Every finding on record at Cape Regency Rehabilitation & Health Care Center

Based on observation and interview, the facility failed to ensure mechanical equipment in the main kitchen was maintained in safe operating condition, specifically (a) the plate warmer cart and (b) the walk-in freezer in the main kitchen. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. Review of the facility's policy titled Dietary Department Guidelines, revised May 2012, indicated but was not limited to the following: -Equipment: Any piece of equipment, dish, or utensil will be discarded when it is cracked, broken, discolored, or abraded. Review of the Town Food Inspection Report, dated 2/6/25 indicated same issue again is with walk-in freezer. Ice is now on boxes and boxes are not allowed to be contaminated with anything. Needs to be addressed again. Review of the Town Food Inspection Report follow up visit, dated 3/24/25 indicated checked walk-in freezer and girls are keeping up with it, but ice is still accumulating on left side and ceiling and on products. On 5/14/25 at 8:30 A.M., the surveyor observed the following in the main kitchen: 1. Plate warmer with no plate covers; 2. Walk-in freezer with: -condensation on the exterior of the freezer door window; -freezer door seal detached from the top right corner of the freezer door - the length of detachment was not measured but visualized to be approximately greater than 4 inches long; -freezer door seal in the bottom right corner cracked with missing part of the seal; -drops of condensation frozen on the ceiling adjacent to the condenser unit above a cardboard box of brownies; -thick ice buildup on boxes below the condenser unit; -thick ice buildup on the freezer floor under the condenser unit; and -slippery floor in the walkable area inside the freezer. During an interview on 5/14/25 at 8:50 A.M., the Food Service Director (FSD) said the plate warmer in the main kitchen did not have plate covers to aid in its practical use. The surveyor touched the side of one plate located in the plate warmer and the plate was lukewarm. The FSD said the plate warmer worked sporadically, which was of concern due to it being an electrical piece of equipment. The FSD said the facility provided the kitchen with an additional plate warming unit received from another facility, however, the acquired plate warming unit did not work and could not be used. The FSD said she expected the current plate warmer in the main kitchen to be in good working condition with all its parts. During an interview on 5/14/25 at 8:50 A.M., the FSD and the surveyor observed the walk-in freezer together. The FSD said the condensation in the freezer had been a concern for a long time. The FSD said there was excessive condensation build up inside the walk-in freezer, particularly on the ceiling, on several boxes of food stored underneath the condenser fans, and on the floor, which were all observed at that time. The FSD said the facility had tried to implement trays on the shelving beneath the condenser fans to catch condensation, but this was not effective as it caused the freezer to go into defrost mode. The FSD said kitchen staff and maintenance were working together to remove and maintain the ice buildup. The FSD said she expected the walk-in freezer to have a door seal that was not compromised and functioned properly to minimize condensation buildup inside the freezer, and for less condensation to occur inside the freezer. During an interview on 5/14/25 at 4:30 P.M., the Administrator and the surveyor observed the plate warmer and the walk-in freezer in the main kitchen. The Administrator said he was new to the facility in recent months and had been working toward accommodating the kitchen and providing repairs. The Administrator said he expected the plate warmer and the walk-in freezer door to function properly and not be compromised. During an interview on 5/15/25 at 10:55 A.M., the FSD said concerns about the walk-in freezer and plate warmer have always been communicated verbally. The FSD said issues with the walk-in freezer have been ongoing since prior to the facility's last survey, and the town Board of Health was also aware. The FSD said she and staff used a hammer to break up the ice and the Administrator had even used a shovel to break up the ice in the freezer. During an interview on 5/15/25 at 10:55 A.M., the FSD said a food vendor representative had taken pictures of the facility's plate warmer today and would reach out to a third-party vendor for repair as he felt it could be fixed. During an interview on 5/15/25 at 12:04 P.M., the Director of Maintenance (DOM) said the walk-in freezer door had not been repaired since it was identified last survey. The DOM said the needed part for the door was ordered but never received or installed due to financial reasons and the workaround was breaking down ice accumulation weekly if not daily. During an interview on 5/15/25 at 12:04 P.M., the DOM said the plate warmer in use had started having issues about three months ago. The DOM said the plate warmer had one working side and there were no covers or domes to place over the stored plates. During an interview on 5/15/25 at 12:04 P.M., the DOM said the facility had previously used TELS (a software platform designed to manage day-to-day challenges of building operations) to manage maintenance requests but had moved to paper reporting; each floor and the kitchen entered maintenance issues in logbooks located on each unit and near the kitchen. The DOM said maintenance constantly monitored the logbooks. The DOM said staff would also call, text, or verbalize maintenance concerns to him. During an interview on 5/16/25 at 11:30 A.M., the freezer repair vendor #2 said a drain was clogged in the walk-in freezer, causing it to go into defrost mode. He said he unclogged the drain which will keep the unit from going into defrost mode and stop the ice from accumulating inside the walk-in freezer and on the boxes. The vendor said one motor was not secured, so he replaced the fan blade and secured the motor on correctly. He said he secured the gasket onto the door with screws but recommended a new door for the walk-in freezer. The vendor said there should have been and should continue to be regular maintenance on the motors and drains he serviced. On 5/16/25 at 11:30 A.M., the surveyor observed, in the walk-in freezer, accumulated water that had dropped down from the condenser motor and froze on the floor and on boxes of stuffed shells, bacon, cheese tortellini, cheese manicotti, lasagna, and turkey breast roast. The freezer repair vendor Service Invoice indicated the technician found the following: -fan blade broken due to fan motor not properly installed to [NAME] -clogged drain -door falling apart and door closure broken causing door not to close -heater wire cut as well so the door cannot defrost -technician replaced broken fan blade and properly installed mount and tested to ensure system functionality; unclogged drain and cleared out dirt/dust/debris; installed new door closer which will help until door can be replaced fully On 5/14/25, 5/15/25, and 5/19/25, the surveyor had requested in-house and vendor maintenance logs and documentation for the walk-in freezer. During an interview on 5/19/25 at 4:29 P.M., the DOM provided the following: -a vendor quote, from freezer repair vendor #1, dated 4/9/24, for the freezer door replacement which indicated 100% deposit was required prior to ordering material or scheduling job; -a facility check request form, dated 4/24/24, indicated a request for check payment to freezer vendor repair #1 to replace the freezer door to comply with the Department of Public Health; an approval signature was indicated and dated 4/24/24; -weekly preventative maintenance log, dated 4/12/24 to 5/12/25, indicated maintenance chipped away ice accumulation in the walk-in freezer on at least a weekly basis and was waiting for the door panel to be replaced. During an interview on 5/19/25 at 4:29 P.M., the DOM said the last coordination effort to repair the walk-in freezer door was the work order quote and the check request from April 2024. During an interview on 5/19/25 at 4:29 P.M., the DOM said a vendor (freezer vendor repair #2) had serviced the walk-in freezer on 5/16/25 after surveyors identified issues. He said the vendor reattached the gasket to the freezer door and had fixed a clog in the condenser drain which reportedly was causing the water drippage from the condenser onto boxes and the floor. The DOM said he was unaware that the drippage was due to a clogged condenser drain as no vendor had been monitoring, maintaining, or providing repair to the freezer unit until 5/16/25. During a telephonic interview on 5/19/25 at 4:35 P.M., the Director of Resident Support Services (DRSS) said the vendor who assessed the walk-in freezer said there was a shattered condenser fan and the freezer door had gasket issues. The DRSS said the walk-in freezer and plate warmer should be in good and safe working condition.

Based on observation, record review, and staff interview, the facility failed to ensure that staff assisted one Resident (#84), out of a total of 23 sampled residents, in replacing bilateral hearing aids that went missing to maintain hearing ability and enhance communication. Findings include: Review of the clinical record indicated Resident #84 was admitted to the facility in February 2024. Review of the Minimum Data Set (MDS) assessment, dated 3/21/25, indicated Resident #84 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating he/she has severe cognitive impairment. The MDS indicated bilateral hearing aids present. Review of the Physician's Orders, dated May 2025, included an Audiology Consult as needed (3/10/25). On the following dates and times, the surveyor observed Resident #84 not wearing hearing aids and was unsuccessful in engaging the Resident in conversation due to their difficulty hearing: -05/14/25 at 09:35 A.M. -05/15/25 at 08:30 A.M. -05/15/25 at 02:08 P.M. -05/16/25 at 08:12 A.M. -05/20/25 at 02:09 P.M. During an interview on 05/16/25 at 02:07 P.M., the Unit Manager said Resident #84 is deaf and does not have hearing aids anymore. The Unit Manager said they have been missing for a while but could not give a specific time. He said the facility has not done anything yet to replace the Resident's hearings aids. On 5/16/25 at 3:00 P.M., the surveyor attempted to contact Resident #84's daughter, but she did not call back. Review of the facility's Appointment Book failed to indicate Resident #84 was scheduled for an appointment to have his/her hearing aids replaced. During an interview on 05/20/25 at 02:14 P.M., Certified Nursing Assistant (CNA) #9 said her assignment changes every two weeks. She said she's providing care for Resident #84 today, but it's been a while. She said she does not know what happened to the Resident's hearing aids or when they went missing. During an interview on 05/20/25 at 02:38 P.M., CNA #8 said the Resident has difficulty hearing and was not aware about the missing hearing aids. During an interview on 5/20/25 at 2:45 P.M., Nurse #3 said the Resident had bilateral hearing aids that they've been unable to locate. She said the social worker was aware, and was not sure why the Resident does not have a new pair of hearing aids yet. During an interview on 5/20/25 at 3:10 P.M, the Social Worker said it was recently brought to her attention that Resident #84's hearing aids were missing. She said nursing staff are responsible for scheduling the residents' appointments when needed; she would need to follow up on it.

Based on record review and interviews, the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to ensure resources were utilized to ensure mechanical equipment was maintained in safe operating condition. Findings include: Review of the Town Food Inspection Report, dated 2/6/25, indicated same issue again is with walk-in freezer. Ice is now on boxes and boxes are not allowed to be contaminated with anything. Needs to be addressed again. Review of the Town Food Inspection Report follow up visit, dated 3/24/25, indicated checked walk-in freezer and girls are keeping up with it, but ice is still accumulating on left side and ceiling and on products. On 5/14/25 at 8:30 A.M., the surveyor observed the following in the main kitchen: walk-in freezer with: -condensation on the exterior of the freezer door window; -freezer door seal detached from the top right corner of the freezer door - the length of detachment was not measured but visualized to be approximately greater than 4 inches long; -freezer door seal in the bottom right corner cracked with missing part of the seal; -drops of condensation frozen on the ceiling adjacent to the condenser unit above a cardboard box of brownies; -thick ice buildup on boxes below the condenser unit; -thick ice buildup on the freezer floor under the condenser unit; and -slippery floor in the walkable area inside the freezer. Review of the facility provided e-mail correspondence, from the Physical Plant Director (Director of Maintenance), dated 2/18/25, copied to the facility administrator, and marked with high importance indicated but was not limited to: -an attempt to have a freezer repair vendor #2 come to the facility to look at the walk-in freezer door because the Health Inspector had noted nothing was being done about it as well as it having been a DPH concern on the previous survey -there had been a quote to replace the door (by freezer repair vendor #1) but the quote was no longer any good because money was owed to freezer repair vendor #1 -freezer repair vendor #2 had not been paid for work that was done as far back as June 2024 and would not come out until invoices were taken care of. During an interview on 5/14/25 at 8:50 A.M., the Food Service Director (FSD) said the condensation in the freezer had been a concern for a long time. The FSD said there was excessive condensation build-up inside the walk-in freezer, particularly on the ceiling, on several boxes of food stored underneath the condenser fans, and on the floor, which were all observed at that time of the interview. The FSD said the facility had tried to implement trays on the shelving beneath the condenser fans to catch condensation, but this was not effective as it caused the freezer to go into defrost mode. The FSD said kitchen staff and maintenance were working together to remove and maintain the ice buildup. The FSD said she expected the walk-in freezer to have a door seal that was not compromised and functioned properly to minimize condensation buildup inside the freezer, and for less condensation to occur inside the freezer. During a follow up interview on 5/15/25 at 10:55 A.M., the FSD said issues with the walk-in freezer have been ongoing since prior to the facility's last survey, and the town Board of Health was also aware. The FSD said she and staff would use a hammer to break up the ice and the Administrator had even used a shovel to break up the ice in the freezer. During an interview on 5/15/25 at 12:04 P.M., the Director of Maintenance (DOM) said the walk-in freezer door had not been repaired since it was identified last survey. The DOM said the needed part for the door was ordered but never received or installed due to financial reasons. On 5/19/25 at 4:29 P.M., the DOM provided the following: -a vendor quote (from freezer vendor #1), dated 4/9/24, for the freezer door replacement which indicated 100% deposit was required prior to ordering material or scheduling job; -a facility check request form, dated 4/24/24, indicated a request for check payment to the freezer vendor #1 to replace the freezer door to comply with the Department of Public Health; an approval signature was indicated and dated 4/24/24; -weekly preventative maintenance log, dated 4/12/24 to 5/12/25, indicated maintenance chipped away ice accumulation in the walk-in freezer on at least a weekly basis and was waiting for the door panel to be replaced. During an interview on 5/19/25 at 4:29 P.M., the DOM said a vendor had serviced the walk-in freezer on 5/16/25 after surveyors identified issues. He said the vendor reattached the gasket to the freezer door and had fixed a clog in the condenser drain which reportedly was causing the water drippage from the condenser onto boxes and the floor. The DOM said he was unaware that the drippage was due to a clogged condenser drain as no vendor had been monitoring, maintaining, or providing repair to the freezer unit until 5/16/25. During an interview on 5/20/25 at 2:30 P.M., the Administrator said he was newer to the facility but freezer repair vendor #2 was in on 5/26/25 and the facility was waiting for an e-mail to come in with a plan/in-voice. The Administrator said he was not sure what transpired prior to his working at the building. Refer to F908

Based on observation and staff interview, the facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests. Findings include: Review of the Pest Control Service Inspection Reports, indicated: -4/3/24: 2 out of 6 inspected exterior bait stations showed activity -10/2/24: 6 out of 6 inspected exterior bait stations showed activity -3/21/25: 5 out of 6 inspected exterior bait stations showed activity -4/2/25: 3 out of 6 inspected exterior bait stations showed activity -5/15/25: 1 out of 6 inspected exterior bait stations showed activity On 5/15/25 at 1:23 P.M., the surveyor observed the dumpster and refuse area. The surveyor observed a large pile of stacked wood pallets, piled up to the top of a wooden fence panel. During an interview on 5/15/25 at 1:25 P.M., the interim Food Service Director said the pallets had been there for a while and was not sure what the plan for them was. During an interview on 5/15/25 at 1:36 P.M., the Director of Maintenance said the pallets had been there since COVID and because the pallets were so old the garbage disposal company would not pick them up. During an interview on 5/15/25 at 1:38 P.M., the Administrator said he was aware of the wood pallets near the dumpster. The Administrator said the facility currently did not have a plan to dispose of them but needed to come up with one.

