Every finding on record at Brewster Village

Based on interview, record review, and policy review, the facility did not ensure the resident environment was free from accident hazards for 1 resident (R) (R3) of 1 sampled resident from a total sample of 12 residents. During cares, staff raised the height of R3's bed but did not lower it prior to leaving the room. R3 fell out of bed and sustained a laceration above the left eye that required sutures. Findings include: Review of R3's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed they were admitted to the facility on [DATE] with diagnoses including weakness and Alzheimer's disease. Review of R3's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/14/26 and located under the MDS tab of the EMR, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Review of R3's care plan, initiated on 1/28/21 and located under the Care Plan tab of the EMR, revealed R3 had an activities of daily living (ADL) self-care deficit as evidenced by memory and coordination problems. The care plan contained interventions for transfer assistance of full lift and 1 assist with moving in bed. Further review revealed R3 had a potential for falls due to a history of falls and had an intervention for assistance with transferring. Review of a progress notewritten by Registered Nurse (RN) 4 revealed R3 fell out of a bed in the highest position on 5/1/26 and hit their head. R3 sustained a 2-inch cut on the left eyebrow and a swollen left eye. The note indicated R3's bed was in the highest position at 6:35 PM. At 6:41 PM, R3 was found on the floor. Further review revealed R3 returned from hospital for treatment of the left eye laceration on 5/2/26 at 1:22 AM with sutures and an order to remove the sutures in 6-7 days. Review of the facility's undated Findings Summary for the incident revealed an investigative review of the circumstances surrounding R3's unwitnessed fall indicated the fall was accidental and occurred after they attempted to get out of bed to find their spouse. It was determined that Certified Nursing Assistant (CNA) 2 did not return R3's bed to an appropriate height and left a sling underneath them when they left the room to seek help from another staff. During an interview on 8/12/26 at 1:19 PM, RN4 said they were standing at the medication closet on 5/1/26 when they heard CNA2 say, Oh no, (R3). RN4 went to R3's room and observed them on the ground with their bed in the highest position. RN4 said CNA2 stated they were changing R3 in bed and left the room without lowering the bed to its original height. RN4 indicated CNA2 was easily distracted and stated staff should never leave a resident in bed in the highest position. RN4 also stated staff should not start a transfer that requires the assistance of 2 staff without 2 staff present. RN4 stated R3 should not have been left in a high position in bed and the fall should not have occurred. During an interview on 8/12/26 at 2:20 PM, CNA3 said there should always be 2 staff present for mechanical lift transfers. CNA3 verified they worked with CNA2 on 5/1/26 and said CNA2 was supposed to change R3 and let CNA3 know when they were finished so CNA3 could assist with the transfer. CNA3 said after staff put a bed in a high position to provide care, they should lower the bed to its normal height before they leave the room. CNA3 verified R3 was a fall risk and said it was important not to leave the bed at a higher height. CNA3 said when they returned to assist with the transfer, R3 had already fallen out of bed. CNA3 said they are 5'9 tall and the bed came to their chest. CNA3 stated there were other times CNA2 forgot to lower a resident's bed. During an interview on 8/13/26 at 10:46 AM, CNA2 said they entered R3's room on 5/1/26 to get them ready for supper. CNA2 changed R3 and placed a Hoyer lift sling underneath them. CNA2 stated they raised R3's bed but didn't lower the bed before they left the room to find CNA3. CNA2 stated it was a bit chaotic at the time and they left R3's room to go downstairs but did not tell CNA3 that R3 was still in bed. When CNA2 returned to the unit, R3 was on the floor. CNA2 said when they left R3's room, they didn't expect to be gone long. CNA2 said when they observed R3 on the floor, R3's head was toward the foot of the bed and they were bleeding above the eye. CNA2 notified the nurse and verified it was not safe to leave R3's bed raised without staff present. During an interview on 8/13/26 at 12:45 PM, R3 stated they tried to get out of bed on 5/1/26. R3 said when they tried to stand up, their feet did not touch the ground because the bed was too high and they fell. During an interview on 8/13/26 at 12:44 PM, the Program Manager (PM) said R3's fall was accidental. The PM verified R3's bed was left in a raised position which didn't cause the fall but could have contributed to it. The PM verified the bed should not have been in a raised position and was unsure how high the bed was at the time of the fall.

Based on interview, record review, and policy review, the facility did not report an allegation of abuse to the State Survey Agency (SSA) in a timely manner for 2 residents (R) (R4 and R5) of 5 sampled residents from a total sample of 12 residents. R4 was yelling from their room on 6/4/26. R5 entered the room and told R4 to shut up. R4 struck R5 on the arm. The allegation of abuse was not reported to the SSA in a timely manner. Findings include: A review of the facility's Abuse, Neglect and Exploitation Prohibition policy, revised 4/2026, revealed: Nursing Home Reporting Requirements for Alleged Incidents of Abuse, Neglect, Exploitation, and Misappropriation require that facilities report allegations of mistreatment by anyone, including villager-to-villager incidents and injuries of unknown source, to the Division of Quality Assurance (DQA) if appropriate. The Administrator or designee will complete the initial and subsequent reporting to DQA utilizing the online portal. Reporting will be completed via the Misconduct Reporting System in accordance with timeliness parameters. Allegations of abuse or allegations which result in serious bodily harm to a villager are to be reported within 2 hours, other allegations are to be reported no later than 24 hours. Review of R5's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed they were admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia. Review of R5's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/8/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. Review of a nursing note, located under the Notes tab of the EMR and dated 6/4/25 at 9:19 PM by Registered Nurse (RN) 2, indicated R5 was wandering in and out of (R4's) room at 7:12 PM. R5 was next to Licensed Practical Nurse (LPN) 2 for 1:1 while staff were administering medications, however, LPN2 left for a moment. R5 became upset and entered R4's room when they heard them yelling. LPN2 heard talking in the room and asked R5 to exit the room. When LPN2 entered the room, they observed R5 standing next to R4's bed. R5 told R4 to shut up. R4 then swung and made contact with R5's arm. Review of R4's admission Record, located under the Profile tab of the EMR, revealed they were admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia, anxiety, and depression. Review of a nursing note, located under the Notes tab of the EMR and dated 6/4/26 by RN2, indicated R4 was yelling at 7:12 PM. R5 entered R4's room, walked toward them, and asked them to be quiet. LPN2 asked R5 to exit the room. As LPN2 got closer, they noted R5 was already near R4 and told them to shut up. R4 swung and made contact with R5's arm. Review of the facility's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report revealed an incident occurred between R4 and R5 on 6/4/26 at 7:12 PM, however, the SSA was not notified until 6/5/26 at 9:18 AM. During an interview on 8/13/26 at 12:44 PM, the Programs Manager (PM) stated the incident that occurred on the evening of 6/4/26 was not reported to the SSA until 6/5/26 because it did not result in serious bodily injury. The PM did not elaborate and stated they could not recall the exact circumstances. During an interview on 8/13/26 at 1:00 PM, the Director of Nursing (DON) stated the facility had 24 hours to report the incident.

Based on staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect all 122 residents residing in the facility. The facility's Legionella water management program did not include a building assessment to identify potential areas of concern where Legionella could develop. R4 was on enhanced barrier precautions (EBP). Staff did not wear appropriate personal protective equipment (PPE) during cares for R4.Findings include: The facility's Water Management Program to Reduce Legionella Growth policy and procedure indicates: Facility risk assessment has identified that potential risk areas would include building water supply system, hot water loop system, fire, and building humidification system . Centers for Disease Control and Prevention (CDC) guidance for Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, dated 6/24/21, indicates: .Describe your Building Water Systems Using Text. You will need to write a simple description of your building water system and devices. This description should include details like where the building connects to the municipal water supply, how it is distributed and where pools, hot tubs, cooling towers, and water heaters or boilers are located. An existing as built diagram of the plumbing system and fixtures may be useful in developing this description .Describe Your Building Water Systems using a Flow Diagram. In addition to developing a written description of your building water systems, you should develop a process flow diagram. The facility's Enhanced Barrier Precautions (EBP): Mitigating Multidrug-Resistant Organism (MDRO) Spread policy, revised 4/2026, indicates: EBP is indicated for high-risk villagers. High-risk will be considered anyone who has an infection or colonization of an MDRO, indwelling medical devices (except peripheral intravenous (IV)), or chronic wounds .Chronic wounds (wounds that do not follow the natural healing process). This may include but are not limited to: pressure injuries, diabetic foot ulcers, venous stasis or arterial ulcers, and non-healing surgical wounds .Identified villagers will be provided care utilizing EBP per Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines. Staff will be required to wear a gown and gloves during high-contact resident care activities .High-contact care includes but may not be limited to: Brushing teeth, combing hair, shaving, dressing, washing up including pericare, bathing/showering, assisting with toileting needs, changing bed linens, transferring, and wound dressing changes. 1. On 4/15/26, Surveyor reviewed the facility's infection prevention and control program, including the facility's Legionella Water Management Program. The facility provided documentation of the Legionella Water Management policy and temperature and flush schedules. The facility's Water Management Program did not contain a facility assessment of the building that identified potential areas of concern where Legionella could develop. Surveyor again requested the facility's Legionella assessment and was given a copy of the Legionella policy. On 4/15/26 at 12:26 PM, Surveyor interviewed Facility Operations Manager (FOM)-C who stated a policy with key points was all FOM-C had. FOM-C stated FOM-C would get back to Surveyor because FOM-C did not have what Surveyor asked for and was not aware a facility assessment was needed. On 4/15/26 at 1:32 PM, FOM-C verified the facility did not have a building assessment that identified potential areas of concern where Legionella could develop. 2. Between 4/13/26 and 4/15/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including stage 4 pressure ulcer of right buttock, osteomyelitis of vertebra, sacral and sacrococcygeal region, and carrier of other infectious diseases. R4's Minimum Data Set (MDS) assessment, dated 3/18/26, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R4 had moderately impaired cognition. A care plan, revised 3/19/26, indicated R4 had osteomyelitis of a stage 4 sacral pressure injury and was at risk for infection due to a chronic wound. The care plan contained a goal for R4 to be comfortable and remain free from infection, including active MDRO infection. The care plan contained interventions to use good hand-washing techniques before and after cares and to use EBP while R4 had a chronic wound. R4's medical record contained the following order: ~ Right ischial tuberosity pressure injury: Cleanse with hypochlorous wound cleanser. Provide a nickel thick layer of Santyl to wound bed by applying to adaptic. Place adaptic against wound bed and use to fill wound. Secure with dry gauze and tape. Cover with part of ABD pad and secure with paper tape twice daily (BID) AM and PM (dated 2/11/26) On 4/13/26 at 8:57 AM, Surveyor observed an EBP sign on R4's door. The sign indicated: Providers and staff must also: Wear gloves and gowns for the following high-contact resident care activities .transferring, dressing, and changing linens. On 4/14/26 at 11:55 AM, Surveyor observed Licensed Practical Nurse (LPN)-H complete wound care for R4's sacral pressure injury. LPN-H wore a gown and gloves during wound care. Followng wound care, LPN-H removed the gown and gloves and asked Certified Nursing Assistant (CNA)-I to assist with repositioning R4. CNA-I entered R4's room, sanitized hands, applied gloves, and assisted LPN-H with repositioning. LPN-H did not wear a gown and gloves while repositioning R4. CNA-I wore gloves during repositioning but not a gown. On 4/14/26 at 12:27 PM, Surveyor interviewed LPN-H who stated R4 was on EBP due to an open coccyx pressure injury. LPN-H verified LPN-H removed PPE after completing R4's dressing change. LPN-H confirmed LPN-H should have kept the gown and gloves on until all direct contact care, including repositioning, was completed. On 4/14/26 at 12:32 PM, Surveyor interviewed CNA-I who verified staff are required to wear a gown and gloves during all direct contact cares for residents on EBP. CNA-I indicated staff should wear a gown and gloves during cares including dressing, repositioning, and transferring. CNA-I verified CNA-I should have worn a gown while repositioning R4. On 4/15/26 at 11:06 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff should wear gowns and gloves during direct cares for residents on EBP due to close contact. DON-B verified repositioning is considered direct care and confirmed staff should have worn a gown and gloves while repositioning R4.

