Every finding on record at Chestnut Woods Rehabilitation and Healthcare CTR

Based on observation and interviews the facility failed to ensure the building and equipment was in good condition and had a homelike environment in 38 out of 40 rooms.Findings include:Review of the facility policy titled Homelike Environment, dated revised February 2021, indicated the following:Residents are provided with a safe, clean, comfortable and homelike environment .Policy Interpretation and Implementation:2. The facility staff and management maximize, to the extent possible, the characteristics of the facility thatreflect a personalized, homelike setting. These characteristics include:a. clean, sanitary and orderly environment On 9/10/2025 at 8:30 A.M. the surveyor observed the following in the first-floor rooms:105A and B: the over the bed table laminate was peeling off.106B: the over the bed table laminate was peeling off.107A: the over the bed table laminate was peeling off, the Bathroom wall had paint missing and bubbled.108A: the over the bed table laminate was peeling off, the bathroom wall had 2 small holes.109A and B: the over the bed table's laminate was peeling off110B: the over the bed table laminate was peeling off111A: the over the bed table laminate was peeling off112A and B: the over the bed table's laminate was peeling off113A: the walls were scuffed.114A: the over the bed table laminate was peeling off and taped115A and B the over the bed table's laminate was peeling off. The bathroom doors were scuffed, the ceiling paint was bubbled and had brown spots, and a radiator panel was lifting off.116A: the corner of the wall was broken and gouged. The wall was scraped.117A and B: the over the bed table's laminate was peeling off, the wall next to the sink had holes, the corners of the walls were gouged.118A and B: the over the bed table's laminate was peeling off.119A and B: the over the bed table's laminate was peeling off and the outside wall is scraped.120: the window screen is broken.121B: the over the bed table laminate was peeling off and a radiator panel is lifting off.122A and B: the over the bed table's laminate was peeling off and the window screen was broken.123A: the wall was scuffed and bed B the over the bed table laminate was peeling off.125: the over the bed table laminate was peeling off. On 9/10/2025 at 7:50 A.M. the surveyor observed the following in the second-floor rooms:205: the walls were scraped.207: the walls were scraped, and the bathroom light didn't work.208A and C: the over the bed table's laminate was peeling off. Bed B nightstand edges chipped.209B: the over the bed table laminate was peeling off, and the wall to the left of the door was gouged and scraped.210: the outside wall was scuffed and the over the bed table laminate was peeling off.211: the wall outside the bathroom door was gouged and the bathroom light had multiple dead bugs.212A: the over the bed table laminate was peeling off.213: the outside wall was scuffed.214B: the over the bed table laminate was peeling off.215B: the over the bed table laminate was peeling off, the bathroom wall had holes, and the toilet paper holder was broken.216A: the over the bed table laminate was peeling off and the entry wall scuffed.217A: nightstand chipped, the outside wall was scuffed. Bed B the over the bed table laminate was peeling off. The bathroom had a hole in the ceiling, and the toilet paper holder was missing.218B: the over the bed table laminate was peeling off and there was a hole in the ceiling above bed C.219B: the over the bed table laminate was peeling off, Bed C the over the bed table laminate was peeling off and leaning. The bathroom toilet was full of feces and was covered with a large clear plastic garbage bag.221A and C: the over the bed table's laminate was peeling off and the outside wall was scuffed.222: the wall outside the bathroom was gouged.223B: the over the bed table laminate was peeling off and the bathroom wall was gouged.225: the over the bed table laminate was peeling off.The radiator cover, in the hallway outside room [ROOM NUMBER], was lifting off exposing sharp edges. During an interview on 9/10/25 at 8:25 A.M., Unit manager #1 said that all needed environmental repairs should be entered into the TELS system (used to communicate environmental repair needs to the maintenance department). During an interview on 9/10/25 at 8:28 A.M., the Maintenance Director said that all of the work request orders in the TELS system have been completed as of today. He then said that he checks the system up to 8 times a day. During an interview on 9/10/25 at 10:40 A.M., the Maintenance Director said that he was not aware of any plans to purchase over the bed tables or any furniture for the resident rooms. During an interview on 9/10/25 at 10:48 A.M., the Administrator said that the above concerns should have been entered into the TELS system. The Administrator then said that she and the Maintenance Director do rounds in the facility on a monthly basis. Review of the facility document titled Monthly Environmental rounds, dated 4/30/25, indicated that only 2 over the bed tables need replacement. The document further indicated that 6 rooms on the first floor and 12 rooms on the second floor needed to be painted.Review of the facility document titled Monthly Environmental rounds, dated 5/28/25, failed to indicate that any over the bed tables need replacement. The document further indicated that four of the six rooms on the first floor that needed to be painted were completed and none of the12 rooms on the second floor had been painted.Review of the facility document titled Monthly Environmental rounds, dated 6/30/25, failed to indicate that any over the bed tables need replacement. The document further indicated that the same four of the six rooms on the first floor that needed to be painted were completed and none of the12 rooms on the second floor had been painted.Review of the facility document titled Monthly Environmental rounds, dated 7/30/25, failed to indicate that any over the bed tables need replacement. The document further indicated that the same four of the six rooms on the first floor that needed to be painted were completed and none of the12 rooms on the second floor had been painted.The surveyor then asked for any purchase orders for over the bed tables in the past six months and the Administrator produced a document titled Purchase Order #CWR175978, dated 9/10/25 at 11:34 A.M., for 44 over the bed tables. The Administrator said that she could not find any other purchase orders.