2. Resident #11 was admitted to the facility in January 2013 with a diagnosis of cirrhosis (scar tissue on the liver). Review of the medical record indicated Resident #11 developed an arterial ulcer (disruption or blockage of the arterial blood flow to an area which causes tissue to die) to the lateral (outside) of the left foot on 3/7/25. Review of the medical record indicated an order for the following treatment was initiated on 3/8/25: -cleanse with Vashe wash (wound cleanser), pat dry, apply Iodosorb gel (an antimicrobial ointment), apply a dry protective dressing followed by a kling (gauze) wrap. Review of the Wound Care Consultant's note, dated 3/28/25, indicated the arterial ulcer to the left lateral foot now had a moderate amount of purulent exudate (thick, opaque fluid with a foul odor that indicates a wound infection). The wound consultant physician recommended the following change of treatment: Vashe wash, Bactroban (a topical antibiotic), a dry protective dressing and gentle kling wrap daily. Review of the March and April 2025 TAR indicated the following treatments were in place for the arterial ulcer on the left lateral foot from 3/30/25 through 4/21/25 -cleanse with Vashe wash, pat dry, apply Iodosorb gel, apply a dry protective dressing followed by a kling wrap every evening shift -Vashe wash, Bactroban, a dry protective dressing and gentle kling wrap every day shift The March and April 2025 TARs indicate staff completed both treatments to the same wound on the left lateral foot daily. Review of the nursing progress notes indicated the wound treatments were clarified on 4/21/25, the order for Iodosorb was discontinued and the Resident would continue to receive the Bactroban treatment to the wound on the evening shift. During an interview on 5/20/25 at 2:00 P.M., Nurse #7 said she was the wound nurse at the facility until April 2025. She said the process was to go around with the wound consultant physician and conduct rounds on residents with wounds. She said on 3/28/25 Resident #11's wound was infected; the wound physician consultant had changed the treatment and the Resident was started on an antibiotic. She said toward the end of April a nurse who did not normally work on that unit had noticed that the Resident had two different treatment orders for the arterial ulcer on the left lateral foot and the Iodosorb order was discontinued at that time. She said some of the nurses who were familiar with the Resident may not have been doing both treatments, but there was no way to know as there were two different orders on two different shifts. She said the treatment with Iodosorb should have been discontinued when the treatment with Bactroban started but had not been. During an interview on 5/20/25 at 3:00 P.M., the Regional Nurse Consultant said she had reviewed the medical record and saw there were two different orders for the same area and there should not have been. On 5/15/25 at 3:43 P.M., the surveyor observed Nurse #6 finishing the wound treatment to the left foot as she applied kling wrap and secured with tape. On 5/16/25 at 3:05 P.M. the surveyor observed the Infection Control Nurse remove the dressing to the left foot of Resident #11. The Infection Control Nurse removed the kling wrap and the surveyor observed an adhesive bandage over the lateral area of the left foot. The adhesive bandage was dated 5/15/25. The surveyor observed Resident #11 grimace as the Infection Control Nurse removed the adhesive bandage. During an interview on 5/16/25 at 3:10 P.M., the Infection Control Nurse said Nurse #6 should not have used an adhesive bandage on the arterial wound. She said the dry protective dressing (gauze), should be held on with kling wrap because the skin was so fragile. During an interview on 5/20/25 at 4:26 P.M., the DON said Resident #11 should not have had an adhesive bandage applied to the left lateral foot as this would be uncomfortable to remove. Based on observation, record review, and interview, the facility failed to ensure two Residents (#6 and #11) with wounds, out of a total sample of 23 residents, received necessary treatment and services to promote healing. Specifically, the facility failed: 1. For Resident #6, to complete weekly skin assessments and to follow the vascular physician's recommendations for care and treatment of a non-pressure wound to the Resident's left right foot; and 2. For Resident #11, to discontinue treatment to an arterial ulcer on the lateral left foot, leading to two different treatments being conducted daily and failed to follow the physician's order for the treatment by applying an adhesive bandage. Findings include: Review of the facility's policy titled Skin and Wounds, reviewed in January 2025, indicated the following: -if a resident presents with a venous, arterial or diabetic ulcer, the wound will be assessed on a weekly basis -non-pressure alterations in skin integrity also include skin tears and post op surgical incisions -ongoing monitoring and evaluation are provided to ensure optimal resident care outcomes -documentation would include: location, measurements, type of wound, thickness, drainage amount/color, appearance of wound bed, appearance of wound edges, appearance of peri wound, effectiveness of treatment 1. Resident #6 was admitted to the facility in April 2025 with diagnoses including osteomyelitis (infection in a bone), right great toe amputation, and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 4/25/25, indicated he/she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Additionally, he/she had an infection of the foot and surgical wound requiring surgical wound care and application of dressings to feet. Review of Resident #6's Hospital Discharge summary, dated [DATE], indicated Resident #6 was treated for right great toe cellulitis with concern for osteomyelitis and had his/her right great toe amputated on 4/11/25. Review of Resident #6's Physician's Orders indicated, but was not limited to, the following: -Treatment Order: Cleanse with normal saline, pat dry, apply betadine gauze to incision follower [sic] by kerlix. Location (Specify) every evening shift every other day and as needed (order date 4/18/25) -Monitor Dressing: Site Right Great Toe every shift (order date 4/18/25) The Resident's Physician's Orders for his/her right great toe treatment failed to specify the treatment's location. Review of Resident #6's Short Consultation/Referral Form, dated 4/29/25, indicated the Resident was seen by his/her foot and ankle surgeon on 4/29/25. The surgeon's wound care recommendations included bandage to the right foot daily after showering, apply ABD (a highly absorbent and non-adhesive gauze pad) over incision, then ace bandage (an elastic compression bandage used to decrease swelling). Review of Resident #6's Non-Pressure Wound Evaluation, dated 4/25/25, indicated it was completed for follow-up weekly assessment of the Resident's right great toe surgical wound. The evaluation failed to include wound measurements. The evaluation indicated the wound had 100% healthy tissue types, a healthy wound edge, and no drainage or odor. Review of Resident #6's skin audits, dated 4/18/25, 4/21/25, 5/5/25, and 5/12/25, failed to include Resident #6's right foot surgical incision measurements or wound description. The Resident's medical record failed to include any additional Non-Pressure Wound Evaluations or wound measurements and descriptions. Review of the Treatment Administration Record (TAR) indicated Resident #6's right foot surgical wound dressing was changed every other day on the evening shift and skin audits were completed on 4/18/25, 4/21/25, 5/5/25, and 5/12/25. Review of the nursing, physician, and physician assistant (PA) Progress Notes for Resident #6 failed to include a description of the Resident's surgical wound or wound measurements after his/her admission to the facility. During an interview on 5/15/25 at 9:03 A.M., Resident #6 said the wound on his/her right foot is healing but he/she still wears a dressing on it. During a subsequent interview on 5/19/25 at 10:19 A.M., Resident #6 said the nurses change his/her right foot dressing every other day and he/she does not know what his/her right foot surgical wound looks like because he/she cannot see it. During an interview on 5/16/25 at 2:20 P.M., the Wound Nurse said she completed wound rounds weekly on residents in the facility with wounds and tracked them on a spreadsheet. She said she was unaware she was supposed to enter the wound information into the electronic health record and had not done that for the three weeks she was conducting wound rounds. She said she last conducted wound rounds on 5/5/25 and had not been able to complete them yet for this week. Review of the Weekly Non-Pressure Injury Record failed to include Resident #6 had been seen during wound rounds. During an interview on 5/19/25 at 11:46 A.M., Unit Manager #1 said the facility's weekly skin assessments are documented in the electronic health record. Unit Manager #1 said the Wound Nurse completes the Non-Pressure Wound Evaluations weekly when she rounds and the weekly wound measurement and description should be documented there. Unit Manager #1 reviewed the Vascular Physician's 4/29/25 treatment recommendations and said the treatment order did not get transcribed and the order should match what the consulting Vascular Physician had recommended on the consult form. During an interview on 5/19/25 at 2:58 P.M., the Assistant Director of Nurses (ADON) said Resident #6's weekly wound measurements and description should be documented in the Non-Pressure Wound Evaluation in the electronic health record. During an interview on 5/20/25 at 2:03 P.M., the Director of Nurses (DON) and Regional Nurse Consultant #1 said Resident #6's wound care assessments and measurements should be documented in the electronic health record. The DON said if the wound nurse was not available, the DON, night shift nursing supervisor, or ADON would complete. The DON said she reviewed Resident #6's wound assessments with Unit Manager #1 who reported the admitting nurse documented the wound measurements in her note on 4/18/25. The DON said she and the ADON were not informed wound measurements were not taken last week. The DON said she and the Regional Nurse Consultant #2 assessed and measured the wound on 5/20/25.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen grout and coving were maintained in a sanitary and safe condition; 2. Ensure walk-in shelving was free of rust; and 3. Ensure food was properly stored, labeled, and dated in three of three unit kitchenettes. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 1-2 Definitions 1-201 Applicability and Terms Defined 1-201.10 Statement of Application and Listing of Terms. Easily Cleanable. (1) Easily cleanable means a characteristic of a surface that: (a) Allows effective removal of soil by normal cleaning methods; (b) Is dependent on the material, design, construction, and installation of the surface; and (c) Varies with the likelihood of the surface's role in introducing pathogenic or toxigenic agents or other contaminants into food based on the surface's approved placement, purpose, and use. Smooth means: (3) A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. 6-201.12 Floors, Walls, and Ceilings, Utility Lines. Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized. 6-201.13 Floor and Wall Junctures, Coved, and Enclosed or Sealed. (A) In FOOD ESTABLISHMENTS in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be coved and closed to no larger than 1 mm (one thirty-second inch). On 5/14/25 at 8:30 A.M., the surveyor observed, in the main kitchen, several areas of compromised coving and/or deeply recessed grouting in areas of the perimeter floor and wall junction. During an interview on 5/13/25 at 8:50 A.M., the Food Service Director (FSD) said the compromised coving and recessed grouting has at times harbored ants and should be repaired. During an interview on 5/13/25 at 4:30 P.M., the Administrator and surveyor observed some areas of the main kitchen floor and wall junctions. The Administrator said he expected those areas to be in good repair. 2. On 5/13/25 at 8:30 A.M., the surveyor observed, in the main kitchen walk-in refrigerator, metal shelving with extensive rust. During an interview on 5/13/25 at 8:50 A.M., the FSD and the surveyor observed the rusted shelving. The FSD said the shelving should be replaced. During an interview on 5/13/25 at 4:30 P.M., the Administrator and surveyor observed the rusted shelving in the walk-in refrigerator. The Administrator said there should be no rust on the shelving. 3. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305 Preventing contamination from the premises 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination 3-305.12 Food Storage, Prohibited Areas. FOOD may not be stored: (G)Under leaking water lines, including leaking automatic fire sprinkler heads, or under lines on which water has condensed; (I) Under other sources of contamination. Review of the facility's policy titled Personal Food Policy, indicated but was not limited to the following: -Families and visitors of residents are permitted to bring food into the facility for the resident's use. However, nursing home residents are at risk for serious complications from foodborne illness which may occur from unsafe food handling practices. In order to ensure the safety of our residents, food may only be brought into the facility in accordance with this policy; -The staff person receiving the personal food shall label the container with the date it was brought into the facility (or the date of preparation, if known) and the name of the resident receiving it; -Dietary aides are responsible for checking nourishment refrigerators daily and discarding any unused refrigerated food after 3 days. Frozen food should be discarded after 3 months. Review of the facility's policy titled Dietary Department Guidelines, revised May 2012, indicated but was not limited to the following: -Foods Not Prepared in the Facility: Foods brought into the facility by family members will be kept in appropriate storage, refrigerated if indicated, and discarded as appropriate. For example, foods that require refrigeration should be discarded after 3 calendar days. On 5/14/25 at 10:30 A.M., the surveyor observed the following in the Unit 1 kitchenette refrigerator: -two prepared containers of cottage cheese, dated 5/9; -one Styrofoam cup filled with liquid with no label or date; -one opened container of Lactaid milk, undated, with the manufacturer label indicating to use within 14 days of opening; -one opened container of almond milk, undated, with the manufacturer label indicating to use within 14 days of opening; -one sealed container of lobster bisque, labeled with resident information and dated 4/23/25, with a manufacturer use by date of 5/1/25; -one takeout container of Chinese food with no label or date; -one prepackaged chicken potpie meal with no label or date; -one bag of frozen fish sticks, bag open to air, no label or date. On 5/14/25 at 10:45 A.M., the surveyor observed the following in the Unit 3 kitchenette refrigerator: -three frozen packages of empanadas, undated; -one opened bottle of water with no label or date. On 5/14/25 at 10:55 A.M., the surveyor observed the following in the Unit 2 kitchenette refrigerator: -one storage bag (unsealed) with an item wrapped in paper towel, labeled with initials, no date; -one store bought container of grapes, no date; -two opened containers of Lactaid milk, one dated 5/14 and one with no date; -a very damp white towel on the bottom of the interior refrigerator. During an interview with observation on 5/13/25 at 4:08 P.M., the FSD said dietary staff stock the unit kitchenettes and monitor items inside the refrigerators for labels and dates. The FSD said staff must label and date food and drink items stored in the kitchenettes and should also label and date any item that is open with the date opened. She said opened items can be stored in the refrigerator for three days and then must be discarded. The FSD and surveyor observed the unit kitchenettes. The FSD said the items that were not labeled and dated should have been, and any food items that are older than three days, such as the cottage cheese dated 5/9, should be discarded. The FSD also said any items past the manufacturer's expiration date, such as the lobster bisque, should also be discarded. During an interview with observation on 5/13/25 at 4:18 P.M., the surveyor observed, in the Unit 2 refrigerator, thick condensation resting on top of single serve puddings located on the top shelf. The surveyor tilted one pudding cup and observed a stream of water pour off the cup. The surveyor observed a damp white cloth underneath several single serve pudding cups on the top shelf, and a very damp white cloth on the bottom of the interior refrigerator. The FSD said she expected the refrigerator to function properly with no condensation dripping onto food items or excessive condensation build up. During an interview on 5/15/25 at 11:20 A.M., Unit Coordinator #1 said the refrigerator in the Unit 2 kitchenette had been leaking for weeks. Certified Nursing Assistant (CNA) #1 said towels were placed in the refrigerator to catch the water drippage, otherwise the water leaked out everywhere. CNA #1 said the towels in the refrigerator were switched out daily. The surveyor observed a brown-colored tinge on some edges of the towels. During an interview on 5/15/25 at 12:04 P.M., the Director of Maintenance (DOM) said a resident had stuffed the Unit 2 kitchenette refrigerator with food, which blocked airflow and caused issues with cooling and defrosting. The DOM said he was currently unaware of any continued condensation and drippage in the Unit 2 kitchenette refrigerator. During an interview on 5/15/25 at 12:13 P.M., the Administrator said a resident on Unit 2 had filled and jammed food into the kitchenette refrigerator, so much so that it blocked the seal and vent and it could not circulate. The Administrator said he had just heard about the refrigerator issue today.

Based on record review and interviews, the facility failed to ensure that medications were accurately reconciled by nursing for one Resident (#76), out of a total sample of 23 residents, to ensure he/she was free from a significant medication error. Specifically, the facility failed to ensure Eliquis (apixaban) (an anticoagulant medication used to treat and prevent blood clots) was administered according to physician's orders following a hospitalization for a left knee joint fusion, resulting in the Resident receiving nine additional doses of the medication. Findings include: Review of the facility's policy titled Nursing Policy & Procedure Manual, last revised 8/4/2024, indicated but was not limited to the following: -The facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors. -Medication reconciliation refers to the process of verifying that the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident at all points throughout his or her stay. -admission processes: Compare orders to hospital records, obtain clarification as needed. -Transcribe orders in accordance with procedures for admission orders. -Have a second nurse review transcribed orders for accuracy. -Perform 24-hour chart checks to verify all new orders have been addressed. Review of the facility's policy titled Medication Error Reporting, dated April 2015, indicated but was not limited to the following: -A medication error is any preventable event that may cause or lead to inappropriate medication use, which the medication is in the control of the health care professional. -A medication error report is to be completed immediately after an error is discovered to ensure proper resident/patient follow-up. -Notify the Nurse Manager/Supervisor immediately. -Medication Error Report is completed. -Follow up notes are written related to event based on evaluation per facility policy. -The nurse manager or shift supervisor investigates the error to determine the cause. -The person finding the error is responsible for completing the Medication Error Report and forwarding it to the Director of Nursing (DON) immediately. -The DON or designee is responsible for evaluating the severity of medication errors on each error using the information on the Medication Error Report. Resident #76 was originally admitted to the facility in August 2024 and had diagnoses including osteomyelitis (infectious inflammation of the bone marrow) of the left tibia/fibula (two long bones in lower leg). Review of the Minimum Data Set (MDS) assessment, dated 1/24/25, indicated Resident #76 had a Brief Interview for Mental Status (BIMS) exam score of 13 out of 15, indicating he/she was cognitively intact. Review of the medical record indicated Resident #76 was hospitalized in May 2025 for a scheduled left knee fusion due to osteomyelitis. Review of the Hospital Discharge summary, dated [DATE] at 4:03 P.M., indicated the Resident was to begin taking Eliquis 2.5 milligram (mg) tablets in the morning and Eliquis 2.5mg before bedtime per day (for a total dose of 5 mg per day) for 30 days. Review of the Physician's Orders and the electronic Medication Administration Record (eMAR) indicated the Eliquis order had been entered twice as follows: Eliquis Order #1: -Eliquis oral tablet 2.5mg: Give one tablet by mouth two times a day for {sic} prevent blood clots. Administered on the following dates and times: 5/11/25 at 8:00 A.M. and 8:00 P.M. 5/12/25 at 8:00 A.M. and 8:00 P.M. 5/13/25 at 8:00 A.M. and 8:00 P.M. 5/14/25 at 8:00 A.M. and 8:00 P.M. 5/15/25 at 8:00 A.M. Eliquis Order #2: -Eliquis oral tab 2.5mg: Give 2.5mg by mouth two times a day for anticoagulation until 6/10/25, for 30 days. Administered on the following dates and times: 5/11/25 at 8:00 A.M. and 5:00 P.M. 5/12/25 at 8:00 A.M. and 5:00 P.M. 5/13/25 at 8:00 A.M. and 5:00 P.M. 5/14/25 at 8:00 A.M. and 5:00 P.M. 5/15/25 at 8:00 A.M. Resident #76 received Eliquis 2.5 mg two tablets (5 mg) for five days in the morning and Eliquis 2.5mg two tablets (5 mg) for four days in the evening, resulting in Resident #76 receiving nine additional doses than indicated on the discharge summary. On 5/15/25 at 2:45 P.M., the surveyor informed Unit Manager (UM) #2 of the possible duplicate order for Eliquis. During an interview on 5/15/25 at 3:40 P.M., UM #2 said it was a repeat order, and she discontinued one of the orders. During an interview on 5/19/25 at 1:15 P.M., UM #2 said when a resident is admitted or re-admitted to the facility the admitting nurse will review the medication list provided on the discharge summary with the provider and enter the orders into the computer. She said the medications are double checked by the management team each morning during clinical report. UM #2 said she reviewed Resident #76's medication orders after the surveyor informed her of the possible duplicate order. UM #2 said she compared the Resident's current orders with the discharge summary provided by the hospital and found it was inadvertently placed into the computer twice. UM #2 said she notified the Assistant Director of Nursing (ADON) of the medication error and was instructed to discontinue one of the orders. UM #2 said she did not complete an incident report or investigation, she only notified her ADON. During an interview on 5/20/25 at 11:47 A.M., the ADON said she had provided care to Resident #76 and administered Eliquis 2.5 mg two tablets at 8:00 A.M., last week. She said she did not question it being a duplicate order because sometimes the dose is increased after surgery, and one of the orders had a stop date and the other did not. The ADON said UM #2 informed her of the duplicate order for Eliquis on 5/15/25 and she instructed UM #2 to discontinue the order. The ADON said when a medication error occurs a medication error report is completed. The ADON said she did not complete a medication error report, she thought UM #2 did. During an interview on 5/20/25 at 12:07 P.M., Nurse #9 said Resident #76 was on Eliquis 2.5 mg one tab by mouth twice a day prior to going to the hospital. She said when Resident #76 returned his/her dose had been increased to Eliquis 2.5mg two tabs by mouth twice a day, and that is what she administered. Nurse #9 said if she did not administer a medication, she would check the box that says no on the eMAR and document the reason in a nursing note. During an interview on 5/20/25 at 12:12 P.M., the surveyor reviewed Resident #76 Eliquis duplicate order EMAR administration with Nurse #8, where she signed as administered. Nurse #8 said she does not recall the Eliquis orders but if she signed it as administered then she administered the medication. During an interview on 5/20/25 at 12:17 P.M., the surveyor reviewed Resident #76 Eliquis duplicate order eMAR administration with Nurse #4, where she signed administered. She said if the eMAR is signed as administered, then she gave the medication. Nurse #4 said if she did not give the medication, she would have documented the reason why it was not given. During an interview on 5/20/25 at 2:49 P.M., the Director of Nursing (DON) said when a resident is re-admitted to the facility they review all of the orders the next morning during the clinical meeting, and compare the orders to the discharge summary medication list. The DON said if there is a medication error, a medication error report is generated and a full investigation is conducted, including witness statements. The surveyor and DON reviewed Resident #76's medical record, and she said there was no documentation of the medication error. She said the proper protocol was not followed.