Based on staff interview and record review, the facility did not report an allegation of neglect to the State Agency (SA) for 1 resident (R) (R24) of 1 sampled resident.R24 reported an allegation of neglect by Van Driver (VD)-E on 3/13/26. R24 stated VD-E did not use a seatbelt or tie-downs during transport to secure R24's wheelchair in the van. VD-E made an abrupt stop which caused R24 to slide in the wheelchair and suffer rib, back, and lower extremity pain and bruising. The facility did not report the allegation of neglect to the SA.Findings include:The facility's Abuse, Neglect and Exploitation Prohibition policy, revised 7/2025, indicates: At [NAME] Village, each villager has the right to be free from abuse, neglect, and misappropriation of property. Villagers must not be subjected to abuse by anyone or mistreatment by anyone, including but not limited to, facility team members, other villagers, consultants, volunteers, team members of other agencies serving the villager, family members or legal guardians, friends or other individuals. This presumes that instances of abuse of all villagers, even those in a coma, can cause physical harm, pain, or mental anguish .It is the responsibility of all team members to immediately take action and intervene in any and all events to protect the safety and welfare of all villagers .reporting/response.[NAME] Village reports all allegations and substantiated incidents of villager's rights violations to all required agencies.On 4/13/26, Surveyor reviewed R24's medical record. R24 had diagnoses including type 2 diabetes, olecranon bursitis of right elbow, discitis, infection and inflammatory reaction due to internal left knee prosthesis, collapsed vertebra, thoracic region sequela of fracture, and paraplegia. R24's Minimum Data Set (MDS) assessment, dated 3/27/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R24 had intact cognition.An Incident Note, dated 3/13/26 at 6:52 PM, indicated R24 tipped out of R24's chair during transport back to the facility and reported stiffness throughout the lower back and lower extremities. R24 was offered Tylenol for pain. R24 asked nursing staff to look at R24's ribs which were increasingly sore. The nurse noted no redness, however, R24 expressed discomfort when minimal pressure was applied. R24's right knee was red. R24 indicated the knee could be red due to an ultrasound from a physical therapy appointment; however, the nurse noted red patches above the knee that appeared be burst blood vessels from the incident.A Physician Progress Note, dated 3/17/26 at 10:47 AM, indicated R24 was assessed. The physician noted R24 was in a wheelchair on the way back from an appointment when the van came to a sudden stop. R24 fell forward and hit R24's feet. R24 reported being stiff and sore and had bruising above the right knee.On 4/15/26 at 1:16 PM, Surveyor interviewed Program Manager (PM)-D who indicated PM-D and Director of Nursing (DON)-B discussed the incident when the incident was reported to PM-D and DON-B on the evening of 3/13/26. PM-D and DON-B concluded the incident was not reportable to the SA since there wasn't acute injury at the time. PM-D and DON-B also indicated R24 was sleeping at the time and couldn't be interviewed. PM-D indicated R24 slid forward in the wheelchair due to an abrupt stop at a stop sign. R24 was not wearing seatbelt and R24's wheelchair was not secured to the van via tie-downs. PM-D and DON-B indicated the incident was not considered an allegation of neglect on the part of VD-E and was not reported to the SA.

Based on staff interview and record review, the facility did not ensure an allegation of neglect was investigated for 1 resident (R) (R24) of 1 sampled resident.R24 reported an allegation of neglect by Van Driver (VD)-E on 3/13/26. R24 stated VD-E did not use a seatbelt or tie-downs during transport to secure R24's wheelchair in the van. VD-E made an abrupt stop which caused R24 to slide in the wheelchair and suffer rib, back, and lower extremity pain and bruising. The facility did not thoroughly investigate the allegation of neglect.Findings include:The facility's Abuse, Neglect and Exploitation Prohibition policy, revised 7/2025, indicates: At [NAME] Village, each villager has the right to be free from abuse, neglect, and misappropriation of property. Villagers must not be subjected to abuse by anyone or mistreatment by anyone, including but not limited to, facility team members, other villagers, consultants, volunteers, team members of other agencies serving the villager, family members or legal guardians, friends or other individuals .It is the responsibility of all team members to immediately take action and intervene in any and all events to protect the safety and welfare of all villagers .[NAME] Village conducts a thorough investigation of all villager-related incidents and allegations of villagers' rights violations. Upon completion of these investigations, reports are filed in compliance with current regulations .On 4/13/26, Surveyor reviewed R24's medical record. R24 had diagnoses including type 2 diabetes, olecranon bursitis of right elbow, discitis, infection and inflammatory reaction due to internal left knee prosthesis, collapsed vertebra, thoracic region sequela of fracture, and paraplegia. R24's Minimum Data Set (MDS) assessment, dated 3/27/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R24 had intact cognition. An Incident Note, dated 3/13/26 at 6:52 PM, indicated R24 tipped out of a wheelchair during transport and reported stiffness throughout the lower back and lower extremities. R24 was offered Tylenol for pain. R24 asked nursing staff to look at R24's ribs which were increasingly sore. The nurse noted no redness, however, R24 expressed discomfort when a minimal amount of pressure wa applied. R24's right knee was red. R24 indicated the knee could be red due to an ultrasound from a physical therapy appointment; however, the nurse noted red patches above the knee that appeared to be burst blood vessels from contact during the incident. A Physician Progress Note, dated 3/17/26 at 10:47 AM, indicated R24 was assessed. The physician noted R24 was in a wheelchair on the way back from an appointment when the van came to a sudden stop. R24 fell forward and hit R24's feet. R24 reported being stiff and sore and had bruising above the right knee.On 4/14/26, Surveyor reviewed the facility's incident report and investigation and noted the following:~ The facility did not interview R24 until 3/16/26. The facility did not monitor R24's right knee bruise or complete pain assessments for R24's rib, back, and lower extremity pain. ~ The facility did not interview VD-E until 3/16/26. The investigation did not contain a statement of VD-E's account of the incident. In addition, facility did not remove VD-E from driving the van pending the outcome of the investigation. (The Maintenance Director sent an email to Program Manager (PM)-D on 3/16/26 that indicated VD-E admitted VD-E did not secure R24's wheelchair in the van. VD-E's account of the incident was not documented.)~ The facility did not interview residents who use the van for transportation to see if they had similar experiences.~ The facility did not provide staff education (for others who drive the van) on the facility's safe transportation or abuse/neglect policy and procedure.On 4/15/26 at 1:16 PM, Surveyor interviewed PM-D and Director of Nursing (DON)-B. PM-D verified PM-D completed the investigation for the incident that occurred on 3/13/26. PM-D and DON-B discussed the incident and concluded since there was no acute injury at the time and R24 was sleeping and could not be interviewed, an internal investigation would be completed when R24 was available to interview. PM-D and DON-B indicated VD-E was interviewed following the incident and was educated on the facility's safe transportation and abuse/neglect policies and procedures. VD-E was also assigned Relias training regarding safe transport. Surveyor requested training documentation for VD-E. Surveyor did not receive documentation that indicated VD-E received training following the incident. DON-B stated R24 was assessed at the time of the incident and had no injuries. DON-B was not aware that R24 reported pain and discomfort and stated DON-B would check if assessments were completed. Surveyor did not recieve pain or skin assessments or documentation indicating the bruise on R24's right knee was monitored.

