Nurse did not immediately report the allegation to her on the morning of 11/18/25She said that she then was busy and did not submit her final report (front page summary that she provided) until 12/9/25 due to being busy and just catching up. The DON said that this must be due to her misunderstanding of the facts that day. She said that she had no additional statements or information related to the investigation than what had been provided to the surveyors. During a follow-up interview on 12/17/25 at 10:00 A.M., the DON said that in hindsight the facility's abuse policy and procedure was not followed when the CNA continued to work and provide care pending an abuse allegation / investigation regarding her. During an interview on 12/17/25 at 10:07 A.M., Nurse #15 said that on 11/18/25 she was Resident #3's nurse and that a little after breakfast, around 10:00 A.M., it was reported to her that Resident #3 was crying hysterically and had reported to other CNAs and the other nurse that his/her CNA #17 had force fed him/her breakfast that morning. Nurse #15 said that she went to see Resident #3 and Resident #3 said that his/her CNA that day was being mean to him/her and had force fed him/her breakfast. Nurse #15 said that the Resident could not tell her the CNAs name, so she looked at the assignment and spoke to the assigned CNA #17. Nurse #15 said that the CNA #17 said that she didn't feed Resident #3 that day, so she said to that CNA, and all the other CNAs working that day, that only CNA #17 was to feed or care for Resident #3 for the remainder of the shift. According to Nurse #15 around lunchtime Resident #3's husband came in and Resident #3 complained again, and the DON was notified of the allegation shortly thereafter. Nurse #15 could not say why she did not notify the DON when the allegation was initially made that morning. Nurse #15 said that Resident #3 was pleasant and alert with some occasional confusion but is able to voice his/her concerns and needs to staff and has made no further allegations since that time. During an interview on 12/17/25 at 10:55 A.M., the Nursing Home Administrator (NHA) explained the facility process when an allegation of abuse was made. The NHA said once the allegation was received, they have the SW interview the resident, they get two to three interviews from any staff that were there, document the information, and follow the facility's abuse policy for reporting and investigating. The NHA said that it was her expectation that the facility's policy and procedure for abuse be implemented immediately.

Based on record review and interview that facility failed to develop a discharge summary that included a recapitulation of a stay for one discharged Resident (#130) out of 3 discharge records reviewed. Findings include: Resident #130 was admitted to the facility in October 2025 and has diagnoses that includes Alzheimer's disease and Chronic Obstructive Pulmonary Disease. Review of the clinical record:- Failed to indicate a discharge note or discharge disposition.- Failed to indicate a recapitulation of Resident #130's stay was documented.- Failed to indicate a Physician's order for discharge.- Failed to indicate a discharge note from the Physician or Nurse Practitioner. During an interview on 12/11/25 at 11:07 A.M., and 2:15 P.M., the Director of Nursing (DON) said that upon discharge the facility should have developed a discharge packet for Resident #130 that included a medication list and a Page one & two (a recapitulation of the Resident's stay) as well as written a discharge note by nursing. The DON said that she reviewed Resident #130's record and in this case that did not happen.

Based on observations, interviews and record review, the facility failed maintain professional standards in the managing and caring for urinary catheter devices for one Resident (#66) out of a total sample of 30 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not placed directly on the floor or on a used trash can.Review of the facility policy titled 'Catheter Care, Urinary', revised August 2022, indicated:-Use aseptic technique when handling or manipulating the drainage system.-Be sure the catheter tubing and drainage bag are kept off the floor. Resident #66 was admitted to the facility in April 2024 with diagnoses including obstructive and reflux uropathy. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/19/25, indicated Resident #66 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. This MDS also indicated Resident #66 had an indwelling urinary catheter. Review of Resident #66's physician's order, initiated 7/13/24, indicated:-Suprapubic catheter care, every shift. Review of Resident #66's plan of care related to indwelling urinary catheter, revised 9/3/25, indicated:-Relocate urine bag to hanging in proper locations and off the floor when Resident #66 puts it down on the floor. On 12/9/25 at 12:19 P.M., the surveyor observed Resident #66 sitting in a wheelchair with his/her urinary catheter drainage bag and tubing directly on the floor in front of him/her. This observation by the surveyor was made from the hallway. There were multiple staff members walking past his/her room delivering lunch trays. On 12/9/25 at 2:07 P.M., the surveyor observed Resident #66 sitting in a wheelchair with his/her urinary catheter drainage bag and tubing directly on the floor in front of him/her. This observation by the surveyor was made from the hallway. There were multiple staff members walking past his/her room. On 12/10/25 at 6:59 A.M., Resident #66 was observed in his/her room with the urinary catheter drainage bag hanging from a trash can that was filled with trash. Resident #66 said staff put the catheter on the trash can and sometimes they put it on the floor if urine isn't draining adequately. Resident #66 said he is concerned about how staff takes care of his/her urinary catheter system because it had blood in it yesterday and thinks he/she has another urinary tract infection. On 12/10/25 at 7:01 A.M., Certified Nurse Assistant (CNA) #11 said she put the urinary catheter drainage bag on the trash can because the urine wasn't draining. CNA #11 was observed handling the urinary catheter bag with bare hands. CNA #11 touched the spout, where urine is drained from, and moved the urinary catheter drainage bag off the trash can and onto the bed frame. CNA #11 also demonstrated how the urinary catheter bag should not be on the floor by placing the urinary catheter bag directly on the floor. During an interview on 12/10/25 at 7:16 A.M., Nurse #10 said the urinary catheter drainage bag or tubing should never be stored on the floor or hanging from a trash can because of risk of infection or injury from it pulling. During an interview on 12/10/25 at 1:08 P.M., the Director of Nursing (DON) said the urinary catheter drainage bag should not have been hanging or touching a trash can. The DON said its care planned that Resident #66 sometimes puts his/her catheter drainage bag on the floor, but that staff should have placed a barrier under it or moved it off the floor and it shouldn't have been on the floor without intervention for over an hour and a half.