Based on observation, interview and record review, the facility failed to maintain a safe environment for two Residents (#35, and #6) out of a total sample of 25 residents to prevent accidents/incidents. Specifically:1. For Resident #35, the facility failed to provide a lid for hot coffee and supervision during meals resulting in the Resident spilling hot coffee onto his/her chest, potentially putting the resident at risk for burns.2. For Resident #6, the facility failed to provide a lid for hot coffee and supervision during meals, potentially putting the resident at risk for burns.Findings include:1. Resident #35 was admitted to the facility in April 2014 and has diagnoses that include athetoid cerebral palsy (condition affecting movement and posture), osteoarthritis (joint disease-causing pain and stiffness), gastro esophageal reflux disease (heartburn), and hemiplegia and hemiparesis (complete paralysis of one side of the body, hemiparesis refers to weakness on one side, allowing for some movement), and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 6/18/25, indicated Resident #35 had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 which indicated moderately impaired cognition. Review of the MDS indicated that Resident #35 requires setup assistance with meals. Review of Resident #35's Quarterly Evaluation Packet dated 6/18/25, indicated Resident #35's Hot Liquid Risk Score was 2-4 Moderate Risk. Safety Interventions included:-Resident to use a cup with a lid.-Resident to be screened by PT/OT for hot liquid safety.-Staff to assist Resident with all hot liquids. Review of Resident #35's medical record failed to indicate that he/she was screened by PT/OT for hot liquid safety after the 6/18/25 assessment.Review of Resident #35's ADL (Activities of Daily Living) care plan dated 12/30/24, indicated:- I require set-up assistance [i.e., opening packages, cutting meat, arranging plate, etc.] I am supervised with eating and drinking. Date Initiated: 7/15/25.-PT/OT evaluation and treatment as ordered. Date Initiated: 12/26/22.Review of Resident #35's care plans failed to indicate interventions for hot liquid safety were updated after the 6/18/25 assessment.On 9/9/25 at 12:28 P.M., the surveyor observed Resident #35 sitting, tilted back in a wheelchair in the communal dining room during the lunch meal. Resident #35 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. There was no lid placed on the table. Staff were present in the dining room passing out breakfast trays, hot coffee and beverages. Resident #35's hands were shaking as he/she was observed spilling the hot coffee onto his/her chest and coffee was visible on his/her shirt. The Resident could be heard saying I spilled it on my shirt. It's hot. Nurse #2 observed the coffee spilling on Resident #35 and said, Are you okay? and then proceeded to walk out of the dining room to assist with passing out breakfast trays.Review of Resident #35's diet slip did not indicate the need for lids with coffee.Review of Resident #35's medical record failed to indicate a skin check was completed after Nurse #2 observed the Resident spill coffee on his/her shirt.On 9/10/25 at 8:04 A.M., the surveyor observed Resident #35 sitting, tilted back in a wheelchair in the communal dining room during the breakfast meal. Resident #35 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. Staff were present in the dining room passing out breakfast trays including hot coffee and beverages.During an interview on 9/10/25 at 8:10 A.M., Supervisor #1 said Resident #35 requires supervision with meals due to cerebral palsy and said he/she can pick up finger foods and drinks but needs help. During an interview on 9/10/25 at 11:40 A.M., Unit Manager #1 said he was not aware that Resident #35 had spilled coffee on his/her chest and said he would expect to be notified and said it is an incident that should have been documented on a skin check and reported.During an observation and interview on 9/10/25 at 11:55 A.M., Supervisor #1 said Resident #35 had a Hot Liquid Assessment completed and needs cups with lids and assistance with hot liquids because he/she has trouble with getting foods and fluids to his/her mouth due to physical limitations and said she was not aware that Resident #35 had spilled coffee on his chest yesterday. Supervisor #1 reviewed the medical record and said there is no documentation that a skin assessment was completed and no progress notes indicating that Resident #35 was assessed by the nurse. Supervisor #1 said Resident #35 must have a skin check and interventions in place to ensure he/she is using lids on the hot coffee cups and is getting assistance with drinking coffee to prevent burns. The Supervisor and the surveyor observed Resident #35's chest and his/her skin was clear. Supervisor #1 said she was going to report the concerns and make sure Resident #35's interventions are implemented. During an interview on 9/10/25 at 12:02 A.M., Nurse #2 said she checked Resident #35's chest after he/she finished eating lunch yesterday, but she did not document it and did not tell anyone about the spilled coffee and said she should have told someone and reported it. Nurse #2 said she worked until 11:00 P.M. yesterday and got busy and forgot. On 9/10/25 at 12:16 P.M., the surveyor walked into the dining room and immediately observed Resident #35 sitting, tilted back in a wheelchair in the communal dining room. Resident #35 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. There was no lid placed on the table. There were no staff present in the dining room during as they were in the hall passing out lunch trays, hot coffee and beverages. Resident #35's hands were shaking as he/she was observed spilling the hot coffee onto his/her chest and coffee was visible on his/her shirt. The Resident could be heard saying I just spilled coffee on myself again. The surveyor had to alert staff in the hall that the Resident spilled hot coffee on his chest.During an interview on 9/10/25 at 12:25 P.M., Unit Manager #1 said the Resident should not be drinking coffee without a lid, and he/she needs to be supervised and should not have been given hot coffee during the lunch meal.At 12:30 P.M., The surveyor used a thermometer to check the temperature of the coffee cup Resident #35 was drinking from and the temperature of the coffee was 130 degrees Fahrenheit; approximately 14 minutes after the Resident spilled the coffee.During an interview on 9/10/25 at 12:36 P.M., the Director of Nurses (DON) said he was not made aware of the incident and said it is concerning for safety and said a skin assessment should have been done immediately yesterday when the nurse witnessed the Resident spill the coffee on his/her chest. The DON said Resident #35's care plan, Kardex and diet slip should have been updated after the hot liquid assessment and said interventions should have been followed to ensure lids were used and safety was maintained. The DON said staff should have been supervising the Resident in the dining room.During an interview on 9/10/25 at 12:45 P.M., the Regional Nurse said interventions related to the hot liquid assessment should have been followed and said Resident #35 should have been supervised while drinking the hot coffee and said it is concerning for burns. During an interview on 9/10/25 at 2:00 P.M., the Food Service Director (FSD) said Residents who require lids on coffee cups would have it written on the diet slip indicating a lid was needed and said he was notified earlier today that Resident #35 needed a lid, so the diet sip was just updated. The FSD showed the surveyor a form titled Dietary Communication -For Long Term Care Menu. The form indicated Resident #35 required adaptive equipment Needs cup with lid for hot liquids all meals dated 9/10/25 signed by licensed Nurse. The FSD said Resident #35 is the only resident who requires Lids on hot coffee and said no other Residents have that listed on the diet slip.2. Resident #6 was admitted to the facility in March 2021 and has diagnoses that include type two diabetes mellitus, lack of coordination and anxiety disorder.Review of the Minimum Data Set (MDS) assessment, dated 8/6/25, indicated Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 which indicated moderate cognitive impairment. Review of MDS indicated that Resident #6 requires setup assistance with meals. Review of Resident #6's Quarterly Evaluation Packet dated 5/2/25 and 8/5/25, indicated Resident #6 's Hot Liquid Risk Score was 01- Low Risk. Safety Interventions included:-Resident to use a cup with a lid.-Resident to be screened by PT/OT for hot liquid safety.-Staff to assist Resident with all hot liquids. Review of Resident #6's risk for burns care plan date Initiated, 5/2/25, indicated, I am at risk for spills and burns from hot liquids r/t (related to):-Resident to be screened by PT/ OT for hot liquids safety.-Resident to use a cup with a lid.-Staff to assist Resident with all hot liquids.Review of Resident #6's ADL (Activities of Daily Living) care plan dated 8/6/25, indicated:- I require set-up assistance [i.e., opening packages, cutting meat, arranging plate, etc.] eating and drinking. Date Initiated: 08/20/2024On 9/9/25 at 8:36 A.M., the surveyor observed Resident #6 in his/her room, sitting up in bed, during the breakfast meal. Resident #6 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. There was no lid placed on the table. No staff were present in the room, and the curtain was pulled halfway across the bed. The Resident was not visible from the hall.On 9/9/25 at 12:15 P.M., the surveyor observed Resident #6 in his/her room, sitting up in bed, during the lunch meal. Resident #6 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. There was no lid placed on the table. No staff were present in the room, and the curtain was pulled halfway across the bed. The Resident was not visible from the hall.On 9/10/25 at 8:01 A.M., the surveyor observed Resident #6 in his/her room, sitting up in bed, during the breakfast meal. Resident #6 picked up a mug containing hot coffee and began to drink from the mug. The mug did not have a lid, and steam could be seen coming from the cup. There was no lid placed on the table. No staff were present in the room, and the curtain was pulled halfway across the bed. The Resident was not visible from the hall.Review of Resident #6's diet slip did not indicate the need for lids with coffee.During an interview on 9/10/25 at 9:07 A.M., Nurse #1 said Resident #6 does not leave the room for meals and said he/she needs assistance with setup and is independent with eating.During an interview on 9/10/25 at 11:16 A.M., the Supervisor said Resident #6 was evaluated for hot liquids and requires assistance with meal set up and said the care plan must be followed. The Supervisor said Resident #6 should have lids with hot coffee and be supervised during meals to prevent spills from hot liquids during meals and said the diet slip should indicate the need for lids.During a follow up interview on 9/10/25 at 11:22 A.M., Unit Manager #1 said he expects staff to follow care plan interventions for supervision with hot liquids with lids and said the plan of care needs to be followed. The Unit Manager said the diet slip should indicate a need for lids on coffee cups as it is an intervention.During an interview on 9/10/25 at 12:44 P.M., the Director of Nurses (DON) said Resident #6's care plan should have been followed, and the diet slip should have been updated after the hot liquid assessment and said interventions should have been followed to ensure lids were used and safety was maintained. The DON said staff should have been supervising the Resident during the meals due to the risk of burns with the coffee.During an interview on 9/10/25 at 2:02 P.M., the Food Service Director (FSD) said Resident #6 does not have lids listed on the diet slip and said there is only one resident who requires Lids on hot coffee in the facility. The FSD said he has not received any documents or requests for Resident #6 to have lids because he saves all communication logs.

Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when one nurse observed made four errors out of 26 opportunities, resulting in a medication error rate of 15.38 %. Those errors impacted three Residents (#85, #99 and #22), out of seven residents observed.Findings include:Review of the facility policy titled, Administering Medications, dated as revised April 2019, indicated the following: Medications are administered in a safe, and timely manner, and as prescribed.3. Staff schedules are arranged to ensure that medications are administered without unnecessary interruptions.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before or after meal orders). Review of the facility policy titled, Insulin Administration, dated August 2021, indicated the following: 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. The following observations were made during the medication pass on the second-floor unit: 1a. Resident #85 was admitted to the facility in July 2025 with diagnoses including type two diabetes mellitus, morbid severe obesity, and anxiety.On 9/10/25 at 8:25 A.M., the surveyor observed Nurse #1 administer the following medications to Resident #85:-6 Units Insulin Lispro (fast-acting medication to manage blood sugar levels), via subcutaneous injection.Review of the active physician's orders indicated the following:- Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 6 unit subcutaneously with meals for Type 2 diabetes. Start Date 7/30/25. Scheduled for 8:00 A.M.The medications were administered after the breakfast meal was consumed by Resident #85.1b. Resident #99 was admitted to the facility in August 2025 with diagnoses including type one diabetes mellitus, encephalopathy, and cognitive communication deficit.On 9/10/25 at 8:27 A.M., the surveyor observed Nurse #1 administer the following medication to Resident #99:-10 Units Insulin Lispro, via subcutaneous injection.Review of the active physician's orders indicated the following:-Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 10 units subcutaneously with meals related to type 1 diabetes mellitus without complications. Start Date 9/4/25. Scheduled for 8:00 A.M.The medications were administered after the breakfast meal was consumed by Resident #99.1c. Resident #22 was admitted to the facility in October 2024 with diagnoses including type two diabetes mellitus and congestive heart failure. On 9/10/25 at 8:42 A.M., the surveyor observed Nurse #1 administer the following medications to Resident #22:-20 Units Insulin Lispro, via subcutaneous injection.-2 Units Insulin Lispro, via subcutaneous injection.Review of the active physician's orders indicated the following:-Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 20 unit subcutaneously in the morning related to type 2 diabetes mellitus without complications. Start Date10/5/24. Scheduled for 8:00 A.M.-Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. Greater than 400 give 12 units and call MD/NP, subcutaneously with meals related to type 2 diabetes mellitus without complications. Start Date 10/5/24. Scheduled for 8:00 A.M.The medications were administered after the breakfast meal was consumed by Resident #22. During an interview on 9/10/25 at 9:05 A.M., Nurse #1 said she should have administered the medications prior to or during the breakfast meal and said she took the blood sugar levels at 7:20 A.M. and was unable to complete the insulin administration because she had to assist with checking the breakfast trays and got behind. During an interview on 9/10/25 at 12:50 P.M., the Director of Nursing said nurses should follow the physician order and administer medications as ordered and said the insulin should be given just prior to or with the breakfast meal and not after.

Based on observation, record review and interview the facility failed to develop a treatment for a pressure area on the right heel for one Resident (#41) out of a total sample of 25 residents.Findings include:Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 2001, indicated that the physician will authorize pertinent orders related to wound treatments, including wound cleansing and dressings. Resident #41 was admitted to the facility in July 2025 with diagnoses including adult failure to thrive, malnutrition and trochanteric fracture of the right femur. Review of the care plan dated 9/5/25 indicated a focus for the following: I have skin breakdown; non pressure wound of the left heel and unstageable DTI (deep tissue injury, a type of pressure related skin injury) of the right heel. Review of the physician's orders dated September 2025 indicated the following order: Left heel; cleanse with normal saline, pat dry and apply xeroform followed by an island dressing one time a day. Further review failed to indicate a treatment for pressure area of the right heel. Review of the Treatment Administration Record (TAR) dated September 2025 indicated that on 9/2/25 the wound area on the left heel was c/d/i (clean, dry and intact). Further review indicated that on 9/3/25 through 9/9/25 the wound area on the left heel was open with a scant amount of drainage. Further review failed to indicate a treatment to the right heel. On 9/9/25 at 7:45 A.M., and 10:13 A.M., the surveyor observed Resident #41 in bed with gauze dressings covering both feet including heels. The surveyor then observed each of the dressings were dated 9/7/25. During an interview on 9/9/25 at 1:40 P.M. Nurse #3 and the surveyor observed Resident #41 in bed with a dressing to both feet dated 9/7/25. Nurse #3 said that the dressing should have been changed on 9/8/25 as the order is for a daily dressing change to the left heel. Nurse #3 then said that she was told that Resident #41 had a DTI to the right heel but hadn't seen it yet. During an interview on 9/10/25 at 12:25 P.M. the Director of Nursing said that the nurses are supposed to follow the physician's orders for dressing changes, and the dressing should have been changed on 9/8/25. He then said that all pressure areas should have a treatment order and be monitored.

Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for three Residents (#17, #68 and #41), out of a total sample of 25 residents. Specifically, 1. For Resident #17, the facility failed to ensure a physician's order was obtained for the use of his/her helmet indicating to staff when to wear and safety precautions.2. For Resident #68 the facility failed to follow a physician's order for a dressing change to the left shin wound.3. for Resident #41 the facility failed to follow a physician's order for a dressing change to the left heel wound.Findings include:1. Resident #17 was admitted to the facility in August 2025 with diagnoses that included traumatic subdural hemorrhage with loss of consciousness, dysphagia, cognitive communication deficit. Review of Resident #17's Minimum Data Set (MDS), dated [DATE], indicated a score of 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS also indicated he/she is dependent on staff for activities of daily living. On 9/9/25 at 8:01 A.M. and throughout survey, the surveyor observed Resident #17 in bed awake at times, being boosted for meals in bed by staff, being provided care in bed and a helmet was observed on his/her nightstand. Review of Resident #17's physician orders on 9/9/25 at 10:30 A.M., failed to indicate an order for the use of the helmet or any precautions for his/her craniotomy. Review of Resident #17's nursing admission note, dated 8/7/25, indicated Pt (patient) underwent evacuation of hematoma. Wears helmet at all times. Review of Resident #17's initial encounter Nurse Practitioner progress note, dated 8/7/25, indicated: Patient has a surgical incision which was evaluated by neurosurgery on July 10 which has not healed sufficiently. Patient needs to wear helmet all the time. Review of Resident #17's nursing progress note, dated 8/20/25, indicated Many attempts to get out of bed unassisted, non-compliant with safety precautions, bed in low position, call light in reach, helmet on. Review of Resident #17's Medical Doctors (MD) and medical directors progress note, dated 8/21/25, indicated Patient needs to wear helmet all the time. Review of Resident #17's Nurse Practitioner progress note, dated 9/3/25, indicated Patient needs to wear helmet all the time. Keep helmet on to protect patient's skull from trauma. Review of Resident #17's Occupational Therapy progress note, dated 9/8/25, indicated Precautions / Contraindications: helmet OOB (out of bed) Craniotomy precautions. Review of Resident #17's fall risk assessment, dated 8/20/25, indicated he/she scored a 12 indicating moderate fall risk. Review of Resident #17's medical record indicated only a behavioral care plan was developed for a one time refusal of helmet use. Further review of the medical record indicated on his/her behavioral documentation for the helmet use indicated no refusals and only one documented nursing note indicated a refusal from the Resident. During an interview on 9/10/25 at 7:55 A.M., Certified Nurse Aide (CNA) #1 said they are unsure of when the helmet needs to be on but could ask the nurse, but the Resident does not have it on now. CNA #1 said the Resident needs to be boosted for meals when in bed and gets his/her activities of daily living in bed and that is done without a helmet on. CNA #1 says the Resident does get out of bed at times and is a fall risk. During an interview on 9/10/25 at 8:05 A.M., Nurse #1 said she has taken care of Resident #17 before and thinks the helmet only needs to be on when he/she is out of bed. Nurse #1 said the admitting nurse should go through the admission paperwork and write orders for the helmet but did not. During an interview on 9/10/25 at 10:35 A.M., Nurse Practitioner (NP) #1 said Resident #17 is a very vulnerable resident as he/she recently had a craniotomy and does not have his/her skull to protect part of the brain anymore. The NP said his/her helmet should always be on because that was what neurology had recommended. The NP said he/she is at risk for injury as he/she could fall out of bed as they are a fall risk, and any rolling could cause his/her head to go into the side rail and half of his/her head is very soft. The NP said she would expect an order would be in place so staff are aware that he/she has a helmet and when it should be on. During an interview on 9/10/25 at 10:52 A.M., the Occupational Therapist (OT) said there should be orders in place for Resident #17's helmet use so the whole team is aware of the plan of care for the Resident. The OT said the Resident is at risk for falls. During an interview on 9/10/25 at 11:56 A.M., the Director of Nurses (DON) said there should have an order in place on admission for the use of the Resident's helmet, so everyone is aware of what the Resident needs. The Resident is a fall risk and has a craniotomy which leaves the brain at risk. 2. Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol indicated that the physician will authorize pertinent orders related to wound treatments, including wound cleansing and dressings. Resident #68 was admitted to the facility in July 2025 with diagnoses including pathological trimalleolar fracture of the left lower leg. Review of the physician's orders dated September 2025 indicated the following order: Left shin wound in the evening for left shin wound, clean with NS (normal saline) apply border dressing q (every) day. On 9/9/25 at 8:35 A.M. the surveyor observed Resident #68 with a gauze dressing covering an ABD (abdominal) pad, to the left lower leg dated 9/7/25. During an interview on 9/09/25 at 1:38 P.M. Nurse #3 and the surveyor observed Resident #68 with a dressing to the left shin dated 9/7/25. Nurse #3 said that the dressing should have been changed on 9/8/25 as the order is for a daily dressing change to the left shin. Nurse #3 also said that the dressing on the wound was not what the physician ordered. During an interview on 9/10/25 at 12:25 P.M. the Director of Nursing said that the nurses are supposed to follow the physician's orders for dressing changes. 3. Resident #41 was admitted to the facility in July 2025 with diagnoses including adult failure to thrive, malnutrition and trochanteric fracture of the right femur. Review of the care plan dated 9/5/25 indicated a focus for the following: I have skin breakdown; non pressure wound of the left heel and unstageable DTI (deep tissue injury, a type of pressure related skin injury) of the right heel. Review of the physician's orders dated September 2025 indicated the following order: Left heel; cleanse with normal saline, pat dry and apply xeroform followed by an island dressing one time a day. Review of the Treatment Administration Record (TAR) dated September 2025 indicated that on 9/2/25 the wound area on the left heel was c/d/i (clean, dry and intact). Further review indicated that on 9/3/25 through 9/9/25 the wound area on the left heel was open with a scant amount of drainage. On 9/9/25 at 7:45 A.M., and 10:13 A.M., the surveyor observed Resident #41 in bed with gauze dressings covering both feet including heels. The surveyor then observed each of the dressings were dated 9/7/25. During an interview on 9/9/25 at 1:40 P.M. Nurse #3 and the surveyor observed Resident #41 in bed with a dressing to both feet dated 9/7/25. Nurse #3 said that the dressing should have been changed on 9/8/25 as the order is for a daily dressing change to the left heel. Nurse #3 then said that she wasn't sure why there was a dressing to the right heel as she was just back from vacation. During an interview on 9/10/25 at 12:25 P.M. the Director of Nursing said that the nurses are supposed to follow the physician's orders for dressing changes, and the dressing should have been changed on 9/8/25.