Based on staff and resident interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R24) of 7 sampled residents.R24 reported that Van Driver (VD)-E did not use tie-downs or a seatbelt to secure R24's wheelchair in the van during transport on 3/13/26. VD-E made an abrupt stop which caused R24 to slide in the wheelchair and resulted in rib, back, and lower extremity pain and bruising to R24's knee. Findings include:The facility's [NAME] Village Van Use (Non-Emergent Transportation) policy, revised 3/2026, indicates: To assign responsibility and coordinate use of the van .Department Leaders, Health Information Associates, and Van Drivers .2. For safety reasons .Non-certified staff are not to boost, hoist, lift, or transfer villagers. In the event there is a questionable issue during transportation, the driver is to call the Building Supervisor. Staff and villagers are required to always use seat belts. If for any reason a villager refuses or removes a safety device during transport, the driver is to call the Building Supervisor and stop transport. Transportation will not be provided if the villager refuses to wear safety equipment. The wheelchair restraint system is to always be used for transportation of villagers who are in wheelchairs, powered wheelchairs, or Broda chairs .On 4/13/26, Surveyor reviewed R24's medical record. R24 had diagnoses including type 2 diabetes, olecranon bursitis of right elbow, discitis, infection and inflammatory reaction due to internal left knee prosthesis, collapsed vertebra, thoracic region sequela of fracture, and paraplegia. R24's Minimum Data Set (MDS) assessment, dated 3/27/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R24 had intact cognition.On 4/13/26 at 10:20 AM, Surveyor interviewed R24 who indicated R24 was injured on 3/13/26 while being transported to a medical appointment. R24 stated R24 does not require a seatbelt, refuses to wear a seatbelt, and has been transported in the facility's van multiple times per week without a seatbelt. R24 stated R24 was routinely secured in the van with wheelchair tie-downs; however, VD-E did not secure R24's wheelchair with tie-downs and R24 was not wearing a seat belt during transport on 3/13/26. R24 stated VD-E made an abrupt stop at a stop sign and R24 slid out of the chair. R24 hit a tool box on the floor of the van, hit R24's right knee, and jammed R24's toes. R24 was assisted back into the wheelchair and brought back to the facility. R24 reported soreness and stiffness in the legs and back, achy ribs, and a swollen knee. A nurse assessed R24. R24 expressed frustration with the facility's follow-up and stated no one from administration spoke to R24 until 3/16/26. R24 was unsure if an investigation was completed. R24 expressed frustration with the assessment of R24's ribs, knee, legs, and back and stated R24 pain and had a swollen knee which concerned R24.An Incident Note, dated 3/13/26 at 6:52 PM, indicated R24 tipped out of a wheelchair during transport and reported stiffness throughout the lower back and lower extremities. R24 was offered Tylenol for pain. R24 asked nursing staff to look at R24's ribs which were increasingly sore. The nurse noted no redness, however, R24 expressed discomfort when minimal pressure was applied. R24's right knee was red. R24 indicated the redness could be due to an ultrasound from a physical therapy appointment; however, the nurse noted red patches above the knee that appeared to be burst blood vessels from contact during the incident. A Physician Progress Note, dated 3/17/26 at 10:47 AM, indicated R24 was assessed. The physician noted R24 was in a wheelchair on the way back from an appointment when the van came to a sudden stop. R24 fell forward and hit R24's feet. R24 reported being stiff and sore and had bruising above the right knee.On 4/16/26 at 10:49 AM, Surveyor interviewed VD-E who stated while transporting R24 to a medical appointment on 3/13/26, R24 dictated the route VD-E should take. VD-E stated VD-E did not know the area well and was driving slowly in the van. VD-E stated VD-E did not feel comfortable transporting residents and abruptly stopped at a stop sign while going approximately 5-7 miles per hour. VD-E stated R24 shifted from the wheelchair which required VD-E to put VD-E's arms under R24's arms and reposition R24 in the wheelchair. VD-E verified R24 was not wearing a seatbelt and was not secured in the van with wheelchair tie-downs. VD-E verified VD-E should not reposition residents which was a reason VD-E was uncomfortable transporting residents. VD-E stated R24 did not fall out of the wheelchair seat but reported soreness in the legs and chest. VD-E brought R24 back to the facility and informed management of the incident. VD-E stated VD-E was hired as a member of the maintenance crew and was unaware the position required VD-E to regularly trasport residents in the van. VD-E indicated VD-E had not previously worked with residents. VD-E stated the training VD-E received prior to transporting residents consisted of shadowing transportations with other members of maintenance and Facility Operations Manager (FOM)-C. VD-E then transported residents with other staff present and eventually transported residents alone. VD-E stated VD-E was informed during training that R24 refused to wear a seatbelt. VD-E was told not to use the seatbelt because R24 would refuse. VD-E stated if VD-E had to use tie-downs for a wheelchair VD-E was unfamiliar with, VD-E had to use a chart to learn how to use tie-downs to secure the wheelchair. VD-E stated VD-E received Relias training (the facility's online training system) on van transportation and safety on 4/13/26. VD-E felt VD-E should have received the training prior to transporting residents. VD-E indicated no other training was provided following the incident on 3/13/26.On 4/16/26 at 1:16 PM, Surveyor interviewed FOM-C who stated the facility has a van driver and maintenance staff also transport residents. FOM-C indicated hands-on training is provided during ride alongs to show and explain how restraints work. FOM-C stated when the trainee is comfortable with the process, the trainee completes ride alongs as the driver a few times before completing transports independently. FOM-C confirmed there is not a skills demonstration check list to indicate the trainee can demonstrate the skills and understands the transportation policy and procedure. FOM-C indicated seatbelts and wheelchair tie-downs should be used during all transports and secured prior to transport. FOM-C was not aware R24 refused to wear a seatbelt during transport. During the interview with FOM-C, Program Manager (PM)-D was present and indicated VD-E received training on the facility's safe transportation of residents and abuse/neglect policies as well as Relias training on safe transport of residents following the incident. Surveyor requested training documentation for VD-E as well as other staff who drove the van. The documentation was not provided. FOM-C indicated the safety plan going forward included an agreement that R24 would wear all safety belts during transport. FOM-C stated FOM-C updated the facility's van transportation policy after the incident to indicate all residents need to be secured before transportation which will not take place if the resident is not secured. If the resident refuses, transportation will not occur and staff will call the supervisor for direction.

Based on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to meet the needs of 2 residents (R) (R138 and R143) of 24 sampled residents.R138 had melatonin at the bedside. R138 did not have a self-administration of medication assessment or a physician order that indicated R138 could safely and accurately self-administer medication or keep medication at the bedside. R143 had four 21 milligram (mg) nicotine patches, an Incruse Ellipta 62.5 microgram (mcg) dry powder inhaler, and a Breo Ellipta 100 mcg/25 mcg dry powder inhaler at the bedside. R143 did not have a self-administration of medication assessment or a physician order that indicated R143 could safely and accurately self-administer medication or keep medication at the bedside.Findings Include:The facility's undated Self-Administration of Medications by Residents policy indicates: Residents who desire to self-administer medications are permitted to do so if the facility's Interdisciplinary Team (IDT) has determined that the practice would be safe for the resident and other residents of the facility .If the resident desires to self-administer medications, an assessment is conducted by the IDT.The IDT assessment results are recorded on the Medication Self-Administration Assessment which is placed in the resident's medical record .All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party.1. From 4/13/26 to 4/15/26, Surveyor reviewed R138's medical record. R138 was admitted to the facility on [DATE] and had a diagnosis of closed right femur fracture. R138's Minimum Data Set (MDS) assessment, dated 4/8/26, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R138's cognition was intact.An activity of daily living (ADL) care plan, dated 3/31/26, indicated R138 needed staff to monitor the risks and benefits of medications, administer medications as ordered, and update the doctor as needed.A fall care plan, dated 3/31/26, indicated R138 needed to monitor the risks and benefits of medications and for a change in mental status.On 4/13/26 at 12:30 PM, Surveyor observed liquid berry-flavored melatonin 10 mg on R138's bedside table. Surveyor interviewed R138 who stated melatonin helped R138 with sleep and R138 had taken melatonin a few times since admission.R138's medical record did not contain a self-administration of medication assessment or an order for melatonin. R138's plan of care did not indicate R138 had sleeplessness or required medication for sleep.On 4/13/26 at 1:08 PM, Surveyor interviewed Registered Nurse (RN)-F who observed the melatonin at R138's bedside with Surveyor and verified R138 should not have melatonin at the bedside. RN-F informed R138 the melatonin would be stored in the medication room.2. From 4/13/26 to 4/15/26, Surveyor reviewed R143's medical record. R143 was admitted to the facility on [DATE] and had a diagnosis of pneumonia. R143's MDS assessment, dated 4/10/26, had a BIMS score of 15 out of 15 which indicated R143's cognition was intact.R143's ADL care plan, dated 4/7/26, indicated R143 needed staff to administer medications as ordered.On 4/13/26 at 12:52 PM, Surveyor observed four 21 mg nicotine patches in an open box, an Incruse Ellipta 62.5 mcg dry powder inhaler in an open box, and a Breo Ellipta 100 mcg/25 mcg dry powder inhaler on top of the dresser next to R143's bed. Surveyor interviewed R143 who stated the medications were from home and R143 had them at the bedside since admission. R143 stated R143 did not use the medications and the nurses provided R143's medications.R143's medical record did not contain a self-administration of medication assessment.R143's medical record contained the following orders: ~ 14 mg/24-hour dose transdermal patch daily in the morning (start date: 4/7/26)~ Fluticasone-umeclidin-vilant 100 mcg/62.5 mcg/25 mcg dry powder inhaler daily (start date: 4/7/26)On 4/13/26 at 1:07 PM, Surveyor interviewed RN-F who verified R143 did not have an order to keep medication at the bedside.On 4/13/26 at 1:10 PM, Surveyor and RN-G observed the medications at R143's bedside and verified with R143 the medications were brought from home and had been at R143's bedside since admission. RN-G removed the medications from the bedside and informed R143 the medications would be stored in the medication room.On 4/14/26 at 3:39 PM, Surveyor interviewed Director of Nursing (DON)-B who stated medications should not be kept at the bedside without an order and indicated a self-administration of medication assessment should be completed.

Based on staff interview and record review, the facility did not ensure adequate supervision and assistance to prevent accidents was provided for 1 resident (R) (R1) of 3 sampled residents.On 2/11/26 at approximately 6:00 AM, R1 had an unwitnessed fall in R1's room and was sent to the emergency room (ER) at approximately 7:00 AM. X-ray results revealed a worsened left humerus fracture, an L1 spinal compression fracture, and a scalp hematoma. On 2/27/26, R1 had surgery to repair the left humerus fracture. The facility's investigation indicated the fall occurred because R1's call light was not in reach and R1 self-transferred to the bathroom. (This example is being cited at past non-compliance.) Findings include:The facility's Fall policy, revised 3/2026, indicates: The focus of care as it relates to falls is to maximize the resident's autonomy, dignity, and self-esteem while trying to reduce falls and injury related to them .fall interventions should be implemented and monitored.On 3/19/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including left humerus (upper arm bone) fracture, adjustment disorder, and weakness. R1's Minimum Data Set (MDS) assessment, dated 2/19/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 discharged from the facility on 3/7/26.An admission Note, dated 2/6/26, indicated R1 was admitted to the facility with an immobilizer on the left arm (due to a recent humerus fracture) and had pain at a level 7 out of 10. R1 had a follow-up appointment on 2/18/26. The note indicated if X-rays did not show improvement, R1 might need shoulder replacement surgery.An admission Fall Risk Assessment, dated 2/6/26, indicated R1 was at risk for falls.A care plan indicated R1 had the potential for falls due to a history of falls and a recent left shoulder fracture. The care plan contained an intervention to ensure R1's call light was within reach.An Incident Note, dated 2/11/26 at 6:45 AM, indicated staff observed R1 on the floor in R1's room at approximately 6:10 AM. R1 complained of pain to the back of the head. R1 was offered pain medication and assisted into bed. A neuro assessment was within normal limits. An immediate intervention was to ensure R1's call light was within reach. Upon review by Registered Nurse (RN)-D, it was determined that Certified Nursing Assistant (CNA)-C did not place R1's call light within reach. RN-D provided education regarding the importance of ensuring call lights are within reach of residents at all times.A Hospital admission Note, dated 2/11/26, indicated R1 sustained a fall at the facility. Repeat imaging revealed a persistent humeral fracture that was possibly more displaced. Staff attempted to control R1's pain with oral medication; however, the pain was intractable and R1 was administered intravenous (IV) pain medication. Left humerus X-ray results, dated 2/11/26, indicated R1 had a comminuted (a severe break where the bone is shattered into three or more pieces) fracture of the neck of the left humerus with lateral displaced proximal fragments.Lumbar spine computed tomography (CT) scan (a noninvasive imaging test that uses X-rays and computers to create detailed 3D images of bones, soft tissue, and blood vessels to diagnose internal injuries) results, dated 2/11/26, indicated R1 had an acute to subacute mild L1 compression fracture (a vertebral collapse at the top of the lumbar spine).A Hospital Discharge Note, dated 2/11/26, indicated R1 had an acute to subacute L1 compression fracture and a possibly increasingly displaced left humeral fracture after recurrent fall upon admission. Orthopedic surgery felt there was no need for a change in care. It was recommended that R1 continue with a sling, have follow-up orthopedic appointments, and use muscle relaxants, lidocaine, and oxycodone for pain control.R1's care plan was updated on 2/11/26 with an intervention for a pendant call light.An Orthopedic Consult Note, dated 2/20/26, indicated R1's X-rays looked worse and left humerus/total shoulder surgery was recommend for the following week. It was recommended that R1 wear a sling at all times.A Hospital Operative Note, dated 2/26/26, indicated R1 had a history of a left shoulder proximal humerus fracture with severe displacement and comminution. Given continued pain and limited motion, R1 chose reverse shoulder arthroplasty with tuberosity fixation (a surgical procedure to replace or resurface a damaged joint using artifical components to relieve severe pain and restore mobility). The risks included bleeding, infection, neurovascular injury, deep vein thrombosis (blood clot), chronic pain, limited motion, weakness, recurrent dislocation, and the need for additional surgery. A Hospital Discharge Note, dated 2/27/26, indicated R1 was treated for a closed 4-part fracture of the proximal humerus with malunion and was to be non-weight bearing to the left upper extremity. It was recommended that R1 wear a sling at all times except for showering and physical therapy.On 3/19/26 at 12:48 PM, Surveyor interviewed CNA-C who verified CNA-C worked with R1 during the night shift from 2/10/26 to 2/11/26 and last saw R1 between 4:30 and 5:30 AM. During CNA-C's last interaction with R1, CNA-C brought R1 to the bathroom and assisted R1 into R1's recliner. CNA-C verified R1's room call light was secured to the bed which was approximately 4 feet from the recliner and out of R1's reach. CNA-C stated CNA-C was educated prior to CNA-C's next shift regarding R1's fall, room call light, and pendant call light. CNA-C was not aware that R1 had a wrist call light on 2/11/26 and did not put it on R1. On 3/19/26 at 8:24 AM, Surveyor interviewed RN-D who stated RN-D was in report at approximately 6:00 AM when a staff received a call from Family Member (FM)-E that R1 had fallen and staff should check on R1. RN-D went to assess R1 and found R1 on the floor. R1 had pain in the left arm. RN-D noted R1's room call light was clipped to the bed and out of R1's reach. R1's wrist call light was in the night stand. RN-D updated the physician and FM-E and sent R1 to the ER for evaluation. RN-D stated R1 consistently used the call light and had not self-transferred any other time during R1's stay.On 3/19/26 at 8:32 AM, Surveyor interviewed FM-E who stated R1 texted FM-E at approximately 6:00 AM that R1 had fallen and needed help. FM-E was not familiar with R1's call light placement but stated R1 was able to use the call light appropriately and make R1's needs known. On 3/19/26 at 9:47 AM, Surveyor interviewed Director of Nursing (DON)-B who verified call lights should be within residents' reach at all times. DON-B stated all residents should have a call light in their room and bathroom and should also have a wrist or pendant call light. DON-B stated R1 initially had a wrist call light but was switched to a pendant call light after the fall. DON-B verified R1's call light was out of reach at the time of the fall. On 3/19/26, Surveyor reviewed a facility-reported incident (FRI) that was submitted to the State Agency (SA) regarding R1's fall with injury. The investigation indicated R1's pendant call light was in the nightstand and room call light was clipped to the bed and out of R1's reach while R1 was asleep in the recliner. R1 fell when R1 self-transferred to the bathroom. DON-B updated R1's care plan and provided education to all nursing and CNA staff to ensure call lights are in reach at all times. DON-B also completed audits to ensure residents' call lights were within reach.