Based on observation, record review and interview for three Residents (#37, #90 and #87) of 26 sampled residents, the facility failed to ensure professional standards of practice were implemented to ensure acceptable parameters of nutritional status. Specifically: 1. for Resident #37, the facility failed to ensure a significant weight loss was verified and assessed resulting in a risk of malnutrition. 2. for Resident #90, the facility failed to implement his/her nutritional care plan resulting in a significant weight loss. 3. for Resident #87, the facility failed to monitor weights resulting in inability to determine if a significant weight loss/gain occurred. Findings include: Review of the facility policy, titled Weight Assessment and Intervention, revised September 2008, indicated the following: * The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. * The Dietician will respond within 24 hours of receipt of written notification. * The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no concerns are noted at this point, weights will be measured monthly thereafter. *Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record. * Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. * The Dietician will respond within 24 hours of receipt of written notification. * The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. * The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant, greater than 5% is severe. 3 months - 7.5% weight loss is significant, greater than 7.5% is severe. 6 months - 10% weight loss is significant, greater than 10% is severe. 1. For Resident #37 the facility failed to ensure a significant weight loss was verified through a re-weigh. Review of the facility's Resident Nutritional Policy and Procedure, dated as revised on 09/2023, indicated the following: Purpose: to promote optimal nutrition and provide a mechanism to identify significant weight changes and implement corrective action as well as providing nutritional interventions for residents with pressure ulcers. Scope: to be followed by nursing, the Nutritional Coordinator, the Food Service Supervisor, and Dietician. Further, the policy indicated: each resident has to be weighed upon admission and, thereafter, a minimum of once a month, or more frequently as medically necessary or as per physician order, by The Nutritional Coordinator (or other individual as designated by nursing) *. If a significant weight loss occurs, defined as five percent (5%) in one month, seven and a half (7.5%) in three months, or ten percent (10%) in six months, the Nutritional Coordinator (or designee) is to notify the Director of Nursing. A list of residents with significant weight loss will also be provided to the unit manager, Minimum Data Set coordinator, and Dietician. -The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. Verbal notification must be confirmed in writing. The Dietician will respond within 24 hours of receipt of written notification. 1. Resident #37 was admitted to the facility in September of 2015 and has diagnoses that include dementia, adult failure to thrive and dysphagia (difficulty in swallowing.) Review of the Minimum Data Set assessment with an Assessment Reference Date of 8/4/23 indicated Resident #37 was assessed by staff as having severely impaired cognitive skills for daily decision making and is dependent on staff for eating. Further, the MDS indicated resident signs and symptoms of possible swallowing disorder indicated: C. coughing or choking during meals or when swallowing medications and was 59 inches in height and weighed 131 pounds. On 10/11/23 at 3:29 P.M., Resident #37 was observed to be thin and frail, and had food staining under his/her mouth. He/she was sitting in a recliner chair in the dining/sitting area. Review of Resident #37's physician's orders indicated the following: -9/23/2023 Diet, House Breakfast, Lunch, Supper puree honey thick, add extra gravy and sauce, super cereal at breakfast, super mashed potatoes at lunch and dinner. -Pt (patient) to use nosey cup all meals to increase coord. And PO (by mouth) intake. -6/30/2021, Aspiration precautions at all times. Review of Resident #37's care plan indicated the following: -Resident at risk for weight loss as r/t (related to) dementia and dysphagia dated 11/8/17, with the goal Resident will be free from significant weight change, dated 11/19/17. Review of the care plan interventions included: -Provide diet as ordered, dated 11/08/17 -Aspiration precautions, 6/30/21 -Provide caloric dense foods such as fortified foods, 10/4/21 -Medicate as ordered, 11/8/17. -Monitor weights, 11/8/17 -Labs as ordered, 11/8/17 -Resident must be fed at all meals, 11/8/17 Speech eval as ordered, 11/8/17. -Dieticians consult prn (as needed), 11/8/17. Review of Resident #37's recorded weight in the medical record indicated the following: -5/2/23 125.6 pounds -8/2/23 130.8 pounds -8/8/23 130.8 pounds -8/22/23 119. 4 pounds (which is an 8.72 percent weight loss, since the 8/8/23 recorded weight and meets the definition of a significant weight loss). -9/15/23 127 pounds. The medical record failed to indicate a re-weigh was recorded after the 8/22/23 significant weight loss. Review of Resident #37's medical record indicated the following: -No dietician notes or assessments in the hard/paper chart. -An assessment by the dietician in the electronic medical record, dated 2/17/23. -No further assessments or progress notes for Resident #37's nutritional status including acknowledgement of the significant weight loss documented on 8/22/23. During an interview on 10/12/23 at 12:17 P.M., Unit Manager #1 said residents are weighed typically monthly and a variation of weight would require notifying the MD (Medical doctor) or Nurse Practitioner and family. When asked if the dietician would be notified UM #1 said the facility has been without a dietician since May 2023. Unit Manager #1 said typically if there is a weight loss a supplement is implemented. UM #1 reviewed Resident #37's recorded weights and said there should have been a re-weigh the day after the 8/22/23 weight to validate if there was a weight loss. UM #1 said she was not made aware of the recorded weight of 119.4 which is significant. UM #1 said speech saw Resident #37 around that time because she was coughing during meals and staff would need to stop feeding him/her, so he/she was not always getting a full feeding. 15016 2. For Resident #90, the facility failed to implement his/her nutritional care plan resulting in a significant weight loss. Review of the Minimum Data Set (MDS), dated [DATE], indicates Resident #90 had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating he/she had moderate cognitive impairment. It indicated Resident # 90 required supervision with eating. Resident #90 was admitted to the facility in May 2022 with diagnoses including a stroke with right sided hemiparesis (weakness) and dysphagia (difficulty swallowing). Review of physician orders indicated orders for a ground diet with pureed vegetables and Two-Cal High Nitrogen supplement 120 milliliters (ml) ordered twice a day. Review of physician orders failed to indicate an order for monthly weights. Review of Resident #90's care plan, dated 2/6/2023, indicated a goal that the Resident's weight will remain stable without significant change. Resident # 90's care plan indicated an intervention to monitor weights monthly. Resident # 90's care plan indicated adaptive feeding equipment and supplements are to be provided as ordered. Review of Resident record indicated Resident #90 was recently readmitted to the facility after a hospital admission for aspiration pneumonia 9/18/23 to 9/22/23. On readmission 9/22/23, Resident #90's readmission assessment. Dated 9/22/23, indicated a weight of 175 pounds. Review of Nurse Practitioner (NP)#2 progress note, dated 9/26/23, indicated a severe weight loss with a diagnosis of protein-calorie malnutrition. This note indicated Resident #90's most recent weight being 173 pounds. During an interview on 10/13/23 at 11:38 A.M., Unit Manager #2 said Resident #90 is weighed monthly. Review of Resident #90's weight variance report, dated 10/13/23, indicated a weight of 173.4 pounds on 9/13/23 and a weight of 123 pounds on 10/6/23, which indicated a 29.07% weight loss in 30 days. During an interview on 10/13/23 at 11:38 A.M., Unit Manager (UM) #2 said Resident #90 was not immediately reweighed following the 10/6/23 weight of 123 pounds. She said the unit manager normally runs a weight variance report after all the monthly weights on the floor are obtained. This report is then reviewed at the risk meeting that is scheduled every Wednesday. UM #2 said this weight was probably inaccurate and Resident #90 would have been reweighed after the risk meeting. UM #2 said she input Resident #90's weight on 10/6/23. She said the risk meeting did not happen on Wednesday, 10/11/23, because the day became too busy, and the Resident was never reweighed. During an interview on 10/13/23 at 12:22 P.M., the Director of Nursing (DON) said Resident #90's documented weight was probably incorrect and a reweigh should be obtained. During an interview on 10/13/23 at 1:10 P.M., the DON said a reweigh was done and Resident #90 weighed 156.4 pounds. During a record review of Resident #90's weight history, the weight loss difference between the 9/13/23 weight of 173.4 pounds and the 10/13/23 reweigh of 156.4 pounds indicates a weight loss of 9.8% which meets the threshold for significant weight loss. During an interview on 10/16/23 at 10:40 A.M., UM #2 said she did not notify the physician/NP of the 10/6/23 weight of 123 pounds or of the 10/13/23 weight of 156.4 pounds. During an interview on 10/17/23 at 9:43 A.M., the DON said she would have expected Resident #90's weight loss to be reported to the provider. During an interview on 10/16/23 at 8:55 A.M., UM #2 said Resident #90 never refuses to be weighed and he/she is weighed using the mechanical lift scale during transfers. During an interview on 10/16/23 at 1:39 P.M., UM #2 said she found no evidence of anyone notifying the physician/NP and she called today to report Resident #90 ' s significant weight loss. UM #2 said NP #2 ordered to check Resident #90 ' s weight weekly for the next four weeks. Review of NP Progress notes, dated 9/26/23 and 10/10/23, indicated a severe weight loss of 19.2 pounds with a diagnosis of malnutrition. It indicated that Resident #90 is receiving nutritional interventions including TwoCal High Nitrogen supplementation at 120 ml twice daily and Ensure Plus supplements 237 ml twice daily. Review of Physician Orders fail to indicate an order for Ensure 237 ml supplement since readmission 9/22/23 noted in Physician Progress note dated 9/26/23 and 10/10/23. During an interview on 10/16/23 at 2:19 P.M., the Nurse Practitioner (NP) #2 said that if a resident had experienced a significant weight change, she would expect to be notified within 48 hours. The NP #2 said that if the weight taken was significantly different from the previous weight that a re-weight would be obtained within 24 hours to confirm the weight change. NP #2 said she was not notified of Resident #90's weight loss, was unaware of the Resident's current weight, and would have expected to have been notified when the significant weight loss was confirmed on 10/13/23. NP #2 said that in her documentation from 9/26/23 and 10/10/23 she was referring to a previous weight loss that had occurred earlier in the year as her documentation system had pulled information from prior encounters. NP #2 said she was unaware, and has not addressed, the most recent weight loss identified on 10/6/23, and confirmed on 10/13/23. 45763 3. For Resident #87, a Resident who relies on enteral nutrition support, the facility failed to monitor the weight as outlined in the facility policy. Resident #87 was admitted to the facility in October, 2023 with diagnoses including Parkinson's Disease, and moderate protein calorie malnutrition. Review of Resident #87's physician orders indicated the Resident does not eat by mouth, and relies completely on enteral nutrition support to meet nutrition needs. Further review of the physician's orders failed to indicate an order to weigh the Resident. Review of Resident #87's Feeding Tube care plan indicated the following: -monitor weights as ordered Review of Resident #87's weight variance report indicated the Resident had not been weighed on admission, or thereafter throughout his/her two-week admission. During an interview on 10/17/23 at 10:10 A.M., Nurse #8 said there should be an admitting order for weights as this is a standard admission order. Nurse #8 said there is no reason a weight could not have been taken as a Hoyer lift is utilized for Resident #87. Nurse #8 said that because there is no unit manager or supervisor standard admission orders are sometimes missed. During an interview on 10/17/23 at 9:36 A.M., the Director of Nursing (DON) said that Residents should have their weight measured on the day of admission, and then weekly thereafter. The DON said ideally a weight order is entered so that staff know to take the Resident's weight. The DON said nursing should take a new weight on admission as they cannot rely on the weight documented in the hospital discharge paperwork. The DON said that sometimes weights are recorded on paper on the unit, but that after looking she could not find evidence that Resident #87's weight was ever measured or recorded. The DON said that if the Resident had refused having his/her weight measured that this would be documented. Review of Resident #87's progress notes failed to indicate the Resident refused to have his/her weight measured. 48990