Based on observation, interview, and record review, the facility to ensure that services provided met professional standards for one Resident (#69), out of 25 total sampled residents. Specifically, for Resident #69, the facility failed to ensure that his/her air mattress was functioning.Findings include:Review of the manufacturers User Manual for the air mattress system indicated the following: -Power switch is at the right side of the control unit.-Turn ON/OFF the power, the pump will start/stop operation. -A visible indicator (green) tells the pressure has reached a preset or user-defined level. -A visible indicator (yellow or red) warns the pressure is below a preset or user-defined level. Operating Instructions4. Turn on the control unit's power. The indicator of the power switch will come on. The control unit starts to pump air into the mattress. Resident #69 was admitted to the facility in August 2025 with diagnoses including hemiplegia (weakness on one side of the body) and dysphagia (difficulty swallowing).Review of the most recent Minimum Data Set (MDS) assessment, dated 8/27/25, indicated that Resident #69 was unable to conduct a Brief Interview for Mental Status exam and was severely cognitively impaired. Further review of the MDS indicated that Resident #69 is dependent on staff for Activities of Daily Living. The MDS also indicated that the Resident is at risk for developing pressure injuries and had a pressure reducing device for bed.On 9/9/25 at 7:52 A.M., the surveyor observed Resident #69 sleeping in bed. Resident #69 had an air mattress on his/her bed. The air mattress was not functioning, and the power switch was turned off.On 9/9/25 at 8:40 A.M., the surveyor observed Resident #69 sitting in bed with a staff member was assisting with the breakfast meal. Resident #69 had an air mattress on his/her bed. The air mattress was not functioning, and the power switch was turned off.On 9/9/25 at 12:11 P.M., the surveyor observed Resident #69 sitting in bed as a staff member was assisting with the lunch meal. Resident #69 had an air mattress on his/her bed. The air mattress was not functioning, and the power switch was turned off.On 9/10/25 at 8:06 A.M., the surveyor observed Resident #69 sleeping in bed. Resident #69 had an air mattress on his/her bed. The air mattress was not functioning, and the power switch was turned off.On 9/10/25 at 8:34 A.M., the surveyor observed Resident #69 sitting in bed as a staff member was assisting with the breakfast meal. Resident #69 had an air mattress on his/her bed. The air mattress was not functioning, and the power switch was turned off.During an observation and interview on 9/10/25 at 11:10 A.M., Certified Nursing Assistant (CNA) #2 and CNA #3, CNA #2 said the air mattress is on and functioning and said she does not touch the air mattress but know it is on because the resident is comfortable. CNA #3 said the air mattress box does not have lights and said the air mattress is working and proceeded to press her hand into the air mattress leaving an indent in the mattress when she removed her hand. The air mattress on the bed remained deflated and not functioning during this time.During an observation and interview on 9/10/25 at 11:32 A.M., Unit Manager #1 checked the air mattress setting and function on Resident #69's bed. He said the air mattress is not getting power and is not functioning. The surveyor and the Unit Manager observed the electrical cord to the air mattress was unplugged and not getting any power. The surveyor pushed the on/off button, and the unit did not have power. Unit Manager #1 said the power cord is too long and needs an extension cord because it keeps coming out of the wall. Review of most recent Norton Assessment (An assessment to determine a resident's risk for skin breakdown), dated 8/22/25, indicated a score of 12, which indicates high risk for skin breakdown.Review of Resident #69's active physician orders indicated: Air Mattress on bed, check inflation (set according to patient preference) and function q (every) shift. Every shift for Prevention. Start Date 8/27/25.During an interview on 9/10/25 at 11:26 P.M., Nurse #1 said she would have expected the staff who provided care to Resident #69 to notice the air mattress was not functioning. Nurse #1 said that Resident #69 did not have any open skin areas but is on hospice and in bed all day and needs an air mattress to prevent skin breakdown.During an interview on 9/10/25 at 11:36 P.M., Unit Manger #1 said Resident #69's air mattress was unplugged and not functioning and said that staff should have noticed the mattress was not functioning. Unit Manager #1 said air mattresses should have a physician's order indicating the appropriate setting, and to check the function of the mattress. She said a non-functioning air mattress places the resident at risk for skin breakdown.During an interview 9/10/25 at 12:44 P.M., The Director of Nurses (DON) said that all residents on an air mattress should have a physician's order followed and said staff must check the function every shift. The DON said that he would expect any staff who enter the room to notice if the air mattress is not functioning. The DON further said that a non-functioning air mattress places the resident at risk for skin breakdown.

Based on observation, record review and interview the facility failed to maintain accurate medical records for two Residents (#41 and #68) out of a total sample of 25 residents. Specifically, the facility failed to accurately document on the Treatment Administration Record that treatments were not completed as ordered for Resident #41 and Resident #68.Review of the facility policy titled Charting and documentation dated revised July 2017 indicated that documentation in the medical record will be objective, complete and accurate. Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol indicated that the physician will authorize pertinent orders related to wound treatments, including wound cleansing and dressings. 1. Resident #41 was admitted to the facility in July 2025 with diagnoses including adult failure to thrive, malnutrition and trochanteric fracture of the right femur.Review of the care plan dated 9/5/25 indicated a focus for the following: I have skin breakdown; non pressure wound of the left heel and unstageable DTI (deep tissue injury, a type of pressure related skin injury) of the right heel. Review of the physician's orders dated September 2025 indicated the following order: Left heel; cleanse with normal saline, pat dry and apply xeroform followed by an island dressing one time a day. Review of the TAR dated September 2025 indicated that on 9/2/25 the wound area on the left heel was c/d/i (clean, dry and intact). Further review indicated that on 9/3/25 through 9/9/25 the wound area on the left heel was open with a scant amount of drainage. Further review indicated that on 9/8/25 the nurse documented that they had completed the treatment to the left heel as ordered. On 9/9/25 at 7:45 A.M., and 10:13 A.M., the surveyor observed Resident #41 in bed with gauze dressings covering both feet including heels. The surveyor then observed each of the dressings were dated 9/7/25. During an interview on 9/9/25 at 1:40 P.M. Nurse #3 and the surveyor observed Resident #41 in bed with a dressing to both feet dated 9/7/25. Nurse #3 said that the dressing should have been changed on 9/8/25 as the order is for a daily dressing change to the left heel. Nurse #3 said that the nurse should not document in the medical record that they completed a dressing change when they had not. During an interview on 9/10/25 at 12:25 P.M. the Director of Nursing said that the nurses are supposed to follow the physician's orders for dressing changes. The DON then said that nurses should not be documenting in the medical record that they completed a dressing change when they had not.2. Resident #68 was admitted to the facility in July 2025 with diagnoses including pathological trimalleolar fracture of the left lower leg. Review of the physician's orders dated September 2025 indicated the following order: Left shin wound in the evening for left shin wound, clean with NS (normal saline) apply border dressing q (every) day. On 9/9/25 at 8:35 A.M. the surveyor observed Resident #68 with a gauze dressing covering an ABD (abdominal) pad, to the left lower leg dated 9/7/25. Review of the Treatment Administration Record dated 9/8/25 indicted that the nurse documented that they had completed the ordered treatment for the dressing change on 9/8/25 as ordered. During an interview on 9/9/25 at 1:38 P.M. Nurse #3 and the surveyor observed Resident #68 with a dressing to the left shin dated 9/7/25. Nurse #3 said that the dressing should have been changed on 9/8/25 as the order is for a daily dressing change to the left shin. Nurse #3 also said that the dressing on the wound was not what the physician ordered. Nurse #3 then said that the nurses should not be documenting in the medical record that they had completed a dressing change when they had not.