Based on staff and resident interview and record review, the facility did not ensure grievances were documented, thoroughly investigated, and resolved for 2 residents (R) (R4 and R5) of 6 sampled residents.On 7/24/25, R4 and R5 reported rough care by staff during an investigation for a facility-reported incident that occurred on 7/23/25. The facility did not document the concerns a grievances, thoroughly investigate the concerns, or provide resolution for R4 and R5.Findings include:The facility's Grievance Policy and Procedure, revised 1/2024, indicates: The purpose of the grievance policy is to ensure the facility makes prompt efforts to resolve grievances .The intent of the grievance process is to support each villager's right to voice grievances ( .those about treatment, care .or violation of rights) and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution .The facility will promote the grievance process throughout the organization. This includes .Educating all those affected by potential grievances or concerns on the facility's grievance process, including but not limited to: a. Villager .c. Employees .B. Grievance Official .The facility will train and designate an individual who is responsible for .b. Receiving and tracking all grievances through to their conclusion .f. Completing written/verbal grievance resolutions/decisions to the villager involved .E. A grievance or concern can be expressed orally to the Grievance Officer or staff or in writing. F. Grievances may be given to any team member who will forward the grievance to the Grievance Officer .G. Any team member who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved, the team member shall escalate that complaint to their supervisor and the Grievance Officer. Upon receipt of a grievance or concern, the Grievance Officer will review the grievance to determine immediately if the grievance meets a reportable complaint-consistent with the facility's abuse prevention policy. The Grievance Officer will initiate the appropriate notification and investigation process .The investigation will consist of .A review of the completed complaint report, an interview with the person(s) reporting the incident if applicable, interviews with any witnesses to the incident or concern .An interview with team members having contact with the villager during the relevant periods or shifts .A root-cause analysis of all circumstances surrounding the incident .On 8/15/25, Surveyor reviewed a facility-reported incident, dated 7/23/25. The investigation indicated during resident interviews completed by Social Worker (SW)-D on 7/24/25, R4 and R5 reported rough cares by staff. R4 indicated Registered Nurse (RN)-I is rough with R4's arm and grabs R4's arm and hand when obtaining R4's blood sugar. R5 indicated an unidentified staff member pulled R5's legs roughly in the wrong direction which caused R5 pain. Surveyor reviewed the facility's grievance file which did not contain grievances from R4 or R5.On 8/15/25 at 1:24 PM, Surveyor interviewed Grievance Officer (GO)-C about grievances for R4 and R5. GO-C indicated all of the facility's grievances were contained in the grievance file. Surveyor showed GO-C copies of R4 and R5's interviews that indicated concerns with rough care and asked if grievances were filed for R4 and R5's concerns. GO-C was aware of the interviews with R4 and R5 and verified the facility did not have documented follow-up regarding the concerns. GO-C indicated if residents express a concern, the concern should be addressed.On 8/15/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including morbid obesity, type 2 diabetes, and generalized anxiety disorder. R4's Minimum Data Set (MDS) assessment, dated 6/13/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R4 had severe cognitive impairment. The MDS assessment also indicated R4 was dependent on staff for cares and mobility. R4 made R4's own healthcare decisions.A progress note, dated 6/11/25, indicated R4 had a Power of Attorney for Healthcare (POAHC) that was not activated.On 8/15/25 at 2:08 PM, Surveyor interviewed R4 regarding R4's report of rough care from RN-I. R4 indicated RN-I is still rough and pulls/grabs R4's arm and fingers during blood sugar checks. R4 confirmed R4 informed SW-D about the concern and also informed RN-I that R4 did not like the treatment. R4 indicated SW-D did not follow-up on the concern. R4 denied pain or bruising, but stated R4 does not like to be grabbed and it is rude the way RN-I talks and grabs R4's fingers. R4 indicated R4 feels safe at the facility.On 8/15/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including chronic pain syndrome, anxiety disorder, and spinal stenosis. R5's MDS assessment, dated 6/23/25, indicated R5 had a BIMS score of 00 out of 15 which indicated R5 had severe cognitive impairment. The MDS assessment also indicated R5 required substantial assistance with mobility such as rolling left and right. R5 had an activated POAHC for healthcare.Surveyor noted R5's plan care did not contain an intervention to handle R5's legs carefully.On 8/15/25 at 2:13 PM, Surveyor interviewed R5 who indicated staff are rough and pull R5's legs which causes pain. R5 indicated R5's legs did not currently hurt and R5 feels safe at the facility.On 8/15/25 at 2:20 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-G and CNA-H who were not aware of R5's concern.On 8/15/25 at 2:25 PM, Surveyor interviewed SW-D who confirmed SW-D completed resident interviews for the facility-reported incident on 7/23/25 but did not recall R4 and R5's concerns and indicated the interviews were given to GO-C. SW-D indicated either SW-D or GO-C should have followed-up and asked if R4 and R5 wanted to file a grievance. SW-D did not know which staff R5 referrred to in the interview. SW-D stated SW-D immediately followed-up with staff after learning of R5's concern so staff would be more careful with R5's legs. SW-D could not recall who SW-D followed-up with but indicated SW-D did not follow-up with RN-I. SW-D was unsure if the staff education was documented and indicated SW-D would check for documentation and follow-up with Surveyor. (The documentation was not provided.)On 8/15/25 at 2:35 PM, Surveyor interviewed RN-F who was aware R5 had concerns about the way staff handled R5's legs which caused pain.On 8/15/25 at 2:38 PM, Surveyor interviewed RN-E who was not aware of rough cares reported by R4 or R5.On 8/15/25 at 4:28 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should have followed-up on R4 and R5's concerns and should have filed grievances.

Based on staff interview and record review, the facility did not ensure a physician was notified of a change in condition for 1 resident (R) (R56) of 7 sampled residents. R56's physician was not notified of skin wounds until 7 days after the wounds were discovered. Findings include: The facility's Notification of Change in Condition/Treatment policy, dated 2/2024, indicates: .Significant changes in the villager's physical, mental, or psychosocial status, or accidents/other incidents shall be reported to the Physician/Nurse Practitioner by the Licensed Nurse .the date, time, and who was notified shall be documented in the villager's medical record . On 1/6/25, Surveyor reviewed R56's medical record. R56 was admitted to the facility on [DATE] and had diagnoses including urinary tract infection (UTI), neurocognitive disorder with Lewy bodies (a form of progressive dementia that affects a person's ability to think, reason, and process information), dementia, type 2 diabetes, and erythema intertrigo (a type of skin rash). R56 had an activated Power of Attorney for Healthcare (POAHC) who was responsible for R56's medical decision-making. R56's Minimum Data Set (MDS) assessment, dated 11/27/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R56 had moderate cognitive impairment. R56's medical record contained nursing progress notes that indicated R56 had 2 small skin shearing areas on the coccyx that were identified on 11/26/24. The nurse initiated barrier cream, a pressure reducing pad on R56's bed and chair, and frequent turning/repositioning. A nursing assessment, dated 11/26/24. indicated the wounds were moisture-associated skin damage (prolonged exposure to excessive moisture) most likely due to urinary and/or stool incontinence. A different barrier cream was ordered and a task was initiated to update the wound team if the wounds worsened. A nursing assessment, dated 12/2/24, indicated the wounds were unstageable pressure injuries. The physician was updated regarding the wounds and treatment plan. On 1/8/25 at 12:15 PM, Surveyor interviewed wound care certified Registered Nurse (RN)-G who verified R56 had preventative skin impairment measures implemented upon admission, including a cushion in R56's chair and repositioning every 2 hours in bed and every hour in chair. RN-G verified the wounds on R56's coccyx were identified on 11/26/24. RN-G verified R56's physician was not notified until 12/2/24 when the wounds were diagnosed as unstageable. RN-G indicated the physician should have been notified when the wounds were discovered on 11/26/24. On 1/8/25 at 1:27 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the physician should have been notified of R56's wounds on 11/26/24.