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose comprehensive plan of care related to the prevention of fall related injuries, included the use floor mats in place on both sides of his/her bed for safety while in bed, the facility failed ensure staff consistently implemented the intervention, when on 9/27/20 Resident #1 fell out of bed, and the floor mats were not in place. Resident #1 was transferred to the Hospital Emergency Department due to a change in condition and was diagnosed fractures of the right hip and right upper arm. Findings include: The Policy, titled Resident Falls Policy and Procedure, dated 8/2019, indicated: -Falls referred to unintentionally coming to rest on the ground, floor, or other lower level, and unless there was evidence suggesting otherwise, and when a resident is found on the floor, a fall is considered to have occurred. -Staff would implement interventions to promote resident safety based on the resident's risk factors. -Interventions would be added to the resident's care plan. Resident #1 was admitted to the Facility in November 2001, [DIAGNOSES REDACTED]. The Quarterly Fall Risk Assessment, dated 8/5/20, indicated Resident #1 was intermittently confused, was chair bound, and required assistance with toileting needs. The Falls Care Plan, dated as initiated 12/4/18 and revised 2/21/20, indicated Resident #1 was at risk for falls and interventions for safety included floor mats to both sides of the bed, and bed locked in lowest position, while in bed. The Treatment Administration Record (TAR), dated 9/1/20 through 9/27/20, indicated floor mats to both sides of Resident #1's bed, while he/she was in bed. The Post Fall Investigation Report, dated 9/28/20, indicated that on 9/27/20, at approximately 6:00 A.M., Resident #1 had an unwitnessed fall, staff did not report the fall, and Resident #1's injuries were discovered at the end of the day. The section of the Report for review of whether the plan of care was followed was left blank. The Hospital History and Physical Report, dated 9/28/20, indicated Resident #1 was diagnosed with [REDACTED]. The Report indicated Resident #1 required surgery to the right [MEDICAL CONDITION]. During interview on 10/15/20 at 12:14 P.M., Nurse #1 said that he worked the 11:00 P.M., to 7:00 A.M., shift on 9/27/20. Nurse #1 said that at 6:00 A.M., on 9/27/20, he found Resident #1 seated on the floor next to his/her bed, and said Resident #1 did not have floor mats next to his/her bed. Although Nurse #1 had acknowledged that he had in fact found Resident #1 on the floor on 9/27/20, and said the floor mats were not in place at this time, there was no documentation to support that at the time of the fall, Resident #1's bed was locked and in the lowest position as well for safety. During interview on 10/19/20 at 11:16 A.M., The Director of Nurses (DON) said that while she was investigating the cause of Resident #1's injuries, since there had initially been no fall reported by staff, her main focus was whether or not a fall had occurred. The DON said Resident #1 should have had floor mats beside his/her bed, as per the Care Plan, and said Resident #1's injuries may have been less severe if the floor mats were in place.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure staff provided care and services that met professional standards of practice, when on 9/27/20 at approximately 6:00 A. M, Resident #1 experienced an unwitnessed fall, although Nurse #1 found Resident #1 on the floor, he did not report or document the fall, there is no documentation to support Nurse #1 assessed Resident #1 for the potential of any injuries, and Nurse #1 did not report the incident to the oncoming day shift nursing staff. Nurse #1 initially denied that Resident #1 fell , however, Nurse #1 later changed his story and acknowledged that Resident #1 did fall in the morning on 9/27/20, and that Resident #1 had been picked up off the floor and put back to bed by staff. Resident #1 was noted by day shift staff to be refusing care and refused to be transferred back to bed by staff, which was not his/her normal behavior. The evening shift staff observed that when staff were finally able to transfer Resident #1 to bed, Resident #1 complained of pain, and his/her right leg and right arm were swollen. Resident #1 was transferred to the Hospital Emergency Department for evaluation and diagnosed with [REDACTED]. Resident #1 required surgical intervention to repair his/her [MEDICAL CONDITION]. Findings include: The Policy, titled Resident Incident and Reporting Procedure, dated 3/2017, indicated all licensed nurses were responsible to document resident incidents, and the supervisor would be notified of all incidents. The Policy indicated follow up for incidents would include resident monitoring and observation. The Policy, titled Falls - Clinical Protocol, dated 3/2018, indicated the staff, with the physician's guidance, would follow up on any fall with associated injury until the resident was deemed stable and any delayed complication such as late fracture were ruled out or resolved. The Policy, titled Resident Falls Policy and Procedure, dated 8/2019, indicated: -Falls referred to unintentionally coming to rest on the ground, floor, or other lower level, and unless there was evidence suggesting otherwise, and when a resident is found on the floor, a fall is considered to have occurred. -The purpose of the Policy was to promote resident safety and an environment free from falls to the extent possible. -The Fall Assessment form would be completed after each fall. -If the resident was assessed to have potential fracture, he/she would not be moved, the physician would be notified, and transportation to the Hospital would be arranged. -If the fall was not witnessed, neurological checks would be initiated and continued for 48 hours, and documented on the Neuro Checks Flow Sheet. -Any resident fall would be reported to the nursing supervisor on duty. -The Nurse would document the fall and initial assessment in the nurses' notes, complete the Quality Assessment and Assurance Incident Report. Resident #1 was admitted to the Facility in November 2001, [DIAGNOSES REDACTED]. The Quarterly Brief Interview for Mental Status (BIMS) assessment, dated 8/7/20, indicated Resident #1 was cognitively impaired. The Falls Care Plan, dated 12/4/18 and revised 2/21/20, indicated Resident #1 was at risk for falls and interventions included that when he/she was in bed, floor mats to be in place on both sides of the bed. The Nurse Progress Note, dated 9/27/20, indicated Resident #1 was up in his/her wheelchair at the beginning of the 7:00 A.M., to 3:00 P.M., shift, and Resident #1 refused care throughout the day. The Note indicated that after the evening meal, staff helped Resident #1 transfer from his/her wheelchair to his/her bed, and Resident #1 was having difficulty bearing weight on his/her right leg. The Note indicated Resident #1 was observed guarding his/her right leg, could not lift his/her right leg, a small cut was observed on his/her lower right leg, and Resident #1's right upper arm was swollen, red, bruised, and painful to touch. The Progress Note indicated Resident #1 was transferred to the Hospital Emergency Department at 9:45 P.M. for evaluation. The Hospital History and Physical Report, dated 9/28/20, indicated Resident #1 was diagnosed with [REDACTED]. The Report indicated Resident #1 required surgery to repair his/her right [MEDICAL CONDITION]. During interview on 10/15/20 at 1:36 P.M., Nurse #2 said she worked 7:00 A.M. to 11:00 P.M., on 9/27/20. Nurse #2 said when she arrived at 7:00 A.M., Resident #1 was seated in his/her wheelchair on the unit. Nurse #2 said she received change of shift report from Nurse #1, who had worked the night shift on that unit. Nurse #2 said Nurse #1 did not report any issues or incidents regarding Resident #1 as having occurred during his (Nurse #1's) shift. Nurse #2 said she had noted that Resident #1 refused care and was tired throughout the day. Nurse #2 said Resident #1 had dementia, and was unable to verbalize pain and would not be able to report to staff that he/she had a fall. Nurse #2 said that after the evening meal, staff assisted Resident #1 to bed, noticed he/she could not bear weight on his/her right leg, that his/her right leg was swollen, and he/she had bruising on his/her right upper arm. Nurse #2 said Resident #1 was transferred to the Hospital Emergency Department at 9:45 P.M., and was diagnosed with [REDACTED]. During interview on 10/15/20 at 12:14 P.M., Nurse #1 said that he worked the 11:00 P.M., to 7:00 A.M., shift on 9/27/20. Nurse #1 said that at 6:00 A.M., on 9/27/20, he found Resident #1 seated on the floor next to his/her bed, and said Resident #1 did not have floor mats next to his/her bed. Nurse #1 said he moved Resident #1's arms and legs and thought he/she did not have any injuries from the fall. Nurse #1 and said he did not assess Resident #1's vital or neurological signs, did not notify the Nurse Supervisor, did not notify the Physician, and did not document the fall. Nurse #1 said he did not document his assessment of Resident #1 anywhere. Nurse #1 said Certified Nurse Aide (CNA) #1 and CNA #2 lifted Resident #1 off the floor and placed him/her in the wheelchair. Review of Nurse #1's written Witness statement, dated 9/27/20, indicated that during his shift, he did not see anything wrong or out of the ordinary regarding Resident #1. Nurse #1 said that when he was interviewed by the Director of Nurses (DON) on 9/27/20 regarding Resident #1's injuries, said he initially denied that Resident #1 had a fall. Nurse #1 said he later admitted to the DON that Resident #1 did fall on 9/27/20, during his shift. Nurse #1 said he could not explain why he did not report Resident #1's fall, and could not explain why he lied to the Director of Nurses when he was initially questioned regarding the fall. Review of Nurse #1's written Witness Statement, dated 9/29/20, indicated that on 9/27/20 he (Nurse #1) found Resident #1 sitting on the floor beside his/her bed. Review of Nurse #1's written Witness Statement, dated 10/2/20, indicated that on 9/27/20, he (Nurse #1) found Resident #1 sitting on the floor next to his/her bed. The Statement indicated he (Nurse #1) and CNA #2 lifted Resident #1 from the floor to his/her wheelchair, and he (Nurse #1) left Resident #1's room. During interview on 10/16/20 at 1:27 P.M., CNA #1 said that on 9/27/20 at 6:00 A.M., Nurse #1 told her Resident #1 needed assistance because he/she was soiled. CNA #1 said when she got to Resident #1's room, he/she was in bed, and said she was not aware that Resident #1 had a fall. During interview on 10/19/20 at 8:31 A.M., CNA #2 said that on 9/27/20 at 6:00 A.M., Nurse #1 told him Resident #1 needed assistance because he/she was soiled. CNA #2 said when he got to Resident #1's room, he/she was in bed. CNA #2 said there were no floor mats next to hi/s her bed, and said he was not aware that Resident #1 had a fall. Information obtained during interviews with CNA #1 and CNA #2 indicated that both CNA's said Resident #1 they found Resident #1 in bed when Nurse #1 told them Resident #1 needed assistance with care, however this conflicts with Nurse #1's interviews and written witness statements, in which Nurse #1 indicated that after finding Resident #1 on the floor, he alleged that CNA #1 and CNA #2 where the ones who picked Resident #1 up off the floor and place him/her in the wheelchair. During interview on 10/15/20 at 7:40 A.M., the Director of Nurses (DON) said Resident #1 had dementia and was unable to verbalize that he/she had a fall. The DON said that Nurse #1, CNA #1, and CNA #2 had worked the 11:00 P.M., to 7:00 A.M., shift on 9/27/20 on the unit where Resident #1 resided. The DON said that when she was investigating Resident #1's injuries, Nurse #1, CNA #1, and CNA #2 initially denied that Resident #1 had a fall, said Nurse #1 later admitted that Resident #1 had a fall. The DON said Nurse #1 should have reported Resident #1's fall to the Nurse Supervisor and the Physician immediately. The DON said day shift staff should have been made aware of Resident #1's fall in order to monitored for changes in his/her condition.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed as being at increased risk for falls and required the use of floor mats next to both sides of his/her bed while he/she was in bed, the Facility failed to ensure staff implemented safety interventions to prevent fall related injuries and failed to ensure staff reported a fall to ensure necessary monitoring was provided to Resident #1 following a fall. On 9/27/20, at approximately 6:00 A.M., Resident #1 was found on the floor beside his/her bed by Nurse #1. Nurse #1 said there were no floor mats next to Resident #1's bed at that time. Nurse #1 said he did not report the incident to the oncoming day shift staff. Later that day Resident #1 was assessed as having pain in his/her right upper leg and right upper arm, was transferred to the Hospital Emergency Department, and was diagnosed with [REDACTED]. Resident #1 required surgery to repair his/her right [MEDICAL CONDITION]. Findings include: The Policy, titled Resident Incident and Reporting Procedure, dated 3/2017, indicated all licensed nurses were responsible to document resident incidents, and the supervisor would be notified of all incidents. The Policy indicated follow up for incidents would include resident monitoring and observation. The Policy, titled Falls - Clinical Protocol, dated 3/2018, indicated the staff, with the physician's guidance, would follow up on any fall with associated injury until the resident was deemed stable and any delayed complication such as late fracture were ruled out or resolved. The Policy, titled Resident Falls Policy and Procedure, dated 8/2019, indicated: -Falls referred to unintentionally coming to rest on the ground, floor, or other lower level, and unless there was evidence suggesting otherwise, and when a resident is found on the floor, a fall is considered to have occurred. -The purpose of the Policy was to promote resident safety and an environment free from falls to the extent possible. -The Fall Assessment form would be completed after each fall. -If the resident was assessed to have potential fracture, he/she would not be moved, the physician would be notified, and transportation to the Hospital would be arranged. -If the fall was not witnessed, neurological checks would be initiated and continued for 48 hours, and documented on the Neuro Checks Flow Sheet. -Any resident fall would be reported to the nursing supervisor on duty. -The Nurse would document the fall and initial assessment in the nurses' notes, complete the Quality Assessment and Assurance Incident Report. Resident #1 was admitted to the Facility in November 2001, [DIAGNOSES REDACTED]. The Quarterly Fall Risk Assessment, dated 8/5/20, indicated Resident #1 was intermittently confused, was chair bound, required assistance with toileting needs and required staff assistance with transfers. The Falls Care Plan, dated as initiated 12/4/18 and revised 2/21/20, indicated Resident #1 was at risk for falls and interventions for safety included floor mats to both sides of the bed, and bed to be locked in lowest position, while in bed. The Treatment Administration Record (TAR), dated 9/1/20 through 9/27/20, indicated Resident #1's physician's orders [REDACTED]. The Post Fall Investigation Report, dated 9/28/20, indicated that on 9/27/20, at approximately 6:00 A.M., Resident #1 had an unwitnessed fall. The Report indicated nursing staff did not report the fall, and Resident #1's injuries were discovered at the end of the day. The Hospital History and Physical Report, dated 9/28/20, indicated Resident #1 was diagnosed with [REDACTED]. The Report indicated Resident #1 required surgery to repair his/her right [MEDICAL CONDITION]. The Nurse Progress Note, dated 9/27/20, indicated Resident #1 was up in his/her wheelchair at the beginning of the 7:00 A.M., to 3:00 P.M., shift, and Resident #1 refused care throughout the day. The Note indicated that after the evening meal, staff helped Resident #1 transfer from his/her wheelchair to his/her bed, and Resident #1 was having difficulty bearing weight on his/her right leg. The Progress Note indicated Resident #1 was observed guarding his/her right leg, could not lift his/her right leg, a small cut was observed on his/her lower right leg, and Resident #1's right upper arm was swollen, red, bruised, and painful to touch. The Progress Note indicated Resident #1 was transferred to the Hospital emergency room at 9:45 P.M. During interview on 10/15/20 at 1:36 P.M., Nurse #2 said she worked 7:00 A.M. to 11:00 P.M., on 9/27/20. Nurse #2 said when she arrived on the unit at 7:00 A.M., at the start of her shift, Resident #1 was seated in his/her wheelchair. Nurse #2 said Nurse #1 did not report any issues or incidents regarding Resident #1 as having occurred during his (Nurse #1's) shift and said Nurse #1 never said anything about Resident #1 being found on the floor. Nurse #2 said Resident #1 had dementia, and was unable to verbalize pain or report that he/she had a fall. Nurse #2 said she noted that Resident #1 refused care and was tired throughout the day. Nurse #2 said that after the evening meal, staff assisted Resident #1 to bed, noticed he/she could not bear weight on his/her right leg, his/her right leg was swollen, and he/she had bruising on his/her right upper arm. Nurse #2 said Resident #1 was transferred to the Hospital Emergency Department at 9:45 P.M., on 9/27/20, and was diagnosed with [REDACTED]. During interview on 10/15/20 at 12:14 P.M., Nurse #1 said that he worked the 11:00 P.M., to 7:00 A.M., shift on 9/27/20. Nurse #1 said that at 6:00 A.M., on 9/27/20, he found Resident #1 seated on the floor next to his/her bed, and said Resident #1 did not have floor mats next to his/her bed. Nurse #1 said he moved Resident #1's arms and legs and thought he/she did not have any injuries from the fall. Nurse #1 and said he did not assess Resident #1's vital or neurological signs, did not notify the Nurse Supervisor, did not notify the Physician, and did not document the fall. Nurse #1 said he did not document his assessment of Resident #1 anywhere. Nurse #1 said Certified Nurse Aide (CNA) #1 and CNA #2 lifted Resident #1 off the floor and placed him/her in the wheelchair. Nurse #1 said that when he was interviewed by the Director of Nurses (DON) on 9/27/20 regarding Resident #1's injuries, he initially denied that he/she had a fall, and said he later admitted that Resident #1 had fallen on his shift. Review of Resident #1's medical record indicated there was no documentation, including a nurse progress related to Resident #1's fall on 9/27/20 from the 11:00 P.M. to 7:00 A.M. shift nurse (Nurse #1). There was no documentation to support the Nurse #1 assessed Resident #1 after finding him/her on the floor, or that neurological signs were assessed and monitored throughout the day, after the resident experienced an unwitnessed fall. Although Nurse #1 had acknowledged that he had in fact found Resident #1 on the floor on 9/27/20, and said the floor mats were not in place at this time, there was no documentation to support that at the time of the fall, Resident #1's bed was locked and in the lowest position as well for safety. During interview on 10/15/20 at 7:40 A.M., the DON said that Nurse #1, CNA #1, and CNA #2 had worked the 11:00 P.M., to 7:00 A.M., shift on 9/27/20 on the unit where Resident #1 resided. The DON said that when she was investigating Resident #1's injuries, Nurse #1, CNA #1, and CNA #2 initially denied that Resident #1 had a fall. The DON said Nurse #1 later admitted that Resident #1 had a fall. The DON said Nurse #1 should have reported Resident #1's fall to the Nurse Supervisor and the Physician immediately, so that the next shift would be aware to monitor Resident #1 for changes in his/her condition throughout the day, and staff potentially would have identified Resident #1's injuries sooner. During interview on 10/19/20 at 11:16 A.M., the DON said Resident #1 should have had floor mats in place next to his/her bed, as indicated in the Care Plan.