Based on interviews, policy and record review the facility failed to ensure weights were obtained for one Resident (#17) out of a total sample of 25 residents. Specifically, for Resident #17 who was assessed as malnourished, the facility failed to obtain his/her weight on readmission or his/her weekly weight per the physician's orders. Findings include:Review of the facility policy titled Weight Assessment and Intervention, dated March 2022, indicated Residents are weighed upon admission and at intervals established by the interdisciplinary team. Resident #17 was readmitted to the facility in September 2025 with diagnoses that included traumatic subdural hemorrhage with loss of consciousness, dysphagia, cognitive communication deficit. Review of Resident #17's Minimum Data Set (MDS), dated [DATE], indicated a score of 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Review of Resident #17's physician order, dated 9/4/25, indicated weekly weights. Review of Resident #17's weights indicated:-8/13/25 110 lbs (pounds) -8/20/25 148.8 lbs No other weights were obtained. Review of Resident #17's nutritional risk assessment, dated 8/21/25, indicated the Resident was malnourished. Monitor weekly weights. Review of Resident #17's nutritional care plan, dated 8/21/25, indicated Obtain weights at ordered intervals. During an interview on 9/10/25 at 11:45 A.M., the Dietitian said Resident #17 is a very vulnerable resident and there have been issues obtaining weights in general. The Dietitian said when a resident is readmitted to the facility the expectation is that staff obtain the weight within 24 hours. The Dietitian said she would expect that the Resident's order for weekly weights would be completed. The Dietitian said it is important to know the resident's weight because his/her weight that was originally obtained on admission was most likely wrong, and the Resident should have been reweighed but was not. During an interview on 9/10/25 at 12:10 P.M., Nurse #1 said when a new admission or readmission comes in, we weigh the resident immediately and put the weight in the electronic medical record (PCC). Nurse #1 said if a resident is a weekly weight the nurse will tell the Certified Nurse Aide (CNA) assigned and then document the weight into PCC. Nurse #1 said there is not a weight book on this floor, the CNA's obtain the weight and tell the nurse who is on duty, then the nurse documents it in PCC. During an interview on 9/10/25 at12:11 P.M., CNA #2 said the staff weigh residents right when they come back from the hospital and tell the nurse the weight and they will put the weight into the computer. CNA #2 said if a resident is a weekly weight or if a weight is needed the nurse will tell the CNA to get the weight.

Based on observations and interviews, the facility failed to ensure staff treated residents in a dignified manner during the dining experience for one Resident (#69) out of a total of 25 sampled residents.Findings include: Review of the facility policy titled Dignity, revised and dated February 2021, indicated the following: - Residents are treated with dignity and respect at all times.-Provided with a dignified dining experience.Resident #69 was admitted to the facility in August 2025 with diagnoses including hemiplegia and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/27/25, indicated that Resident #69 was unable to conduct a Brief Interview for Mental Status exam and was severely cognitively impaired. Further review of the MDS indicated that Resident #69 is dependent on staff for eating and received a mechanically altered therapeutic diet. On 9/9/25 at 8:40 A.M., a staff member was observed feeding Resident #69 who was lying in bed while standing over them, not at eye level. The bed was low to the ground. On 9/9/25 at 12:11 P.M., a staff member was observed feeding Resident #69 who was lying in bed while standing over them, not at eye level. The bed was low to the ground. On 9/10/25 at 8:34 A.M., a staff member was observed feeding Resident #69 who was lying in bed while standing over them, not at eye level. The bed was low to the ground. On 9/10/25 at 12:17 P.M., a staff member was observed feeding Resident #69 who was lying in bed while standing over them, not at eye level. The bed was low to the ground. During an interview on 9/10/25 at 12:30 P.M., Unit Manager #1 said staff should not be standing over residents while assisting them with feeding. During an interview on 9/10/25 at 12:44 P.M., the Director of Nursing said staff should not be standing over residents while assisting them with feeding and should be at eye level.

Based on record review and interview, the facility failed to ensure the physician reviewed the pharmacy monthly medication review within 30 days for one (Resident #32) out of a total of 26 sampled residents. Findings include:Review of the facility's policy titled Medication Regimen Review dated July 2025 indicated:A licensed pharmacist reviews the medication regimen of each resident at least monthly.Time Frame for Reporting:- Within three business days of the MRR (medication regimen review), the consultant pharmacist provides a written report to the attending physician for each resident identified as having a medication irregularity that is deemed not life-threatening.- The consultant pharmacist provides the director of nursing services and medical director with a written, signed, and dated copy of all medication regimen reports., the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them. - Irregularities that do not present a risk to a person's life, health, or safety will be addressed within 30 days of receiving the MMR from the consultant pharmacist. Resident #32 was admitted to the facility in August 2025, and has active diagnoses which include diabetes mellitus, kidney disease and hypertension. Review of Resident #32's Minimum Data Set assessment dated [DATE] indicated a Brief Interview for Mental Status score of 8, indicating moderately impaired cognition.Review of Resident #32's physician orders on 9/9/25 indicated:Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 MCG/ACT (Fluticasone Umeclidinium Vilanterol) dated 8/6/25.Acetaminophen Oral Tablet 325 MG (Acetaminophen). Give 2 tablets by mouth every 6 hours as needed for pain dated 8/5/25.Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk). Give 17 grams by mouth every 24 hours as needed for Constipation dated 8/5/25.Review of Resident #32's medical record indicated that on 8/7/25 the consulting pharmacist generated an MMR report for the physician to review new recommendations. The medical record did not include this report.On 9/9/25 at 2:17 P.M., the surveyor requested from the Director of Nursing (DON) Resident #32's MMR report dated 8/7/25. The DON provided the report on 9/10/25.Review of Resident #32's MMR Consultant Pharmacist Recommendations to Nursing, dated 8/7/25 indicated:1. Please add a max daily dose of 3 grams to the Acetaminophen orders from all sources.2. Resident is receiving Trelegy Ellipta Inhaler. Please add rinse mouth after using to order and MAR to avoid thrush formation.3. Recommend updating the current polyethylene glycol (Miralax) order to include the following directions: Mix 17 grams (1 capful) in at least 4 ounces of liquid and take by mouth.Review of Resident #32's MMR Consultant Pharmacist Recommendations to Nursing indicated the physician initialed his/her agreement to the recommendations. The physician's initial was not dated. Review of Resident #32's physician's orders on 9/10/25 indicated the consulting pharmacist's recommendations were updated on this same day, 9/10/25; 35 days after the pharmacist wrote the report.The surveyor reviewed Resident #32's physician orders on 9/10/25 and these included:Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 MCG/ACT (Fluticasone Umeclidinium Vilanterol). Rinse mouth to avoid thrust formation dated 9/10/25Acetaminophen Oral Tablet 325 MG (Acetaminophen). Give 2 tablets by mouth every 6 hours as needed for pain. Maximum daily dose of 3 grams dated 9/10/25.Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk). Give 17 grams by mouth every 24 hours as needed for Constipation. Mix 17 grams (1 capful) in at least 4 ounces of liquid and take by mouth dated 9/10/25.During an interview on 9/10/25 at 12:33 P.M., the DON and Regional Nurse said it is the facility's policy to address irregularities that do not present a risk to a person's life, health, or safety within 30 days of receiving the MMR from the consultant pharmacist.