Based on staff interview and record review, the facility did not ensure vaccines were offered for 2 residents (R) (R80 and R36) of 5 sampled residents. R80 and R36 were not offered Prevnar 20 (PCV20) vaccines. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13(R)) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20(R)) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23(R)) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults [AGE] years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. For adults [AGE] years or older who have received PCV13, give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. The facility's Pneumococcal Vaccine policy, revised 5/2024, indicates: All villagers [AGE] years of age or older should be offered the pneumococcal vaccine unless medically contraindicated. For adults [AGE] years and older who have not previously received any pneumococcal vaccine, the CDC recommends you give 1 dose of PCV20. If PCV20 is used, their pneumococcal vaccinations are complete. For adults [AGE] years or older who have only received a PPSV23, the CDC recommends you give 1 dose of PCV20. The PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Their pneumococcal vaccinations are now complete. For adults [AGE] years and older who have only received PCV13, the CDC recommends you give 1 dose of PCV20. The PCV20 dose should be administered at least one year after the most recent PPSV13 as previously recommended. Their pneumococcal vaccinations are now complete. For Adults [AGE] years or older who have received the PVC20, their pneumococcal vaccinations are complete. 1. From 1/6/25 to 1/8/25, Surveyor reviewed R80's medical record. R80 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's dementia. R80's Minimum Data Set (MDS) assessment, dated 10/22/24, indicated R80 had severely impaired cognition. R80 had an activated Power of Attorney (POA). R80's medical record indicated R80 declined the PCV13 and PPSV23 vaccines on dated 6/11/21. R80's medical record did not indicate R80 was offered or received the PCV20 vaccine. 2. From 1/6/25 to 1/8/25, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's dementia. R36's MDS assessment, dated 12/27/24, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R36 had moderately impaired cognition. R36 had an activated POA. R36's medical record indicated R36 received the PCV13 vaccine on 6/20/16 and the PPSV23 vaccine on 3/5/08 (at [AGE] years of age). R36's medical record did not indicate R36 was offered or received the PCV20 vaccine. On 1/8/25 at 1:15 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R80 and R36 were not offered the PCV20 vaccine. According to the CDC guidelines, DON-B verified the PCV20 vaccine should have been offered to R80 and R36.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R78 and R22) of 5 sampled residents observed during the provision of care. In addition, the facility did not have the appropriate transmission-based precautions in place for 1 (R214) of 3 sampled residents. Certified Nursing Assistant (CNA)-C did not appropriately cleanse hands or change gloves during incontinence care for R78. R22 was on enhanced barrier precautions (EBP). CNA-M and CNA-N did not don the appropriate personal protective equipment (PPE) during care for R22. R214 had a diagnosis of pneumonia and was symptomatic. R214 was not on droplet precautions. Findings include: The Facility's Hand/Hygiene Policy, dated 4/24, indicates: Hand hygiene is considered the single most important approach for preventing the spread of infection .Guidelines: 1. Cleanse your hands either with soap and water or alcohol-based hand gel: Before and after villager contact; Before and after any contact with villager environment, belongings, or equipment; Before and after wearing gloves; After moving from a dirty to clean area (i.e., moving between body sites, after touching any unsanitized area on a surface before touching anything else); During cares. The Facility's Enhanced Barrier Precautions Policy, dated 8/22, indicates: 1. EBP is an infection prevention and control intervention to reduce the spread of multidrug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high-contact resident care activity .EBP is primarily intended to apply to care that occurs within a resident's room where high-contact resident care activities, including transfers, are bundled together with other high-contact activity, such as part of morning or evening care. This extended contact with the resident and their environment increases the risk of MDROs spreading to staffs' hands and clothes .5. EBP is indicated .for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. The facility's Infection Surveillance policy, revised 8/2024, indicates: .1. When a resident exhibits signs/symptoms of a suspected infection .RN: .Review and ensure all policies and procedures are followed specific to presenting symptoms. C. Infection/Preventionist/Nursing Supervisor: .Monitor documentation until symptoms resolve and ensure interventions are initiated and appropriate. The Centers for Disease Control (CDC) at CDC.gov indicates: Transmission based precautions are the second tier of basic infection control and are to be used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use droplet precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. 1. From 1/6/25 to 1/8/25, Surveyor reviewed R78's medical record. R78 was admitted to facility on 12/28/23 and had diagnoses including Parkinson's disease, dementia, urinary retention, overactive bladder, obstructive uropathy, benign prostatic hyperplasia (BPH), and urogenital implants. R78's Minimum Data Set (MDS) assessment, dated 12/26/24, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R78 was severely cognitively impaired. The MDS also indicated R78 was dependent on staff for transfers, hygiene, toileting and dressing. R78 had a history of urinary tract infections (UTIs) on 8/20/24 and 10/12/24. On 1/8/25 at 9:24 AM, Surveyor observed CNA-C and CNA-D provide catheter care for R78. CNA-C and CNA-D washed hands and donned gloves. CNA-C washed R78's face, hands, and under arms with a wash cloth. CNA-C and CNA-D then unfastened R78's soiled brief. CNA-C cleansed R78's Foley catheter tubing from the suprapubic site downward and dried the tubing with a towel. CNA-C and CNA-D then rolled R78 on the left side and CNA-C removed R78's soiled brief. With the same soiled gloves, CNA-C cleansed R78's buttocks from front to back two times. With the same soiled gloves, CNA-C applied barrier cream to R78's buttocks. CNA-C then removed the right glove and donned a clean glove without washing or sanitizing CNA-C's right hand. CNA-C and CNA-D then put a clean brief underneath R78. CNA-C touched the clean brief, R78, and R78's sheets. With the same soiled gloves, CNA-C fastened R78's brief and put a clean shirt on R78. CNA-C then bagged the soiled linens and brief, removed gloves, and washed hands. On 1/8/25 at 9:42 AM, Surveyor interviewed CNA-C who verified CNA-C did not appropriately change gloves or cleanse hands during the provision of care for R78. 45943 2. From 1/6/25 to 1/8/25, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis (MS), anxiety, and obstructive and reflux uropathy. R22's MDS assessment, dated 11/13/24, indicated R22 was not cognitively impaired. R22 was R22's own decision maker. R22 had a urostomy due to incontinence and was on EBP. On 1/7/25 at 1:41 PM, Surveyor observed an EBP sign on R22's door and observed CNA-M empty R22's urostomy bag while wearing a gown, gloves, and a mask. CNA-M then removed CMA-M's gown and gloves and called for assistance. On 1/7/25 at 1:51 PM, Surveyor observed CNA-M and CNA-N reposition R22 with pillows. CNA-M and CNA-N wore masks, but did not wear gowns and gloves when repositioning R22. CNA-M and CNA-N touched R22, R22's bed linens, and R22's pillows. On 1/7/25 at 1:57 PM, Surveyor interviewed CNA-M and CNA-N who verified CNA-M and CNA-N should have worn gowns and gloves while providing care for R22. CNA-M indicated EBP should be used when providing care to residents who have catheters, wounds, tube feedings, and ostomies. On 1/8/25 at 11:52 AM, Surveyor interviewed Director of Nursing (DON)-B who verified EBP should be used during high-contact care when a resident has an indwelling device, chronic wound, or history of an MDRO. DON-B verified repositioning a resident is considered high-contact care. DON-B also indicated DON-B expects staff to complete hand hygiene after removing soiled gloves before donning clean gloves. DON-B indicated R22 did not have an MDRO but verified R22 had a wound and a urostomy. 43361 3. From 1/6/25 to 1/8/25, Surveyor reviewed R214's medical record. R214 was admitted to the facility on [DATE] and had diagnoses including pneumonia and muscle weakness. R214's MDS assessment, dated 12/3/24, had a BIMS score of 11 out of 15 which indicated R214 had moderate cognitive impairment. On 1/6/25 at 10:03 AM, Surveyor observed R214 in R214's room and noted a contact precautions sign on R214's door. A progress note, dated 1/3/25 at 5:25 PM, indicated new orders were received to start IM (intramuscular) Rocephin 1 gram with lidocaine for 5 days. A progress note, dated 1/4/25 at 9:53 PM, indicated R214 had a respiratory condition with fatigue and an occasional cough. A progress note, dated 1/5/25 at 2:59 PM, indicated R214 had an ongoing change in condition, including poor appetite and poor oral intake. R214 took sips but refused all AM meds due to nausea and spitting up mucus. A progress note, dated 1/6/25 at 3:33 PM, indicated R214 had pneumonia, respiratory fatigue, and a productive cough with green/yellow phlegm. R214's lungs were diminished bilaterally with even respirations. R214 had an unlabored frequent cough. On 1/7/25, Surveyor noted R214 was no longer on precautions and there was no precautions sign or PPE cart outside R214's room. On 1/8/25 at 11:41 AM, Surveyor interviewed Registered Nurse (RN)-H who verified R214 was on precautions on 1/6/25 but was taken off because R214 had pneumonia. RN-H indicated R214 exhibited symptoms and was placed on contact precautions during testing. When Surveyor indicated R214's progress notes indicated R214 was coughing up phlegm, RN-H verified that was correct. RN-H indicated R214 was not leaving R214's room and was started on Hospice that morning. RN-H also indicated staff were wearing masks throughout the facility. On 1/8/25 at 12:40 PM, Surveyor interviewed DON-B. When Surveyor indicated R214's progress notes indicated R214 coughed up yellow and green phlegm on 1/6/25 and was currently on an antibiotic for pneumonia, DON-B indicated if R214 was still coughing up sputum, R214 should be on droplet precautions. DON-B also confirmed staff should change their masks upon exiting R214's room.