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), the Facility failed to ensure Certified Nurse Aide (CNA) #1 reviewed and followed Resident #1's plan of care related to mobility. When CNA #1, unassisted by another staff person completed a stand pivot transfer on Resident #1, who required two person, non-weight bearing assistance with transfers, and as a result Resident #1 sustained a displaced [MEDICAL CONDITION] (smaller calf bone) and a spiral [MEDICAL CONDITION] (the larger the two calf bones). Findings include: The Procedure titled, Resident Activities of Daily Living (ADL) Guide/Kardex, dated as revised in (MONTH) 2012, indicated it's purpose was to ensure CNAs are provided with a complete and updated source for resident care needs and to carry their ADL Guide/Kardex with them to refer to during the course of their shift. Resident #1's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, was totally dependent for care and required the assistance of two staff persons for dressing, bed mobility and transfers. The Resident ADL Guide/Kardex, dated 05/28/18, indicated Resident #1 required two person, non-weight bearing, assistance with transfers. The 3:00 P.M. to 11:00 P.M. Four Person Assignment Sheet, dated 06/23/18, indicated Resident #1 was a two person assist for transfers. The Quality Assessment and Assurance Incident Report, dated 06/23/18, indicated that at 7:15 P.M. on 06/23/18 Nurse #1 was called into Resident #1's bedroom by a CNA caring for him/her, Nurse #1 assessed Resident #1 and found a bruised, raised area on Resident#1's left shin. The Nursing Supervisor's Interdisciplinary Progress Note, dated 06/23/18 at 07:53 P.M., indicated upon assessment, the Nursing Supervisor found a painful, large raised purple and blue area on Resident #1's left shin, Nurse Practitioner was contacted and an X-ray was ordered without delay. The Radiology Report, dated 06/23/18, indicated an X-ray conducted at the Facility, per the report Resident #1 had mildly displaced fractures involving the left tibia and fibula diaphyses. Nurse #1's Interdisciplinary Progress Note, dated 06/24/18 at 12:51 A.M., indicated in response to a CNA reporting that Resident #1 was crying out in pain, Nurse #1 assessed Resident #1, contacted the Nursing Supervisor to also assess Resident #1, an X-ray determined there were fractures to the left lower leg and Resident #1 was sent to the Hospital as ordered, for further evaluation. The Hospital's Diagnostic Radiology Report, dated 06/24/18, indicated an X-ray conducted at 12:52 A.M. indicated Resident #1 had a displaced comminuted oblique fracture through the left fibular shaft proximally, and a slightly displaced spiral fracture through the mid to distal shaft of the left tibia. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:00 P.M. on 09/11/18. CNA #1 said she placed Resident #1, who was seated on a wheelchair, alongside the bed and locked the wheels. CNA #1 said she picked up Resident #1, without assistance, to a standing position by holding him/her under the armpits. CNA #1 said she pivoted Resident #1 toward the bed and sat him/her on the bed before lifting his/her legs up onto the bed. CNA #1 said Resident #1 immediately upon transfer, in a voice expressive of pain said my leg is broken. CNA #1 said she reported the complaint of pain to Nurse #1. CNA #1 said she was aware that the Resident ADL Guide/Kardex was available. CNA #1 said the Resident ADL Guide/Kardex provided information on requirements to be followed to provide care for residents, which included resident transfer status. CNA #1 said she did not review Resident #1's Resident ADL Guide/Kardex and did not know his/her transfer status requirement. CNA #1 said she received the Unit's Assignment Sheet which documented Resident #1's transfer status requirement. CNA #1 said she did not recall whether or not she reviewed Resident #1's transfer requirement on the Assignment Sheet for the shift. The Surveyor interviewed Nurse #1 at 11:15 A.M. on 09/11/18. Nurse #1 said she observed Resident #1 during dinner and he/she had no signs or symptoms of pain. Nurse #1 said Resident #1 had not complained of pain until after CNA #1 transferred him/her to bed. The Surveyor interviewed the Director of Nurses (DON) at 4:15 P.M. on 09/11/18. The DON said CNAs were required to follow residents' plan of care which was documented on the Resident ADL Guide/Kardex. The DON said CNA #1 told her she transferred Resident #1 unassisted, had done a one person unassisted transfer for Resident #1 many times in the past, and admitted she knew that Resident #1 required two persons for transfers.

Based on records reviewed and interviews, for one of five sampled residents (Resident #1), the Facility failed to ensure staff provide the care necessary to prevent an accident with injury. When on 06/23/18 at approximatley 7:15 P.M, Resident #1 who was non-weight bearing and required a two person assist with all transfers, sustained a displaced [MEDICAL CONDITION] shaft and a slightly displaced spiral [MEDICAL CONDITION] (lower leg bones), after Certified Nurse Aide (CNA) #1, alone, transferred Resident #1 back to bed using a stand pivot transfer, without being assisted by another staff person. Findings include: The Procedure titled, Resident Activities of Daily Living (ADL) Guide/Kardex, dated as revised in (MONTH) 2012, indicated it's purpose was to ensure CNAs are provided with a complete and updated source for resident care needs and to carry their ADL Guide/Kardex with them to refer to during the course of their shift. Resident #1's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired, was totally dependent for care and required two staff persons assistance for dressing, bed mobility and transfers. The Resident ADL Guide/Kardex, dated 05/28/18, indicated Resident #1 required two staff persons, was non-weight bearing, assistance with transfers. The 3:00 P.M. to 11:00 P.M. Four Person Assignment Sheet, dated 06/23/18, indicated Resident #1 was a two person assist for transfers. The Quality Assessment and Assurance Incident Report, dated 06/23/18, indicated that at 7:15 P.M. on 06/23/18 Nurse #1 was called into Resident #1's bedroom by a CNA caring for him/her, Nurse #1 assessed Resident #1 and found a bruised, raised area to the left shin. The Nursing Supervisor's Interdisciplinary Progress Note, dated 06/23/18 at 07:53 P.M., indicated upon assessment, the Nursing Supervisor found a painful, large raised purple and blue area to Resident #1's left shin, Nurse Practitioner was contacted and an X-ray was ordered without delay. The Radiology Report, dated 06/23/18, indicated an X-ray conducted at the Facility indicated Resident #1 had mildly displaced fractures involving the left tibia and fibula diaphyses. Nurse #1's Interdisciplinary Progress Note, dated 06/24/18 at 12:51 A.M., indicated in response to a CNA reporting that Resident #1 was crying out in pain, Nurse #1 assessed Resident #1, contacted the Nursing Supervisor to also assess Resident #1, an X-ray determined there were fractures to the left lower leg and Resident #1 was transferred to the Hospital, as ordered for further evaluation. The Hospital's Diagnostic Radiology Report, dated 06/24/18, indicated an X-ray was conducted at 12:52 A.M., the Report findings noted Resident #1 had a displaced comminuted oblique fracture through the left fibular shaft proximally, and a slightly displaced spiral fracture through the mid to distal shaft of the left tibia. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 2:00 P.M. on 09/11/18. CNA #1 said the Resident ADL Guide/Kardex provided information on requirements to be followed to provide care for residents, which included resident transfer status. CNA #1 said she did not review Resident #1's Resident ADL Guide/Kardex and did not know his/her transfer status requirement. CNA #1 said she received the Unit's Assignment Sheet which documented Resident #1's transfer status requirement. CNA #1 said she could not recall whether or not she reviewed Resident #1's transfer requirement on the Assignment Sheet for the shift. CNA #1 said she asked other CNAs, who were behind a privacy curtain, for assistance and received no response. CNA #1 said when she was ready to transfer Resident #1, none of the nursing staff were in the room and she transferred Resident #1 unassisted. CNA #1 said she placed Resident #1, who was seated in a wheelchair, alongside the bed and locked the wheels. CNA #1 said she picked up Resident #1, without assistance, to a standing position by holding him/her under the armpits. CNA #1 said she pivoted Resident #1 toward the bed and sat him/her on the bed before lifting his/her legs up onto the bed. CNA #1 said Resident #1 immediately upon transfer, in a voice expressive of pain said my leg is broken. CNA #1 said she had performed a one person stand and pivot transfer for Resident #1 many times before without complaint from Resident #1. CNA #1 said she reported the incident to Nurse #1 who was in the hallway by the medication cart. The Surveyor interviewed CNA #2 at 1:18 P.M. on 09/04/18. CNA #2 said on 06/23/18 she was assisting Resident #1's roommate while CNA #1 was providing care for Resident #1. CNA #2 said she heard Resident #1 yell out my leg, looked around the privacy curtain at CNA #1, and saw Resident #1 had been transferred to bed. The Surveyor interviewed Nurse #1 at 11:15 A.M. on 09/11/18. Nurse #1 said she was unaware that any CNAs, including CNA #1, were performing a one person transfer for Resident #1. Nurse #1 said she was assigned to the side of the Unit where Resident #1 resided. Nurse #1 said she was available to assist CNAs if a second person was required. Nurse #1 said she was not asked to assist with Resident #1's transfer and was not aware CNA #1 performed the transfer unassisted. The Surveyor interviewed the Director of Nurses (DON) at 4:15 P.M. on 09/11/18. The DON said CNA #1 told her she transferred Resident #1 unassisted, had done a one person unassisted transfer for Resident #1 many times in the past and admitted she knew that Resident #1 required a two person transfer.