Based on observation, policy review and interviews, the facility failed to provide care and maintenance of a peripheral inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#237), out of a total sample of 21 residents. Specifically, the facility failed to implement dressing changes routinely as required. Findings include: Review of the facility policy titled 'Central Venous Catheter Care and Dressing Changes' dated March 2022, indicated the following but not limited to: -Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g, damp, loosened or visibly soiled). -Maintain sterile dressing ( transparent semi-permeable membrane (TSM) dressing or sterile gauze for all central vascular access devices. The type of dressing is based on the condition of then resident and his or her preference. -Change the dressing if it becomes damp loosened or visibly soiled and: a. Every seven days for TSM dressing -measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. Resident #237 was admitted to the facility in August 2024 with diagnoses including dependent on parenteral nutrition. Review of Resident #237 Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 12 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident had an intravenous access line. On 9/10/24 at 8:50 A.M., the surveyor observed Resident #237 lying in his/her bed with a PICC line to his/her right upper arm. The dressing on the insertion site was transparent and dated 8/25. Review of the physician orders dated 8/29/24 indicated the following: -IV (midline, PICC, CVAD) change transparent dressing on admission and then every 7 days. Caps to be changed during dressing change. Every day shift every 7 days. Review of Resident #237's medication administration record (MAR), dated 8/30/24, indicated nursing implemented the PICC dressing change as ordered. During an interview on 9/11/24 at 12:29 P.M., Nurse #3 said PICC line dressing changes are done upon admission and then weekly. During an interview on 9/11/24 at 12:35 P.M., Unit Manager #2 said dressing changes should be done weekly. When asked if the date on the dressing should have been different from 8/25/24 she said yes. During an interview on 9/11/24 at 12:40 P.M., the Director of Nursing said PICC line dressing should be changed upon admission and every 7 days.

Based on observation, record review and interview, the facility failed to meet professional standards of quality for four Residents (#49, #15, #42 and #17), out of a total sample of 21 residents. Specifically: 1) For Resident #49 the facility failed to follow physician orders for weekly skin checks. 2) For Resident #15 the facility failed to complete skin checks as ordered. 3) For Resident #42 the facility failed to implement air mattress setting as indicated in the physician order. 4) For Resident #17 the facility failed to to obtain weekly weights according to physician's order. Findings Include: Review of the facility policy, titled Assessment of Skin Condition and Integrity, adopted March 2021, indicated, but was not limited to, the following: Skin Assessment: 1) Conduct a comprehensive head-to-toe skin assessment upon admission, weekly, prior to discharge and as needed. a.) During the skin assessment, inspect for: i. Presence of skin impairment(s); ii. Type of skin impairment(s); and iii. Location of skin impairment(s); 2) Inspect the skin daily when performing or assisting with personal care or ADL's (activities of daily living). Documentation: 1. The type of skin assessment(s) conducted. 2. The date and time and type of skin care provided, if appropriate. 3. The name and title of the individual who conducted the assessment. 4. The condition of the resident's skin. 5. Any new change(s) in the resident's skin condition, if identified. a. If a new skin alteration is noted, initiate a weekly wound progress report. b. Reassess the alteration weekly until the area is healed or the resident is discharged . 6. Develop, review and/or update the resident-centered care plan and interventions, as needed. 7. If the resident refused the skin assessment, document the reason for refusal and the resident's response to the explanation of the risks for refusing the procedure, the benefits of accepting and available alternatives. 1. Resident #49 was admitted to the facility in June 2024 with a diagnosis of diabetes. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #49 scored a 9 out of a possible 15 on a Brief Interview for Mental Status (BIMS), indicating the Resident had moderate cognitive impairment. Review of Resident #49's Follow-Up Wound Clinic Note, dated 2/13/24, indicated the Resident was seen by an outpatient wound clinic on 2/13/24 and that the Resident had a chronic diabetic ulcer on his/her right foot. Review of a Nurse Practitioner Progress Note, dated 8/27/24, indicated Resident #49 had an ulcer on his/her right foot. Review of Resident #49's active physician orders indicated the following order: - Skin Checks weekly on Friday 7-3 (shift), initiated 7/12/24. Review of Resident #49's care plans indicated the Resident had skin breakdown and/or potential for skin breakdown r/t (related to) neck collar, and decreased functional status with the following intervention: Document skin checks weekly and PRN (as needed), initiated 7/3/24. Review of Resident #49's medical record failed to indicate that a skin check was completed on 8/30/24 or 9/6/24 as ordered; indicating a skin check had not been completed in over two weeks. Review of Resident #49's medical record failed to indicate the Resident had refused skin checks. During an interview on 9/12/24 at 8:46 A.M., Nurse #4 said skin checks were done weekly and documented in the evaluation section of the electronic medical record. During an interview on 9/12/24 at 9:05 A.M., Unit Manager #2 said skin checks were done weekly and documented in the evaluation section of the electronic medical record. During an interview and observation on 9/12/24 at 9:07 A.M., Resident #49 said he/she had a chronic wound on his/her right foot. Unit Manager #2 and the surveyor observed Resident #49's right foot wound. During an interview on 9/12/24 at 12:32 P.M., Nurse Practitioner #1 said she would expect nurses to follow physician orders. During an interview on 9/12/24 at 1:59 P.M., the Director of Nursing (DON) said nurses complete skin checks weekly, and that if a resident refuses a skin check that this would be documented. During a follow-up interview on 9/12/24 at 2:44 P.M., the DON said that he would expect nurses to complete and document a full skin evaluation when completing the physician-ordered weekly skin check. 46339 2. Resident #15 was admitted to the facility in December 2020 with diagnoses including Dementia and Parkinson's disease. Review of Resident #15's Minimum Data Set (MDS) assessment, dated 6/19/24, indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status indicating he/she was severely cognitively impaired. The MDS further indicated the Resident is dependent of staff for activities of daily living. Review of the current physician orders indicated the following: -Skin checks weekly on Thursday 3-11 every evening shift. Every Thursday for monitoring. Review of the clinical record indicated a skin assessment evaluation had not been completed since 8/8/24. During an interview on 9/11/24 at 12:25 P.M., Nurse #3 said a weekly skin assessment should be completed as ordered, the nurses document in the treatment administration record and also complete a skin evaluation assessment. During an interview on 9/12/24 at 8:37 A.M., Unit Manager #2 said weekly skin checks should be completed as ordered and if refusal the nurse would document in the nurse progress notes. During an interview on 9/12/24 at 9:49 A.M., the Director of Nursing said weekly skin checks should be completed weekly and a skin evaluation assessment completed 3. Resident #42 was admitted to the facility in July 2023 with diagnosis including unspecified abnormalities of gait and mobility. Review of Resident #42 Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status indicating he/she was cognitively intact. Review of Resident #42's current physician order indicated the following: -Air mattress on bed check function and placement set according to weight every shift. Review of Resident #42's active Activity of daily living (ADL) care plan indicated an intervention dated 10/16/23 'Resident requires air mattress on bed check inflation set according to weight'. On 9/10/24 at 8:55 A.M., the surveyor observed Resident #42 lying in his/her bed the air mattress was set to 350 lbs (pounds). On 9/10/24 at 4:02 P.M., the surveyor observed Resident #42 lying in his/her bed the air mattress was set at 350 lbs. On 9/11/24 at 7:00 A.M., the surveyor observed Resident #42 lying in his/her bed the air mattress was set at 350 lbs. Review of Resident #42's most recent weight dated 8/5/24 indicated the following: -140.4 lbs. During an interview and an observation on 9/11/24 at 9:26 A.M., the surveyor and Nurse #3 observed Resident #42 lying in bed. His/her air mattress was set at 350 lbs. Nurse #3 said the mattress should be set according to the resident's weight. During an interview on 9/12/24 at 8:38 A.M., Unit Manager #2 said the air mattress setting is based on the resident's weight. She said Resident #42 prefers a firm surface and the orders should reflect that. During an interview on 9/12/24 at 9:08 A.M., the Director of Nursing said the air mattress should be set per resident's weight. The physician order should be followed as ordered. 50338 4. Review of the facility policy titled Weight Assessment and Intervention dated March 2022, indicated the following: -Resident weights are monitored for undesirable or unintended weight loss or gain. -Residents are weighed upon admission and at intervals established by the interdisciplinary team and/or as ordered by the physician. -Weights are recorded in each unit's weight record chart and in the individual's medical record. Resident #17 was admitted to the facility in July 2024 with diagnoses including epilepsy, dysphagia, gastrostomy status, and malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/24/24, indicated that Resident #17 was rarely/never understood and a staff assessment for Brief Interview for Mental Status (BIMS) indicated severe cognitive impairment. This MDS indicated Resident #17 was dependent on a feeding tube to administer his/her nutrition and hydration related to difficulty swallowing and malnutrition. Review of this MDS also indicated Resident #17 had unplanned weight loss. On 9/10/24 at 8:30 A.M., the surveyor observed Resident #17 in his/her room receiving enteral feeding (nutrition delivered through a feeding tube) via electronic pump. Review of Resident #17's active physician's order indicated the following orders: -NPO (nothing by mouth) initiated 7/19/24. -Enteral feed order in the evening down at 10 am Enteral: Jevity 1.5 Cal liquid (a nutritionally fortified formula) via feeding tube every shift, feeding pump set at 95 ml/hour for 16 hours, total volume 1520 ml initiated 7/19/24. -Free water flushes of 150 ml every four hours initiated 7/19/24. Review of Resident #17's active physician's orders indicated the following order: -Weights weekly every Thursday, initiated 7/18/24. Review of Resident #17's plan of care related to nutrition, dated 7/18/24, indicated the Resident required enteral tube feeding related to malnutrition and dysphagia with the following interventions: -Weights at ordered intervals. -Obtain and monitor lab/diagnostic work as ordered. -Dietitian to evaluate nutritional status and make recommendations as applicable PRN (as needed). Review of Resident #17's August and September 2024 Medication Administration Record (MAR) indicated weekly weights one time a day every Thursday with the following recorded: 8/2/24- left blank. 8/8/24- left blank. 8/15/24- refused. There was no further documentation that Resident #17 refused to be weighed. 8/22/24- left blank. 8/29/24- left blank. 9/5/24- left blank. Review of Resident #17's nursing progress notes, dated 8/2, 8/8, 8/22, 8/29 and 9/5 failed to indicate Resident #17 had refused to be weighed or that the physician had been notified that the Resident had not been weighed. Review of Resident #17's nursing progress note, dated August 15, 2024, indicated patient was off floor and outside with family, unable to obtain weight, physician aware. Review of Resident #17's weight summary, indicated recorded weights: 7/18/24- 106.4 pounds. 8/19/24- 107.0 pounds. 9/12/24- 105.8 pounds. Review of Resident #17's nutritional risk assessment, dated 7/25/24, indicated the Resident's estimated ideal body weight (IBW) was 130 pounds and that the most recent recorded weight dated 7/18/24 was 106.4 pounds. Further review of the nutritional risk assessment indicated that the dietitian had recommended to continue with the current nutritional regimen and to monitor weights weekly. Review of Resident #17's nutrition note, dated 9/10/24, indicated that the Resident continued weekly weight checks, dietitian will continue to monitor and reassess as needed. During an interview on 9/11/24 at 12:25 P.M., Unit Manager #2 said all residents were discussed during weekly rounds with the clinical team and that the physician reviews all residents. Unit Manager #2 was not aware that Resident #17 did not have a weight recorded since 8/19/24. During an interview on 9/12/24 at 1:22 P.M., the dietitian said the clinical team meet weekly to discuss weights. Her expectation is for the physician order to be followed. The dietitian said up to date weights are needed to calculate appropriate caloric needs and enteral orders. During an interview on 9/12/24 at 12:33 P.M., Nurse Practitioner #1 said she would expect a resident receiving enteral nutrition to be weighed at least weekly and that it was important for weights to be obtained correctly so that orders for jevity can be determined. During an interview on 9/12/24 at 1:04 P.M., the Director of Nursing (DON) said he would expect physician orders to be followed. The DON said if a weight was not obtained that a note should have been written and it was not.