Based on staff interview and record review, the facility did not ensure adequate monitoring for 1 resident (R) (R47) of 5 residents reviewed for psychotropic medications. R47 was prescribed diazepam (an antianxiety medication), quetiapine fumarate (an antipsychotic medication), and mirtazapine (an antidepressant medication). R47's medical record did not contain monitoring interventions for adverse reactions to the psychotropic medications. Findings include: The facility's undated Psychotropic Drug Monitoring policy indicates: Psychotropic medication is any medication that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to .antipsychotic, antidepressant, antianxiety, and hypnotic .Residents who receive psychotropic medications are monitored to evaluate the effectiveness of the medication. Every effort is made to ensure the residents receiving these medications obtain the maximum benefit with the minimum of untoward effects. Procedure: .Effects of the medications are documented as a part of the care planning process .4) The need for and response to therapy are monitored and documented in the resident's medical record .Psychotropic drug monitoring guidelines include but may not be limited to: Antianxiety/Sedative Drugs: .2) Behavioral monitoring charting or similar mechanisms are used to document the resident's need for and response to drug therapy. Antidepressants: .3) The resident's subjective and/or objective improvement or maintenance of function is documented. 4) The resident is evaluated periodically for continued need for the antidepressant medication .Antipsychotics: .2) Residents receive antipsychotic medication only for behaviors that are quantitatively and objectively documented through the use of behavioral monitoring charts or a similar mechanism. 3) Residents receive antipsychotic medication only for behaviors that are persistent, that are not caused by preventable reasons, and are causing the resident to: a) Present a danger to self or others. b) Continuously scream, yell, or pace. c) Experience psychotic symptoms (such as hallucinations, paranoia, delusions) .6) Residents who are receiving antipsychotic drug therapy are adequately monitored for significant side effects of such therapy . From 1/6/25 to 1/8/25, Surveyor reviewed R47's medical record. R47 was admitted to the facility on [DATE] with diagnoses including non-traumatic brain dysfunction (anoxic brain injury), insomnia, bipolar disorder, and severe unspecified dementia with agitation. R47's Minimum Data Set (MDS) assessment, dated 10/23/24, indicated R47 was rarely/never understood. R47 had a Guardian. R47's medical record contained the following psychotropic medication orders: ~ diazepam 5 milligram (mg) tablet three times daily (TID) for anxiety/bipolar disorder ~ quetiapine fumarate 300 mg every morning for bipolar disorder ~ quetiapine fumarate 200 mg two times daily (BID) for bipolar disorder ~ mirtazapine 30 mg at bedtime (HS) for major depressive disorder R47's medical record did not contain monitoring interventions for adverse reactions to the psychotropic medications. On 1/8/25 at 11:13 AM, Surveyor interviewed Registered Nurse (RN)-L regarding psychotropic side effect/adverse reaction monitoring for R47. RN-L reviewed R47's medical record and indicated RN-L could not find any monitoring interventions for R47's psychotropic medications. RN-L and Surveyor reviewed R47's Medication Administration Record (MAR) and care plan which did not contain side effect/adverse reaction monitoring interventions. On 1/8/25 at 11:26 AM, Surveyor interviewed Director of Nursing (DON)-B who verified there were no adverse reaction psychotropic medication monitoring interventions in R47's medical record.

Based on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to meet the needs of 1 resident (R) (R99) of 29 sampled residents. On 1/7/24 at approximately 2:00 PM, Surveyor observed a tube of 1% hydrocortisone (anti-itch cream) cream on a shelf under R99's refrigerator. Findings include: The facility's undated Self-Administration of Medications by Residents policy indicates: .If the resident desires to self-administer medication, an assessment is conducted by the Interdisciplinary Team .If the resident demonstrates the ability to safely self-administer medication, a further assessment of the safety of bedside medication storage is conducted .The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if unlocked storage is ineffective .The beside medication record is reviewed on each nursing shift, and the administration information is transferred to the Medication Administration Record (MAR) kept at the nursing station. Notation of each self-administered dose is made by placing a check mark in the appropriate space . On 1/6/25, Surveyor reviewed R99's medical record. R99 was admitted to the facility on [DATE] and had diagnoses including acute kidney failure, chronic respiratory failure, type 2 diabetes, end stage renal disease, and dependence on renal dialysis (blood purifying treatment given when kidneys are not functioning). R99's Minimum Data Set (MDS) assessment, dated 10/24/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R99 did not have impaired cognition. R99 was responsible for R99's medical decision-making On 1/7/25 at 1:01 PM, Surveyor interviewed R99 and R99's daughter. R99 indicated via a Spanish interpreter that R99 needed an ointment. R99's daughter indicated R99 complained of an itchy back and R99's daughter applied Vasoline or a prednisone-like cream that was kept under R99's refrigerator when R99's daughter visited, including yesterday. On 1/7/25 at approximately 2:00 PM, Surveyor observed an open tube of 1% hydrocortisone cream on a shelf under R99's refrigerator. On 1/7/25 at approximately 2:30 PM, Surveyor reviewed R99's medical record which did not contain a self-administration of medication assessment or a medication storage assessment. On 1/7/25 at 3:51 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R99 did not have a self-administration of medication assessment, therefore, no medications should be in R99's room.

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R99) of 1 resident received appropriate dialysis care and services. R99 received dialysis services. R99 did not have a dialysis care plan to ensure coordination of care and monitoring of R99's fistula (a surgically created connection between an artery and a vein in the arm). Findings include: The facility's Dialysis Coordination policy, dated 6/2024, indicates: Each villager that has outpatient dialysis services will be monitored for risk factors and complications which may include .Access Site Monitoring: .Nursing will .initiate hemodialysis (HD) care plan . On 1/6/25, Surveyor reviewed R99's medical record. R99 was admitted to the facility on [DATE] and had diagnoses including acute kidney failure, chronic respiratory failure, type 2 diabetes, end stage renal disease, and dependence on renal dialysis (blood purifying treatment given when kidneys are not functioning). R99 was responsible for R99's healthcare decisions. R99's Minimum Data Set (MDS) assessment, dated 10/24/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R99 did not have impaired cognition. On 1/6/25 at 1:30 PM, Surveyor interviewed R99 (with R99's daughter interpreting). R99 indicated staff did not consistently assist R99 with personal hygiene prior to leaving the facility for dialysis. R99 indicated R99 still had on pajama pants because R99 did not receive assistance that day which was a dialysis day. On 1/7/25 at 12:37 PM, Surveyor reviewed R99's plan of care, dated 7/16/24, which did not contain a dialysis care plan and did not indicate R99 attended dialysis or had a right arm fistula. The care plan indicated R99 needed help with daily hygiene in the morning including set-up with oral care and assistance with dressing. On 1/7/25 at 1:01 PM, Surveyor interviewed R99 via a Spanish interpreter service. R99 indicated dialysis staff monitor R99's fistula, but facility staff do not. On 1/7/25 at 3:30 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R99's plan of care should include dialysis and fistula monitoring. DON-B indicated Certified Nursing Assistants (CNAs) should know when R99 has dialysis appointments and should know not to check R99's blood pressure on the right arm due to R99's fistula.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R10) of 3 sampled residents received the necessary care and treatment for oxygen therapy. R10 had a physician order for 2-6 liters per minute (LPM) of oxygen and used oxygen continuously. R10 did not have a care plan for oxygen use. In addition, R10's oxygen tubing was not changed after R10 was diagnosed with pneumonia. Findings include: The facility's undated Changing of Disposable Respiratory Supplies policy indicates: Nasal cannula and oxygen tubing: Change when device becomes soiled, discolored, stiff or every 3 months. Discard if resident recently had a respiratory infection. From 1/6/25 to 1/8/25, Surveyor reviewed R10's medical record. R10 had diagnoses including congestive heart failure (CHF), dementia, and pneumonia. R10's Minimum Data Set (MDS) assessment, dated 2/2/24, had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R10 had severe cognitive impairment. R10 had a physician order, dated 10/23/24, for 2-6 LPM of oxygen via nasal cannula. R10's medical record did not contain a care plan for oxygen use. R10's medical record indicated R10 was diagnosed with pneumonia on 10/23/24 and had orders for a chest X-ray, antibiotics, and oxygen. R10's medical record did not contain documentation that indicated R10's nasal cannula and oxygen tubing were changed from 10/24/24 to 1/6/25 even though the facility's policy indicated respiratory devices should be discarded if a resident had a recent respiratory infection. On 1/6/25 at 9:35 AM, Surveyor observed R10 using oxygen at 2 LPM via nasal cannula. On 1/7/25 at 9:01 AM, Surveyor interviewed Registered Nurse (RN)-E who indicated R10's medical record did not indicate when R10's oxygen tubing was last changed. RN-E indicated there should be documentation on R10's Treatment Administration Record (TAR) to verify when oxygen tubing is changed. On 1/8/25 at 11:24 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R10 should have had a care plan for oxygen therapy and indicated a care plan was added on 1/7/25. DON-B indicated residents' oxygen tubing should be changed every 7 days and with a respiratory infection.

Based on observation and staff interview, the facility did not ensure call lights were within reach for 3 residents (R) (R80, R83, and R93) of 4 sampled residents. During multiple observations between 1/6/25 and 1/8/25, R80 did not have a call light within reach. On 1/8/25, R83 was observed without a call light within reach. On 1/6/25, R93 was observed without a call light within reach. Findings include: The facility did not have a policy on ensuring call lights were within reach of residents. 1. From 1/6/25 to 1/8/25, Surveyor reviewed R83's medical record. R83 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, generalized anxiety disorder, major depressive disorder, and encounter for palliative care. R83's Minimum Data Set (MDS) assessment, dated 10/29/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R83 had moderately impaired cognition. R83's activities of daily living (ADL) care plan contained an intervention (dated 3/8/23) that indicated: I use the following notification devices: wall call light On 1/6/25 at 9:53 AM, Surveyor observed R83 in bed asleep. Surveyor noted R83's call light was wrapped around the lower rail of R83's bed and hung toward the floor. Surveyor noted had bilateral hand contractures. On 1/7/25 at 10:57 AM, Surveyor observed R83 in bed covered with blankets with R83's hands exposed. R83's call light was wrapped around a bed rail and hung toward the floor. When Surveyor asked if R83 could reach the call light, R83 said no. When Surveyor asked what R83 would do if R83 needed help, R83 indicated R83 didn't know. When asked if R83 wanted the call light within reach, R83 said yes. Surveyor then exited R83's room and found Registered Nurse (RN)-I who verified R83's call light was not within reach. RN-I indicated R83's call light should be within reach. RN-I indicated Hospice staff just gave R83 a shower and probably forgot to give R83 the call light. Surveyor informed RN-I of Surveyor's observation on 1/6/25 when R83's call light was also not within reach. RN-I indicated RN-I would provide education. On 1/8/25 at 9:00 AM, Surveyor observed R83 in bed and noted R83's call light was again wrapped around the lower rail of the bed and hung toward the floor out of R83's reach. On 1/8/25 at 9:02 AM, Surveyor showed Certified Nursing Assistant (CNA)-J R83's call light. CNA-J verified R83 was unable to reach the call light. CNA-J indicated R83's hands were so contracted that CNA-J did not think R83 could push the call light. When Surveyor asked if a soft touch call light had been tried with R83, CNA-J didn't think so but stated CNA-J would ask. 2. From 1/6/25 to 1/8/25, Surveyor reviewed R80's medical record. R80 was admitted to the facility on [DATE] and had diagnoses including aphasia, cerebral infarction due to thrombosis of right middle cerebral artery, vascular dementia, and hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebral infarction affecting the left non-dominant side. R80's MDS assessment, dated 10/22/24, indicated R80 was severely cognitively impaired. R80's ADL care plan contained an intervention (dated 6/10/21) that indicated: I use the following notification devices: wall call light. On 1/8/25 at 9:00 AM, Surveyor observed R80 in a Broda chair in R80's room. R80's call light was wrapped around the lower rail of R80's bed approximately 3 feet from R80's Broda chair. R80 was not able to mobilize R80's self in the chair and was unable to answer Surveyor's questions. On 1/8/25 at 9:02 AM, Surveyor interviewed CNA-J who confirmed R80's call light was out of reach. When CNA-J gave R80 the call light, R80 pushed the call light repeatedly. CNA-J indicated R80 did not know how to use the call light. When Surveyor asked CNA-J to place the call light in R80's lap, R80 picked up the call light and pushed it. Surveyor asked CNA-J if the facility had tried a soft touch call light or other type of call light. CNA-J did not know. On 1/8/25 at 11:10 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility did not have a policy regarding call light access and indicated it was a standard of care for residents to have call lights within reach. DON-B indicated the facility had different options for call lights. If a resident isn't mobile, DON-B indicated DON-B expects a resident's call light to be within reach despite the resident's cognitive level. 50479 3. From 1/6/25 to 1/8/25, Surveyor reviewed R93's medical record. R93 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's dementia and left-sided hemiplegia (weakness on one side of the body). R93's MDS assessment, dated 8/21/24, indicated R93 had moderate cognitive impairment. R93's most recent MDS assessment did not contain a BIMS assessment. R93's care plan, dated 7/6/23 with a goal of 2/11/25, stated, I have potential for falls .ensure my call light is within reach. On 1/6/25 at 10:52 AM, Surveyor observed R93 in a chair in R93's room. Surveyor noted R93's call light was hanging next to R93's bed which was across the room and not within R93's reach. On 1/6/25 at 10:57 AM, Surveyor interviewed CNA-K who confirmed R93's call light was not within reach and placed the call light within reach of R93.