Based on record review and interview, the facility failed to consult the physician and notify family when the resident exhibited increased symptoms of depression and attempted suiside for 1 sampled resident, (#3), out of a total of 24 sampled residents. Findings include: Review of the Facility's Resident Change in Condition Policy, dated 10/7/16, indicated the following: Procedure: Whenever there is a change in a resident's condition, the nurse will follow protocols in accordance to the Nursing Procedure Manual. The resident's Physician, legal representative and/or responsible party is to be notified. For Resident #3, the facility failed to consult with his/her physician and notify his/her family after the resident had become increasingly tearful, vocalized feelings of helplessness, became withdrawn and refused to eat occasional meals beginning on 8/14/17. On 8/24/17, Resident #3 told nursing staff he/she had intentions of killing himself/herself. Approximately one hour later, Resident #3 stabbed himself/herself in the chest with a butter knife wrapped in a sock. Resident #3 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Review of Resident #3's most recent Minimum Data Set, (MDS), dated [DATE], indicated that he/she scored a 12 out of 15 on the Brief Interview for Mental status, indicating Resident #3 has moderate cognitive impairment. Review of a nursing progress note dated 8/14/17 indicated the following: Newly transferred from 2 East. Resident cried for awhile before falling asleep .Offered fluid and snack, he/she refused, refused vital signs taken.This morning when staff went to check on him/her with morning meds, resident stated, I did not sleep well last night, I miss my (spouse) Review of a social service note dated 8/14/17 indicated the following: SW met with resident on this date in order to assess how he/she was feeling about being moved to 2 West away from his/her spouse.Resident appears down and was laying in his/her bed. Review of a nursing progress note dated 8/20/17 indicated the following: .Before lunch resident came back to this unit and stated to this nurse, My (spouse) doesn't know me anymore, he/she doesn't love me. Why can't I be over there with him/her? He/She is sick you know and I think I have a touch of it. Resident then chose not to have lunch, drink or have any snacks throughout the day and when re-approached, resident stated I am sick to my stomach over losing my (spouse). He/She doesn't know who I am. Review of a social service note dated 8/22/17 indicated the following: Resident expressed that he/she has been feeling down and helpless as he/she feels he/she can't help his/her spouse anymore now that he/she is on another unit.He/she was able to verbalize his/her feelings however he/she continued to be in a down, somewhat agitated mood even after being brought up stairs. There was no evidence in the clinical record that Resident #3's physician, psychiatric services or family were notified about his/her depressive symptoms on 8/14/17, 8/20/17, and 8/22/17. A nursing progress note dated 8/24/17 indicated the following: At 7:30 A.M., resident chose not to allow this nurse to obtain (Capillary Blood Sugar) and stated, I just want to do nothing Resident chose not to eat or get out of bed. Resident did use call light and when staff would answer the light resident stated, I'm going to kill myself, Call a lawyer and I'll sign the paperwork. Unit manager and social worker notified. This nurse went to assess resident . This nurse did a full sweep of resident room and found no weapon or anything that could have been used to self inflict harm. At 10:55 A.M. this nurse was notified by CNA that when she answered residents call light that when she went into the room resident was holding a butter knife to the upper right side of his/her chest .ADON, unit manager and social worker notified, this nurse obtained order to send resident to ED for eval per MD. Resident #3 returned to the facility from the hospital on [DATE]. During interview with Resident #3's Physician on 8/31/17, he said that he was aware that Resident #3 had attempted suicide, but was not aware that Resident#3 had been exhibiting depressive symptoms in the days leading up to the attempt, or that approximately 1 hour before Resident #3 attempted suicide, the resident told staff he/she had intentions to harm himself/herself. The ADON was interviewed on 8/31/17, 9/1/17, and 9/5/17. The ADON could not explain why Resident #3's physician or family was not notified after he/she displayed an increase in depressive symptoms and behavior.

Based on record review and interview, the facility failed to identify, adequately assess, and respond to increasing depressive symptoms, and attempted suicide for 1 resident, (#3), out of a total of 24 sampled residents. Findings include: For Resident #3, the facility failed to provide psychiatric services when he/she began to display signs and symptoms of increased depression beginning on 8/14/17. On 8/24/17, Resident #3 told nursing staff he/she had intentions of killing himself/herself. Approximately one hour later, Resident #3 stabbed himself/herself in the chest with a butter knife wrapped in a sock that/he she had taken from the dinning room. Resident #3 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Review of Resident #3's most recent Minimum Data Set, (MDS), dated [DATE], indicated that he/she scored a 12 out of 15 on the Brief Interview for Mental status, indicating Resident #3 has moderate cognitive impairment. Additional review of Resident #3's Quarterly and Comprehensive MDS' dated 5/1/17 and 7/28/17, indicated that he/she at times had feelings of depression, being tired or having little energy. Resident #3's clinical record indicated that he/she was admitted to the facility with a physician's orders [REDACTED]. A careplan meeting note dated 5/8/17 indicated that the use of [MEDICATION NAME] for his/her depression was effective. A consent form for a psychiatric referral was obtained on 8/14/17. Despite the resident's increased symptoms of depression, psychiatric services was not notified in an attempt to provide services. Review of a nursing progress note dated 8/14/17 indicated the following: Newly transferred from 2 East. (The facility assessed and determined that the transfer was necessary to Resident #3's and his/her spouses' safety and well being). Resident cried for awhile before falling asleep .Offered fluid and snack, he/she refused, refused vital signs taken.This morning when staff went to check on him/her with morning meds, resident stated, I did not sleep well last night, I miss my (spouse). Review of a social service note dated 8/14/17 indicated the following: SW met with resident on this date in order to assess how he/she was feeling about being moved to 2 West away from his/her spouse.Resident appears down and was laying in his/her bed. Review of a nursing progress note dated 8/20/17 indicated the following: .Before lunch resident came back to this unit and stated to this nurse, My (spouse) doesn't know me anymore, he/she doesn't love me. Why can't I be over there with him/her? He/She is sick you know and I think I have a touch of it. Resident then chose not to have lunch, drink or have any snacks throughout the day and when re-approached, resident stated I am sick to my stomach over losing my (spouse). He/She doesn't know who I am.Social worker in facility today and made aware. Review of a social service note dated 8/22/17 indicated the following: Resident expressed that he/she has been feeling down and helpless as he/she feels he/she can't help his/her spouse anymore now that he/she is on another unit.He/she was able to verbalize his/her feelings however he/she continued to be in a down somewhat agitated mood even after being brought up stairs. There was no evidence in the clinical record that Resident #3's was adequately assessed for increased depressive symptoms or that care plans were reviewed or changed despite Resident #3's documented depressive symptoms on 8/14/17, 8/20/17, or 8/22/17. A nursing progress note dated 8/24/17 indicated the following: At 7:30 A.M., resident chose not to allow this nurse to obtain (Capillary Blood Sugar) and stated .I just want to do nothing Resident chose not to eat or get out of bed. Resident did use call light and when staff would answer the light resident stated, I'm going to kill myself, Call a lawyer and I'll sign the paperwork. Unit manager and social worker notified. This nurse went to assess resident who was laying in bed and when asked what his plan was he stated, I don't have one. This nurse did a full sweep of resident room and found no weapon or anything that could have been used to self inflict harm. At 10:55 A.M. this nurse was notified by CNA that when she answered residents call light that when she went into the room resident was holding a butter knife to the upper right side of his/her chest .ADON, unit manager and social worker notified, this nurse obtained order to send resident to ED for eval per MD. Resident #3 returned to the facility from the hospital on [DATE]. Review of the Suicide Threats Policy, dated 2007 indicated the following: 1. Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. 2. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the charge Nurse/Supervisor and/or Director of Nursing Services of such threats. 3. A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. 8. Staff shall document details of the situation objectively in the resident's medical record. Review of the Facility's Suicide Risk Assessment form, dated 10/2012 includes information regarding resident risk factors, protective factors, suicide inquiry regarding ideation, plans, behaviors, and intent and also risk level. The form also includes a section on documenting risk level with rationale, treatment plan to address/reduce current risk and roles for family and healthcare proxy. There was no evidence in the clinical record that a complete suicide risk assessment was done, per facility policy, or that Resident #3's physician or family were notified about his/her reported suicidal ideation prior to Resident #3 stabbing himself/herself in the chest. Nurse #1 was interviewed on 8/31/17, 9/1/17, and 9/3/17. Nurse #1 said that on 8/24/17 she was passing medications on the unit. She said that Resident #3 told her that he/she was going to kill himself/herself and that the Unit Manager, ADON and Social Worker were in a meeting at that time. Nurse #1 said she assessed Resident #3 for suicide risk, (not using the formal facility form per facility procedure which includes risk factors, protective factors, risk level interventions and treatment planning), and was told by Resident #3 that he/she did not have a plan. She said she left the resident room to alert the ADON who was in a morning meeting. She then returned to Resident #3 and swept the room for items that could be used for self harm, (she said she did not find the knife as it was hidden in a sock), and said that she did not secure Resident #3's call light, (something that has the potential to cause self injury). Nurse #1 said she was pretty sure she alerted the Nurse Practitioner, or words to that effect, but not Resident #3's physician per facility policy. She said that she was instructed by the ADON to keep an eye on him/her or words to that effect. On 8/31/17, the Surveyor interviewed the Nurse Practitioner who works with the facility's Medical Director, (not Resident #3's physician), who wrote the order for Resident #3 to be transferred to the hospital on [DATE]. She said that she happened to be on the unit on 8/24/17 when Resident #3 stabbed himself/herself. She said that she was not made aware that approximately one hour before Resident #3's suicide attempt, he/she had told staff he/she was going to himself/herself. Unit Manager #2 was interviewed on 8/31/17, 9/1/17, and 9/5/17. Unit Manager #2 said she had not contacted the physician or psychiatric services for Resident #3. The Social Worker was interviewed on 8/31/17 and on 9/1/17. The Social Worker said that she visited Resident #3 on two occasions for support prior to his/her suicide attempt, as he/she was struggling with adjusting to being moved on a new unit. During interview with the Psychiatric Nurse on 8/31/17, she said that Resident #3 was not seen prior to 8/24/17 because consent forms needed to be signed by a family member. Review of Resident #3's psychiatric consent forms indicated that they were signed 8/14/17; 10 days prior to his/her suicide attempt and when he/she first began exhibiting signs of depression. During interview with the Psychiatric Program Director on 8/31/17 and 9/1/17, she said that she was not aware that Resident #3 had been referred for psychiatric services prior to 8/24/17; 17 days after the referral was initially written on 8/8/17. During interview with Resident #3's Physician on 8/31/17, he said that he was aware that Resident #3 had attempted suicide, but was not aware that Resident#3 had been exhibiting increasingly depressive symptoms in the days leading up to the attempt. He said he did not know that approximately 1 hour before Resident #3 attempted suicide, the resident told staff he/she had intentions to harm himself/herself. He also said that was not aware that psychiatric services had not seen the resident until 8/25/17. The ADON was interviewed on 8/31/17, 9/1/17, and 9/5/17. The ADON could not say why Resident #3's physician or psychiatric services were not notified when Resident #3 began to have increased symptoms of depression including crying, withdrawing, declining some meals, and the expression of feelings of helplessness as documented beginning on 8/14/17 and leading up to his/her suicide attempt on 8/24/17. She said that Resident #3 should have been seen sooner by psychiatric services. The ADON and the Administrator were interviewed on 9/1/17. The ADON and the Administrator said that there is no facility policy or procedures in place to determine when referrals or contact with psychiatric services should take place for residents who are exhibiting depressive symptoms. They also said there is no monitoring system in place for residents to ensure psychiatric services are provided in a timely manner. Despite documented behaviors of increased sadness, self isolation, continual refusal of meals and tearfulness, the facility failed to respond to and address Resident #3's symptoms of depression. Additionally, the facility failed to follow its Suicide Threats Policy by failing to alert Resident #3's physician to obtain guidance and direction in appropriate response to his/her suicidal ideation.