Based on document review and interview, the facility failed to ensure that monthly medication regimen reviews (MRR) were communicated to the physician and addressed in a timely manner for one Resident (#76), out of a total sample of 23 residents. Specifically, the facility failed to: a. Ensure a recommendation from October 2024 by the pharmacy consultant to evaluate continued need of Oxycontin and MS Contin (both opioid medications that are used for severe pain) was reviewed and responded to by the provider; and b. Ensure February 2025 consultant pharmacist recommendations were acted upon timely to clarify the need for Protonix (reduces stomach acid) 40 milligrams (mg) twice a day, and to evaluate the need for continued use of as needed Oxycodone (medication used for breakthrough pain). Findings include: Review of the facility's policy titled Medication Regimen Review Monthly Report, dated as revised December 2019, indicated but was not limited to the following: -The Consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. -The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. -All findings and recommendations are reported to the director of nursing and the attending physician, the medical director and the administrator. Review of the facility's policy titled Documentation and Communication of Consultant Pharmacist Recommendations, dated as last revised December 2019, indicated but was not limited to the following: -The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist's observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate timely fashion. -The timing of these recommendations should enable a response prior to the next medication regimen review. -Recommendations are acted upon and documented by the facility staff and/or the prescriber. -If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the medical director. Resident #76 was admitted to the facility in August 2024 and had diagnoses including osteomyelitis (infectious inflammation of the bone marrow) of the left tibia/fibula (two long bones in lower leg). a. Review of the medical record indicated a full MRR was completed by the consultant pharmacist in October 2024 and to see report for irregularities and/or recommendations. The record failed to indicate what those irregularities were or that they were addressed by a physician. Review of the MRR from October 2024 indicated that there was a recommendation left to the prescriber as follows: -Resident is receiving the following medication(s) Oxycontin and MS Contin. Please evaluate continued need. If discontinue (DC) is not indicated, please note diagnosis DX/medical necessity of current therapy in progress note. The physician/prescriber response section was blank, indicating the recommendation was never addressed or reviewed by the physician/prescriber. b. Review of the medical record indicated a full MRR was completed by the consultant pharmacist in February 2025 and to see report for irregularities and/or recommendations. Review of the MRR from February 2025 indicated that there were two recommendations left to the prescriber as follows: -This resident has been receiving the proton pump inhibitor Protonix 40mg twice a day (BID) for more than 12 weeks. Could the ongoing need for this therapy be re-assessed at this time? The physician/prescriber response section was checked I agree. Please see new order. The recommendation was signed by the physician and dated 4/9/25, two months after the recommendation was received. -Please review current as needed oxycodone use has been used 63 and 55 times between December 2024-January 2025. The physician/prescriber response section was checked I agree, please see new order. The recommendation was signed by the physician and dated 4/9/25, two months after the recommendation was received. During an interview on 5/20/25 at 12:29 P.M., the Pharmacy Consultant said he completes the monthly reports and sends them to the Director of Nursing (DON). He expects the facility to review and respond to the recommendations prior to his next monthly review. During an interview on 5/20/25 at 2:33 P.M., the DON said pharmacy recommendations are supposed to be completed within 30 days of receipt. She said the October 2024 recommendation was not addressed by the provider as it should have been it must have been an oversight. She said the February 2025 recommendations were reviewed and responded to late. She said they should have been reviewed by the provider within 30 days.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections; 2. Review and document laboratory results for a total of 71 patients on two out of two units swabbed for Group A Streptococcus, as a measure of surveillance after three identified residents who resided in the facility tested positive; 3. Ensure proper hand hygiene was completed prior to meals for residents eating in the first floor dining area; 4. Ensure appropriate personal protective equipment (PPE) was utilized for Resident #27, who was on Enhanced Barrier Precautions (EBP), while providing direct care; 5. Follow proper hand hygiene standards while administering an injection to Resident #40; 6. Follow infection control standards for Resident #60 while completing a dressing change; 7. Follow proper hand hygiene standards while administering a nasal spray to Resident #20; 8. Ensure proper cleaning and disinfecting of shared resident equipment after use; and 9. Ensure staff implemented appropriate use of PPE for Resident #76 on Contact Precautions and follow infection control standards while completing a dressing change. Findings include: 1. Review of the facility assessment, dated 4/29/25 and reviewed with the QAA/QAPI committee on 4/29/25, indicated but was not limited to: -Services provided based on resident need: a. Infection prevention and control: Identification and containment of infections, prevention of infections. Resident and family education related to infection and the prevention of infection. Review of the facility's policy titled The Infection Prevention Program, revised 3/2024, included but was not limited to the following: -This facility follows the professional standards set forth as recommended by the CDC/OSHA. The goal of the Infection Prevention Program is to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. -The facility has a system in place for the prevention, identification, reporting, investigation and control of infections and communicable disease of residents, staff, and visitors. -Responsibility for ongoing collection and analysis of data and required follow up is assigned to the Infection Preventionist (IP). -Elements of the Infection Prevention Program includes monitoring and documenting infections, tracking and analyzing outbreaks of infections, managing resident health initiatives and provision of early, uniform identification and reporting of infections. -The IP will perform surveillance and investigation of infections to prevent, to the extent possible, the onset and spread of infection. -Analyze trends and clusters of infection, and any increase in the rate of infection or resistant organisms, in a timely manner. -Maintain the monthly infection reports by unit to record each resident infection. Review of the facility's policy titled Surveillance for Healthcare, dated as revised 3/2024, included but was not limited to the following: -Surveillance is defined as the ongoing, systematic collection, analysis, interpretation and dissemination of data. -The facility will closely monitor all residents who exhibit signs/symptoms of infection. The IP will record the information on the Infection Control Log. -The IP will gather additional data for infection tracking and reporting and provide consultation and education as needed. -The IP or designee will monitor the residents with infections and/or potential infections by completing the Monthly Infection Report by Unit. Review of the Monthly Resident Infection and Antibiotic Stewardship Report Tool, identified as the facility's line listings, indicated the information needed for completion included but was not limited to: the date, resident name, site of infection, type of infection, culture results, signs and symptoms of infection, and treatment/intervention. Further review of the line listings from January 2025 through April 2025 indicated but was not limited to the following: -The January 2025 report tool had missing documentation for 22 out of 26 residents. Specifically, 22 of the 25 residents had no documented signs and symptoms of an illness. -The February 2025 report tool had missing documentation for 14 out of 15 residents. Specifically, 14 of the 15 residents had no documented signs and symptoms of an illness. -The March 2025 report tool had missing documentation for 18 out of 21 residents. Specifically, 18 of the 21 residents had no documented signs and symptoms of an illness. -The April 2025 report tool had missing documentation for 9 out of 12 residents. Specifically, 9 of the 12 residents had no documented signs and symptoms of an illness. During an interview on 5/19/25 at 3:39 P.M., the Director of Nurses (DON) said the facility utilizes McGeer criteria to determine if an infection is present. She said each unit has an infection binder where nurses would document infections present. She said the nurses should document the signs and symptoms in the medical record and on the line listings to determine if McGeer criteria is met prior to treating. The surveyor and DON reviewed the line listings from January through April 2025 together. The DON further said she remembers line listings being a concern last year and that symptoms were not identified. After reviewing the line listings, the DON said the documentation is inconsistent and should be written on the line listing and in the medical record. 2. Review of the Group A Streptococcus surveillance testing on two units within the facility indicated a total of 71 residents were swabbed to rule out the organism. On 5/19/25 at 1:10 P.M., the DON was able to provide the surveyor laboratory results for the first-floor unit, but said she was awaiting the second floor results, despite being in the medical record at this time. On 5/19/25 at 2:15 P.M., the surveyors reviewed the records of all 71 residents. Each medical record indicated the test results for the surveillance testing were resulted and uploaded to the electronic medical record on 5/16/25. Each of the labs indicated the lab result had not been reviewed and the medical record failed to indicate documentation that the laboratory result was reviewed and results were documented. During an interview on 05/19/25 at 4:26 P.M., the DON said it is the expectation that nurses review the labs as they come into the facility. She said the laboratory results returned on 5/16/25 and the nurses on the units should have checked the results to see if any of the residents were positive. She said it is her expectation that all nurses document in the medical record when lab results are reviewed and the results. She further said once the physician reviewed the lab result, it would then show as reviewed in the medical record. The DON reviewed the results for one of the 71 residents and was unable to locate documentation related to the laboratory results being reviewed for the infection surveillance of Group A Streptococcus. 3. Review of the facility's policy titled Section I - The Infection Prevention Program, revised 3/2024, indicated but was not limited to the following: - Hand Hygiene: + When to Wash Hands (at a minimum): before eating and drinking. Review of the facility's policy titled Hand Hygiene, dated April 2015, indicated but was not limited to the following: - Policy: to protect residents/patient from health-care associated infections. - When to use Alcohol Hand Sanitizer: encouraging residents use prior to eating or group activities. On 5/14/25 at 12:08 P.M., the surveyor made the following observations in the first-floor main dining room: - Drinks were provided to 10 residents in the dining room by facility staff. No hand hygiene was performed by staff prior to providing or after serving drinks to residents. No residents were observed to perform or be provided hand hygiene. - At 12:35 P.M., trays arrived for residents in the dining room area. No hand hygiene was provided to residents prior to meals being delivered to tables. On 5/15/25 at 12:24 P.M., the surveyor made the following observations in the first-floor main dining room: - 10 residents were seated at tables throughout the dining area. - No hand hygiene was performed for residents prior to meals being delivered. - No hand hygiene was performed by staff prior to delivering trays and/or after delivering meals to residents in the dining area. During an interview on 5/20/25 at 1:12 P.M., Nurse #5 said hand hygiene should be performed prior to meals times. Nurse #5 said residents should have hand hygiene completed prior to being served meals. During an interview on 5/30/25 at 2:02 P.M., the DON said her expectation was for hand hygiene to be completed prior to mealtime and after mealtimes for both staff and residents. 4. Review of the facility's policy titled Enhanced Barrier Precautions Policy, undated, indicated but was not limited to: - It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms (MDROs). Novel or targeted MDROs are organisms that are resistant to all or most antibiotics tested, are uncommon in a geographic area, or have special genes that allow them to spread their resistance to other germs. - Enhanced barrier precautions require the use of gown and gloves for certain residents during specific high-contact resident care activities in which there is an increased risk for transmission of multi-drug resistant organisms. - High-contact resident care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care. - Signage will be posted on the door or wall outside of the resident room indicating the need for enhanced barrier precautions, the required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. Resident #27 was admitted to the facility in November 2024 with diagnoses including right above knee amputation, sepsis, and infection of the skin and subcutaneous tissue. Review of Resident #27's Physician's Orders indicated but were not limited to the following: - 5/14/25: Enhanced Barrier Precautions (EBP): RLE (right lower extremity) wound. On 5/19/25 at 8:10 A.M., the surveyor observed the Centers for Disease Control and Prevention (CDC) EBP sign posted on the wall outside of Resident #27's room. The sign indicated prior to entering the room: everyone must clean their hands and that providers and staff must wear gloves and a gown for high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and wound care. Gowns and gloves were in a bin outside of the room's door. On 5/19/25 at 10:59 A.M., the surveyor observed the following: - Certified Nursing Assistant (CNA) #1 entered Resident #27's room without performing hand hygiene, wearing a gown, or wearing gloves. Resident #27 who was in his/her wheelchair followed CNA #1 into the room. - CNA #1 was observed making Resident #27's bed, including touching linens in the room. - CNA #1 drew the curtain while standing next to Resident #27. - CNA #1 exited the room with a bag of linens and Resident #27 was in bed. During an interview on 5/19/25 at 11:06 A.M., CNA #1 said she assisted transferring Resident #27 from his/her wheelchair to his/her bed. CNA #1 said she also removed linens from Resident #27's room. CNA #1 said she did not have to wear any PPE when working with Resident #27. During an interview on 5/19/25 at 11:26 A.M., Nurse #1 said staff need to wear PPE when performing high contact activities with Resident #27. Nurse #1 and the surveyor reviewed the observations made in Resident #27's room. Nurse #1 said CNA #1 should have been wearing a gown and gloves if assisting Resident #27 with transferring and changing linens. During an interview on 5/19/25 at 3:02 P.M., the DON said when staff are working or assisting residents on EBPs they must wear gowns and gloves. The DON said CNA #1 should have been wearing a gown and gloves to provide direct care to Resident #27. 5. Review of the facility's policy titled Medication Administration by Route or Dosage, dated as revised March 2017, indicated but was not limited to the following: -Subcutaneous Injections: Wash hands, wear gloves Review of the facility's policy titled Hand Hygiene, dated April 2015, indicated but was not limited to the following: -To protect residents from health care associated infections -When to use alcohol hand sanitizer -Only when visible soil is absent -After contact with resident intact skin -After removing gloves -Before entering the resident room -Before exiting the resident rooms -Before and after dressing changes On 5/14/25 at 9:17 A.M., the surveyor observed Nurse #4 standing next to her medication cart that was located at the nursing station. Resident #40 requested she administer their Trulicity (GLP-1 injection used to treat type II diabetes), before he/she leaves the unit. Nurse #4 reached into her medication cart and took out the medication and an alcohol swab pad. Nurse #4 did not perform hand hygiene or don (put on) gloves. She lifted Resident #40's left shirt sleeve, cleansed the area with the alcohol pad, and administered the injection with her bare hands. Nurse #4 then disposed of the used injection into the sharps container that was located on her medication cart. Nurse #4 did not perform hand hygiene. She then went to her keypad and mouse on the computer that was located on top of the medication cart and began typing. On 5/14/25 at 9:19 A.M., Nurse #4 then walked to the coffee cart and poured a cup of coffee, walked down the hall and entered an office out of the surveyor's view. At no time did the surveyor observe Nurse #4 perform hand hygiene. During an interview on 05/14/25 at 9:21 A.M., Nurse #4 said she is supposed to wear gloves while administering an injection but did not. She said she gave the injection at the nursing station because the Resident requested it. Nurse #4 said she should have used hand sanitizer before and after she gave the injection but forgot. 6. Review of the facility's policy titled Clean Dressing Technique, undated, indicated but was not limited to the following: -Licensed staff members will use clean dressing technique for all dressing changes unless otherwise specified by the MD. -Sanitize hands -Establish clean field (can be unsterile plastic field, clean linen, etc.) -Gather supplies and place on clean field, including several clean gloves -Sanitize hands and apply clean gloves -Remove old dressing and discard in plastic bag -Remove gloves, sanitize hands and apply clean gloves -Cleanse wound with solution ordered. -Remove gloves, sanitize hands and apply clean gloves -Dress wound -Remove gloves and sanitize hands Resident #60 was admitted to the facility in November 2024 with diagnosis including type II diabetes. Review of the Physician's Order indicated the following: -Left foot second toe normal saline wash, followed by bacitracin, oil emulsion and clean dry dressing, change daily. Order discontinued on 5/12/25 During an interview with observation on 5/14/25 at 10:28 A.M., Nurse #4 said Resident #60 requested a covering be applied to his/her left second toe and she was going to apply a dressing. The surveyor observed the following: -On the Resident's overbed table was an open ripped box of donuts and a remote control, visible crumbs, circular stains which appeared to be left from drinks and a large puddle of a clear liquid substance pooling on the edge of the table. -Nurse #4 placed a pile of open 4x4 gauze pads directly onto the overbed table, along with a 2x2 bordered gauze dressing with the date and her initials written on it, and a single-use container of normal saline. -Nurse #4 then opened the container of normal saline and squirted it onto the whole pile of open 4x4 gauze. -Nurse #4 took the top 4x4 gauze and rubbed the gauze on Resident #60's second left toe and then placed the used gauze back onto the overbed table (next to the pile of normal saline soaked 4x4 gauze). -Nurse #4 then took the 2x2 bordered gauze and covered Resident #60 left second toe with the dressing. -Nurse #4 then removed all the dressing supplies, disposed of them in the trash, removed her gloves, and performed hand hygiene. During an interview on 5/14/25 at 12:01 P.M., Nurse #4 said she was not aware she had to place a clean barrier between the clean dressing supplies and the table. She said she should have cleaned the table before putting the clean dressing supplies on it, but did not have any cleaning wipes with her. Nurse #4 said she was going to put the clean dressing supplies on the Resident's bed but figured that it was worse than the bed table. 7. Review of the facility's policy titled Decontamination of Resident Items, undated, indicated but was not limited to the following: -It is the policy of this facility to reduce and/or prevent the spread of infection through indirect contact by cleaning, sanitizing or disinfecting resident equipment, medical devices and the environment -Items require disinfection after each use using a disinfectant wipe. During an observation on 5/14/25 at 12:10 P.M., the surveyor observed Nurse #4 with the blood pressure machine on wheels take Resident #76 blood pressure in the hallway as follows: Nurse #4 applied the blood pressure cuff to Resident #76's left arm. Nurse #4 did not clean the cuff prior to applying it to the Resident's arm. Once she completed the blood pressure, she returned the machine to the center of the hallway and plugged it in. Nurse #4 did not clean the blood pressure cuff after use. During an interview on 5/14/25 at 12:12 P.M., Nurse #4 said she should have cleaned the blood pressure cuff after she used it, but the machine did not have any cleaning wipes in the basket. 8. On 5/15/25 at 8:35 A.M., the surveyor observed Nurse #12 prepare Resident #20's medications which included the following: -Flonase 50 micrograms (mcg) (treats allergies) nasal spray -Nurse #12 entered Resident #20's room with the Flonase in her hand and administered one squirt into each nostril of Resident #20. -Nurse #12 handed the Resident a tissue and exited the room. -Nurse #12 did not perform hand hygiene after administering the medication. -Nurse #12 then returned to the medication cart and began documenting in the medical record. During an interview on 5/15/25 at 8:39 A.M., Nurse #12 said she should have performed hand hygiene after administering the medications and before touching her medication cart, but she did not have any hand sanitizer on her cart available for use. 9. Resident #76 was admitted to the facility in August 2024 and had diagnoses including osteomyelitis (infectious inflammation of the bone marrow) of the left tibia/fibula (two long bones in lower leg). Review of the Physician's Orders indicated the following: -Maintain contact precautions -Remove wound vac dressing on or about seven days post-op and apply light dressing On 5/15/25 at 10:58 A.M., the surveyor observed a sign posted outside of Resident #76's room that said Contact Precautions everyone must: Clean their hands, including before entering and when leaving room. Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Nurse #4 was observed inside the room adjusting Resident #76's bed linens. Nurse #4 was not wearing a gown or gloves. Nurse #4 then exited the room, did not perform hand hygiene, and walked down the hall, then entered the clean utility room. On 5/15/25 at 11:00 A.M., the surveyor observed Nurse #4 enter Resident #76's room again and did not perform hand hygiene prior to entering. Nurse #4 did not put on a gown or gloves prior to entering. Nurse #4 placed a hand towel on Resident #76's overbed table, and placed a pile of 4x4 open gauze dressings, one 4x4 bordered gauze with the date 5/15/25 and her initials on it, and a single use tube of normal saline. During an interview on 5/15/25 at 11:01 A.M., Unit Manager (UM) #2 observed Nurse #4 in the room with the surveyor. UM #2 reviewed the contact precaution sign posted outside of Resident #76's room and said everyone must perform hand hygiene and wear a gown and gloves prior to entering the room. UM #2 said Nurse #4 should have on a gown and gloves while she is in the room, and she does not. On 5/15/25 at 11:02 A.M., the surveyor and UM #2 observed Nurse #4 exit Resident #76's room and perform hand hygiene. Nurse #4, UM#2 and the surveyor reviewed the contact precaution sign together and Nurse #4 said she only needs to wear a gown and gloves if she is going to touch the Resident. The surveyor reviewed the earlier observation with Nurse #4 in the room adjusting the Resident's linen and not performing hand hygiene after exiting the room. Nurse #4 said the Resident requested her to fix his/her bedding and it was not her intention to touch the Resident without a gown or gloves on. Nurse #4 said she always uses hand sanitizer when she leaves a resident's room but was focused on getting the supplies ready to complete a dressing change. On 5/15/25 at 11:09 A.M., the surveyor observed Nurse #4 and UM #2 administer a dressing to Resident #76. The surveyor observed the following: -Nurse #4 and UM #2 performed hand hygiene and donned a protective gown and gloves and entered the room. -On the overbed table was a hand towel with a pile of 4x4 open gauze dressings, one 4x4 bordered gauze with the date 5/15/25 and her initials on it, and a single use tube of normal saline. -Nurse #4 began to remove the dressing from Resident #76's left knee, exposing the Resident's incision line and creating a small superficial skin tear above the incision line, that was actively bleeding. -Nurse #4 grabbed the pile of 4x4 gauze with the same gloves used to remove the old dressing, and squirted the normal saline onto the gauze, and cleansed the incision line. -Nurse #4 did not change her gloves or perform hand hygiene. She then discarded the gauze and took more from the pile, squirted normal saline onto the gauze and cleansed the skin tear. -Nurse #4 did not change her gloves or perform hand hygiene. -Resident #76's phone was placed on the overbed table, next to the dressing supplies. The phone rang, and Nurse #4 grabbed the phone with her gloves and handed it to the Resident. -Nurse #4 then took the phone from the Resident and put it back onto the bed table, with her gloves still on. -UM #2 handed Nurse #4 a large, bordered gauze dressing, and Nurse #4 placed it on the bed table, and removed a Sharpie (pen) from her pocket, wearing her gloves. -Nurse #4 wrote the date and her initials on the dressing and applied it to Resident #76's incision line. Nurse #4 did not change her gloves or perform hand hygiene. -Nurse #4 then took the 4x4 gauze with the same gloves and squirted normal saline onto it. She cleansed the skin tear above the incision line, discarded the gauze, and then took the smaller 4x4 bordered dressing and applied it to the skin tear. -Nurse #4 did not change her gloves or perform hand hygiene. -Nurse #4 then discarded all dressing supplies, removed her gloves and gown, performed hand hygiene, and exited the room. During an interview on 5/15/25 at 11:54 A.M., Nurse #4 said she should have changed her gloves in between removing the old dressing and applying the clean one. She said when she set up the clean field, she did not bring in any more gloves, she only had the ones she was wearing for use. She said she should not have touched the Resident's phone during the dressing change, but when it rang, she just handed it to the Resident. During an interview on 5/15/25 at 12:11 P.M., UM #2 said Nurse #4 should have changed her gloves in between removing the dirty dressing, cleansing the incision and applying the clean dressing. She said Nurse #4 should have brought in a box of gloves and a bottle of hand sanitizer with her to complete a dressing change. UM #2 said by using the same gloves and not performing hand hygiene it increases the risk of the incision becoming infected. During an interview on 5/15/25 at 12:20 P.M., the Infection Control Nurse (ICN) said Resident #76 is on contact precautions for MRSA (Methicillin-resistant Staphylococcus aureus) (antibiotic resistant infection) in his/her left knee. The ICN said use of a protective gown and gloves are required anytime you enter the room. During an interview on 5/20/25 at 2:02 P.M., the DON said her expectation is when a nurse completes a clean dressing change, they must clean the table with an antibacterial cleanser, place a clean barrier in between the dressing supplies and the table. She said dressing supplies should never be placed directly onto the surface. The DON said nurses must cleanse their hands and change their gloves in between removing the old dressing and touching the clean dressings. The DON said all shared resident equipment must be cleansed after use. She said the best practice is to clean the equipment before and after use. The DON said all staff must adhere to the precaution signs. She said no one should enter a contact precaution room without donning a protective gown and gloves first. The DON said hand hygiene must be performed before and after administering medications. She said gloves must be worn to administer nasal sprays and to give injections.

Based on record review and interview, the facility failed to ensure advanced directives for one Resident (#116), out of total sample of 23 residents, were executed in accordance with the Resident's wishes, specifically, their Medical Orders for Life Sustaining Treatment (MOLST medical order form that relays instructions between health professionals about a patient's care based on an individual's right to accept or refuse medical treatment). Findings include: The Facility does not have a policy for Advanced Directive formulation. Resident #116 was admitted to the facility in April 2025 with diagnoses including vascular dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 4/17/25, indicated Resident #116 scored 3 out of 15 on the Brief Interview for Mental Status exam which indicated he/she had severe cognitive impairment. On 05/14/25 at 01:54 P.M., the surveyor and Unit Manager #3 reviewed Resident #116's electronic medical record which indicated that the Resident's code status was Full Code. Review of the paper record included a valid MOLST, dated 1/16/25, indicating Resident #116's wishes were for Do Not Resuscitate, Do Not Intubate, Transfer to Hospital. The medical record failed to indicate the MOLST was enacted by the facility. During an interview on 5/16/25 at 1:48 P.M., Unit Manager (UM) #3 reviewed Resident #116's paper medical record and said a valid MOLST was signed by the Resident's Health Care Agent in January (prior to admission). The facility did not enact the Resident's MOLST, instead making the Resident a Full Code.

Based on interview and record review, the facility failed to notify the Resident's physician and activated Health Care Proxy (HCP) about a significant medication error so as to re-evaluate the potential need to alter the treatment plan for one Resident (#76), from a total sample of 23 residents. Specifically, the facility failed to notify the primary physician and health care proxy of a medication reconciliation error resulting in Resident #76 receiving nine additional doses of Eliquis (apixaban) (an anticoagulant medication used to treat and prevent blood clots). Findings include: Review of the facility's policy titled Medication Error Reporting, dated April 2015, indicated, but was not limited to the following: -A medication error is any preventable event that may cause or lead to inappropriate medication use, which the medication is in the control of the health care professional. -A medication error report is to be completed immediately after an error is discovered to ensure proper resident/patient follow-up. -Notify the Nurse Manager/Supervisor immediately -The person finding the error is responsible for completing the Medication Error Report and forwarding it to the Director of Nursing (DON) immediately -The DON or designee is responsible for evaluating the severity of medication errors on each error using the information on the Medication Error Report Review of the facility's policy titled Condition: Significant Change, dated April 2015, indicated but was not limited to the following: -Professional staff will communicate with the physician, resident/patient, and family regarding changes in condition to provide timely communication of resident/patient status change which is essential to quality care management. -The physician, resident/patient and/or responsible party will be notified by the nurse in the event of a change in condition. -This notification shall be documented in the clinical record. Resident #76 was admitted to the facility in August 2024 with diagnoses including osteomyelitis (infectious inflammation of the bone marrow) of the left tibia/fibula (two long bones in lower leg). Review of the Minimum Data Set (MDS) assessment, dated 1/24/25, indicated Resident #76 had a Brief Interview for Mental Status (BIMS) exam score of 13 out of 15, indicating he/she was cognitively intact. Resident #76's Health Care Proxy (HCP) was invoked on 11/13/24 due to encephalopathy (disturbance in brain function due to infection). Review of the medical record indicated Resident #76 was hospitalized in May 2025 for a scheduled left knee fusion due to osteomyelitis. Review of the Discharge summary, dated [DATE] at 4:03 P.M., indicated the Resident was to begin taking Eliquis 2.5 milligram (mg) tablets in the morning and Eliquis 2.5mg before bedtime per day (for a total dose of 5 mg per day) for 30 days. Review of the Physician's Orders and the electronic Medication Administration Record (eMAR) indicated the Eliquis order had been entered twice as follows: Eliquis Order #1: -Eliquis oral tablet 2.5mg: Give one tablet by mouth two times a day for {sic} prevent blood clots. Administered on the following dates and times: 5/11/25 at 8:00 A.M. and 8:00 P.M. 5/12/25 at 8:00 A.M. and 8:00 P.M. 5/13/25 at 8:00 A.M. and 8:00 P.M. 5/14/25 at 8:00 A.M. and 8:00 P.M. 5/15/25 at 8:00 A.M. Eliquis Order #2: -Eliquis oral tab 2.5mg: Give 2.5mg by mouth two times a day for anticoagulation until 6/10/25, for 30 days. Administered on the following dates and times: 5/11/25 at 8:00 A.M. and 5:00 P.M. 5/12/25 at 8:00 A.M. and 5:00 P.M. 5/13/25 at 8:00 A.M. and 5:00 P.M. 5/14/25 at 8:00 A.M. and 5:00 P.M. 5/15/25 at 8:00 A.M. Further review of the eMAR indicated Resident #76 received Eliquis 2.5 mg two tablets (5 mg) for five days in the morning and Eliquis 2.5mg two tablets (5 mg) for four days in the evening, resulting in Resident #76 receiving nine additional doses of the medication than indicated on the discharge summary. On 5/15/25 at 2:45 P.M., the surveyor informed Unit Manager (UM) #2 of the possible duplicate order for Eliquis. During an interview on 5/15/25 at 3:40 P.M., UM #2 said it was a repeat order, and she discontinued one of the orders. Review of the physician's orders on 5/19/25 indicated one of the Eliquis orders had been discontinued on 5/15/25. Further review of the physician and nursing progress notes failed to indicate the physician, or HCP had been notified of the nine extra doses administered of Eliquis 2.5mg due to the duplicate order. During an interview on 5/19/25 at 1:15 P.M., UM #2 said she reviewed Resident #76's medication orders after the surveyor informed her of the possible duplicate order. UM #2 said she compared the Resident's current orders with the discharge summary provided by the hospital and found it was inadvertently placed into the computer twice. UM #2 said she notified the Assistant Director of Nursing (ADON) of the medication error and was instructed to discontinue one of the orders. UM #2 said she did not notify the physician or the HCP of the error, and she did not complete an incident report or investigation, she only notified her ADON. During an interview on 5/20/25 at 10:43 A.M., Family Member #1 said Resident #76's HCP has been invoked because he/she had developed confusion from an infection. She said she spoke with a nurse when Resident #76 returned from the hospital and reviewed his/her pain medication regimen. She said the facility has not discussed any other concerns with her. During an interview on 5/20/25 at 11:47 A.M., the ADON said UM #2 informed her of the duplicate order for Eliquis on 5/15/25 and she instructed UM #2 to notify the physician and discontinue the order. The ADON said when a medication error occurs the physician and HCP must be notified and a medication error report completed. The ADON said she did not notify the physician, HCP or complete a medication error report. She said she thought UM #2 did and would have to investigate it now. During an interview on 5/20/25 at 2:49 P.M., the Director of Nursing (DON) said when there is a suspected medication error, the nurse must notify the DON, the family and the physician. She said the resident must also be monitored for potential complications due to the error, and implement any new physician orders. The surveyor and DON reviewed Resident #76's medical record, and she said there is no documentation of the medication error or physician/HCP notification. She said the proper protocol was not followed.