Based on observation, resident and staff interview, and record review, the facility did not ensure 1 resident (R) (R99) of 1 sampled resident was able to be informed of and participate in medical treatment/medical decisions in a language R99 could understand. R99's primary language was Spanish. R99 indicated a preference for staff to use interpreter services to ensure R99 could communicate medical treatment needs. Interpreter services were not consistently provided. In addition, R99's care plan did not address R99's language barrier. Findings include: The facility's undated Communication with Sensory Impaired Villagers policy indicates: .Interpreters and auxiliary aids will be provided at no cost to the villager. Villagers requiring an interpreter or an auxiliary aid should indicate to our staff that these services are required .Upon admission or as the need arises, the Minimum Data Set (MDS) Coordinator or the Social Worker shall assess the need for special communication provisions to sensory-impaired individuals, and document any need in the medical record .Upon initial review of the medical record, the Social Worker shall assist the villager and/or family members, and arrange for special communication provisions as desired . The facility's Care Planning Procedure policy, dated 10/2024, indicates: .care plan is developed that includes measurable objectives and time tables to meet the villager's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment .Each individual has the right to determine the care and treatment they wish for themselves .Aspects of villager life for the team to discuss and consider for care plan approaches will include, but not be limited to: Personal Care .Dietary/Cultural preferences .Communication/memory . On 1/6/25, Surveyor reviewed R99's medical record. R99 was admitted to the facility on [DATE] and had diagnoses including acute kidney failure, chronic respiratory failure, type 2 diabetes, end stage renal disease, and dependence on renal dialysis. R99's MDS assessment, dated 10/24/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R99 was not cognitively impaired. R99's MDS assessment, dated 10/30/24, indicated R99's preferred language was Spanish and R99 preferred an interpreter to communicate with a doctor or healthcare staff. R99 was responsible for R99's healthcare decisions. R99's care plan did not address communication including the need for an interpreter or list the language that R99 understood. A Social Services progress note, dated 7/16/24 (prior to admission), indicated R99 spoke Spanish and an interpreter would be needed as appropriate. A Social Services progress note, dated 10/24/24, indicated the Social Worker spoke with R99 through R99's cousin (as a translator) when R99 returned from a medical appointment. A Social Services progress note, dated 11/15/24, indicated the Social Worker spoke with R99 through R99's cousin's wife (who served as a translator) regarding Medicaid liability. In addition, multiple nursing progress notes from 7/16/24 through 11/15/24 indicated there was a communication barrier as R99 spoke Spanish and minimal English. The notes indicated R99 could answer basic questions and did well with gestures. On 1/7/25 at 1:01 PM, Surveyor interviewed R99 via a Spanish interpreter. Through the interpreter, R99 indicated R99 had difficulty communicating R99's needs to staff. R99 indicated R99's daughter communicated R99's needs to staff, however, R99's daughter was not always available to help. R99 indicated when R99 was admitted to the facility staff offered the use of an interpreter, however, staff don't offer an interpreter anymore. R99 indicated R99 primarily communicates with gestures or very simple questions from staff but preferred staff use an interpreter so R99 could understand and communicate better. R99 indicated R99 tried to communicate to staff that R99 needed medication for itchiness but was not successful. R99 stated R99's daughter puts cream on R99's itchy back but does not come daily to apply the cream and R99 is still itchy. R99 indicated staff did not inform R99 how to request an interpreter. R99 reiterated a second time that R99 preferred staff use an interpreter instead of waiting for R99's daughter to translate. R99 stated when R99 tried to tell staff that R99 disliked a breakfast food, staff gave R99 more of the food R99 disliked. R99 indicated that occurred because because R99 could not communicate R99's likes and dislikes to staff. On 1/7/25 at 1:01 PM, Surveyor observed a piece of paper with an interpreter contact number taped on R99's closet door approximately 5 feet off the ground which was above the line of sight for R99 who was wheelchair bound. On 1/7/25 at 2:13 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated when R99 wakes up at 7:00 or 7:15 AM, staff bring hygiene supplies. CNA-F indicated CNA-F would use an interpreter if CNA-F did not understand R99, however, R99 could speak a little English and use gestures to communicate. CNA-F indicated there was an interpreter phone number on the phone that CNA-F carried. CNA-F indicated if staff did not understand R99, an interpreter would be called. On 1/7/25 at 3:03 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R99 was able to communicate with staff via simple questions and answers. DON-B indicated more complex things were translated through R99's daughter. DON-B stated staff have access to an interpreter on the facility's phones. DON-B indicated nurses complete assessments for R99 by asking simple questions. Surveyor informed DON-B that R99 complained of itchiness that R99 was not able to communicate to nursing staff. DON-B indicated R99 should be able to initiate a conversation with staff. DON-B confirmed R99's care plan did not address a language barrier.

Based on staff interview and record review, the facility did not ensure coordination of Hospice services for 3 Residents (R) (R104, R20, and R54) of 3 residents reviewed for Hospice services. R104 received Hospice services. The facility did not have a Hospice care plan or visit notes and did not have a facility care plan regarding Hospice services. R20 received Hospice services. The facility did not have a Hospice care plan or visit notes. R54 received Hospice services. The facility did not have Hospice care plan or visit notes. Findings include: The facility's Hospice Services policy, with a revised date of 1/2023, indicated: .9. Hospice nurses touch base with the Neighborhood Coordinator or .Nurse on each visit. Other Hospice staff contact the Neighborhood Coordinator, SW (Social Worker), or Nurse at their discretion. 10. Hospice staff document in the Hospice section and on the Physicians Orders within the health record. The facility's Hospice contract, with a review date of 2/19/21, indicated: .Plan of Care: a written plan prepared for each hospice patient, containing an assessment of the patient's needs, identification of services to be provided, and a detailed description of the scope and frequency of services needed to meet the patient's and his or her family's needs. The Plan of Care specifies which services and supplies are related to the patient's terminal illness, and, therefore will be furnished by Hospice. Part II. Services to be provided by Hospice - B. Hospice will develop, at the time a resident of the Facility is admitted into Hospice's program, a Plan of Care for the management and palliation of the resident's terminal illness .The plan of care will be updated as often as the patient condition requires, but no less frequently than every 15 days. Any changes in the Plan of Care must be discussed with the Hospice patient or his or her representative and the Facility's representatives and must be approved by the Hospice before being implemented. C. Hospice will furnish a copy of each Hospice patient's care plan to the facility at the time of the resident's admission into Hospice's program. In addition, for each Hospice patient residing in the Facility, Hospice will also provide Facility with (i) a copy of the Hospice patient's Hospice election form and any advance directives specific to such patient, (ii) a copy of the physician certification and recertification of terminal illness specific to each hospice patient .(v) Hospice medication information specific to each Hospice patient, and (vi) copies of Hospice physician and attending physician, if any, orders specific to each Hospice patient. 1. R104 was admitted to the facility on [DATE] with diagnoses including dementia and encounter for palliative care. R104's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status score (BIMS) of 0 out of 15 which indicated R104 had severely impaired cognition. R104 had an activated Power of Attorney (POA) for Healthcare (POA-E) and started on Hospice services prior to R104's admission to the facility. Between 11/27/23 and 11/29/23, Surveyor reviewed R104's medical record which did not contain a Hospice care plan developed by the facility, a care plan developed by Hospice, visit notes, or a visit schedule. On 11/27/23 at 11:24 AM, Surveyor interviewed POA-E who confirmed R104 received Hospice services from Hospice Provider (HP)-F and started Hospice services just prior to admission to the facility. POA-E indicated care from the facility's staff was excellent, however, POA-E had not seen much of Hospice staff and indicated communication with HP-F was not great. POA-E indicated POA-E did not know when Hospice staff were coming to visit, if they visited, or how the visit went. POA-E indicated POA-E did not see Hospice visit notes and did not receive regular phone calls with updates. POA-E also indicated there was not a binder in R104's room for visit notes. On 11/28/23 at 11:48 PM, Surveyor interviewed Registered Nurse (RN)-G who indicated R104 had a care conference last week that HP-F attended via phone. RN-G indicated communication and the schedule were discussed with HP-F at the care conference because there were issues. RN-G stated RN-G had not seen any improvement since the care conference and RN-G was not sure if R104 was assigned a nurse or team yet. RN-G indicated there should be a Hospice binder and a Hospice tab in R104's chart for Hospice staff to leave paperwork. Surveyor and RN-G reviewed R104's paper chart and noted R104 had neither. RN-G also could not locate Hospice visit notes or a Hospice care plan for R104. RN-G indicated RN-G would contact HP-F to see when they were coming. RN-G indicated R104's spouse visited regularly and it would be nice to know when Hospice staff were coming so R1's spouse could have some respite time. On 11/28/23 at 3:44 PM, Surveyor interviewed Social Services Coordinator (SSC)-C regarding R104's facility Hospice care plan. SSC-C confirmed R104 should have a facility Hospice care plan in addition to a care plan developed by Hospice. SSC-C indicated R104 was admitted to the facility on Hospice services so the care plan should have been automatically added. 2. R20 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, Alzheimer's disease, and encounter for palliative care. R20's MDS assessment, dated 11/16/23, contained a BIMS score of 9 out of 15 which indicated R10 had moderately impaired cognition. R20 had an activated POA for Healthchare. Between 11/27/23 and 11/29/23, Surveyor reviewed R20's medical record and noted R20 began Hospice services with HP-F on 11/6/23. Surveyor noted R20's medical record did not contain a care plan provided by Hospice, visit notes, or a visit schedule. On 11/28/23 at 1:14 PM, Surveyor interviewed RN-G regarding R20's Hospice binder. RN-G pulled R20's Hospice binder from the shelf and handed it to Surveyor. The front of the binder contained the names of Hospice team members. Surveyor noted the binder was empty. Surveyor reviewed R20's paper chart and noted the Hospice tab was also empty. RN-G indicated the facility's social workers and nurses contacted HP-F and indicated communication with HP-F was difficult though it wasn't for lack of effort by the facility. On 11/28/23 at 1:23 PM, Surveyor interviewed RN-H who indicated R20's Hospice care plan and visit notes should be in R20's Hospice binder or in the Hospice tab of R20's paper chart. When Surveyor indicated both areas were empty, RN-H indicated RN-H was not surprised and RN-H was not impressed with HP-F's services. RN-H indicated Hospice staff should leave paperwork after visits. RN-H indicated RN-H tried to coordinate R20's care needs with HP-F yesterday (11/27/23), but no one from HP-F showed up. 3. From 11/27/23 through 11/29/23, Surveyor reviewed R54's medical record which indicated R54 started Hospice services on 9/29/23. Surveyor noted Hospice nurse visits were to start on 10/1/23 twice per week for 1 week then 1 once per week for 13 weeks. Hospice nurse aide visits were to start on 10/1/23 twice per week for 12 weeks then once per week for 1 week. Surveyor was unable to locate any Hospice visit notes. On 11/29/23 at 11:38 AM, RN-D reviewed R54's Hospice binder and paper chart with Surveyor. RN-D verified R54's Hospice binder and paper chart did not contain Hospice visit notes. RN-D verbalized an expectation that Hospice staff leave communication documentation in R54's Hospice binder or paper chart. On 11/28/23 at 3:08 PM, Surveyor interviewed SSC-C who verified SSC-C is the facility's designee for Hospice services. SSC-C indicated R54 had a Hospice care plan in R54's paper chart from 2 months ago, however, SSC-C had seen nothing since then. SSC-C contacted Hospice staff and discovered the Hospice team working with the facility isn't consistent. Per SSC-C, Hospice was working on getting the facility the paperwork and care plans needed for the residents who received Hospice services. SSC-C indicated Hospice has a newer nurse and will provide education to the nurse on what needs to happen for the residents who receive their services. SSC-C also indicated Hospice staff should be leave paperwork in residents' Hospice binders. SSC-C indicated one of the facility's units pulls the paperwork out of the binder to place in residents' paper charts and the other keeps the information in the binder. SSC-C verified Hospice should provide Hospice care plans and visit notes. SSC-S indicated the resident's nurse or care team coordinates to determine who contacts family when needed. SSC-C confirmed the process needs improvement. On 11/29/23 at 10:47 AM, SSC-C provided a Hospice visit note for R104, R20, and R54. SSC-C indicated SSC-C learned HP-F has a portal where HP-F uploads items. SSC-C stated SSC-C was currently going through the portal and printing the necessary items. SSC-C stated SSC-C would provide a visit schedule to family as well. SSC-C indicated the facility and HP-F need to come up with a better process. 45942