Based on interviews and record review, for 1 of 11 sampled residents (Resident #1), the Facility failed to ensure Certified Nurse Aide (CNA) #2 did not abuse Resident #1. On different dates throughout September 2015, CNA #2 repeatedly threatened to slap Resident #1, told Resident #1 he/she was annoying, and made other demeaning comments directly to Resident #1 while in the presence of other residents and staff members. On 10/2/15, CNA #2 told Resident #1, I'm not taking you to the bathroom because you're nothing but a [***] ing cry baby, Findings include: Resident #1's Minimum Data Set (MDS), dated [DATE], indicated he/she understood others and was usually able to make his/her self understood; had moderate cognitive impairment; required extensive staff assistance with transfers and toileting; used a walker and wheelchair for mobility; frequently incontinent of bowel and bladder; and was diagnosed with [REDACTED]. Resident #1's Plan of Care for Activities, dated 5/8/14, indicated he/she gets weepy during the day and while attending social activities. Interventions included: show understanding and move to calm, quiet areas, as needed. The Surveyor interviewed CNA #1 at 11:40 A.M. on 12/2/15. CNA #1 said she was supervising the Dining Room on 10/2/15, and at approximately 1:25 P.M., Resident #1 asked to be brought to the bathroom. CNA #1 said she told Resident #1 he/she would need to wait a few minutes until another staff member was available. CNA #1 said that CNA #2 was scheduled to relieve her in the Dining Room at 1:30 P.M. CNA #1 said that Resident #1 began to cry softly. CNA #1 said that this was Resident #1's baseline behavior when told he/she needed to wait. CNA #1 said that CNA #2 arrived to the room and saw Resident #1 and asked in an impatient tone of voice, Why is he/she crying now? or words to that effect. CNA #1 said she told CNA #2 that Resident #1 needed to use the bathroom. CNA #1 said that CNA #2 walked over to Resident #1, leaned down into his/her face and made eye contact, lowered her voice and said, I'm not taking you to the bathroom because you're nothing but a [***] ing cry baby, or words to that effect. CNA #1 said that Resident #1 began to sob. The Surveyor interviewed CNA #4 at 9:30 A.M. on 12/4/15. CNA #4 said that on more than one occasion, CNA #2 told her in Spanish (CNA #4 spoke Spanish), in the Dining Room while they supervised residents, that she felt like slapping Resident #1. CNA #4 said that numerous times she heard or observed CNA #2 tell Resident #1 he/she was, such a cry baby, or words to that effect. CNA #4 said sometimes Resident #1 accidentally bumped into CNA #2 and CNA #2 would became irritated and say aloud that Resident #1 hit her on purpose and that Resident #1 was not actually confused. CNA #4 said that when Resident #1 tried to leave the Dining Room to use the bathroom, CNA #2 would bring him/her back to a table and tell him/her to wait, but would never assist Resident #1 to use the bathroom. The Surveyor interviewed CNA #5 at 3:55 P.M. on 12/2/15. CNA #5 said she witnessed CNA #2 scold Resident #1,like a child, when he/she requested to go to the bathroom and called him/her a cry baby when Resident #1 began to cry. CNA #5 said that CNA #2 told Resident #1 that he/she gets what he/she wants every time because he/she cries and that he/she knows what he/she is doing. CNA #5 said that CNA #2 told Resident #1 that he/she did not have dementia and misbehaved intentionally. CNA #5 said that when CNA #2 supervised the Dining Room she refused to bring Resident #1 to the bathroom, but would bring other residents. CNA #5 said that these incidents occurred frequently during approximately the last 2 weeks of September 2015. The Surveyor interviewed CNA #6 at 2:15 P.M. on 12/7/15. CNA #6 said that on different occasions during approximately the last 2 weeks of September 2015, she heard CNA #2 tell Resident #1 he/she was a cry baby and annoying. CNA #6 indicated she witnessed CNA #2 intentionally prevent Resident #1 from leaving the Dinning Room by blocking his/her path with a chair, and another time with a walker. The Surveyor interviewed CNA #7 at 3:12 P.M. on 12/8/15. CNA #7 said that on a few occasions during approximately the last 2 weeks of September 2015, she witnessed CNA #2 tell staff , she's so annoying, and I can't stand her, while walking away from Resident #1 in the Dining Room. CNA #7 said she did not know if Resident #1 could hear CNA #2's comments, or not. The Surveyor interviewed Nurse #2 at 2:40 P.M. on 12/8/15. Nurse #2 said she witnessed Resident #1 ask CNA #2 to bring him/her to the bathroom and CNA #2 raised her voice in an angry, impatient tone, I just brought you to the bathroom, you want to go again!. Nurse #2 said she counseled CNA #2 to remember that she was working with cognitively impaired residents and to be respectful.

Based on interview and record review for 3 of 22 sampled staff members, (CNA #4, CNA #5 and CNA#6) during September 2015, staff did not report to the Administrator repeated alleged acts of abuse committed by CNA #2 against Resident #1, per facility policy. - Once the Administrator was made aware of the allegations of abuse by CNA #2 against Resident #1, he failed to report to the Department of Public Health these allegations of repeated abuse that were made by CNA #4, CNA #5 and CNA #6 against CNA #2 between 10/3/15 to 10/13/15. Findings include: 1. The Facility's incident report to the Department of Public Health, dated 10/6/15, indicated that on 10/2/15, CNA #2 allegedly told Resident #1,You're a [***] ing cry baby, I'm not taking you to the bathroom. On 12/02/15, while at the Facility to investigate the 10/2/15 incident, the Surveyor reviewed the Facility's internal investigation, including the written statements provided by its staff. CNA #4's written statements, dated 10/3/15 and 10/6/15, indicated on many occasions CNA #2 told other staff in the Dining Room (in Spanish), that she wanted to slap Resident #1. CNA #4 indicated that CNA #2 also said she believed that Resident #1 was not confused and she wanted to slap Resident #1 because she meant to bump into her (CNA #2) with his/her wheelchair. CNA #4 indicated that numerous times CNA #2 called Resident #1 a cry baby. CNA #5's written statement, dated 10/3/15, indicated that CNA #2 told Resident #1 she would not take him/her to the bathroom because she was a cry baby and she gets what she wants every time because she knows what he/she is doing. CNA #5 indicated that CNA #2 told Resident #1 that he/she did not have dementia and was pretending to be confused. CNA #5 indicated that CNA #2 talked toward and scolded Resident #1 like a child. CNA #6's written statements, dated 10/3/15 and 10/13/15, indicated that CNA #2 prevented Resident #1 from leaving the Dining Room in his/her wheelchair by blocking his/her path with a chair and another time with a walker. CNA #6 indicated that Resident #1 cried when prevented from leaving the Dining Room. CNA #6 indicated that CNA #2 called Resident #1 a cry baby and annoying. 2. The Administrator said that Facility management was unaware of CNA #4's, CNA #5's and CNA #6's allegations against CNA #2 until the initiation of the 10/2/15 investigation. The Administrator said the Facility did not report these additional allegations of abuse provided by CNA #4, CNA #5 and CNA #6 to the Department of Public Health. The Health Care Facility Reporting system indicated the Facility did not submit these additional reportable allegations involving CNA #2.

Based on interview and record review, for 6 of 22 sampled employees (CNA #4, CNA #5, CNA #6, the Administrator, the Director of Nurses and the Director of Social Services) the Facility failed to ensure it implemented its Abuse Policy and Procedures between approximately July and October 2015. Findings include: 1. The Facility's incident report to the Department of Public Health, dated 10/6/15, indicated that on 10/2/15, CNA #2 allegedly told Resident #1,You're a [***] ing cry baby, I'm not taking you to the bathroom. On 12/02/15, while at the Facility to investigate the 10/2/15 incident, the Surveyor reviewed the Facility's internal investigation, including the written statements provided by its staff. CNA #4, CNA #5 and CNA #6 indicated that during September 2015, they observed CNA #2 commit repeated acts of abuse against Resident #1. The Surveyor interviewed the Administrator at 9:00 A.M. on 12/2/15. The Administrator said he was unaware CNA #2's alleged abusive behaviors against Resident #1 prior to 10/2/15, when direct care staff reported the 10/02/15 incident and then provided statements during the internal investigation. The Administrator said that these staff failed to report these allegations of abuse. The Facility's Abuse Policy, dated 5/19/09, indicated it is the responsibility of all staff to report to the Executive Director (the Administrator) if there is any potential or suspected abuse. 2. The Administrator said that management uncovered the additional allegations of abuse made by CNA #4, CNA #5 and CNA #6, including the threats of slapping and repeated name calling, during the internal investigation. The Administrator said the Facility did not report these additional allegations of abuse committed by CNA #2 to the Department of Public Health. The Health Care Facility Reporting system indicated the Facility did not submit these additional reportable allegations involving CNA #2. The Facility's Abuse Policy indicated that all reports of suspected abuse must be immediately reported within 24 hours to the Department of Public Health. 3. The Director of Nurses's (DON) personnel file indicated a Certified Nurse Aide Registry verification report was not present. The Surveyor interviewed the Administrator at 3:30 P.M. on 12/7/15. The Administrator said that when the Facility hired the DON, they did not verify her status through the Certified Nurse Aide Registry. The Facility's Abuse Policy indicated the Facility shall conduct CNA Registry verification for all employment applicants. 4. The educational file for the Director of Social Services indicated the last in-service on abuse training and prevention that she attended occurred in July 2014, approximately 4 months past the required due date. The Surveyor interviewed the Administrator at 3:30 P.M. on 12/7/15. The Administrator said it was Facility policy for all staff to receive annual in-service training on abuse policies and procedures The Administrator said that a review of the Director of Social Services' educational files, including on-line records, indicated she had not taken an online abuse prevention and training class since July 2014. The Facility's abuse policy indicated that all staff members shall be in-serviced on the Abuse Prevention Program at least annually.