Based on observations and interviews, the facility failed to ensure residents had a homelike environment. Specifically, the facility failed to: 1. Ensure a comfortable and homelike dining experience in one of three dining rooms; and 2. Repair a water damaged wall area around a built-in wall unit air conditioner. Findings include: 1. During dining observations throughout the survey on 5/14/25, 5/15/25, and 5/16/25, surveyors observed the following: On 5/14/25 from 8:15 A.M. through 8:30 A.M., the surveyor observed the third-floor dining room: -Five residents were seated at one round folding table (different than the other five tables), no tablecloth, all breakfast meals were served on trays -Seven out of 13 residents were served from the first meal truck and all meals were served on the meal trays -None of the six tables had tablecloths -At 8:38 A.M., the remaining six residents received their breakfast meal with the plates, bowls and cups remaining on the meal trays. On 5/14/25 at 12:30 P.M., the surveyor observed the third-floor unit dining room. All six tables had maroon tablecloths and all plates, bowls and cups were served on the table and not on a meal tray. On 5/15/25 at 8:20 A.M., the surveyor observed the third-floor unit dining room: -Five residents were seated at the round folding table, which did not have a tablecloth -All breakfast plates, bowls and cups were served on the meal tray -None of the six tables had tablecloths On 5/15/25 at 12:00 P.M., the surveyor observed the third-floor unit dining room to be set up with tablecloths. On 5/16/25 at 8:30 A.M., the surveyor observed the third-floor unit dining room to be set up without tablecloths. During an interview on 5/16/25 at 12:39 P.M., Unit Manager #3 said the tables should always have tablecloths and when he inquired with the staff about why they were not using tablecloths at breakfast they had told him, This is how we do it. During an interview on 5/16/25 at 1:02 P.M., the Assistant Director of Nurses (ADON) said the third-floor unit was the only dining room used during breakfast time. She said staff should be putting tablecloths on the tables for all meals, including breakfast. She said the plates, bowls and cups should come off the serving tray for all meals and not just breakfast. During an interview on 5/16/25 at 2:29 P.M., the ADON said there was no facility policy regarding the dining experience of residents. 2. On 5/16/25 at 7:58 A.M., the surveyor observed the first-floor resident hallway with a built-in wall unit air conditioner located below a three-pane window. The area of wall between the windowsill and the built-in air conditioner had black speckles and was wet with clear liquid to the touch. The area to the right of the air conditioner had bubbling paint and was wet with spackle to the touch. The surveyor observed quick constant drips of water landing on the outside of the air conditioner. During an interview with observation on 5/16/25 at 3:23 P.M., the Director of Maintenance said the spackle had been applied to the right side of the air conditioner unit that morning and when he touched it at this time, at least 7 hours later, it continued to be wet to the touch. He said he had not noticed the black speckles between the windowsill and the air conditioner unit and had not realized it was wet to the touch. The surveyor and the Director of Maintenance went outside and observed the air conditioner above the first-floor unit built-in air conditioner to be dripping directly on to the first-floor unit. He said he thought this unit had a drip pan to prevent the upstairs air conditioner from hitting the outside siding. He touched the outside siding above the air conditioner and said it was soaked through and that was why the wall on the inside was wet.

2. Resident #24 was admitted to the facility in December 2022 with diagnoses which included cerebral infarction (stroke) and senile degeneration (impaired cognition). Review of the MDS assessment, dated 4/23/25, indicated Resident #24 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of Resident #24's Self-Administration of Medication assessments, dated 12/30/24 and 3/22/25, indicated he/she did not desire to self-administer medication. Review of Resident #24's Physician's Orders indicated but was not limited to: -Flonase allergy relief nasal suspension 50 mcg/act (fluticasone propionate nasal spray), 1 spray in both nostrils two times a day for dry, irritated nares. May self-administer and keep at the bedside, dated 3/17/25. Further review of Resident #24's Physician's Order (3/17/25) indicated the ability/desire to self-administer Flonase predated the Self-Administration of Medication Assessment (3/22/25) and his/her record did reflect the 3/22/25 change. On the following dates of survey, the surveyor observed medication unsecured in Resident #24's room: -5/14/25 at 9:10 A.M., there was a box containing a bottle of fluticasone propionate nasal spray on his/her overbed table, -5/15/25 at 7:35 A.M., there was a box containing a bottle of fluticasone propionate nasal spray in a pink basin on his/her wheelchair at the bedside. During an interview on 5/20/25 at 9:46 A.M., Resident #24 said he/she used to keep her Flonase in the room but somebody took it away and now the nurses bring it in for him/her. During an interview on 5/20/25 at 10:02 A.M., Nurse #5 said when a resident wants to keep medication at the bedside an assessment needs to be conducted to ensure the resident understood the medication and the order and was able to safely administer the medication and then the medication should be secure in the room when not being used by the resident. Nurse # 5 said the facility had keys to the bedside table for safe keeping. Nurse #5 said Resident #24 should not have medication at the bedside. 3. Resident #23 was admitted to the facility in January 2020 with diagnoses which included COPD. Review of the MDS assessment, dated 5/2/25, indicated Resident #22 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of Resident #23's Self-Administration of Medication assessment, dated 4/25/25, indicated he/she did not desire to self-administer medication. Review of Resident #23's Physician's Order indicated but were not limited to: -fluticasone-salmeterol inhalation aerosol powder breath activated 250-50 mcg/act (fluticasone-salmeterol) 1 application inhale orally two times a day for treat asthma rinse mouth after each use, 4/15/25 On 5/14/25 at 9:16 A.M., the surveyor observed a box containing a fluticasone salmeterol (steroid and bronchodilator combination) inhaler unsecured and on Resident #23's overbed table. During an interview on 5/20/25 at 9:49 A.M., Resident #23 said the day the inhaler was on his/her overbed table was because the night nurse left it behind. Resident #23 said he/she was not supposed to have it. During an interview on 5/20/25 at 10:02 A.M., Nurse #5 said Resident #23 should not have medication at the bedside. During an interview on 5/20/25 at 11:32 A.M., the Director of Nurses (DON) said she was not sure if the non-narcotic medication should have been locked but that medication should be in a safe place acceptable to the residents. The DON said she needed to review the policy to see if the medications needed to be locked or not. Based on observation, record review and interview, the facility failed to ensure medications were labeled and stored in accordance with acceptable professional standards for three Residents (#64, #24, #23), of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #64, to ensure the Resident's inhaler and allergy nasal spray medications were stored securely; 2. For Resident #24, to ensure the Resident's nasal spray medication was stored securely; and 3. For Resident #23, to ensure the Resident's inhaler medication was stored securely. Findings include: Review of the facility's policy titled Medication Storage in the Facility, undated, indicated but was not limited to the following: - Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. - The manner of storage prevents access by other residents. 1. Resident #64 was admitted to the facility in March 2025 with diagnoses including chronic obstructive pulmonary disease (COPD) and shortness of breath (SOB). Review of the Minimum Data Set (MDS) assessment, dated 5/5/25, indicated Resident #64 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #64's Self-Administration Medication assessment, dated 5/13/25 and 5/14/25 indicated he/she desired to self-administer medications. Furthermore, the assessments indicated he/she was safe to administer Mometasone Furoate Inhalation Aerosol Powder Breath Activated Inhaler, Albuterol Sulfate Inhalation Aerosol Power Breath Activated Inhaler, and Anoro Ellipta Inhalation Aerosol Powder Breath Activated Inhaler. Review of Resident #64's Physician's Orders included but were not limited to: - 5/14/25: May self-administer and keep at bedside. Patient wishes to self-administer Mometasone Furoate, Albuterol Sulfate, Anoro Ellipta. - 5/13/25: Mometasone Furoate Inhalation Aerosol Powder Breath Activated 220 MCG/ACT; two puff inhale orally one time a day related to COPD; unsupervised self-administration; rinse mouth with water each use to prevent incidence of candidiasis. - 4/29/25: Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 108 (90 Base) MCG/ACT; two puff inhale orally every four hours as needed for SOB; unsupervised self-administration. - 4/29/25: Anoro Ellipta Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/ACT; one puff inhale orally one time a day related to COPD; Unsupervised self-administration. - 4/29/25: Fluticasone Propionate Nasal Suspension 50 MCG/ACT; two sprays in each nostril one time a day for allergy. On the follow dates of the survey, the surveyor observed medication unsecured in Resident #64's room: - 5/14/25 at 9:12 A.M., there were boxes containing Fluticasone Propionate Nasal Spray, Mometasone Furoate Inhalation Aerosol Powder Breath Activated Inhaler, Albuterol Sulfate Inhalation Aerosol Power Breath Activated Inhaler, and Anoro Ellipta Inhalation Aerosol Powder Breath Activated Inhaler on top of his/her bedside nightstand. - 5/15/25 at 9:18 A.M., therer were boxes containing Fluticasone Propionate Nasal Spray, Mometasone Furoate Inhalation Aerosol Powder Breath Activated Inhaler, Albuterol Sulfate Inhalation Aerosol Power Breath Activated Inhaler, and Anoro Ellipta Inhalation Aerosol Powder Breath Activated Inhaler on top of his/her bedside nightstand. During an interview on 5/15/25 at 9:18 A.M., Resident #64 said he/she is able to self-administer the inhaler medications. The Resident said he/she prefers to keep inhaler medications at the bedside and typically leaves them in or on the nightstand. During an interview on 5/20/25 at 9:53 A.M., Nurse #10 said Resident #64 is able to self-administer inhaler medications and they are left at the bedside. Nurse #10 said she was not sure if the medications needed to be locked or secured but he/she stores them in the nightstand next to their bed. Nurse #10 said medications should not be left out on top of the nightstand and should be kept in the drawer. During an interview on 5/20/25 at 10:10 A.M., Unit Manager (UM) #1 said Resident #64 was able to self-administer his/her inhaler medications, but the Fluticasone Propionate Nasal Spray medication should not have been left at the bedside as he/she is not able to self-administer that medication. UM #1 said medications should be stored in the top drawer of his/her nightstand and it should be locked.

Based on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program. Findings include: Review of the facility's policy titled Infection Control Prevention Program - Antibiotic Stewardship, revised 3/2024, indicated but was not limited to the following: - It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's infection prevention and control program. The goal of this program is to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use. - The facility will establish an antimicrobial stewardship team (AMS) dedicated to improving antimicrobial use. - The core members of the AMS team will include, but not be limited to the Medical Director, Pharmacy Consultant, Director of Nurses (DON), and Infection Preventionist (IP). - The facility uses the Updated McGeer's criteria to define infections. - When symptoms of an infection are identified, the following measures will be implemented: nursing staff shall notify MD (physician)/APRN (nurse practitioner) and responsible party; symptoms will be reviewed with the MD/APRN and further testing will be obtained per MD/APRN order; test results will be reviewed with the MD/APRN when available; all orders will include dose, duration, and indication of antibiotic; the duration of the ABT (antibiotic) therapy will be defined and/or regularly reviewed by the prescriber; antibiotics will be reassessed 48-72 hours after initiation to ensure the antibiotic is still indicated or adjustments should be made. - All infections will be tracked [NAME] (sic) the IP or designee and reviewed for trends. Review of the facility's policy titled Infection Control Prevention Program - Antibiotic Prescribing Practices, revised 3/2024, indicated but was not limited to the following: - Goal: to improve antibiotic ordering practices within the facility. - It is the policy of this facility that antibiotic prescribing practices are implemented as part of the facility's Antibiotic Stewardship Program for the purpose of optimizing the treatment of infections and to reduce adverse events associated with the antibiotic use. - The decision to prescribe an antibiotic will be guided by medical knowledge, best practices, and professional guidelines. - Antibiotics will be administered only as prescribed by the physician or other authorized practitioner. - Reassessment of the antibiotic will be conducted after 2-3 days for appropriateness factoring in results of diagnostic tests, laboratory results, and/or changes in the clinical status of the resident. Review of the facility's policy titled Infection Control Prevention Program - Surveillance for Healthcare-Associated Infections (HAIs), revised 3/2024, indicated but was not limited to the following: - This facility will closely monitor all residents who exhibit signs/symptoms of infection. - The nurse or nursing assistant will notify the IP of suspected infections, who will record the information of the Infection Control Log. - Document in the narrative nurses notes every shift of presence or absence of symptoms. Review of the facility's Surveillance Sheets for May 2025 indicated but were not limited to the following: Resident #29 had an upper respiratory infection (URI) concern with an onset date of 5/12/25. The surveillance indicated that the concern did not rise to the level of infection as determined by the facility criteria, however an antibiotic was prescribed for five days. Review of Resident #29's nursing progress notes indicated an antibiotic was initiated on 5/12/25 with no symptoms documented. A late entry note for 5/12/25 was written after the concern for antibiotic usage was brought to the facility's attention and indicated the Resident had congestion. Further review of the physician and nurse practitioner progress notes indicated on 5/14/25 Resident #29 had a congested cough. No further specific signs or symptoms of infection were indicated in the medical record. Review of Resident #29's medical record, including nursing, physician and nurse practitioner progress notes, failed to indicate reasoning for continued antibiotic usage even though the symptoms did not meet McGeer criteria. Resident #99 had a skin concern with an onset date of 5/1/25. The surveillance indicated that the concern did not rise to the level of infection as determined by the facility criteria, however an antibiotic was prescribed for seven days. Review of Resident #99's nursing progress notes indicated on 4/28/25 he/she had some swelling to their right lower extremity. The nursing progress notes on 5/1/25 indicated an antibiotic was started for seven days. Further review of the physician and nurse practitioner progress notes failed to include information related to the right lower extremity infection. No further specific signs or symptoms of infection were indicated in the medical record. Review of Resident #99's medical record, including nursing, physician and nurse practitioner progress notes, failed to indicate reasoning for continued antibiotic usage even though the symptoms did not meet McGeer criteria. During an interview on 5/20/25 at 7:52 A.M., the Director of Nursing (DON) said the medical record should contain documentation of all the residents' signs and symptoms of infection. The DON said the IP documents in progress notes when a resident does not meet antibiotic usage criteria, and any conversations had with the prescriber. The DON said progress notes should identify a prescriber's rationale for continued use of an antibiotic that does not meet McGeer criteria. The DON said there needs to be clearer documentation in the medical record indicating the residents' signs and symptoms of infection and/or rationale for continued antibiotic usage.

Based on record review and interview, the facility failed to ensure two Residents (#23 and #87), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended pneumococcal vaccination, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner. Specifically, the facility failed: 1. For Resident #23, to ensure the Resident's medical record included documentation that indicated the Resident/Resident's Representative was provided education regarding the benefits and potential side effects of pneumococcal vaccination and declined vaccination; and 2. For Resident #87, to ensure the Resident's medical record included documentation that indicated the Resident/Resident's Representative was provided education regarding the benefits and potential side effects of pneumococcal vaccination and either consented to receive or refused vaccination. Findings include: Review of the facility's policy titled Immunization of Residents, revised October 2024, indicated, but was not limited to, the following: -All eligible residents will be offered the influenza and pneumococcal vaccines unless medically contraindicated. The resident or the resident's legal representative will be provided education regarding the pros and cons of the vaccine prior to administration. The resident or resident's legal representative has the right to refuse the vaccine. -Procedure for Pneumococcal Vaccination of Residents *Each resident or their responsible party will be asked on admission if they have previously had any pneumococcal vaccinations and their age at the time of vaccination. *The pneumococcal conjugate vaccine will be offered to all eligible residents and the risks and benefits will be provided to the resident or resident's legal representative prior to administration of the vaccine. The resident or resident's legal representative has the right to refuse the vaccine. *Adults aged 65 years or older who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Pneumococcal Vaccine Timing for Adults, dated October 2024, indicated but was not limited to the following: Adults 50 years or older: -No prior pneumococcal vaccine history (or received PCV7 at any age and no other pneumococcal vaccines): *Option A: Administer PCV20 or PCV21 for all adults 50 years or older who have never received any pneumococcal vaccine *Option B: Administer PCV15 followed by pneumococcal polysaccharide vaccine (PPSV23) at least a year later -Received PPSV23 only (at any age): *Option A: Administer PCV20 or PCV21 at least a year later *Option B: Administer PCV15 at least a year later -Received PCV13 only (at any age): *Administer PCV20 or PCV21 at least a year later -Received PCV13 at any age and PPSV23 at younger than 65 years: *Administer PCV20 or PCV21 at least five years later 1. Resident #23 was admitted to the facility in February 2024 and was [AGE] years old. Review of Resident #23's electronic health record indicated the Resident refused pneumococcal conjugate vaccination. Review of the Resident's full medical record failed to indicate the Resident's pneumococcal vaccination history had been obtained or that the Resident's eligibility for the pneumococcal vaccine had been determined. Further review failed to indicate any education was provided to the Resident or their legally responsible party or that a consent or declination form for pneumococcal conjugate vaccination was obtained. 2. Resident #87 was admitted to the facility in March 2025 and was [AGE] years old. Review of Resident #87's electronic health record failed to indicate the Resident had received or refused a pneumococcal conjugate vaccine. Review of the Resident's full medical record failed to indicate any pneumococcal vaccination history had been obtained or that the Resident's eligibility for the pneumococcal vaccine had been determined. Further review failed to indicate any education was provided to the Resident or their legally responsible party or that a consent or declination form was obtained. During an interview on 5/20/25 at 11:29 A.M., the Director of Nurses said she could not find the pneumococcal consent/declination forms for Resident #23 or Resident #87 that should be in the Residents' medical records.