Based on interview and record review, the facility did not develop a policy for Covid-19 vaccination of residents and ensure education regarding risks and benefits of Covid-19 vaccination was provided to residents/resident representatives. Facility did not have a policy to address Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus and at the time of this situation considered pandemic, meaning worldwide spread) vaccination for residents. Facility medical records did not contain documented proof R112's guardian was educated regarding Covid-19 vaccination for informed decision prior to declining vaccine for R112. Facility vaccination rate was 88%. Findings include: Facility provided policy titled Vaccine Preventable Disease - Residents with revision date of 5/2022 stated, It is the policy of Brewster Village to offer villagers (residents) the following vaccines in an effort to reduce vaccine preventable disease. [CONDITION(S)]-[MEDICATION(S)] . Influenza . [MEDICATION(S)] & Prevnar . [CONDITION(S)]-[CONDITION(S)]-[CONDITION(S)] . [CONDITION(S)] Vaccine . This document did not mention the Covid-19 vaccine. This document did not mention whether or not staff were to provide education to residents or resident representatives regarding individual vaccinations. On 10/19/22, Surveyor reviewed R112's medical record. R112 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R112's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) was not completed as R112 was rarely/never understood. R112's medical record contained an Order on Petition for Successor Guardian (SG), dated 05/30/18 which indicated R112's SG was responsible for R112's health-care decisions. R112's medical record contained Vaccine Declination forms for vaccines other than Covid-19 vaccine, signed by R112's SG, which included reference to education provided. R112's medical record did not contain a Vaccine Declination form for Covid-19 vaccine. On 10/19/22, Surveyor reviewed facility provided email sent to SG dated 07/28/22 which stated, .We are working on setting up a Covid vaccine clinic here at Brewster Village. If you would be interested in having [R112] receive the vaccine, just let us know. Otherwise, we will keep [R112] off the list . There was no response from SG. 10/19/22 at 10:59 AM, Surveyor interviewed Infection Preventionist (IP) I who verified the above email did not address education regarding Covid-19 vaccine. IP I indicated IP I would look for a response from SG and for Covid-19 vaccine education provided to SG. On 10/19/22, Surveyor reviewed facility provided email sent to SG dated 02/08/22 which stated, .Would you like [R112] to receive the Covid-19 vaccination if a clinic is offered here at BV (Brewster Village)? Just let me know . On 10/19/22, Surveyor reviewed facility provided email response sent from SG dated 02/09/22 which stated, .Thanks for the offer, but I would still like to decline the vaccine for [R112] at this time . On 10/19/22 at 11:58 AM, Surveyor interviewed IP I who verified the email dated 02/08/22 did not contain education on Covid-19 vaccine. On 10/19/22 at 11:59 AM, Surveyor interviewed Director of Nursing (DON) B who stated, We do not have a Covid-19 vaccine policy for villagers (residents).

Based on record review and staff interviews, the facility did not ensure residents at risk for wandering and elopement were kept from eloping for 1 Resident (R) (R1) of 3 residents reviewed for elopement risk. R1 was at risk for elopement and wandered out of the facility on 7/06/19 resulting in a fall with injuries that included fractures to the left hand. R1's care plan did not address wandering and elopement risk. Findings include: An investigation was conducted due to an anonymous complaint which indicated on 7/6/19, while R1 was engaged in a group activity, R1 wandered away from the facility and was found to by lying on the ground with injuries sustained from the fall. Surveyor review of R1's medical record indicated on 9/4/18 the facility care team decided to place a wanderguard on R1, however, the medical record did not specifically indicate the rationale for placing the wanderguard on R1. R1's medical record further indicated on 2/20/19 the facility care team decided to discontinue R1's wanderguard based on R1's continued removal and hiding of the wanderguard. Records do not indicate alternate elopement prevention or monitoring was put into place after removal of R1's wanderguard. Records further do not indicate R1's POAHC (Power of Attorney for Health Care) was notified regarding the decision to remove R1's wanderguard. On 8/22/19 at 12:10 PM, Surveyor interviewed Life Enrichment Coordinator (LEC-C) regarding the elopement of R1 on 7/6/19. LEC-C indicated on 7/6/19, R1 was invited to a large group activity in the atrium of the facility by LEC-C, however R1 initially declined. LEC-C stated while escorting other residents to the activity, LEC-C observed R1 outside the unit R1 resided on. LEC-C indicated LEC-C was not concerned about R1 being outside the unit R1 resided on as it is the practice of the nursing home to allow residents to walk about the facility if they choose to do so. LEC-C indicated the next time LEC-C was made aware of R1's whereabouts was when LEC-C was asked to bring a wheelchair outside to assist R1 back into the building. Record review of nursing notes from the incident of 7/6/19 indicated there were not any witnesses to R1's elopement from the facility. The nursing notes indicated R1 possibly wandered out the front entrance of facility unaccompanied, and was found behind the facility where she had fallen by the loading dock and dumpsters. R1 was found lying in a prone position after being observed by staff. Staff responded to assist R1 who was assessed to have broken glasses, a laceration to R1's 4th digit of R1's right hand/tip of finger, bilateral knee abrasions, left lateral palm bruising, and a laceration to R1's left eyebrow. The MD (Medical Doctor) and R1's POAHC were updated regarding R1's condition. R1 was placed on the nurse alert board to monitor R1's injuries. The interventions that were put in place by the nursing home staff on 7/6/19, after R1 was found outside of the facility and injured, consisted of encouraging R1 to use R1's walker while ambulating and a previously implemented wanderguard that had been discontinued was ordered again for R1. R1's nursing notes indicated that on 7/7/19 the POAHC expressed concerns of continued swelling in R1's left hand and requested the facility obtain an x-ray of R1's left hand. R1's x-ray showed unspecified fracture of second, third, and forth metacarpal bones. R1's physician orders [REDACTED]. R1's nursing notes indicated the wanderguard was placed on R1 on 7/12/19. On 8/22/19 at 11:50 AM, Surveyor interviewed DON-B (Director of Nursing) regarding the elopement of R1 on 7/6/19. DON-B indicated R1 was not wearing a wanderguard at the time of R1's elopement. DON-B also indicated elopement assessments were not done in the facility, further explaining wanderguard placement for possible elopement was determined by the residents' care team. The care team consisted of unit nurses, social worker, and CNA's (Certified Nursing Assistants) who discuss resident changes/needs and make recommendations for possible elopement prevention. Additionally, DON-B stated the unit RN (Registered Nurse) had daily discussions with R1's POAHC and felt confident the discontinuation of R1's wanderguard was discussed. On 8/22/19 at 12:30 PM, Surveyor interviewed DON-B regarding why the wanderguard was ordered on [DATE] but not placed on R1 until 7/12/19. DON-B stated the delay in wanderguard placement was due to lack of availability of wanderguard devices in the facility. DON-B further stated it was the responsibility of the maintenance department to obtain the wanderguard devices and because there was not a device available in the facility, one needed to be ordered. On 8/22/19 at 1:30 PM, Surveyor interviewed DON-B regarding safety interventions that were initiated for R1 from 7/6/19 until the wanderguard was applied, 7/12/19. DON-B indicated the facility did not put any safety interventions in place from 7/6/19-7/12/19 to prevent R1 from further elopement. DON-B indicated that on 8/15/19, the staff implemented a baseline which was a monitoring tool used for residents who have a wanderguard in place. The baseline is used to document the number of times residents with wanderguards were witnessed attempting to go to the front door to exit the building. DON-B explained the CNA staff were responsible for this monitoring; however, DON-B stated the facility does not provide 1:1 monitoring of residents. It was noted by the Surveyor that based on the location of where R1 resides in the facility, the staff cannot visually monitor the whereabouts of R1 unless the staff follow R1 off the unit R1 resides on. On 8/22/19 at 3:45 PM, Surveyor interviewed NHA-A who indicated the front entrance/exit is usually unlocked from 6:00 AM-10:00 PM every day. A staff person occupies a reception desk near the entrance/exit from approximately 8:00 AM - 4:30 PM Monday through Friday. The NHA-A further indicated the desk is not always occupied by staff, and it is not the responsibility of the staff in this position to monitor residents who are coming to and leaving from the facility. On 8/22/19 at 4:10 PM, Surveyor interviewed NHA-A regarding monitoring of wanderguard placement on residents related to R1 previously removing and hiding the wanderguard. NHA-A stated the facility does not have a system in place to monitor wanderguard placement on residents.