Based on interview and record review, for 1 of 11 sampled residents (Resident #1), the Facility failed to protect Resident #1 from repeated abusive and demeaning behaviors by its staff and to ensure Resident #1's quality of life. On different dates throughout September 2015 and on 10/2/15, Certified Nurse Aide (CNA) #2 told Resident #1, you're nothing but a [***] ing cry baby, repeatedly threatened to slap Resident #1, told Resident #1 he/she was annoying, and made other demeaning comments directly to Resident #1 while in the presence of other residents and staff members. Findings include: Resident #1's Minimum Data Set (MDS), dated [DATE], indicated he/she understood others and was usually able to maker his/her self understood; had moderate cognitive impairment; required extensive staff assistance with transfers and toileting; used a walker and wheelchair for mobility; frequently incontinent of bowel and bladder; and was diagnosed with [REDACTED]. Resident #1's Plan of Care for Activities, dated 5/8/14, indicated he/she gets weepy during the day and during social activities. Interventions included: show understanding and move to calm, quiet areas, as needed. The Surveyor interviewed CNA #1 at 11:40 A.M. on 12/2/15. CNA #1 said that Resident #1 was crying softly in the Dining Room because CNA #1 told him/her he/she needed to wait a few minutes before someone could take him/her to the bathroom. CNA #1 said that this was Resident #1's baseline behavior when told he/she needed to wait. CNA #1 said that CNA #2 arrived to the room and saw Resident #1 and asked in an impatient tone of voice, Why is he/she crying now? or words to that effect. CNA #1 said she told CNA #2 that Resident #1 needed to use the bathroom. CNA #1 said that CNA #2 walked over to Resident #1, leaned down into his/her face and made eye contact, lowered her voice and said, I'm not taking you to the bathroom because you're nothing but a [***] ing cry baby, or words to that effect. CNA #1 said that Resident #1 began to sob. The Surveyor interviewed CNA #4 at 9:30 A.M. on 12/4/15. CNA #4 said that on more than one occasion CNA #2 told her in Spanish (CNA #4 spoke Spanish), in the Dining Room while they supervised residents, that she felt like slapping Resident #1. CNA #4 said that numerous times she heard or observed CNA #2 tell Resident #1 he/she was, such a cry baby, or words to that effect. CNA #4 said sometimes Resident #1 accidentally bumped into CNA #2 and CNA #2 would became irritated and say aloud that Resident #1 hit her on purpose and that Resident #1 was not actually confused. CNA #4 said that when Resident #1 tried to leave the Dining Room to use the bathroom, CNA #2 would bring him/her back to a table and tell him/her to wait, but would never assist Resident #1 to use the bathroom. The Surveyor interviewed CNA #5 at 3:55 P.M. on 12/2/15. CNA #5 said she witnessed CNA #2 scold Resident #1,like a child, when he/she requested to go to the bathroom and called him/her a cry baby when Resident #1 began to cry. CNA #5 said that CNA #2 told Resident #1 that he/she gets what he/she wants every time because he/she cries and that he/she knows what he/she is doing. CNA #5 said that CNA #2 has told Resident #1 that he/she does not have dementia and he/she misbehaves on purpose. CNA #5 said that when CNA #2 supervised the Dining Room she refused to bring Resident #1 to the bathroom, but would bring other residents. CNA #5 said that these incidents occured frequently during approximately the last 2 weeks of September 2015. The Surveyor interviewed CNA #6 at 2:15 P.M. on 12/7/15. CNA #6 said that on different occasions during approximately the last 2 weeks of September 2015, she heard CNA #2 tell Resident #1 he/she was a cry baby and annoying. CNA #6 indicated she witnessed CNA #2 intentionally prevent Resident #1 from leaving the Dinning Room by blocking his/her path with a chair, and another time with a walker. The Surveyor interviewed CNA #7 at 3:12 P.M. on 12/8/15. CNA #7 said that on a few occassions during approximately the last 2 weeks of September 2015, CNA #2 told staff , she's so annoying, and I can't stand her, while walking away from Resident #1 in the Dining Room. CNA #7 said she did not know if Resident #1 could hear CNA #2's comments, or not. The Surveyor interviewed Nurse #2 at 2:40 P.M. on 12/8/15. Nurse #2 said she witnessed Resident #1 ask CNA #2 to bring him/her to the bathroom and CNA #2 raised her voice in an angry, impatient tone, I just brought you to the bathroom, you want to go again!. Nurse #2 said she counseled CNA #2 to remember that she was working with cognitively impaired residents and to be respectful.

Based on interview and record review for 1 of 11 sampled residents (Resident #1), the Facility failed to implement Resident #1's Plan of Care for Activities of Daily Living (ADLs) and Activities. During September 2015 and on 10/2/15, Certified Nurse Aide (CNA) #1 repeatedly taunted Resident #1, in the presence of other staff, for crying and refused to assist him/her to the bathroom. These behaviors were identified in Resident #1's plan of care with specific interventions to be implemented. Findings include: Resident #1's Minimum Data Set (MDS), dated [DATE], indicated he/she understood others and was usually able to make his/her self understood; had moderate cognitive impairment; required extensive staff assistance with transfers and toileting; used a walker and wheelchair for mobility; frequently incontinent of bowel and bladder; and was diagnosed with [REDACTED]. Resident #1's Plan of Care for ADLs, dated 1/28/14, indicated he/she had a decreased ability to complete his/her ADLs secondary to a [MEDICAL CONDITION]. Interventions included encourage to participate in ADL care as able. The Plan of Care for Activities, dated 5/8/14, indicated he/she gets weepy during the day and while attending social activities. Interventions included show understanding and move to calm, quiet areas, as needed. The Surveyor interviewed CNA #1 at 11:40 A.M. on 12/2/15. CNA #1 said she was supervising the Dining Room on 10/2/15, and at approximately 1:25 P.M. Resident #1 asked to be brought to the bathroom. CNA #1 said she told Resident #1 he/she would need to wait a few minutes until another staff member was available. CNA #1 said that CNA #2 was scheduled to relieve her in the Dining Room at 1:30 P.M. CNA #1 said that Resident #1 began to cry softly. CNA #1 said that this was Resident #1's baseline behavior when told he/she needed to wait. CNA #1 said that CNA #2 arrived to the room and saw Resident #1 and asked in an impatient tone of voice, Why is he/she crying now? or words to that effect. CNA #1 said she told CNA #2 that Resident #1 needed to use the bathroom. CNA #1 said that CNA #2 walked over to Resident #1, leaned down into his/her face and made eye contact, lowered her voice and said, I'm not taking you to the bathroom because you're nothing but a [***] ing cry baby, or words to that effect. CNA #1 said that Resident #1 began to sob. The Surveyor interviewed CNA #4 at 9:30 A.M. on 12/4/15. CNA #4 said that numerous times she heard or observed CNA #2 tell Resident #1 he/she was, such a cry baby, or words to that effect. CNA #4 said that when Resident #1 tried to leave the Dining Room to use the bathroom, CNA #2 would bring him/her back to a table and tell him/her to wait, but would never assist Resident #1 to use the bathroom. The Surveyor interviewed CNA #5 at 3:55 P.M. on 12/2/15. CNA #5 said she witnessed CNA #2 scold Resident #1,like a child, when he/she requested to go to the bathroom and called him/her a cry baby when Resident #1 began to cry. CNA #5 said that CNA #2 told Resident #1 that he/she gets what he/she wants every time because he/she cries and that he/she knows what he/she is doing. CNA #5 said that CNA #2 told Resident #1 that he/she did not have dementia and misbehaved intentionally. CNA #5 said that when CNA #2 supervised the Dining Room she refused to bring Resident #1 to the bathroom, but would bring other residents. CNA #5 said that these incidents occurred frequently during approximately the last 2 weeks of September 2015. The Surveyor interviewed CNA #6 at 2:15 P.M. on 12/7/15. CNA #6 said that on different occasions during approximately the last 2 weeks of September 2015, she heard CNA #2 tell Resident #1 he/she was a cry baby and annoying. CNA #6 indicated she witnessed CNA #2 intentionally prevent Resident #1 from leaving the Dinning Room by blocking his/her path with a chair, and another time with a walker. The Surveyor interviewed Nurse #2 at 2:40 P.M. on 12/8/15. Nurse #2 said she witnessed Resident #1 ask CNA #2 to bring him/her to the bathroom and CNA #2 raised her voice in an angry, impatient tone, I just brought you to the bathroom, you want to go again!. Nurse #2 said she counseled CNA #2 to remember that she was working with cognitively impaired residents and to be respectful.

Based on record reviews, interviews and observation, for one of three sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was supervised during ambulation to prevent injury, per the plan of care. On 6/27/12 nursing staff left Resident #1 standing alone (using a rolling walker) in his/her bedroom and he/she fell and sustained a laceration to the left side of the forehead. Resident #1 was sent to the Hospital and treated with sutures. Resident #1's plan of nursing care indicated that he/she was at risk for falls and required close supervision while ambulating with a rolling walker. Findings include: Resident #1's CNA care card (undated) indicated Resident #1 used either a walker or a wheelchair for locomotion and that staff provided mobility assistance. The care card indicated staff provided transfer and toileting assistance to Resident #1. Resident #1's most recent functional maintenance program note, dated 9/07/10, indicated Resident #1 was at risk for falls and required supervision for functional mobility (while using the rolling walker). Resident #1's physical therapy discharge note, dated 9/09/10, indicated Resident #1 required close supervision when ambulating with the rolling walker. Resident #1's rehabilitation therapy screen, dated 1/21/11, indicated Resident #1 was "ambulating with staff at baseline". Resident #1's plan of nursing care (last reviewed in June 2012) indicated Resident #1 exhibited impaired mobility related to general weakness and tremors. Care plan goals included Resident #1 will cooperate with cueing and reminders to use an assistive device (rolling walker) when ambulating. Care plan interventions included: remind and encourage (Resident #1) to call for assistance prior to transfer and ambulation and to ambulate with continual supervision. Resident #1's plan of nursing care indicated there was no reference to Resident #1 routinely not following the plan of care or staff interventions to address the potential adverse consequences of not following the plan of care. Resident #1's nurse's note, dated 6/27/12, 1:30 P.M., indicated Resident #1 fell to the bedroom floor while trying to toilet himself/herself. The note indicated Resident #1 told staff that he/she tried to toilet himself/herself because he/she had an urge to urinate. The note indicated nursing staff assessed Resident #1 and determined he/she sustained a gash to the left side of the forehead and the left cheek was slightly red. The note indicated Resident #1 was sent to the Hospital for treatment and received sutures to the wound. Review of Resident #1's Minimum Data Set (MDS) report, dated 6/29/12, indicated the following conditions: no significant cognitive deficits; required staff assistance with mobility and transfers and toileting and used a walker or wheelchair for mobility. The Surveyor interviewed Resident #1 on 7/24/12 at 11:10 A.M. Resident #1 said that, prior to the 6/27/12 fall, Resident #1 walked independently with a rolling walker in his/her bedroom and throughout the unit. Resident #1 said that he/she did not need staff assistance while using his/her rolling walker. The Surveyor observed Resident #1's bathroom on 7/24/12 at 11:10 A.M. Resident #1's bathroom had 2 entry doors, 1 of which adjoined another resident bedroom. The Surveyor interviewed Nurse #1 on 7/24/12 at 11:25 A.M. Nurse #1 said that Resident #1 was alert and fully oriented and was independent in most activities. Nurse #1 said that Resident #1 was assessed by rehabilitation staff as requiring the assistance of 1 staff person for ambulation, but that Resident #1 sometimes was able to safely ambulate independently. Nurse #1 said that, prior to the 6/27/11 incident, nursing staff could safely leave Resident #1 standing, without staff supervision, for short periods of time. Nurse #1 said that Resident #1 had good safety awareness. The Surveyor interviewed CNA #2 on 7/24/12 at 12:00 P.M. CNA #2 said that he and other staff were aware that Resident #1 often walked to his/her bedroom without staff supervision and also walked into his/her bathroom without staff supervision. The Surveyor interviewed CNA #3 on 7/24/12 at 12:10 P.M. CNA #3 said that Resident #1 did not need direct staff assistance or supervision for ambulation and that Resident #1 was able to walk with a rolling walker independently. CNA #3 said that Resident #1 had good safety awareness and knew what he/she was capable of performing. The Surveyor interviewed the Rehabilitation Director on 7/24/12 at 12:40 P.M. The Rehabilitation Director said that, based on the 9/09/10 physical therapy evaluation, Resident #1 required staff to closely supervise him/her during ambulation. The Rehabilitation Director said that, once a staff member left Resident #1 alone in the bedroom standing with his/her rolling walker, Resident #1 was no longer being supervised. The Rehabilitation Director said that nursing staff had not informed him, prior to the 6/27/12 fall, that Resident #1 routinely ambulated without staff supervision. The Rehabilitation Director said that this information would normally be discussed between interdisciplinary staff and a new care plan intervention would be developed to address this problem. The Surveyor interviewed CNA #1 on 7/24/12 at 12:45 P.M. CNA #1 said that, prior to the incident, Resident #1 was steady on his/her feet and staff sometimes allowed Resident #1 to walk on the unit without supervision.