2. Resident #68 was admitted to the facility in September 2022 with diagnoses including retention of urine, hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine), and obstructive and reflux uropathy (obstructive uropathy is a condition in which the flow of urine is blocked, causing urine to back up and injure one or both kidneys). Review of the MDS assessment, dated 04/11/25, indicated Resident #68 was cognitively impaired, as evidenced by a BIMS score of 1 out of 15. Further review of the MDS indicated he/she had an indwelling catheter. On 05/14/25 at 10:30 A.M., the surveyor observed Resident #68 lying in bed with the urinary drainage bag positioned on the left upper rail of the bed, facing the doorway. The drainage bag was fully visible and not placed in a private bag to conceal it from view. On 05/15/25 at 08:50 A.M., the surveyor observed Resident #68 sitting in bed, with the urinary drainage bag positioned on the left upper bed rail. The bag contained visible urine and was not placed in a privacy bag. During an interview on 05/15/25 at 09:00 A.M., CNA #10, along with the surveyor, observed the Resident's urinary catheter bag positioned on the left upper side rail facing the doorway, without a privacy bag. CNA #10 stated that there should be a privacy bag covering the catheter bag but was unsure why the overnight staff did not apply one. During an interview on 05/16/25 at 02:05 P.M., Unit Manager #3 stated that staff are required to keep urinary catheter bags covered to maintain privacy. During an interview on 05/20/25 at 11:45 A.M., the Director of Nursing stated that she was unaware that Resident #68's urinary drainage bag had not been covered for privacy. She said that it should always be placed in a privacy bag. During an interview on 05/20/25 at 01:45 P.M., CNA #9 stated that the catheter drainage bag must be covered to uphold the Resident's dignity. During an interview on 05/20/25 at 02:40 P.M., CNA #8 stated that the urinary catheter drainage bag must be covered to maintain the Resident's privacy. Based on observation, interview, and record review, the facility failed to ensure two Residents (#47 and #68) were treated with dignity and respect, in a total sample of 23 residents. Specifically, the facility failed: 1. To engage with Resident #47 using their preferred name (their first name shortened to a nickname), after being informed of the preferred name by the family; and 2. To provide a privacy bag to cover the urinary catheter bag of Resident #68. Findings include: 1. Review of the facility's policy titled Comprehensive Care Plans, dated November 2017, indicated the following: -recognizing each resident as an individual, we identify and meet those needs in a resident-centered environment -care plans reflect resident preferences Resident #47 was admitted to the facility in October 2024 with a diagnosis of bipolar disorder with a history of mental illness. Review of the Minimum Data Set (MDS) assessment, dated 4/11/25, indicated Resident #47 scored 15 out of 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact and the Resident had an activated Health Care Proxy. Review of the medical record indicated Resident #47 had participated in the initial Social Service and Recreation interviews and was able to provide his/her own history. Review of the medical record indicated Resident #47 had been verbal and participating in conversations and then after many months at the facility had started whispering and was difficult to understand. The medical record failed to indicate Resident #47 had been asked what he/she preferred to be called. Review of the care plans for Resident #47 failed to indicate the Resident's preferred name and referred to the Resident as Resident or {Full First Name}. During an interview on 5/14/25 at 11:40 A.M., the sister of Resident #47 said she lived five hours away and had been unable to visit the Resident in the last six months. She said there may have been a communication issue because the staff had been calling the Resident by his/her last name and then demonstrated {last name}, {last name}. She said she had to tell the staff what the Resident's name was and when the staff said the Resident's preferred name the Resident had responded right away, adding something as simple as that might be helpful. She said she was putting a sign up in the Resident's room indicating the Resident's preferred name. On 5/14/25 at 4:21 P.M., the surveyor observed Resident #47 lying in bed. There was a handwritten sign on the bulletin board in the Resident's room and one on the Resident's headboard indicating the Resident preferred to be called by their nickname. During an interview on 5/15/25 at 10:52 A.M., Certified Nursing Assistant (CNA) #6 said Resident #47 could resist care at times and needed a lot of redirection. She said the Resident whispered and did not always speak full sentences but could make his/her needs known. She said the staff usually called the Resident {Last Name}, but that she had seen a sign in the Resident's room this morning indicating to call the Resident by their nickname. During an interview on 5/15/25 at 11:35 A.M., Unit Manager #3 said Resident #47 had transferred to this unit in January 2025 and had been whispering when he/she arrived to the unit. He said he was not sure why the staff called the Resident {Last Name} and had just learned from the family that the Resident preferred to be called their nickname. On 5/15/25 at 3:45 P.M., the surveyor observed Nurse #3 redirect Resident #47 away from the elevator and said the following: {Last name}, let's get a ginger ale {Last name}, let's get a cookie The Resident was observed to start to walk away and the nurse responded, {Last Name}, {Last Name} then began to walk Resident #47 toward their room saying come {Last Name}. {Last Name}? During an interview on 5/16/25 at 9:10 A.M., Social Worker #2 said she did not know the sister of Resident #47 had placed signs in the Resident's room indicating the Resident's preferred name. She said she had always referred to the Resident by their nickname. She said she was not sure if the facility had ever asked the Resident what their preferred name was, but the staff should be following it. She said she had heard staff call the Resident by their last name, but she was not sure how that had initiated. She said all staff should be made aware of the Resident's preference to be called by their nickname.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who during the night shift (11:00 P.M. to 7:00 A.M.) on 03/07/25 into 03/08/25 had an unwitnessed fall, and was found in the bathroom kneeling on the floor, the Facility failed to ensure the Provider and Family Member #1, were notified. Findings include: Review of the Facility's Policy, titled Condition: Significant Change, dated April 2015, indicated the following: -staff will communicate with the physician, resident/patient, and family regarding changes in condition to provide timely communication of resident/patient status change which is essential to quality care management - the physician, resident/patient and/or responsible party will be notified by the nurse in the event of a change in condition -this notification shall be documented in the clinical record Review of the Facility's Policy, titled Falls Management, dated as reviewed/revised April 2024 indicated the following: -anytime a resident is found on the floor, a fall is considered to have occurred -post fall, once a resident/patient is clinically evaluated as being stable, vital signs, neurological signs, range of motion, and evaluation of cognitive status will be documented -neurological checks are to be documented on the neurological flow sheet for 72 hours in the following circumstances: resident/patient states that he/she hit head, physical evidence resident hit head, and an unwitnessed fall; resident/patient should continue to be monitored for 72 hours after a fall to evaluate for latent injury, with documentation in the medical record Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 03/13/25, indicated on 03/08/25 at approximately 6:00 A.M., Resident #1 was found by a Certified Nurse Aide (CNA, later identified as CNA #1) kneeling on his/her right knee in the residents' shared bathroom. The Report indicated that the nurse (later identified as Nurse #1) on duty that day was notified. The Report further indicated that Nurse #1 gave Resident #1 his/her medications and he/she did not complain of pain. Resident #1 was admitted to the Facility in February 2025, diagnoses included displaced comminuted fracture (bone breaks into three or more pieces) of shaft of humerus (upper left arm), difficulty in walking, anxiety disorder, chronic kidney disease stage 2, hypertension, chronic obstructive pulmonary disease, and hyperlipidemia (high cholesterol). During an interview on 04/22/25 at 3:19 P.M., (which included review of her written statement) CNA #1 said on 03/08/25 around 6:00 A.M., she was called to Resident #1's room by his/her roommate, who told her that Resident #1 was on the floor in the bathroom. CNA #1 said she found Resident #1 kneeling on his/her right knee in front of the sink and as she approached Resident #1, he/she grabbed onto her (CNA#1) shirt and said, I just want to stand up, so she helped Resident #1 get up. CNA #1 said she asked Resident #1 if he/she fell and said Resident #1 told her (CNA #1) that he/she did not fall and had just slipped because there was water on the floor. CNA #1 said Resident #1 said he/she was okay, was not in pain, so she assisted him/her back to bed. CNA #1 said she told Nurse #1 she found Resident #1 on the bathroom floor, that he/she slipped in water, was not in pain and assisted him/her back to bed. During an interview on 04/28/25 at 10:54 A.M., (which included review of her written statement) Nurse #1 said on 03/08/25, CNA #1 told her that she found Resident #1 in the bathroom on the floor on one knee. Nurse #1 said she went to give Resident #1 his/her morning medication, he/she was in bed, and that she asked Resident #1 how he/she was. Nurse #1 said Resident #1 told her that he/she was fine. Nurse #1 said Resident #1 appeared to be in no apparent distress, that she assessed his/her range of motion (ROM), and he/she did not complain of pain. Nurse #1 said Resident #1 did not tell her that he/she had fallen. Nurse #1 said she did not think Resident #1's incident was an actual fall because she had not seen him/her on the floor. Nurse #1 said that CNA #1 had assisted him/her back to bed after being found on the bathroom floor and CNA #1 told her (Nurse #1) that Resident #1 had said he/she was okay. Nurse #1 said she did not complete an incident report regarding the fall. Nurse #1 said she did not document Resident #1's fall or her assessment of him/her after the fall and did not notify the Physician, or Family Member #1 of the unwitnessed fall. Nurse #1 said anytime a resident is found on the floor it is considered a fall. Nurse #1 said she did not follow the Facility's policies, but said she should have. Review of Resident #1's medical record indicated that there was no documentation to support that Nurse #1 notified his/her Physician and Family Member #1 of the unwitnessed fall. Review of Resident #1's Incident Report, dated 03/09/25, (completed by Nurse #4), indicated that Resident #1 stated to Nurse #4 that he/she fell in the bathroom at 6:00 A.M. (the previous day), that after using the toilet he/she took a step, then slipped in either water or urine, fell into the bathroom door and then fell to the floor hitting his/her right side in the rib area. The Report indicated that a CNA (identified as CNA #1) was called into the room by the resident in the adjoining room, and CNA #1 then helped him/her up off the floor. The Report indicated the Physician and Director of Nursing were notified (03/09/25). Review of Resident #1's Nurse Progress Note, dated 03/10/25, (written by Nurse #4), indicated that Resident #1 was noted to be in severe pain this A.M., and he/she complained of worsening right-sided pain. The Note indicated that Resident #1 was sent to the Hospital Emergency Department via rescue, and returned with a diagnosis of a T11 compression fracture and a new order for oxycodone (opioid, analgesic) as needed for severe pain. During a telephone interview on 05/01/25 at 11:14 A.M., the Director of Nursing (DON) said she was notified on 03/09/25 by Nurse #4 that Resident #1 had sustained an unwitnessed fall (on 03/08/25). The DON said she spoke to Nurse #1, who said CNA #1 informed her (Nurse #1) that she found Resident #1 kneeling on his/her right knee in the bathroom. The DON said Nurse #1 said she gave Resident #1 his/her morning medication and he/she did not complain of any pain or say he/she had fallen. The DON said Nurse #1 did not document Resident #1's fall in his/her medical record, and did not notify the Physician or Family Member #1. The DON said Nurse #1 did not follow the Facility's Policy. The DON said her expectation is always best practice, patient-centered care and that all Facility Protocols and Policies are being followed by the nurses.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who during the night shift (11:00 P.M. to 7:00 A.M.) on 03/07/25 into 03/08/25 was found on the bathroom floor after an unwitnessed fall by nursing staff, the facility failed to ensure he/she was provided care and services that met professional standards of nursing practice, when although Nurse #1 said she assessed Resident #1 after the incident, she did not document it, did not complete an incident report or write a progress note, and did not report the unwitnessed fall to the oncoming shift nurse, so he/she could be monitored. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Facility's Policy, titled Accidents/Incidents, dated April 2015, indicated the following: -it is the responsibility of the staff to report all accident and incidents which occur at the facility -reporting of accidents/incidents; must be reported to the supervisor, and appropriate documentation completed -the investigation of accident/incident form will be used for resident/patients; be completed for each incident -the Administrator and Director of Nursing will be made aware of all such incidents that have occurred, and will review completed reports Review of the Facility's Policy, titled Falls Management, dated as reviewed/revised April 2024 indicated the following: -anytime a resident is found on the floor, a fall is considered to have occurred -post fall, once a resident/patient is clinically evaluated as being stable, vital signs, neurological signs, range of motion, and evaluation of cognitive status will be documented -neurological checks are to be documented on the neurological flow sheet for 72 hours in the following circumstances: resident/patient states that he/she hit head, physical evidence resident hit head, and an unwitnessed fall; resident/patient should continue to be monitored for 72 hours after a fall to evaluate for latent injury, with documentation in the medical record Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/13/25, indicated on 03/08/25 at approximately 6:00 A.M., Resident #1 was found by a Certified Nurse Aide (CNA, later identified as CNA #1) kneeling on his/her right knee in the residents' shared bathroom. The Report further indicated that Resident #1 was sent to the hospital (on 3/09/25) for complaints of flank (area between the ribs and hip on either side of the body) pain and an X-ray indicated he/she had a small compression fracture in his/her thoracic vertebrae. Resident #1 was admitted to the Facility in February 2025, diagnoses included displaced comminuted fracture (bone breaks into three or more pieces) of shaft of humerus (upper left arm), difficulty in walking, anxiety disorder, chronic kidney disease stage 2, hypertension, chronic obstructive pulmonary disease, and hyperlipidemia (high cholesterol). During an interview on 04/22/25 at 3:19 P.M., (which included review of her written statement) CNA #1 said on 03/08/25 around 6:00 A.M. she was called to Resident #1's by his/her roommate who reported that Resident #1 was on the floor in the bathroom. CNA #1 said she found Resident #1 kneeling on his/her right knee in front of the sink and as she approached Resident #1, he/she grabbed onto her (CNA#1) shirt and said, I just want to stand up. CNA #1 said Resident #1 told her (CNA #1) that he/she did not fall but had just slipped because there was water on the floor. CNA #1 said Resident #1 told her he/she was okay, said he/she was not in pain, that she helped Resident #1 change his/her clothes because they were wet and then assisted him/her back to bed. CNA #1 said she reported to Nurse #1 that she found Resident #1 on the bathroom floor, that he/she reported he/she had slipped in water, was not in pain and that she assisted him/her back to bed. During an interview on 04/28/25 at 10:54 A.M., (which included review of her written statement) Nurse #1 said on 03/08/25 sometime after 6:00 A.M., CNA #1 told her that she found Resident #1 in the bathroom on the floor on one knee. Nurse #1 said when she went to give Resident #1 his/her morning medication, he/she was in bed, and she asked Resident #1 how he/she was. Nurse #1 said Resident #1 told her that he/she was fine. Nurse #1 said Resident #1 appeared to be in no apparent distress, that she assessed his/her range of motion (ROM), and he/she did not complain of pain or say that he/she had fallen. Nurse #1 said she did not think Resident #1's incident was an actual fall because she did not see him/her on the floor. Nurse #1 said that CNA #1 also told her (Nurse #1) that Resident #1 had said he/she was okay. Nurse #1 said that anytime a resident is found on the floor it is considered a fall. Nurse #1 said she did not complete an incident report regarding the unwitnessed fall, and did not document Resident #1's fall or her assessment of him/her after the fall. Nurse #1 she did not notify the Physician, or Family Member #1 of the unwitnessed fall. Nurse #1 said she could not recall if she informed the oncoming shift nurse during change of shift report that morning about Resident #1's unwitnessed fall. Review of Resident #1's medical record indicated that there was no documentation to support that Nurse #1 assessed Resident #1 for potential injury or pain on 03/08/25 after he/she had an unwitnessed fall, including completing an incident report related to being found on the floor by staff, or that the DON and/or Administrator were notified, as required. During an interview on 04/28/25 at 11:33 A.M., Nurse #2 said on 03/08/25 she worked the 7:00 A.M. to 3:00 P.M. shift, and that she was not informed during change of shift report by the 11:00 P.M. to 7:00 A.M. nurse (Nurse #1) that Resident #1 was found on the floor earlier that morning. Nurse #2 said Resident #1 received his/her scheduled pain medication and did not complain of any pain during her shift. Review of Resident #1's Nurse Progress Note, dated 03/08/25 (written by the Assistant Director Nursing (ADON), indicated that Resident #1 complained of back pain, stated he/she had a fall the night prior. The Note indicated that the day shift nurse reported she was not informed (by the night shift nurse) that Resident #1 fell during the overnight shift. The Note indicated Resident #1 was questioned and stated that he/she did not fall, said he/she slipped in the bathroom and stumbled. The Note indicated that Resident #1 requested to be transferred to the hospital for an X-ray of his/her back but was advised (by the ADON) that an X-ray could be ordered in house, and he/she agreed. During an interview on 04/22/25 at 4:03 P.M., the ADON said she worked from 4:00 P.M. to 11:00 P.M. on 03/08/25 on Resident #1's unit. The ADON said Resident #1 complained of back pain and she asked him/her what happened, and Resident #1 told her (ADON) that he/she fell the night before. The ADON said she then asked Resident #1 where he/she fell , and Resident #1 said I did not fall, I stumbled in the bathroom. The ADON said she called Nurse #2 who had worked on the unit from 7:00 A.M. to 3:00 P.M. and asked her (Nurse #2) if Resident #1 had fallen. The ADON said Nurse #2 told her Resident #1 had no complaints and had not reported to her that he/she fell . Review of Resident #1's Incident Report, dated 03/09/25, (completed by Nurse #4), indicated that Resident #1 stated to Nurse #4 that he/she fell in the bathroom (on 3/08/25) at 6:00 A.M., that after using the toilet he/she took a step, then slipped in either water or urine, fell into the bathroom door and then reported that he/she fell to the floor hitting the right side his/her ribs. The Report indicated that a CNA (CNA #1) was called into the room by the resident in the adjoining room, and CNA #1 then helped him/her up off the floor. The Report indicated the Physician and Director of Nursing were notified (on 03/09/25). Review of Resident #1's Nurse Progress Note, dated 03/09/25 (written by Nurse #4), indicated that Resident #1 complained of right sided rib pain, reported that he/she may have a fracture because he/she hit his/her ribs during a fall. The Note indicated that Resident #1 reported that he/she did not tell the nurse because he/she was afraid it would hold up his/her upcoming discharge from the Facility. The Note further indicated that Resident #1's pain level was a 9/10 (a pain scale where 0 is no pain and 10 is the worst pain possible), he/she appeared visibly distressed, was given ibuprofen and a STAT (immediately or without delay) X-ray was ordered. Review of Resident #1's Nurse Progress Note, dated 03/10/25, (written by Nurse #4), indicated Resident #1 noted to be in severe pain this A.M., he/she complained of worsening right-sided pain. The Note indicated that Resident #1 was sent to the Hospital Emergency Department via rescue, and he/she returned with a diagnosis of a T11 compression fracture and a new order for oxycodone, as needed for severe pain. Review of Resident #1's Hospital After Visit Summary, dated 03/10/25, indicated he/she was seen for a chief complaint of rib injury. The Summary indicated Resident #1's Computed Tomography (CT) scan (imaging test that uses X-rays) of his/her chest, abdomen, and pelvis showed a new mild compression deformity (small compression fracture) of the superior endplate (the top surface of a vertebral body in the spine) of his/her T11 (eleventh thoracic vertebra in the spine). During a telephone interview on 05/01/25 at 11:14 A.M., the Director of Nursing (DON) said she was notified on 03/09/25 by Nurse #4 that Resident #1 had sustained an unwitnessed fall (on 03/08/25). The DON said she spoke to Nurse #1, who said CNA #1 informed her (Nurse #1) that she found Resident #1 kneeling on his/her right knee in the bathroom. The DON said Nurse #1 said that when she gave Resident #1 his/her morning medication, he/she did not complain of any pain or say he/she had fallen. The DON said Nurse #1 did not complete any assessments, did not document Resident #1's unwitnessed fall in his/her medical record, and did not inform the oncoming shift Nurse. The DON said Nurse #1 should have assessed Resident #1 and followed the Facility's Policy related to an unwitnessed fall, but she did not. The DON said her expectation is always best practice, patient-centered care and that all Facility Protocols and Policies are being followed by the nurses. The DON said she holds the nurses to the highest standard for professional conduct for residents' safety.

Based on observation, interview, and policy review, the facility failed to: 1. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections; 2. Ensure staff performed hand hygiene in between each resident during a medication pass and did not touch the medications with their bare hands; 3. Ensure staff performed hand hygiene in between glove changes during a dressing change treatment for Resident #257; and 4. Ensure transmission based precautions (TBP) were implemented according to Centers for Disease Control and Prevention (CDC) guidance for Resident #21. Findings include: 1. Review of the facility's policy titled The Infection Prevention Program, dated as revised October 2022, included but was not limited to the following: -This facility follows the professional standards set forth as recommended by the CDC/OSHA. The goal of the Infection Prevention Program is to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. -The facility has a system in place for the prevention, identification, reporting, investigation and control of infections and communicable disease of residents, staff, and visitors. -Responsibility for ongoing collection and analysis of data and required follow up is assigned to the Infection Preventionist (IP). -Elements of the Infection Prevention Program includes monitoring and documenting infections, tracking and analyzing outbreaks of infections, managing resident health initiatives and provision of early, uniform identification and reporting of infections. -The IP will perform surveillance and investigation of infections to prevent, to the extent possible, the onset and spread of infection. -Analyze trends and clusters of infection, and any increase in the rate of infection or resistant organisms, in a timely manner. -Maintain the monthly infection reports by unit to record each resident infection Review of the facility's policy titled Surveillance for Healthcare, dated as revised October 2022, included but not limited to the following: -Surveillance is defined as the ongoing, systematic collection, analysis, interpretation and dissemination of data. -The facility will closely monitor all residents who exhibit signs/symptoms of infection. The IP will record the information on the Infection Control Log. -The IP will gather additional data for infection tracking and reporting and provide consultation and education as needed. -The IP or designee will monitor the residents with infections and/or potential infections by completing the Monthly Infection Report by Unit. Review of the facility's Monthly Resident Infection and Antibiotic Stewardship Report tool for the months of December 2023, January 2024, and February 2024, indicated but was not limited to the following: -The December 2023 report tool had missing documentation for 23 out of 25 residents. Specifically, 23 of the 25 residents had no documented signs and symptoms of an illness. -The January 2024 report tool had missing documentation for 16 out of 16 residents. Specifically, 2 of the 16 residents had no documented site of infection and 16 out of 16 residents had no signs or symptoms of an illness. -The February 2024 report tool had missing documentation for 11 out of 13 residents. Specifically, 11 of the 13 residents had no signs or symptoms of an illness; and 2 of the 13 residents had no documentation to determine if their illness/infection was a Healthcare acquired or Community acquired infection (HAI/CAI). During an interview on 3/28/24 at 10:05 A.M., with the Staff Development Coordinator (SDC) who is assisting the IP with surveillance, and the IP, the SDC said she only has surveillance for residents taking antibiotics, and not any other potential illnesses for other residents. She said the facility utilizes McGeer Criteria to analyze if an illness is an infection. She said she is new to this position and will attempt to find additional surveillance information and provide it to the surveyor. The SDC reviewed the report tools for December 2023, January 2024, and February 2024 with the surveyor and said the report tool was incomplete. The IP reviewed the report tools for December 2023, January 2024 and February 2024 with the surveyor and said the tools are not complete. During an interview on 3/28/24 at 11:25 A.M., the IP said when a resident has signs and symptoms of an infection it is documented in the medical record, and not placed on the infection report tool for tracking and trending infections. She said the report tool is only used for antibiotics, and should include other illness. She said the facility's primary IP, who is on a leave of absence, would produce a monthly infection report by unit, but she does not know where they would get the information to produce the report or how that is completed. During an interview on 3/28/24 at 12:12 P.M., the SDC and IP said they could not locate any additional surveillance information. During an interview on 3/28/24 at 1:39 P.M., the Director of Nursing (DON) said the expectation is for infection surveillance to be complete on residents whether they are on antibiotics or not. She said the IP is expected to document all information on the monthly infection report tools for tracking and trending of illnesses and symptoms to prevent the spread of infection, as much as possible. She reviewed the infection report tool for the months of December 2023, January 2024, and February 2024 with the surveyor and said the monthly surveillance tool was incomplete. On 4/1/24 at 11:41 A.M., the DON provided the surveyor with documentation from previous outbreaks which did not include any further monthly surveillance data of illnesses. 43935 2. Review of the facility's policy titled: Medication Administration - Oral, dated June 2015, indicated but was not limited to the following: Procedure: - Verify medication administration record for orders and identify the resident - perform hand hygiene (HH) - prepare medications for one resident at a time - do not touch the medication when opening the bottle or unit package - administer the medications - stay with the resident as they swallow the medications - perform HH On 3/27/24 at 7:46 A.M., the surveyor observed Nurse #1 passing medications and observed the following: - Nurse #1 was not observed to perform HH prior to preparing Klonopin 0.25 (milligrams) mg for Resident #3 by popping it from the unit package directly into her hand prior to placing it into a cup - Nurse #1 was not observed to perform HH after administering the Klonopin to Resident #3 or prior to preparing the medications for Resident #71; - Nurse #1 popped a Metoprolol ER 25 mg directly into her hand from the unit package for Resident #71 and administered the medication to the Resident then performed HH; - Nurse #1 popped a Metformin 500 mg tablet directly into her hand prior to placing it into a cup to administer to Resident #7, she then administered the medication to the Resident, but was not observed to perform HH after administering the medication to Resident #7; - Nurse #1 was not observed to perform HH prior to preparing medications for Resident #21; she popped an Aricept 5 mg tablet directly into her hand prior to placing it into a cup and administering it to Resident #21; - Nurse #1 then prepared medications for Resident #41, but was not observed to perform HH prior to preparing the medication of Humalog insulin and liquid protein. During an interview on 3/27/24 at 8:00 A.M., Nurse #1 said she should not be popping pills directly into her hand, especially since she did not perform HH before and after preparation and administration of each individual resident's medications. She said not performing HH before and after each resident was a potential infection control issue and her hands would be considered dirty. During an interview on 3/28/24 at 12:51 P.M., the Regional Nurse said Nurse #1 should not be popping medications into her hand and medications should not come in contact with the nurse's hands for infection control reasons. She said the policy and standard of practice dictates that nurses perform HH before and after preparing medications for each resident they are administering medications to and that expectation was not met as it should have been. 3. Review of the facility's policy titled Clean Dressing Technique, dated July 2017, indicated but was not limited to the following: - licensed staff nurses will use clean dressing technique for all dressing changes unless otherwise specified by the physician Procedure: - sanitize hands and apply clean gloves; remove old dressing and dispose of in plastic trash bag - remove gloves, sanitize hands and apply clean gloves; cleanse wound - remove gloves, sanitize hands and apply clean gloves; apply medications and/or dressing to wound - remove gloves and sanitize hands Resident #257 was admitted to the facility in March 2024 with a pressure ulcer to his/her sacrum (lower back just above the buttocks). On 3/28/24 at 11:20 A.M., the surveyor observed Nurse #2 perform a dressing change of Resident #257's sacral wound as follows: Nurse #2 performed HH by sanitizing her hands with ABHR (alcohol based hand rub) and put on clean gloves; she then removed the old dressing from the Resident's sacrum and removed her gloves throwing them in the trash with the dirty dressing. She was not observed to perform HH after removing her gloves. She then applied a new pair of clean gloves and cleansed the wound as prescribed. She removed her dirty gloves and put on a new pair of gloves without performing HH. She applied the prescribed treatment and cover dressing to the Resident's wound. She was observed to remove her dirty gloves and reposition the Resident for comfort. Prior to leaving the room she was observed to perform HH with ABHR. During an interview on 3/28/24 at 11:20 A.M., Nurse #2 said she should have performed ABHR HH in between each change of her gloves and did not and she made an error by not completing that step. During an interview on 3/28/24 at 12:50 P.M., the Regional Nurse said the nurse should have performed HH each time she removed a pair of dirty gloves and prior to putting on a clean pair of gloves per the facility policy and infection control standard. 49424 4. Review of the facility's policy titled Contact Precautions, dated July 2017, indicated but was not limited to: -Gowns and gloves should be put on before entering the resident's room and removed when leaving the room followed by hand hygiene. -Use contact precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as environmental surfaces or direct resident care. -The use of appropriate transmission-based precautions when a resident develops symptoms of a transmissible infection or arrives in the facility with symptoms of infection (pending laboratory confirmation) reduces transmission opportunities. An example of this would be a strong suspicion of Clostridium Difficile (C. Diff) [a bacterium that causes an infection of the colon] or sudden onset nausea or vomiting. Resident #21 was admitted to the facility in December 2023 with the following diagnoses: encounter for orthopedic aftercare following surgical amputation, osteomyelitis, and cellulitis of lower limb. On 3/26/24 at 1:09 P.M., the surveyor observed a sign posted outside of Resident #21's room that indicated Enhanced Barrier Precautions: Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: -dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with the toileting device care or use, and wound care. On 3/26/24 at 1:10 P.M., the surveyor observed Activity Assistant #1 enter Resident #21's room and hand Resident #21 information for the daily activities. The surveyor did not observe Activity Assistant #1 perform hand hygiene prior to entering or exiting the room. During an interview on 3/26/24 at 1:12 P.M., the Activity Assistant said that she wasn't sure what the precautions were for the room and that she would just wear a mask in the resident room. Review of Resident #21's record indicated that he/she had a physician's order for contact precautions that was initiated on 3/22/24. Review of a nursing progress note, dated 3/22/24, indicated that the Resident was having loose bowel movements and the physician ordered a stool sample be obtained for C. Diff toxin and culture and sensitivity two times. During an interview on 3/26/24 at 1:15 P.M., Unit Manager #1 said that Resident #21 should be on contact precautions until C. Diff is ruled out through laboratory results. She said she wasn't sure why the signage did not reflect contact precautions because she was not working yesterday and came in late today. On 3/26/24 at 1:33 P.M., Unit Manager #1 said the sign that was up was correct and that the enhanced barrier precautions indicated use of gloves, hand hygiene, and gowns. She said that the precautions in place were the correct ones and appropriate for the Resident. On 3/26/24 at 2:16 P.M., the surveyor observed a contact precaution sign posted outside of Resident 21's room. The bright yellow sign indicated: - Everyone must clean their hands, including before entering and when leaving the room. - Providers and staff must also put on gloves before room entry. Discard gloves before room exit. - Put on Gown before room entry. Discard gown before room exit. - Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. During an interview on 3/28/24 at 10:17 A.M., the Staff Development Coordinator said the contact precautions sign was the correct sign for Resident #21 and the enhanced barrier precautions sign was placed accidentally and the staff should have been practicing contact precautions to reduce the risk of transmission of C. Diff. During an interview on 4/1/24 at 10:47 A.M., the Regional Nurse said that Resident #21 should be on contact precautions if the staff are awaiting results for suspicion of C. Diff. She said that enhanced barrier precautions and contact precautions are not the same and that contact precautions are used to prevent the transmission of C. Diff.

Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response and rationale for review with the Resident Council. Findings include: Review of the facility's policy titled Resident Council, last revised 10/2015, indicated the following: - It is the policy of this home that the Recreation Department will provide support and assistance in the formation of a Resident Council. - The residents will have an opportunity to express their concerns or grievances, contribute ideas and make recommendations regarding the operation of the home. - Resident Council will meet monthly. - Maintain written minutes including residents in attendance, opening, adjournment times, discussions and/or actions that take place. - Notify Department Heads in writing of concerns that come up during the meeting. - Retain a copy of the resolutions that address each concern. - Retain minutes on file for a minimum of one (1) year. - Review Residents Rights through Resident Council meetings. During the entrance conference on 3/26/24 at 8:56 A.M., the surveyor requested three months of Resident Council minutes, with the approval from the Resident Council President. On 3/27/24 at 11:00 A.M., the surveyor held a group meeting with 15 residents in attendance. The residents said they prefer to hold Resident Council monthly. The Resident Council said facility staff attend to document any of their concerns. The residents said similar concerns are brought forward monthly. The Resident Council said they are unsure of what happens to concerns once they are brought forward, and little follow up on concerns is brought back to the group monthly. Review of the Resident Council Meeting Minutes, dated 1/19/24, indicated but was not limited to the following unresolved concerns: - Call lights on first and second floor units; - Staff not wearing name tags or wearing name tags where they can be seen; - Staff wearing ear buds or on their phones; and - Staff speaking in different languages. Review of the Resident Council Meeting Minutes, dated 2/26/24, indicated but was not limited to the following unresolved concerns: - Third shift name tags are still a concern; - Call lights are being answered better on day shifts, but still a concern on evening shift; and - Staff using cell phones in resident care areas. Review of the Resident Council Meeting Minutes, dated 3/2024, indicated but was not limited to the following unresolved concerns: - Name tags are not being worn by staff or in visible areas. Further review of the Resident Council Meeting Minutes provided failed to indicate a resolution to group concerns were reviewed and discussed with the group. Review of the Resident Council Meeting Minutes failed to include group grievance or resolution forms related to on-going concerns brought forward by the group. During an interview on 3/27/24 at 2:11 P.M., the Social Worker said Resident Council concerns are brought forward to her by the Recreation Director. The Social Worker said she documents concerns from the group in the grievance log. The Social Worker said once a resolution has been completed, she brings the information forward to the Recreation Director to review with the group. Review of the Grievance Log Binder failed to indicate any grievances/concerns brought forward by the Resident Council for the previous three months. During an interview on 3/27/24 at 3:27 P.M., the Recreation Director said after the Resident Council meeting any concerns are brought forward to the Administrator and Director of Nurses. The Recreation Director said she reviews concerns the next morning during the interdisciplinary team meeting with all department heads. The Recreation Director said she verbally reviews concerns and does not provide the interdisciplinary team with information in writing. The Recreation Director said concerns are addressed by the department affected. The Recreation Director said she did not have anything in writing related to resolution of concerns from the previous three months. The Recreation Director said she does not document the Resident Council group or individual concerns brought forward in the meeting in writing. The Recreation Director said she typically just tells the department head they affect. The Recreation Director said she does not review resolution plans with the Resident Council. During an interview on 3/28/24 at 11:14 A.M., the Administrator said issues/concerns brought forward by the Resident Council are brought forward to him by the Recreation Director after each meeting. The Administrator said he receives the meeting minutes from the Recreation Director and brings forwards the information to each department head. The Administrator said he expects each department head to follow up with a resolution to any specific concerns related to them. The Administrator said if an individual resident brings forward a concern in the Resident Council meeting, he would expect a grievance form to be completed. The Administrator said when the Resident Council group brings forward a concern, then those would be addressed by each department for resolutions. The Administrator said the Recreation Director should review resolutions to the Resident Council concerns at the start of each meeting.

Based on observation, interviews, record review, and policy review, the facility failed to ensure staff identified, addressed, and monitored significant weight changes for two Residents (#106 and #65) with unplanned, significant weight changes, out of a total sample of 25 residents. In addition, the facility failed to weigh residents according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, the facility failed 1. For Resident #106, to ensure the Resident was weighed upon admission and weekly as ordered and implement nutrition recommendations timely to prevent weight loss. 2. For Resident #65, to ensure the Resident was weighed per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility's policy titled Weights, dated August 2015, indicated the following: The following resident/patients are weighed weekly X 4 weeks: *Newly admitted resident/patients (unless clinically not indicated). *Residents/patients with an unanticipated, unplanned weight loss of >5% in one month. *Residents/patients with a new tube feeding. *Residents/patients with an MD (physician) order for weekly weights. *Other residents/patients at the discretion of the IDT (Interdisciplinary Team). *Thereafter, residents will be weighed monthly, unless clinically indicated. *The same scale should be used for each weighing of a particular resident/patient to ensure consistency and more accurate weights. If a change must occur, note the change on the weight sheet. Scales should not be moved from their location-movement effects calibration. If there is a wheelchair scale, residents/patients area weighed in a designated wheelchair that has been pre-weighed. If there is not a designated scale, the resident/patient's wheelchair will be weighed separately each time the resident/patient is weighed. *All weight loss/gain of three (3) pounds or more on a resident weighing 100 pounds or less and weight loss/gain of five (5) pounds or more on a resident weighing 100 pounds or more requires a reweigh for verification. A reweigh is done on the same scale, with a licensed nurse present. *Weights are documented in the resident's/patient's medical record and/or weight book. *If a significant weight loss/gain is identified (>5% in 30 days or >10% in 6 months), IDT, Dietitian, Physician and family are notified. *All Residents are reviewed by the IDT and the resident/resident's responsible party and interventions implemented as appropriate and are monitored weekly. 1. Resident #106 was admitted to the facility in June 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor observed Resident #106 as follows: *On 9/19/22 at 9:35 A.M., the Resident was eating breakfast in the dayroom and ate approximately 50% of the eggs but did not eat anything else. *On 9/19/22 at 1:15 P.M., the Resident was not eating, and his/her grilled cheese sandwich was stuffed in a coffee mug. The Resident did not eat anything else. *On 9/21/22 1:00 P.M., the Resident was sitting in the day room and had received grilled cheese sandwich and tomato soup, pudding, milk, and hot chocolate. The Resident ate a few bites of pudding and drank the hot chocolate. Review of Resident #106's meal intake indicated the following: *9/19/22 for breakfast, the staff documented that the Resident ate 26-50% *9/19/22 for lunch, the staff documented that the Resident ate 51-75% *9/21/22 for lunch the staff documented that the Resident ate 51-75% For the three meals observed, the documentation did not match the surveyor's observations. Review of the June 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - the Resident was on a vegetarian diet (regular consistency), soup and grilled cheese at lunch and dinner (will eat eggs, no red or white meat). - the Resident is to be weighed on admission and for 4 consecutive weeks. Review of the Nutrition Assessment completed by the dietitian, dated 6/3/22, indicated the Resident was 64 inches tall, but there was no documented weight. The dietitian determined the Resident's calorie, protein, fluid needs based on the resident's reported usual weight of 130 pounds due to the admission weight had not been obtained. The dietitian documented the Resident is alert but baseline confusion and poor historian. The dietitian determined the Resident's intake was inadequate based on consuming less than 50% at meals. The documented plan was to obtain an admission weight, add multivitamins, and trial an Ensure plus supplement. Review of the Resident's care plans, dated 6/3/22, indicated the Resident was at risk for nutritional decline related to variable intake of food and beverage. The interventions, dated 6/3/22, included: *Administer Vitamin/Mineral supplements per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] * Encourage/provide intake of fluids throughout the day *Monitor weight/weight change per MD order (revised 6/22/22) *Monitor/evaluate energy intake and/or food/beverage intake via meal intake records and observation. *Notify RD, family and physician of any abnormal biochemical data *Notify RD, family and physician of any s/s [signs and symptoms] of dehydration *Provide meals per physician's diet order *Provide medical food supplement Review of the Minimum Data Set (MDS) assessment, dated 6/7/22, indicated the Resident's Brief Interview for Mental Status (BIMS) score was 7 out of 15 indicating severe cognitive impairment. The MDS also indicated the Resident required supervision with meals including set up, was 64 inches tall and weighed 130 pounds. Review of the Nutrition Progress note, dated 6/21/22, indicated the dietitian was asked to see the Resident due to reported decreased food intake and to obtain food preferences. The dietitian documented that she obtained addition food preferences, although the resident was identified as severely cognitively impaired. The dietitian documented the plan as follows: 1. Continue with vegetarian diet and provide food preferences as able. 2. Obtain admission weight and weekly 3. Consider trial of Ensure plus 237 ml per day if po intake remains decreased 4. Multi-vitamin if not already ordered Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the Resident still had not been weighed as of 6/21/22 when the dietitian documented another request in her progress note to obtain the Resident's weight. Review of the Resident's Weight Summary indicated the first weight obtained was on 7/5/22, one month after admission. The documented weights were as follows: 7/5/22- 121.8 pounds 7/12/22- 117 pounds Review of the Nutrition Progress note, dated 7/14/22, indicated the Resident continued on a vegetarian diet, noted to receive soup and grilled cheese sandwich at lunch and supper. The dietitian documented that she spoke with the food manager who said the Resident does complete weekly menus, but generally consumes less than 50% of meals with occasional meal refusal. The dietitian documented that multivitamins, [MEDICATION(S)] (appetite stimulant), and weekly weight had been ordered. The dietitian documented that the Resident had lost 4.8 pounds in the past week and would trial Ensure plus and monitor tolerance and monitor weekly weights. Consider two times weekly. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Ensure plus had an order date of 7/23/22 *Vitamin and mineral supplements had an order date of 8/8/22 Further review of the Resident's weight summary indicated the following: 7/19/22-117.2 pounds 7/27/22-117.4 pounds 8/4/22- 117 pounds Review of the Nutrition assessment dated [DATE] indicated the Resident weighed 117 pounds, representing a 4% weight loss in 1 month (not significant) and [MEDICATION(S)] level below normal. The dietitian documented that the Resident's appetite was poor, and that the Resident has had a nutritional decline. Goal identified was to prevent further weight loss. The plan was to continue with diet and supplements, monitor/chart/recommend as needed and consult RD as needed. Despite the decline in the resident's nutritional status, there were no new interventions attempted to prevent further weight loss. Further review of the Resident's Weight Summary indicated the following: 8/23/22- 115 pounds 9/1/22- 115.4 pounds 9/13/22- 115.1 pounds There was a delay in obtaining the Resident's admission weight by one month, and when obtained, the Resident wasn't re-assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident was not weighed weekly per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 9/21/22 at 3:15 P.M., the dietitian said she was not familiar with Resident #106 but would review. The Dietitian said she reviews weight history through PCC (point click care) electronic medical record system and monitors changes in weights, however she was not aware of the Resident's recent weight loss. The Dietitian said she was not aware that Resident #106 receives soup and grilled cheese sandwich every lunch and supper meal and it should not be a substitute for the vegetarian meal. 2.) Resident #65 was admitted to the facility in March 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 8/2022, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating the Resident has moderate cognitive impairment. Further review indicated Resident #65 required set up for meals, was 70 inches tall, weighed 215 pounds, and received a regular texture diet. Review of the medical record indicated that on 2/14/22 the Resident had a weight of 234.6 pounds. Further review indicated that on 3/2/22 the Resident had a weight of 214 pounds. This indicated a weight loss of 20.6 pounds in 16 days. Weight documentation indicated the Resident was not re-weighed until 3/7/22 to identify accuracy of the weight loss. Review of the Nurse Progress Notes did not indicate any documented evidence that the physician or the dietitian were notified of the weight loss per the facility policy. Further review of the medical record indicated the Dietitian evaluated the Resident on 3/11/22, nine days after the weight loss was identified. The Dietitian's documentation on 3/11/22 indicated the Resident had decreased oral intake and a decrease in snacks brought in from family. The Resident was re-weighed three times to validate the accuracy of the weight loss. Further documentation by the Dietitian indicated the Resident had a significant reduction in fluid in legs/ankle. The Dietitian initiated Ensure (dietary supplement) three times a day in response to the weight loss. Review of the Nurse Progress notes did not indicate any documented evidence that the Resident was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medical Nutrition Therapy Assessment, dated 5/12/22, indicated the Resident's weight loss was positive due to a significant reduction in fluid/[CONDITION(S)] and that the Resident continued to be on [MEDICATION(S)]. Plan was for the Resident to be on weekly weights. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Dietitian's Note, dated 6/30/22, indicated to continue weekly weights for accuracy/assess for significant weight changes. Review of the Resident Weight Report indicated weights were obtained monthly on 6/22/22, 7/15/22, 8/17/22, and 9/19/22, and not weekly per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the facility policy, residents with weight loss should be monitored weekly and discussed with the Interdisciplinary team (IDT). Review of the medical record did not provide any documented evidence that Resident #65 was monitored weekly or discussed with the IDT. During an interview on 9/21/22 at 3:30 P.M., the Dietitian said that weights are done weekly when there are fluctuations with a Resident's weight. She said that if weights are not being done weekly then she emails the Director of Nurses. She said weekly weights are put in PCC (Point Click Care, Electronic Medical Record). The Dietitian said that she was not here during the weight loss of this Resident so she could not speak to the weight loss or what was done for this Resident.