Based on record review and interview, the facility failed to: 1. ensure medication administration was accurately documented for two Residents (#33 and #35) and 2. failed to accurately document blood pressure readings for one Resident (#37) out of a total of 21 sampled Residents. Findings include: 1a. Resident #33 was readmitted to the facility in September 2024 with diagnoses including chronic obstructive pulmonary disease, dysphagia and venous insufficiency. Review of the Minimum Data Set Assessment (MDS) 8/26/24 indicated Resident #33 scored 15 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #33 requires assistance with bathing, dressing and toileting. Review of the September 2024 Medication Administrative Record (MAR) indicated the following medication were not documented as administered on the 7:00 A.M. - 3:00 P.M. shift on 9/8/24: Aripiprazole (an antipsychotic medication) Oral Tablet 5 MG: Give one tablet by mouth one time a day, 9/4/24. Aspirin Oral Tablet Chewable 81 MG: Give one tablet by mouth one time daily, 8/14/24 Fenofibrate Micronized (a medication used to lower cholesterol) Oral Capsule 200 MG: Give one tablet by mouth in one time a day, 9/4/24 Fexofenadine HCL (an antihistamine) 180 MG Tablet: Give one tablet by mouth daily, 8/14/24 Furosemide (a diuretic) Oral Tablet 20 MG: Give two tablets by mouth one time a day, 9/4/24 Duloxetine (an antidepressant) HCL Oral Capsule Delayed Release 60 MG: Give one capsule by mouth two times a day, 9/4/24 Fluticasone-Salmeterol Inhalation (an inhaler) 500-50 MCG/ACT: One puff inhale orally every morning and at bedtime, 9/3/24 Levetiracetam (an anticonvulsant) Oral Tablet 250 MG: Give two tablet by mouth, 9/4/24 Gabapentin (a pain medication) Oral Capsule 100 MG: Give two tablets by mouth three times a day related to pain. Humalog Kwikpen (insulin) Subcutaneous Solution 100 UNIT/ML: inject per sliding scale with meals, 9/4/24 Metformin (a medication used to treat diabetes) HCL Oral Tablet 500 MG: Give one tablet by mouth with meals, 9/4/24 1b. Resident #35 was admitted to the facility in October 2021 with diagnoses including, dementia, cerebral infarction, and diabetes. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #35 scored three out of a possible 15 indicating severe cognitively impairment. The MDS also indicated Resident #35 is dependent on staff for activities of daily living. Review of the September 2024 Medication Administrative Record (MAR) indicated the following medication were not documented as administered on the 7:00 A.M. - 3:00 P.M. shift on 9/8/24: Amlodipine Besylate tablet 10 MG (a medication used to treat hypertension): give one tablet via G-tube, 12/14/22 Aspirin Tablet Chewable: Give 81 mg via G-tube one time a day, 6/14/24 Clopidogrel Bisulfate (a medication used to lower risk of a stroke) tablet 75 MG: give one tablet via G-tube one time a day, 12/14/22 Escitalopram Oxalate Tablet (an antidepressant): Give 20 mg via G-tube one time a day, 8/28/24 Ezetimibe (a medication used to lower cholesterol) 10 MG tablet: Give one tablet via G-tube one time a day; 12/14/22 Pantoprazole Sodium Packet (a medication used to treat acid reflux) 40 MG: Give one packet via G-tube one time a day, 12/14/22 Polyethylene Glycol 3350 Kit (a medication used to treat constipation): Give 17 gram via G-tube one time a day; 12/14/22 Venlafaxine (an antidepressant) HCL Oral Tablet 75 MG Give .5 tablet via G-tube one time a day Carvedilol (a medication used to treat hypertension) Tablet 25 MG: Give one tablet via G-tube every morning and at bedtime; 12/14/22 Ferrous Sulfate (used to treat low iron): Give 325 MG via G-tube two times a day; 10/10/22 Sennosides (a laxative) Tablet 8.6 MG: Give 2 tablets via G-tube two times a day; 12/14/22 Humalog Injection Solution (insulin) 100 unit/ml: Inject six unit subcutaneously with meals, 8/13/24 Novolog Flexpen Subcutaneous Solution (insulin) 100 unit/ml: Inject per sliding scale subcutaneously before meals, 7/18/23 During an interview on 9/11/24 at 1:33 P.M., the Director of Nursing said that blank spaces on the MAR could be the result of the nurse forgetting to document the administration of the medication. 45343 2. Resident #37 was admitted to the facility in September 2023 with a diagnosis of end stage renal disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/14/24, indicated that Resident #37 scored a 12 out of 15 on the Brief Interview for Mental Status exam indicating Resident #37 had moderate cognitive impairment. The MDS further indicated Resident #37 received dialysis treatment. Review of Resident #37's active physician's orders indicated the following: - No blood draws, IV, BPs (blood pressure) on left arm (shunt/dialysis access arm), every shift related to end stage renal disease. Date initiated 9/11/23. Review of Resident #37's blood pressure readings indicated nursing obtained his/her blood pressure using his/her left arm on the following dates: 7/5/24, 7/12/24, 7/13/24, 8/10/24, 8/11/24, 8/16/24, 8/17/24, 8/18/24, 8/19/24, 8/20/24, 8/22/24, 8/26/24, 9/3/24, 9/5/24, 9/6/24, 9/7/24, and 9/8/24. During an interview on 9/11/24 at 9:25 A.M., Resident #37 said staff never take blood pressure readings from his/her left arm, and that staff only use his/her right arm for blood pressure readings. During an interview on 9/12/24 at 8:40 A.M., Nurse #2 said Resident #37's left arm should not be used to take his/her blood pressure and it should be documented correctly in the medical record. Nurse #2 said it must have been documented in the left arm in error. During an interview on 9/12/24 at 10:07 A.M., The Director of Nursing (DON) said his expectation was that nurses accurately document which arm the blood pressure was taken from, and that documentation should reflect exactly what was completed by nursing.