Based on observation, staff interview and record review, the facility failed to ensure that 1 resident (#5) , who had a prosthetic eye, in a total sample of 22 residents, received proper treatment and care for this prosthesis. Findings include: Resident #5, who resides on the One West Unit, has [DIAGNOSES REDACTED]. The Resident's record revealed that the Resident was seen at the facility on 1/25/2010 by a physician from an outside eye care group, and the plan documented on this eye exam was to monitor, remove and clean the prosthetic eye one time a month. However, there was no evidence that the facility developed and implemented a plan of care to monitor, remove and clean the prosthetic eye one time a month. This was confirmed through record review and interview with the Unit Manager and Director of Nurses on 6/17/11 at 4:30 pm. Review of the record revealed that the Resident was treated with an antibiotic ointment to both eyes for an eye infection in 10/2010. Review of the nurses' notes for this Resident revealed that on 4/14/11, "Resident (#5's) right eye noted to be closed with crusty dark brown drainage. Area washed with warm water scrub several times, resident then able to open eye, eye remained watery. Call out to MD as resident would not allow this writer to remove prosthetic eye and became aggressive when attempt awaiting return call." The nurse's note on 4/15/11 documented, "Resident alert, confused at baseline. Right eye noted with moderate amount of dried drainage, eye unable to open. Cleansed with warm cloth, still unable to open, Call returned from MD, recommend resident see ophthalmologist. Appointment scheduled." The Resident was seen by an ophthalmologist on 4/15/11. The consultation request to the ophthalmologist on 4/15/11 documented, "right eye is prosthetic and eyelids have been shut for 48 hours - drainage present." The Consultant Ophthalmologist report on 4/15/11 documented: "Findings: "angular blepharitis right eye (inflammation that primarily affects the outer corners of the eye lids) unable to clean prosthetic secondary to patient uncooperative. The recommendation was antibiotic ointment to the right eye four times a day for a week. If not better, may need eye/nose/throat follow up with Resident's regular ophthalmologist." On 6/17/11 at 3:10 pm, the Resident was observed sitting in the multipurpose room on the Unit. The Resident was noted to have dried cream colored drainage on the corners of the right outer eyelid. When Unit Manager #2 was asked about the care of the Resident's right eye prosthesis, this Nurse responded, "We try to clean the outside of the eye. Sometimes (the Resident) will let you, sometimes (the Resident) won't." The Nurse further stated that the Resident's eye had not been soaked lately. Between the date of the ophthalmologist visit on 4/15/11, and the date of the survey on 6/21/11, the Resident's record only included evidence that the Resident's eyes were cleansed by a nurse one time and that was on 4/18/11. This was confirmed through interview with Unit Manager #2 and the Director of Nurses on 6/17/11 at 4:30 pm. In addition, review of the Resident's record on 6/17/11, revealed that there was no evidence of monitoring, removal and cleaning of the prosthetic right eye over the past year. This was confirmed through interview with Unit Manager #2 and the Director of Nurses on 6/17/11 at 4:30 pm. At 4:45 pm on 6/17/11, Nurse Manager reported just speaking with the ophthalmologist, and indicated that it was not necessary to remove the Resident's right eye and clean it, as this ophthalmologist reported that this removal and cleaning was not necessary unless there were signs and symptoms of an infection. Further interview with this nurse at this time, revealed that the Resident's right eye drainage which could be a sign of infection, was not reported to the ophthalmologist, during this phone call. At 4:50 pm on 6/17/11, the Director of Nurses confirmed that this eye drainage should have been reported to the ophthalmologist. On 6/21/11 at 8:05 am, Resident #5 was observed with cream colored dried drainage on the outer eyelid of the right eye. There was also redness noted under the eyelid with a section under the eye that was deep red and almost looked as if it was a scab. On 6/21/11 at 8:50 am, the Director of Nurses (DON) reported trying unsuccessfully to remove the Resident's prosthetic right eye on 6/18/11. The Director of Nurses said that this may have caused the irritation under the Resident's right eye. The DON further reported ordering an appliance (suction device) to use to remove the prosthetic eye and that the plan was to have the prosthetic eye removed and cleaned monthly by an eye doctor belonging to a health service group that saw residents at the nursing home. The DON further indicated that the Resident's eyes were very dry and that there was a new physician order, dated 6/18/11, for natural tears three times a day every shift to the right eye and twice daily to the left eye. In addition, on 6/21/11, there was a physician order: "May have (health services) remove and clean prosthetic eye monthly." The facility failed to establish a plan of care and follow the plan of care for Resident #5's eye prosthesis.

Based on record review and interviews, for one of one sampled resident (the Resident), the Facility failed to ensure adequate supervision was provided while the Resident used the merri-walker (ambulation device with seat) when on 9/4/10 at 10:50 PM, the Resident was found on the floor of a resident room, tipped over in the ambulation device. Although the Physical Therapist recommended the merri-walker to be used with direct supervision due to the Resident's impaired cognition and decreased safety awareness, the staff assigned to care for the Resident at the time of the incident were unaware of where the Resident was until the Resident was observed on the floor by a nurse arriving to work the night shift. The resident sustained [REDACTED]. The findings included: The Resident's annual Minimum Data Set assessment, dated 8/7/10, indicated the Resident had memory impairment, no recall, and moderate impairment with decision making. The assessment indicated the Resident was easily distracted and mental function varied over the course of the day. The assessment indicated the Resident wandered (defined as moved with no rational purpose and seemingly oblivious to needs or safety) and the behavior was not easily altered. The Resident's plan of care, initiates 6/19/09 and last updated during 2010, indicated the Resident was assessed as being at risk for falls due to cognitive loss, decreased coordination, medication use, and occasional urinary incontinence. The physical therapy note, dated 8/23/10, indicated the therapist discussed with the Unit Manager about the proper supervision of the Resident when in the merri-walker. The short-term goal was that the Resident needed to be supervised "at all times" in the ambulation device, The physical therapy discharge note, dated 8/26/10, indicated the re-assessment was completed to determine the Resident's ability to use the merri-walker. The note indicated the discharge recommendations were for ambulation device, "use as tolerated (with) direct supervision..." due to decreased cognition and safety. The Physical Therapist was interviewed at 3 PM on 9/23/10. The Physical Therapist said the Physical Therapist did approve the use of the merri-walker, but with supervision because the Physical Therapist wanted the staff to know where the Resident was when in the device. The Physical Therapist said the level of supervision was that the staff needed to have their eyes on the Resident and know where the Resident was while in the device to ensure the Resident was in a safe environment. The Physical Therapist said the intention was not for the Resident to use the device while not being supervised by staff and the Physical Therapist was very concerned that the Resident fell alone while in the device and staff were not aware the Resident had fallen. Physical Therapy Assistant #1 was interviewed at various times on 9/17/10. Physical Therapy Assistant #1 said the Resident was evaluated by physical therapy to determine whether an ambulation device was appropriate for use by the Resident. Physical Therapy Assistant #1 said there was no official policy on use of a merri-walker or other type of ambulation device. Physical Therapy Assistant #1 said the Resident was discharged at a supervised level from therapy. When asked by the Surveyor to explain what the level of supervision was when discharged , Physical Therapy Assistant #1 told the Surveyor that staff needed to have their eyes on the Resident at all times, but it could be from a distance. Physical Therapy Assistant #2 was interviewed at 1:50 PM on 9/17/10. Physical Therapy Assistant #2 said that generally speaking when a resident used merri-walker the staff needed to know where that resident was at all times to be able to redirect or assist the resident. The Unit Manager was interviewed at 3:40 PM on 9/17/10. The Unit Manager said the Resident was supposed to be directly supervised when using the ambulation device. The Unit Manager was asked by the Surveyor to define direct. The Unit Manager said that direct supervision was defined as keeping the resident within view of staff at all times. The nurse's note, dated 9/4/10, indicated that at 10:30 PM (later determined to be 10:50 PM) the Resident was found on the floor after having fallen from the merri-walker. The note indicated the Resident's nose was swollen and bleeding, the covering physician was informed, and the Resident was transferred to the emergency department for evaluation. The 9/5/10 nurse's note indicated the Resident returned from the emergency department at 4 AM with a [DIAGNOSES REDACTED]. Nurse #4 was interviewed at 10:35 AM on 9/29/10. Nurse #4 said the use of the ambulation device was new to the Resident. Nurse #4 said that during the night, Resident did use the ambulation device when Resident was anxious and did not want to remain in bed. Nurse #4 said the Resident was supposed to be directly supervised when in the device and the staff did the best they could, given other job responsibilities to ensure the Resident was supervised when in the device. Nurse #4 said that as Nurse #4 entered the nursing unit prior to 11 PM on 9/4/10, Nurse #4 heard the Resident moaning and when Nurse #4 looked to the right, Nurse #4 observed the Resident on the tipped over in ambulation device on the floor. Nurse #4 said that Nurse #4 did not observe any staff member near the area of in the hall, but thought Nurse #4 may have observed some activity at the nurses' station. Nurse #4 said that Nurse #4 called for the assistance of staff, who responded to assist the Resident. Nurse #1 was interviewed at 4:43 PM on 9/23/10. Nurse #1 said that at 10 PM, Nurse #1 left the nurses' station to perform treatments with the residents. Nurse #1 said that at 10:50 PM, Nurse #1 was called to a room at the end of the hall and upon entering the room, Nurse #1 observed the Resident on the floor tipped over while in the merriwalker(ambulation device). Nurse #1 said that Nurse #1 was not aware the Resident had been out of bed and in the ambulation device prior to observing the Resident on the floor. Nurse #1 said the Resident had apparent bleeding from the face and nose, and Nurse #1 contacted a physician and arranged for the Resident to be transferred to the Hospital. Nurse #1 said residents were supposed to be supervised when in a merri-walker to ensure they were in no danger, but on 9/4/10, no staff member informed Nurse #1 that the Resident needed to be left without supervision while in the device. The emergency department records, dated 9/5/10, indicated the Resident had a nasal fracture. Certified Nursing Assistant (CNA) #1 was interviewed at 5:21 PM on 9/23/10. CNA #2 was interviewed at 4:05 PM on 9/17/10. CNA #1 and CNA #2 said that they were the only nursing assistants who worked on the nursing unit after 10 PM on 9/4/10. CNA #1 and CNA #2 said the Resident attempted to get out of bed on more than one occasion during the evening of 9/4/10. CNA #1 and CNA #2 said though the staff assisted the Resident to use the bathroom and offered the Resident a snack, the Resident did not want to return to bed and therefore remained at the nurses' station with CNA #1 and CNA #2 until approximately 10:45 PM. CNA #2 said that CNA #2 and CNA #1 needed to assist the other residents with care and therefore left the Resident seated in the ambulation device at the nurses' station. CNA #1 and CNA #2 said that approximately 10 to 15 minutes later, they were called to a room at the end of the hall and upon arrival observed the Resident on the floor tipped over in the merri-walker device. CNA #2 said both nurses were seated at the nurses' station when CNA #1 and CNA #2 left the Resident but CNA #2 told the Surveyor that CNA #2 did not think the Resident required any direct supervision when in the device and was free to go and CNA #2 assumed the Resident was safe in the device. CNA #1 said that Nurse #1 was not at the nurses' station when CNA #1 and CNA #2 left the Resident at the nurses' station in the ambulation device. CNA #1 said the second nurse was at the nurses' station, but CNA #1 and CNA #2 did not inform either nurse they were leaving the Resident in the walker to go perform rounds and CNA #1 said that he could not definitely say that the second nurse was aware that CNA #1 and CNA #2 left the Resident to perform rounds. At 1:20 PM on 9/17/10, the Surveyor observed two residents in merri-walkers in the day room and at the time, the two residents were being directly observed by staff.