Based on record review, observation and staff and resident interviews, the facility failed to ensure acceptable parameters of nutritional status and accurate weight measurements were obtained to prevent unplanned, significant weight loss for 2 residents (#32 and #28), from a total sample of 24 residents. Findings include: Review of the facility's Weights Policy dated 8/2015, indicated the following: -All weight loss/gain of 3 pounds of more on a resident weighing 100 pounds of less and weight loss/gain of 5 pounds or more on a resident weighing 100 pounds or more requires a re-weight for verification. A reweigh is done on the same scale, with a licensed nurse present. -Weights are documented in the resident's medical record. -If a significant weight loss/gain is identified (>5% in 30 days or >10% in 6 months), the interdisciplinary team (IDT), Dietitian, physician, and family are notified. -All resident's with a significant weight loss are reviewed by the IDT and the resident/responsible party and interventions implemented as appropriate are monitored weekly. 1. For Resident #32, the facility failed to identify, assess and implement the nutritional plan of care timely with a resident who was identified at nutritional risk and to prevent a significant, unintentional weight loss. Resident #32 was admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with a reference date of 6/12/19, indicated that Resident #32 had severe cognitive impairments as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. He/she required supervision with meals, was 70 inches tall, weighed 238 pounds, had an unintentional weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, was not on a physician prescribed weight loss regimen, and no therapeutic diets were indicated. Review of the Dietitian's assessments/progress notes indicated a timeframe of approximately 6 months from 9/27/18 through 3/11/19 with no nutritional assessments, progress notes, or nutritional interventions for Resident #32 in the clinical record or care plan. During an interview with the facility Dietitian on 9/9/19 at 2:40 P.M., she said she was hired on (MONTH) 4, 2019. Her first assessment on Resident #32 wasn't until a quarterly progress note, on 3/11/19 which stated the following: -Resident #32 weighed 280 pounds. The Dietitian's assessment identified that the resident's meal intakes ranged from 0-100%, although his/her weight remained stable, within their usual body weight range of 280 to 290 pounds. The plan in the Dietitian's note was to monitor weights, have no significant changes in weight in 1 month or 6 month timeframe's, and to monitor meals intakes. The dietitian did not document the resident's estimated nutritional needs or make any nutrition recommendations for the resident. Review of the physician's orders [REDACTED]. The dietary orders did not indicate any other interventions to address Resident #32's nutritional needs. The resident had an order in place to be weighed weekly (order was written since 2/27/19). Review of the weight summary report, given to the surveyor by Unit Manager #3 on 9/11/19 at 2:40 P.M., indicated the following weights: -11/15/18 - 280 pounds -01/01/19 - 280 pounds -05/22/19 - 238 pounds -06/07/19 - 238 pounds -07/05/19 - 231.4 pounds -08/27/19 - 225.6 pounds Resident #32 experienced a significant unintentional weight loss of 42 pounds (15%), from 1/1/19 (280 pounds) to 5/22/19 (238 pounds), according to the weights listed above, from the weight summary report. Review of the medical record indicated the dietitian failed to document or assess that a 42 pound weight loss occurred. The resident remained on a House/Regular diet and no interventions were implemented. Further review of the medical record indicated a quarterly Registered Dietitian (RD) note, written on 6/14/19, which indicated the following: -Resident #32 weighed 238 pounds. The Dietitian's assessment identified that the resident's meal intakes ranged from 0-100%. The assessment failed to address the 42 pound weight loss (15%) in 6 months. There were no dietary interventions implemented. On 7/5/19 a reweigh was obtained with a documented weight of 231.4 pounds, representing a total weight loss of 48.6 pounds, (17.4%) weight loss in 6 months. A review of the medical record revealed there was no indication the RD or MD had been notified of the significant weight loss. Subsequent review of the medical record indicated the next quarterly Dietitian progress note, on 8/26/19, which stated the following: -Resident #32 weighed 231 pounds, new usual weight range 230 to 240 pounds. There was no indication as to why the new weight range was 50 pounds lower than his/her previous usual weight range. The diet order remained Regular/House diet. The RD did not recommend any nutrition interventions. During interview with Unit Manager #3 on 9/12/19 at 8:29 [NAME]M., the weight summary was reviewed and Unit Manager #3 said the staff obtained another reweigh last night and that the new weight was now 208. 2# (9/11/19). The total overall weight loss was 25.64% or 71.8 pounds since 1/1/19. Unit Manager #3 said sometimes the resident declines to be weighed, but other than that, she couldn't state any other reason why Resident #32 lost weight. The Unit Manager and surveyor reviewed the medical record together and could not find any dietary interventions initiated in the medical record. 2. For Resident #28, the facility failed to assess interventions of a resident who had significant, unintentional weight loss. Resident #28 was admitted to the facility in 12/2017 with [DIAGNOSES REDACTED]. The Annual MDS, dated [DATE], indicated that Resident #28 had moderate impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 11 out of 15. Resident #28 required extensive supervision that included staff providing encouragement and cueing. The MDS indicated that the resident was 66 inches tall and weighed 192 pounds. Review of the weight summary report indicated the following weights: -12/5/18 - 192 pounds -12/18/18 - 172 pounds -12/28/18 - 172 pounds -1/1/19 - 172 pounds -1/9/19 - 174 pounds - A 9.38 % or 18 pound unintentional weight loss in 1 month. On 3/4/19 during review of the dieticians quarterly nutrition note, the note indicated that Resident #28 refused weekly weights and that no new weight had been obtained for more than 1 month. The dietitian indicated Resident #28 was 66 inches tall and his/her usual body weight was between 195 lbs. - 205 lbs. The dietitian indicated the resident's diet was house with dysphagia texture, thin liquids and the resident consumed between 50 to 100% of each meal. The note indicated goals included maintenance of an intake greater than 75% and resident to have no significant weight changes and for the resident to accept the diet. Review of the nutritional care plan, initiated on 12/13/18, indicated the interdisciplinary team had reviewed the plan of care on 3/26/19, 6/7/19, 8/23/19, and again on 9/6/19. The plan of care did not address the significant, unintended weight loss. On 3/4/19, a second care plan for nutrition was initiated. The care plan addressed the same issues as the care plan that was initiated on 12/13/18. The care plan was vague, did not address the significant weight loss and had not been reviewed since 3/4/19. The goals were not consistent with the dietitian's 3/4/19 note, which indicated the resident's usual and expected normal body weight was 195 pounds to 205 pounds. The plan of care indicated a usual body weight of 170 to 174 pounds and a goal of not losing an additional loss of 5 pounds or below, would be considered inadequate. In addition, the care plan indicated the resident refused to be weighed, refused supplements, had meals in main dining room and was to receive double portions at meals Review of the weight record indicated the Resident's weights following the 3/4/19 progress note were: -3/22/19 - 169.4 pounds. -3/28/19 - 169. 2 pounds; an 11.8 % weight loss in 90 days. On 3/29/19, the dietitian indicated that Resident #28 had a significant weight loss of 12% in 180 days. She documented a weight of 172.2 pounds, not the 3/28/19 weight of 169.2 pounds, which was documented in the electronic record. The dietitian's assessment indicated the resident does not like pancakes or scrambled eggs, eats in the dining room and refuses weekly weights. She indicated the resident had been receiving the nutritional supplement Ensure, but would discontinue the Ensure and replace it with the supplement Med Pass, 4 times daily. There was no calculation of Resident #28's nutritional and fluid needs. The dietitian indicated that the resident's weight was stable for the past 30 to 90 days. However, review of the weight record indicated there had been 2 weights obtained between 1/9/19 and 3/28/19. Review of the medical record indicated the resident had refused to be weighed on 1 occasion according to a nurse's note, on 2/18/19. On 9/9/19, the dietitian indicated Resident #28's intake was between 75 to 100 %, and that his/her nutritional needs were being met and that the resident refused to be weighed. The assessment failed to indicate what the resident's nutritional needs were and there was no documentation of any additional weight refusals by Resident #28 since 2/19/19. During observations of Resident #28 on 9/8/19 from 10:00 [NAME]M. - 1:45 P.M., on 9/10/19 from 9:00 [NAME]M. - 1:30 P.M. and on 9/11/19 during episodic visits throughout the day until 2:00 P.M., he/she was observed lying in bed. The Resident was not observed out of bed or in the dining room for any of the 3 meals observed. The staff brought Resident #28 his/her meal and set the meal up, staff were not observed encouraging the resident to eat. During the observations, Resident #28 was slow to respond and did not report any food concerns, nor was he/she observed refusing anything. During interview with the Dietitian and the Corporate Dietitian on 9/12/19 at 2:55 P.M. the surveyor reviewed Resident #28's significant unintentional weight loss and the facility's failure to identify, and make an effort to intervene and complete an adequate dietary assessment. The Corporate Dietitian said she would address the issues.

Based on record review and interview, the Facility failed for one of three sampled residents (Resident #2), to ensure that Resident #2 was assisted with transfers and ambulation with the use of gripper socks and a gait belt per Plan of Care which resulted in an avoidable injury. On 2/13/17, Certified Nurse Aide (CNA) #1 provided assistance to Resident #2 in the bathroom with transfers and ambulation without the use of gripper socks and a gait belt. Resident #2 experienced a loss of balance, fell , and hit his/her head on the door jam. Resident #2 sustained a laceration to his/her head requiring 8 staples to close the wound. Findings include. Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 2/16/17, indicated Resident #2 was severely cognitively impaired. The MDS indicated Resident #2 required limited assistance of one person for transfers on and off the toilet and ambulation between locations in his/her room. Resident #2's Care Plan for Fall Risk, initiated 5/17/16 and updated last on 12/8/16, indicated Resident #2 was at risk for falls related to a history of falls and muscle weakness. Interventions included use of assistive device, and appropriate footwear to include gripper socks at all times. The CNA Resident Care Card, utilized by the CNA's providing care, indicated Resident #2 needed assist of one person for toileting and transfers, with gripper socks in place at all times. Review of the Facility policy, Gait Belt Use, indicated gait belts are used to prevent injury and/or discomfort to the resident during transfer and ambulation tasks in which staff are called upon to provide physical assistance. The policy indicated gait belts must be used when physically transferring or ambulating residents. Resident #2 was unable to be interviewed due to his/her impaired cognition. The Accident/Incident and Investigation Report, dated 2/13/17, indicated at 7:45 A.M., as CNA #1 provided assistance to Resident #2 in the bathroom, Resident #2 lost his/her balance, and hit his/her head on the door jam. The incident report indicated Resident #2 was transferred to the emergency room for treatment of [REDACTED].#1 admitted she failed to place gripper socks on Resident #1 and use the gait belt as she assisted Resident #1 with transfers in the bathroom, which was not consistent with Resident #2's plan of care or the Facility policy on Gait Belt Use. The Surveyor interviewed CNA #1 at 2:28 P.M., on 4/7/17. CNA #1 said although she was aware Resident #2's plan of care indicated he/she required gripper socks at all times, and required transfer and ambulation with a gait belt, she did not use the appropriate interventions as she provided assistance to Resident #2 in the bathroom. CNA #1 said Resident #2 loss balance, fell and hit his/her head on the door jam. The Surveyor interviewed the Director of Nurses at 9:00 A.M., and throughout the day on 4/7/17. The Director of Nurses said it the expectation that all care providers review care cards and plans of care for appropriate interventions, and that all care be provided per resident's plan of care. The DON said CNA #1 should have placed gripper socks on Resident #2 and used the gait belt with transfer and ambulation of Resident #2. Resident #2 was transferred to the emergency room for treatment of [REDACTED].#2 was assessed to have a 4 centimeter posterior (back) scalp laceration requiring 8 staples to close the laceration.

Based on record review and interview, the Facility failed for one of three sampled residents (Resident #2), to ensure staff implemented the plan of care. Resident #2 required gripper socks and use of a gait belt at all times for transfers and ambulation. On 2/13/17, Certified Nurse Aide (CNA) #1 provided assistance to Resident #2 with transfers and ambulation in the bathroom without the use of gripper socks and a gait belt; and Resident #2 experienced a loss of balance, sustained a laceration to his/her head which required 8 staples to close the wound. Findings include: Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 2/16/17, indicated Resident #2 was severely cognitively impaired. The MDS indicated Resident #2 required limited assistance of one person for transfers on and off the toilet and ambulation between locations in his/her room. Resident #2's Care Plan for Fall Risk, initiated 5/17/16 and updated last on 12/8/16, indicated Resident #2 was at risk for falls related to a history of falls and muscle weakness. Interventions included use of assistive device, and appropriate footwear to include gripper socks at all times. The CNA Resident Care Card, utilized by the CNA's providing care, indicated Resident #2 needed assist of one person for toileting and transfers, with gripper socks in place at all times. Review of the Facility policy, Gait Belt Use, indicated gait belts are used to prevent injury and/or discomfort to the resident during transfer and ambulation tasks in which staff are called upon to provide physical assistance. The policy indicated gait belts must be used when physically transferring or ambulating residents. Resident #2 was unable to be interviewed due to his/her impaired cognition. The Accident/Incident and Investigation Report, dated 2/13/17, indicated at 7:45 A.M., as CNA #1 provided assistance to Resident #2 in the bathroom, Resident #2 lost his/her balance, and hit his/her head on the door jam. The incident report indicated Resident #2 was transferred to the emergency room for treatment of [REDACTED].#1 admitted she failed to place gripper socks on Resident #1 and use the gait belt as she assisted Resident #1 with transfers in the bathroom, which was not consistent with Resident #2's plan of care. The Surveyor interviewed CNA #1 at 2:28 P.M., on 4/7/17. CNA #1 said although she was aware Resident #2's plan of care indicated he/she required gripper socks at all times, and required transfer and ambulation with a gait belt, she did not use the appropriate interventions as she provided assistance to Resident #2 in the bathroom. The Surveyor interviewed the Director of Nurses at 9:00 A.M., and throughout the day on 4/7/17. The Director of Nurses said it the expectation that all care providers review care cards and plans of care for appropriate interventions, and that all care be provided per resident's plan of care. The DON said CNA #1 should have placed gripper socks on Resident #2 and used the gait belt with transfer and ambulation of Resident #2. Resident #2 was transferred to the emergency room for treatment of [REDACTED].

Based on record review and interviews, the facility failed for 4 ( #2, #8, #11, #12) of 23 sampled residents, to notify the physician and/or the legal representative when there was a change of status that may result in the need to alter treatment. Findings include: 1.) For Resident #12 the facility failed to notify the physician/nurse practitioner of a change in mental status, despite nursing progress notes which indicate a change in cognition and concerns voiced by the Resident's family member and health care proxy days prior to being hospitalized . Resident #12 was hospitalized for [REDACTED]. The Resident required medication adjustment and a new treatment approach to prevent further adverse consequences. Resident #12 was hospitalized for [REDACTED]. Resident #12 was admitted to the facility in 8/2015 with the following pertinent Diagnoses: [REDACTED]. Review of the quarterly Minimum Data Set on 2/22/16 (MDS of 12/1/2015 and 6 days prior to hospitalization ) indicated that the Resident's baseline cognition status was intact with a Brief Interview for Mental Status (BIMS) of 13/15 (13-15 =cognitively intact), no indications of [MEDICAL CONDITION], with no behaviors or change in mental status. Review of the nursing progress notes, 5 days prior to hospitalization , indicated the following: 12/2/15: Alert with baseline confusion-found pt ambulating without walker in hallway and re-directed. 12/3/15: Pt very lethargic and slow to respond verbally. Occupational Therapy reported difficulty with dressing, grooming, unable to follow direction and difficulty with hands to button blouse. 10:00 P.M.: found in another bed and re-directed 12/4/15: Pt lethargic with some confusion noted 12/7/15: Resident went to a previously scheduled medical appointment and was admitted to the hospital. On 2/23/16 at 12:15 P.M. the Surveyor interviewed Unit Manager #2 (UM). The UM said that the Resident's baseline is up and down and that staff did not notice a mental status change prior to the Resident's hospitalization . The Surveyor asked how the staff were evaluating for increased ammonia levels and increased ascites, without conducting abdominal girths. The UM said Well, he/she is end stage. On 2/23/16 at 4:00 P.M., the Surveyor interviewed the Nurse Practioner (NP) over the telephone. The NP said that she was starting to get to know the Resident, but at baseline the Resident was his/her own person and capable of making decisions. She also said that on the days leading up to the Resident's hospitalization , the staff did not notify her of a change in baseline cognition. She said that the Resident gets very lethargic when his/her ammonia levels are high. She also said that the staff all have different opinions of the Resident's baseline cognition. She also said that it's a good idea to get abdominal girths because he/she might need to be tapped (fluid removal of peritoneal cavity). She said that ammonia lab levels were drawn every three weeks or if the Resident was symptomatic. (Refer to F-309) 2. For Resident #8, the facility failed to notify the activated health care proxy of his/her elopement from the facility. Resident #8 was admitted to the facility in 3/2015 with dementia with behavioral disturbance and adjustment disorder with depressed mood. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 11/27/15 indicated that Resident #8 had a brief interview for mental status (BIMS) score of 10 out of 15 indicating the Resident had moderate cognitive impairment. It also identified the Resident as having an activated health care proxy. Review of incident report dated 6/19/15, indicated that Resident #8 eloped from the facility at 8:00 P.M. and the responsible party was notified at 9:30 P.M. During telephone interview on 2/24/16 at 2:00 P.M., Resident #8's activated health care proxy (HCP) said that she had gone out to dinner the evening of 6/19/16 and upon her return home at 10:00 P.M., found Resident #8 lying on the living room couch. The HCP said that she had not been contacted by the facility and immediately called to alert them that Resident #8 was at her home. (Please refer to F 323) 3. For Resident #2, the facility failed to notify the activated health care proxy of a change in dosage of the antipsychotic medication [MEDICATION NAME] to address a new onset of intermittent behavioral outburst and mood lability. Resident #2 was admitted to the facility in 5/2013 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS with a reference date of 1/14/16, indicated that the Resident had a BIMS score of 10 out of 15 indicating the Resident had moderate cognitive impairment. It also identified the Resident as having an activated health care proxy. Review of the medical record indicated that Resident #2's health care proxy was activated on 4/2/15. Review of the facility's psychiatric consultant note dated 2/17/16 indicated that Resident #2 was exhibiting intermittent behavioral outbursts and mood lability with a medication recommendation of [MEDICATION NAME] 12.5 mg (milligrams) daily as needed for agitation. Review of the February 2016 physician's orders [REDACTED].#2 had a standing order for [MEDICATION NAME] 25 mg daily. Review of physician's interim orders dated 2/19/16 indicated that Resident #2 had an order for [REDACTED]. Further review of the medical record provided no documented evidence that Resident #2's activated health care proxy was notified of the change in dosage of the antipsychotic medication. During interview with Unit Manager #1 on 2/23/16 at 1:30 P.M., she could not identify if Resident #2's health care proxy was notified of the change in dosage of the antipsychotic medication. 4. For Resident #11, the facility failed to notify the physician when the Resident had a change in her respiratory status that may have altered the course of treatment. Resident #11 was admitted to the facility in 6/2014 and had active [DIAGNOSES REDACTED]. Review of the clinical record indicated that on 8/4/15 the physician ordered to check the Resident's oxygen saturation (O2 sat) level every shift and to administer oxygen as needed, at 1 - 4 liters per minute via nasal cannula to maintain O2 sat above 90 percent (%). Review of the 1/2016 treatment administration record (TAR) indicated that the Resident had a pattern of low O2 sat levels beginning on 1/12/16 - 1/31/16 documented for the 3:00-11:00 P.M. shift. These levels consistently ranged from 82% to 84%. (Continued low oxygen levels may lead to respiratory or [MEDICAL CONDITION]). On 2/24/16 at 8:45 A.M. Unit Manager (UM) #1 was interviewed by the surveyor regarding the oxygen therapy for Resident #11. UM #1 was asked (using the January 2016 TAR and existing nursing documentation as a reference) if she was concerned about the Resident's pattern of low O2 sats on the 3:00-11:00 P.M. shift. UM #1 said that 84 % was the baseline on 3:00-11:00 P.M. UM #1 was asked if the physician and UM #1 was notified about the progressive low O2 sats said no because they already had an existing order for oxygen therapy. UM #1 said if the Resident O2 sats fell below 80% they would contact the physician. The physician was interviewed on 1/24/16 at 10:30 A.M. and said that the Resident was recently hospitalized for [REDACTED]. The physician (reviewed the January 2016 TAR) said that she was not aware that the Resident had a pattern of oxygen desaturation on the 3:00-11:00 P.M. shift in January. The physician said she should be contacted because the findings could be early [MEDICAL CONDITION]. (Please refer to F 309)

Based on record review, observation and interview, the facility failed to: assess and monitor for changes in Resident condition, according to the plan of care for 2 Residents, (#11 and #12) from a total sample of 23 Residents. Findings include: 1.) For Resident #12, the facility staff failed to monitor and provide adequate care and treatment to a Resident with [MEDICAL CONDITION], which resulted in a 10 day hospitalization . Resident #12 was admitted to the facility in ,[DATE] with the following pertinent Diagnoses: [REDACTED]. Review of the [DATE] quarterly Minimum Data Set (MDS) (6 days prior to hospitalization ), indicated that the Resident's baseline cognition status was intact with a Brief Interview for Mental Status (BIMS) of 13 (,[DATE] =cognitively intact), no indications of [MEDICAL CONDITION], with no behaviors or change in mental status. Review of the Resident's Care Plan for Cognitive Loss indicated the following Potential Concern and Approach: *Potential Concern- Mental status concerns at times due to metabolic [MEDICAL CONDITION] and increased ammonia levels. The facility did not develop a Care Plan to address the needs of the Resident's [DIAGNOSES REDACTED]. According to Nursing Times (16.07.14 / Vol 110 No 29), Nursing Care for End Stage Liver Disease ([DATE]), for the care and treatment of [REDACTED]. *mental capacity needs to be assessed regularly (Per record review, staff did no recognize the Resident's mental status change, despite nursing progress notes indicating increased lethargy, unable to answer questions, unable to transfer to chair and unable to button blouse 4 days prior to admission). *evacuating bowel content (such as using [MEDICATION NAME]) for at least two stools/day (Per record review, the Resident was receiving [MEDICATION NAME], however the bowel monitoring reports for ,[DATE], ,[DATE] and ,[DATE] indicated gaps with no bowel movements for 2 days at a time and therefore, staff unable to assess the potential for elevated ammonia levels). *Monitor for ascites (collection of fluid in the peritoneal cavity) which can cause abdominal discomfort, breathlessness and restricted mobility due to the large volume of fluid collection. (Per record review, abdominal girths were not being done and weights were done weekly, but the dietitian said that she was relying on nursing staff to determine if weight gain was from fluid or true weight gain). Review of the nursing progress notes, 5 days prior to hospitalization , indicated the following: [DATE]: Alert with baseline confusion-found pt ambulating without walker in hallway and re-directed. [DATE]: Pt very lethargic and slow to respond verbally. Occupational Therapy reported difficulty with dressing, grooming, unable to follow direction and difficulty with hands to button blouse. (There was no indication that the physician was informed of this mental staus change.) 10:00 P.M.: found in another bed and re-directed [DATE]: Pt lethargic with some confusion noted [DATE] and [DATE]: no indication of progress notes [DATE]: Resident went to a previously scheduled medical appt and was admitted to the hospital. Review of the hospital Discharge Summary dated [DATE] indicated the following: admitted with altered mental status with evidence of staring and poor attention x 5 days-improved with increased bowel movements/[MEDICATION NAME] increased-[MEDICAL CONDITION] has been complicated by ascites requiring large-volume paracentesis and hepatic [MEDICAL CONDITION]. Transplant evaluation on hold given cognition issues-will have neuro-psych testing and cognitive neurology follow-up as an outpatient. Review of the Resident's ammonia levels were as follows: Ammonia levels (range =,[DATE]): [DATE]=47, [DATE]=67 On [DATE] at 3:30 P.M., the Surveyor interviewed the Resident and the Resident's family member (who is also the Health Care Proxy-HCP). The HCP said that the Resident was not him/herself the week prior to the Resident's hospitalization and that the facility staff did nothing about it. The HCP also said that he/she knew the Resident better than anyone and recognized the increased lethargy and spaciness of the Resident, which is not his/her baseline. The HCP said that he/she took the Resident for a previously scheduled appointment and due to the Resident's increased confusion, the hospital staff admitted the Resident for ten days with altered mental status. The Resident also told the Surveyor that he/she has had up to 6 liters of fluid removed from his/her abdomen in the past. Review of the dietitian's notes and weights on indicated the following (after re-admission to the facility): [DATE]: weight= 155 pounds (#) and on [DATE] weight= 163.08# or >8# increase) [DATE]: continues with weight gain since returning from hospital and continues with good intakes at meals and between meals On [DATE] at 12:15 P.M. the Surveyor interviewed Unit Manager #2 (UM #2). The UM said that the Resident's baseline is up and down and that staff did not notice a mental status change prior to the Resident's hospitalization . The Surveyor asked how the staff were evaluating for increased ammonia levels and increased ascites, without conducting abdominal girths. UM #2 said Well, he/she is end stage. On [DATE] at 4:00 P.M., the Surveyor interviewed the Nurse Practitioner (NP) over the telephone. The NP said that she was starting to get to know the Resident, but at baseline the Resident was his/her own person and capable of making decisions. She also said that on the days leading up to the Resident's hospitalization , the staff did not notify her of a change in baseline cognition. She said that the Resident gets very lethargic when his/her ammonia levels are high. She also said that the staff all have different opinions of the Resident's baseline cognition. She also said that it's a good idea to get abdominal girths because he/she might need to be tapped (fluid removal of peritoneal cavity). She said that ammonia lab levels were drawn every three weeks or if the Resident was symptomatic. The Surveyor asked how staff would determine if he/she were symptomatic. The NP said that she will have staff tighten up the care plan regarding regarding cognition parameters, bowel movement frequency and abdominal girth measurements. The Surveyor interviewed the staff nurse on [DATE] at 8:40 A.M. Staff Nurse #1 confirmed that the physician/NP was not notified. The Staff Nurse said that the Resident did fluctuate with lethargy, but ultimately, it was up to the UM to decide when to call the physician of a change in mental status. On [DATE] at 8:30 A.M., the Surveyor interviewed the dietitian and asked how she was determining dry weight gain versus increased ascites weight gain. She said that she relies on the nursing staff. She also said that staff used to measure abdominal girths, but couldn't remember why they had stopped. She said that she does remember the Resident as being spacey prior to being hospitalized and that he/she was better now. 2. For Resident #11, the facility failed to monitor for changes in respiratory status and provide adequate oxygen therapy which resulted in the Resident calling 911 for medical assistance and subsequent 7 day hospitalization . Resident #11 was admitted to the facility ,[DATE] and had active [DIAGNOSES REDACTED]. Review of the [DATE], quarterly Minimum Data Set (MDS) assessment indicated that Resident #11 was cognitively intact and was identified as receiving oxygen therapy. Review of the clinical record on [DATE] indicated that on [DATE] the physician ordered to check the Resident's oxygen saturation (O2 sat) level every shift and to administer oxygen as needed, at 1 - 4 liters per minute via nasal cannula to maintain O2 sat above 90 percent (%). (Below 90% is considered low resulting in hypoxemia (low blood oxygen). Below 80% may compromise organ function, such as the brain and heart, and must promptly be addressed) Review of the ,[DATE] treatment administration record (TAR) indicated that the Resident had a pattern of low O2 sat levels beginning on [DATE] - [DATE] documented for the 3:00 11:00 P.M. shift. These levels consistently ranged 82% to 84% (Continued low oxygen levels may lead to respiratory or [MEDICAL CONDITION].) During this period of low O2 sat levels, there was no consistent documentation that indicated if the Resident was administered oxygen therapy and/or how many liters of oxygen the Resident required to increase and then maintain the sat level over 90% as per the physician's orders [REDACTED].M.-3:00 P.M. shift indicated that Resident #11's, O2 sat was 90% and the 3:,[DATE]:00 P.M. shift indicated the O2 sat was 82%. Per physician order, the Resident should be administered ,[DATE] liters of oxygen to bring the level above 90% and there was no indication in nursing documentation that this was completed. Review of the [DATE], ,[DATE] shift nurse's progress note indicated that the Resident complained of shortness of breath for a O2 sat of 65% on room air. The Resident was administered 2 liters of oxygen via a mask, the O2 sat increased to 99% and the Resident's shortness of breath resolved. During lunch (one hour later) at 1:00 P.M., the Resident was noted to be weak and and slightly confused. The O2 sat taken at that time was 75% with oxygen administered at 2 liters via a nasal cannula. The physician was paged and arrived immediately to evaluate the Resident and ordered for the oxygen to be increased to 4 liters (even though there were already existing orders for oxygen at 1 - 4 liters) and to apply a mask (instead of a nasal cannula). When Resident oxygen levels improved to 100% the oxygen therapy was deceased to 2 liters with the O2 sat remaining at 95%. The physician ordered a chest x-ray (for a question of [MEDICAL CONDITION] versus pneumonia), a stat dose of the [MEDICATION NAME] (diuretic)), a reduction in [MEDICATION NAME] (antihypertensive) and a reduction in [MEDICATION NAME] (mood stabilizer) due to sedation. Review of the [DATE] chest x-ray findings indicated that the Resident had modest cardiomegaly with mild [MEDICAL CONDITION] and a right upper lobe pneumonia. The physician was contacted with the results at 3:40 P.M. and ordered a repeat dose of [MEDICATION NAME] and to monitor the Resident's temperature. At 6:40 P.M., the 3:,[DATE]:00 P.M. shift nurse documented that Resident's condition had gotten worse after the second dose of [MEDICATION NAME] prompting a call to the physician. The Resident had developed a temperature of 101.2 degrees, an elevated heart rate of 86 and an increased respiratory rate of 22. The O2 sat had decreased to 83% on 2 liters of oxygen (not the 4 liters previously ordered by the physician). The physician ordered to give the Resident the antibiotic [MEDICATION NAME] 500 milligrams daily for seven days. The 6:46 P.M. nurse's note indicated that the physician said if the Resident can't swallow place a call to the nephew to see if he wants the Resident to send him/her to the hospital. At 7:00 P.M. the nurse's note indicated that she had spoken with the Resident (his/her own decision maker) at 6:30 P.M. who was anxious and wanting to go to the hospital. The nurse's note indicated explained to the patient that (he/she) was starting on antibiotic, on neb RX (nebulizer treatments) every 2 hours, being given (Tylenol) for temperature and that we would continue to monitor (his/her) condition. Review of the 7:15 P.M. nurse's note indicated that the paramedics arrived and indicated that Resident #11 had called 911 to take (him/her) to the hospital. Review of the hospital transfer form completed by the 3:,[DATE]:00 P.M. supervisor indicated that Resident #11 was receiving 2 liters of oxygen via a nasal cannula (not the 4 liters previously ordered by the MD) at the time of the 911 transfer. Review of the [DATE] ambulance trip report indicated that Resident #11's initial vital signs at 19:58 P.M. were as follows: blood pressure of ,[DATE], pulse rate of 106, respirations of 36, and a O2 sat of 75%. Per the [DATE] hospital discharge summary Resident #11 was admitted to the hospital with [REDACTED]. On [DATE] at 8:45 A.M. Unit Manager (UM) #1 interviewed regarding the oxygen therapy. UM #1 was asked how the nurses monitor the need for oxygen therapy. UM #1 said that Resident #11 had existing orders for O2 sats every shift and that the goal of oxygen therapy was to maintain the O2 sat above 90% using 1 - 4 liters of oxygen via a nasal cannula. UM #1 was asked (using the [DATE] TAR and existing nursing documentation as a reference) if she was concerned about the Resident's pattern of low O2 sats on the 3:,[DATE]:00 P.M. shift said that 84 % was the baseline on ,[DATE]. UM #1 was asked if the physician was notified about the progressive low O2 sats said no because they already had an existing order for oxygen therapy. UM #1 said if the Resident O2 sats fell below 80% they would contact the physician. UM #1 was asked how the nurses determine how much oxygen to give when the Resident had a low O2 sat said the nurses start at 1 liter and work their way up to 4 liters as needed. UM #1 was asked how the nurses determine if increasing O2 was successful in raising the oxygen level above 90% as ordered (there was no documentation of any interventions described by UM #1) said the Resident would be assessed on the next shift. The physician was interviewed on [DATE] at 10:30 A.M. and said that the Resident was recently hospitalized for [REDACTED]. The physician (reviewed the TAR) said that she was not aware that the Resident had a pattern of oxygen desaturation on the 3:,[DATE]:00 P.M. shift in January. The physician said she should be contacted because the findings could represent a sign of early [MEDICAL CONDITIONS].

Based on record review, staff and family interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents/elopements per facility policy for 2 Residents (#8 and #18) of 23 sampled Residents. Findings include: A. Elopement The Facility's Elopement Policy (April 2015) includes the following: -The Licensed Nurse will conduct an Elopement Risk Screen on admission, quarterly, and upon change of condition. - A plan of care must be formulated with the Interdisciplinary Team to determine the need for wander management system bracelet and documented in the Care Plan For Resident #8, the facility failed to provide adequate supervision and effective interventions to prevent an elopement from the facility in a Resident with a history of elopement. Resident #8 was admitted to the facility in 3/2015 and had [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 11/27/15, indicated that Resident #8 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating the Resident had moderate cognitive impairment. It also identified the Resident as having an activated health care proxy (HCP). During review of the medical record on 2/22/16, a social service note dated 6/08/15 indicated that Resident #8 had recently eloped from the facility and was found outside. Review of the care plan for elopement risk (initiated on 6/01/15) identified a history of elopement, verbalizations of wanting to leave the facility and a goal that Resident will remain within the facility unless supervised. Approaches identified to achieve this goal included the following: offer support to Resident with desire to leave and evaluate need for additional supervision and obtain order per procedure. Further review of the medical record failed to identify the Resident's elopement on the elopement risk assessment conducted on 6/01/15 and 6/08/15 and failed to show evidence that an evaluation for need of additional supervision was done as indicated on the care plan. Review of the nursing notes and Incident Report Investigation both dated 6/19/15 indicated that Resident #8 eloped from the facility. The medication nurse discovered that the Resident was not in his/her room during the 8:00 P.M. medication pass. Further review of the incident report indicated that the Resident's family was called to see if they had taken Resident #8 out of the building. The nursing notes documented that the family stated that they did not take the Resident out, but he/she was there at their house. (During interview, the HCP/family said that they came home and found the Resident lying on the couch and was not notified by the facility). During telephone interview on 2/24/16 at 2:00 P.M., Resident #8's activated HCP said that she had gone out to dinner the evening of 6/19/16 and upon her return home at 10:00 P.M., found Resident #8 lying on the living room couch. The HCP said that Resident #8 told her that he/she had walked out of the facility, walked through the parking lot to the end of the driveway and was picked up by a nice man and given a ride to his/her home. The HCP said that she immediately called the facility at 10:00 P.M. to alert them that Resident #8 was at her home and was told that they were aware he/she was missing and were still searching for the Resident. During interview with the Director of Nursing Services (DNS) and Director of Social Services on 2/25/16 at 8:15 A.M., the DNS said that staff did not notice that Resident #8 was missing until the evening medications were given at 8:00 P.M. She said that the facility called the HCP at 9:30 P.M. (per the HCP, she was not called. The HCP called the facility) to alert her that Resident #8 was missing and the HCP said that the Resident was at her home (approximately 10 miles from the facility). The Surveyor asked the DNS how the Resident got to his/her HCP's house and she said that someone must have picked him/her up in the parking lot because he/she would not have been able to walk to their home. B. Falls For Resident #18, the facility failed to provide supervision/assistance necessary to prevent 13 unwitnessed falls, resulting in three separate injuries including a fractured hip from 3/6/15 to 2/24/16. Resident #18 was admitted to the facility in 1/2009 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) signed as completed on 3/6/15, indicated that the Resident had no behaviors, required supervision for ambulation, assist with toileting, was incontinent of bowel and bladder and had experienced a fall since last quarter. Review of the Fall Risk assessment dated [DATE], the Resident scored 12 (greater than 10 represents high risk). Review of the care plan, initially dated 9/19/14 and updated as needed, identified that Resident #18 had a history of [REDACTED]. The approaches included: 1. Use fall risk screen to identify risk factors 2. Report falls to physician and responsible party. 3. Provide environmental adaptations including call light within reach (may not ring related to cognitive decline) and areas free from clutter. 4. Remind Resident and reinforce safety awareness including lock brakes on bed and assist with transfer and supervise ambulation. 5. Invite and encourage with activities. 6. Referral for screen and treatment when needed (PT,OT,SLP). 7. Provide Resident and family teaching to include: safety measure to Resident fall risk and what to do if a fall occurs. The clinical record and facility incident reports were reviewed on 2/24/16 indicating the following: Resident #18 sustained falls on 3/6/15, 4/19/15 and 5/6/15 all of which were unwitnessed and unsupervised while in his/her bedroom, hallway or bathroom. The Resident CNA care card was updated and indicated that the Resident required an assist of 1 person for toileting, may not be left alone in the bathroom and continual supervision with ambulation. -On 5/18/15 at 4:30 P.M. the Resident was found on the floor in another Resident's room. The investigation indicated that the Resident now required distant supervision. However, the Resident's care card was updated on 5/6/15 and indicated that the Resident required assistance with ambulation. -On 6/9/15 at 4:30 A.M. the Resident was found lying on his/her back on the floor next to the bed. Review of the incident report indicated that the Resident got tangled up in the blanket and had an unwitnessed fall and rolled out of bed. The care plan was updated to include a scoop (perimeter) mattress. An annual MDS signed as completed on 6/10/15, indicated that the Resident scored a 1 of 15 on the BIMS (Brief Interview for Mental Status) indicating severe cognitive impairment, had no behaviors, required assist with transfer and ambulation (with physical assist of 1) and extensive assist with toileting with 1 staff member. The MDS also indicated that the Resident had 2 or more falls. -On 7/25/15 at 5:30 P.M. the Resident was found on the floor outside the unit dayroom. The Resident stood up in the dayroom and walked out to the hallway unsupervised. The incident report indicated that the Resident did not use the rolling walker. The staff was interviewed and identified that at the time of the fall, there was no one in the dayroom supervising the Residents. Despite the Resident's poor cognition, the care plan was updated to remind the Resident to use the rolling walker and obtain a PT screen. The PT screen was conducted on 7/28/15 and indicated that the Resident present with baseline confusion and increased lethargy and was currently receiving skilled physical therapy. -On 7/29/15 at 2:45 P.M. the Resident was found on the floor again next to the bed. The CNA reported that she heard yelling help me. The Resident attempted to self transfer to bed. The Resident's walker was at the bedside. The staff was interviewed and no one provided supervision to the Resident at the time of the fall. -The Resident had a third fall out of bed on 8/11/15 at 3:15 P.M. and was found sitting on the edge of the floor mat with two pillows. Despite the intervention of a perimeter mattress on 6/9/15, the Resident continued to fall out of bed. The investigation indicated that the Resident stated he/she was hungry and wanted a snack. The care plan was updated to reflect that the Resident was to receive a 2:00 P.M. and a 3:00 P.M. snack. A PT screen was conducted and identified that the Resident was not currently on services and got out of bed because he/she was hungry. -On 1/12/16 at 6:45 P.M. the Resident was found sitting on the floor in another Resident's room for the second time. The Resident was ambulating the halls unsupervised, wandered in room 321 and fell . The care plan had already identified that the Resident required assist with ambulation. -On 1/13/16 an inservice was provided to staff regarding the use of a gait belt and to ensure the Resident does not walk alone secondary to frequent falls. -On 1/18/16 at 4 P.M. the Resident was found incontinent, on the floor in another Resident's room. There was no change to the care plan. -On 1/21/16 at 7:05 A.M. the Resident was found on the floor next to the bed for the 5th time. The resident sustained [REDACTED]. The incident report indicated that the Resident attempted to get out of bed without assistance and the alarming floor mats were sounding. On 2/19/16 at 2:30 P.M. the Resident was found sitting on the floor next to the bed for the 6th time. The incident report indicated that the Resident was ambulating unassisted to the hallway. On 2/24/16 at 6:40 P.M. the Resident had an unwitnessed fall in the dayroom. Review of the incident report indicated that the Resident stood up from the wheel chair unattended and fell . The Resident complained of pain and was sent out to the emergency department and subsequently admitted for a femur fracture requiring surgery. Review of the witness statements indicated that 1 staff member was in the dining room cleaning dishes and heard the Resident say help and turned around and noted an empty wheel chair. Another staff member was present but was attending to another Resident. The Resident returned to the facility on [DATE] with a Left intertrochanteric femur fracture status [REDACTED]. The DNS was interviewed on 2/25/16 at 10:00 A.M. and reviewed Resident #18's fall history. The DNS said that the Resident was difficult to monitor due to behaviors and requires constant supervision.

Complaint # 12-0475 Based on record review and interviews, for one of three sampled residents (Resident #1), The Facility failed to ensure that Resident #1 was transferred from bed to wheelchair with the assistance of two staff persons as indicated in his/her plan of care, when on 10/21/11, a certified nurse aide (CNA) transferred Resident #1 by herself and Resident #1 sustained serious injury (a large 4 centimeter (cm) by 3 cm skin laceration with subcutaneous tissue/fat exposed) to the left front calf area when the CNA dropped Resident #1 against the front of the wheelchair. Resident #1 was sent to the Hospital Emergency Department and because of the way the wound occurred , the emergency physician said there was no skin to suture, and the wound was packed. The Admission Nursing Assessment, dated 8/11/11, indicated that Resident #1 was initially assessed as an assist of one person for transfers and bed mobility. The Admission Nursing Assessment indicated Resident #1 was alert and oriented. Resident #1's plan of care, dated 9/22/11, indicated Resident #1 needed minimum to maximum assist with activities of daily living (ADL's), related to weakness, status [REDACTED].#1 tired easily. The plan of care indicated for bed mobility, transfers, and toileting, Resident #1 required the assistance of two persons. On 6/26/12 at 12:50 P.M., the Surveyor interviewed Family Member #1. Family Member #1 said she received a telephone call from Nurse Manager #1 on 10/21/11. Family Member #1 said Nurse Manager #1 told her that Resident #1 had a slight skin tear. Family Member #1 said she met Resident #1 at the Hospital Emergency Department and observed a large hole in Resident #1's left front calf area and tendons were visible. The nurse's note, dated 10/21/11 at 8:30 A.M., indicated that Resident #1 received morning care and was then transferred by the CNA from the bed to the wheelchair utilizing physical assist, stand, pivot, transfer. The nurse's note indicated that Resident #1 stated "just took a hunk of skin out of my leg". The nurse's note indicated that Resident #1's legs were assessed and blood was noted on the floor below the left leg. The nurse's note indicated that Resident #1's elastic stocking was removed and a large 4 centimeter (cm) by 3 cm skin laceration with subcutaneous tissue/fat was exposed. The nurse's note indicated that Physician #1 and Family Member #1 were called and return calls were pending. The nurse's note indicated the area was cleansed and a dry sterile dressing was applied. The nurse's note, dated 10/21/11 at 8:45 A.M., indicated that Physician #1's office returned the call and gave an order from Physician #1 to transfer Resident #1 to the Hospital for evaluation. The nurse's note indicated that Family Member #1 called and would meet Resident #1 at the Hospital. The nurse's note indicated that the CNA was unable to determine where the injury occurred during Resident #1's transfer. The nurse's note indicated that Resident #1's wheelchair had brake extenders that may have been involved, however, Nurse Manager #1 was unable to determine the contact site causing injury. On 6/19/12 at 2:12 P.M., the Surveyor interviewed Nurse Manager #1. Nurse Manager #1 said CNA #1 who was involved in Resident #1's transfer on 10/21/11, was a regular CNA on the unit and familiar with Resident #1. Nurse Manager #1 said on the morning of 10/21/11, Nurse #1 asked her to come to Resident #1's room and assess Resident #1's leg. Nurse Manager #1 said Resident #1 had an open laceration with tissue visible. Nurse Manager #1 said she asked CNA #1 how the injury occurred and CNA #1 told her she stood Resident #1 from the bed using a gait belt and seated Resident #1 in the wheelchair. . Nurse Manager #1 said she could not recall if Resident #1 had foot pedals in place on the wheelchair but she thought Resident #1 used brake extenders. On 6/19/12 at 10:00 A.M., the Surveyor interviewed the Director of Nurses (DON). The DON said CNA #1 left the Facility shortly after Resident #1's injury. The DON said the information she received after CNA #1 left the Facility was that CNA #1 moved from the area. On 6/19/12 at 1:45 P.M., the Surveyor interviewed the DON. The DON said in her investigation into Resident #1's injury of 10/21/11, Nurse #1 told her that she was present in Resident #1's room at the time of the incident. The DON said in her opinion, CNA #1 had not followed Resident #1's plan of care for a two person transfer when Nurse #1 was close by, but had not physically assisted with the transfer. The DON said Nurse #1 told her that Nurse #1's hand was there in case she was needed if Resident #1 lost balance but as Nurse #1 had not actually had hands on Resident #1 she did not feel the care plan was followed. The DON said she spoke to CNA #1, however, CNA #1 had not written a statement. On 6/19/12 at 2:00 P.M., the Surveyor interviewed Nurse #1. Nurse #1 said that on 10/21/11, she worked on the 7:00 A.M. - 3:00 P.M. shift. Nurse #1 said she was present in Resident #1's room at the time of Resident #1's incident. Nurse #1 said she could not recall if she was holding the wheelchair when Resident #1 was pivoted from the bed to the wheelchair with a stand pivot. Nurse #1 said she could not recall if foot pedals were present on the wheelchair at the time of transfer or if a gait belt was used during the transfer. Nurse #1 said Resident #1 yelled out as Resident #1 was about to sit in the wheelchair and she observed blood on the elastic stocking. Nurse #1 said she could not recall anything that Resident #1 might have gotten the leg caught on as it was the front of the lower leg. Nurse #1 said the wound appeared like the skin had been pushed away by something but no blood was observed on any part of the wheelchair. The written statement of Nurse #1, dated 10/21/11, indicated Nurse #1 was present in Resident #1's room during Resident #1's transfer from the bed to the wheelchair as Nurse #1 was acting as a stand-by assist. Nurse #1's written statement indicated as Resident #1 was being turned to be seated in the wheelchair, Resident #1 yelled ouch, just as Resident #1 was seated. On 6/28/12 at 2:15 P.M., the Surveyor interviewed Resident #1. Resident #1 said there were two short brakes on the wheelchair Resident #1 used and brake extensions had been put in place. Resident #1 said one of the brake extenders got the inside of Resident #1's shin as Resident #1 was dumped into the wheelchair. Resident #1 said to Resident #1's knowledge at the time of the incident, there was only one CNA present, no gait belt was used, and no nurse was present. Resident #1 said Resident #1 was sent to the Hospital Emergency Department and because of the way the wound occurred , the emergency physician said there was no skin to suture. Resident #1 said the wound was packed and Resident #1 was sent back to the Facility. Family Member #1 said he/she was told by the DON that the CNA was alone when she transferred Resident #1. A review of the Facility's investigation into Resident #1's incident/injury of 10/21/11 included documentation dated 10/25/11, that CNA #1 was counseled after she failed to follow Resident #1's plan of care for a two person transfer.