Based on observation, record review and interview, the facility failed to 1. ensure staff initiated and followed Enhanced Barrier Precautions for one Resident (#33) out of a total of 21 sampled residents, and 2. failed to ensure shared medical equipment was properly cleaned between the use of residents during the medication pass. Findings include: Review of the Enhanced Barrier Precautions policy, dated August 2022 indicated: 1. Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not apply otherwise. Gloves and gown are applied prior to performing high contact resident care activity (as opposed to entering the room). 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP's include: dressing, transferring, device care or use (central line, urinary catheter, feeding tube, etc); wound care. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 10. Signs are posted including the type of precautions and PPE (personal protective equipment) required. 11. PPE is readily available. 1. Resident #33 was initially admitted to the facility in August 2024 with diagnoses including chronic obstructive pulmonary disease, dysphagia and venous insufficiency. Review of the Minimum Data Set Assessment (MDS) 8/26/24 indicated Resident #33 scored 15 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #33 requires assistance toileting and did not have an indwelling catheter. During routine observations on 9/10/24 and 9/11/24, the surveyor observed signs on various doors on the 2nd floor unit indicating the residents in the room were on EBP. There was no sign on Resident #33's door. On 9/11/24 at 12:59 P.M., the surveyors observed Resident #33 resting in bed with a catheter bag hanging off the side of the bed. The surveyors observed Nurse #1 prepare and complete dressing changes on Resident #33's arms without donning a gown. Review of Resident #33's clinical record failed to indicate physicians orders or care plans were initiated for EBP. During an interview on 9/12/24 at 7:49 A.M., Nurse #2 said that Resident #33 had a catheter and should be on EBP. Nurse #2 said residents on EBP have signs posted on their doors to alert staff. Nurse #2 then joined the surveyor and observed there was no signage or cart of PPE outside of Resident #33's room. On 9/12/24 at 7:55 A.M. the surveyor observed Certified Nursing Aide (CNA) #1 and CNA #2 reposition Resident #33 in bed without wearing gowns. During an interview on 9/12/24 at 8:05 A.M., CNA #3 said that Resident #33 has had a catheter since he/she was admitted to the unit (on 9/3/24). During an interview on 9/12/24 at 9:51 A.M., the Director of Nursing (DON) said that residents with catheters should be on EBP. 46339 2. The facility failed to sanitize shared medical equipment after entering a precaution room. Review of facility policy titled 'Cleaning and disinfecting of Resident-Care Items and Equipment' revised September 2022 indicated the following but not limited to: -Reusable items are cleaned and disinfected or sterilized between residents. During a medication observation pass on 9/11/24 at 9:56 A.M., the surveyor observed Nurse #4 remove a blood pressure cuff from the medication cart and brought it into Resident #64's room. The signage on the doorway indicated that the Resident was on enhanced barrier precaution indicating he/she could have the potential for infections. Nurse #4 was then observed bringing back the blood pressure cuff and placed it back in the medication cart without disinfecting it. On 9/11/24 at 9:59 A.M., the surveyor observed Nurse #4 bring into Resident #64's room a blood pressure tower, Nurse #4 proceeded to check the Resident's blood pressure, she then brought the blood pressure tower machine and left it in the hallway without disinfecting it. During an interview on 9/11/24 at 12:43 P.M., Nurse #4 said she should have sanitized the blood pressure equipment after using them in the enhanced barrier precaution room. During an interview on 9/12/24 at 9:44 A.M., the Director of Nursing said shared medical equipment should be sanitized after each use.

Based on observation record review and interview, the facility failed to provide necessary treatment and care for one Resident (#33) out of a total of 21 sampled residents. Specifically, the facility failed to ensure treatment orders were initiated for Resident #33's skin tears. Findings include: Review of the Wound Treatment policy, dated April 2024, indicated: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure. Resident #33 was readmitted to the facility in September 2024 with diagnoses including chronic obstructive pulmonary disease, dysphagia and venous insufficiency. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #33 scored 15 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #33 requires assistance with bathing and dressing. During an interview on 9/10/24 at 8:57 A.M., the surveyor observed Resident #33 in bed. Resident #33's right arm was resting on his/her lap and had a dressing dated 9/7/24 on the forearm. Resident #33 said he/she could not recall what happened to his/her arm or why he/she had a dressing. The surveyor was unable to observe Resident #33's left arm. Review of the physicians orders on 9/10/24 at 11:30 A.M., failed to indicate any active treatment orders were in place for Resident #33. Review of Resident #33's care plans failed to indicate he/she had any wounds requiring treatment. Review of the Weekly Skin Check dated 9/3/24 indicated Resident #93 had open areas on both his/her arms. The skin check did not indicate measurements or descriptions of the wounds Review of the hospital discharge paperwork dated 9/3/24 indicated Resident #33 had skin tears on his/her right and left forearm requiring dressings. Review of the hospice note dated 9/4/24 indicated the following: Some bruising noted to upper extremities, bandages to both arms perhaps from IV placements. Pt (patient) declines further assessment of the skin. Review of the Nurse Practitioner Note dated 9/5/24: Skin: No rash, warm and dry; left forearm dressing clean dry and intact. On 9/11/24 at 7:31 A.M., the surveyor observed Resident #33 asleep in bed with a bandage on his/her right arm dated 9/10/24. The surveyor was unable to observe Resident #33's left arm. During an interview on 9/11/24 at 7:43 A.M., Unit Manager #1 said that Resident #33 was admitted with wounds from the hospital that needed daily dressings. Unit Manager #1 said orders for treatment were not in place until yesterday, (9/10/24). Review of Resident #33's physicians orders on 9/11/24 at 7:44 A.M., indicated: -Wound Description for Site: RIGHT ARM: Normal Saline Wash, Pat dry and apply Xeroform followed by an Island dressing. Ordered 9/10/24 -Wound Description for Site: LEFT ARM; Normal Saline Wash, Pat dry and apply Xeroform followed by an Island dressing. Ordered 9/10/24 Further review of Resident #33's physicians orders indicated that the treatments for the Resident's wounds were implemented seven days after they were first identified by the facility. On 9/11/24 at 12:59 P.M. the surveyors observed Resident #33's dressing changes. Nurse #1 removed the dressings and the surveyors observed Resident #33 had skin tears on his/her bilateral forearms with some drainage and swelling. During an interview on 9/11/24 at 1:33 P.M., the Director of Nursing said that when residents are admitted from the hospital with wounds it is expected that orders to treat the wounds would implemented.

Based on observation, record review and interview, the facility failed to ensure physicians orders and care plans related to the use of a catheter were implemented for one Resident (#33) out of a total of 21 sampled residents. Findings include: Review of the Urinary Incontinence - Clinical Protocol policy dated April 2018 indicated: Assessment and Recognition: As part of the initial assessment, the physician will help identify individuals with impaired urinary continence. For example, review of a hospital discharge summary may reveal that the individual was incontinent with or without catheter placement during a recent hospitalization . Resident #33 was initially admitted to the facility in August 2024 with diagnoses including chronic obstructive pulmonary disease, dysphagia and venous insufficiency. Review of the Minimum Data Set Assessment (MDS) 8/26/24 indicated Resident #33 scored 15 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #33 requires assistance toileting and did not have an indwelling catheter. Review of Resident #33's physicians orders failed to indicate any orders in place regarding the use or care of a catheter. Review of Resident #33's care plans indicated: Focus: I have urinary incontinence r/t (related to) physical limitations. 8/13/24 Interventions: Provide incontinence care and apply moisture barrier as needed. Observe buttocks, peri-area and groin during care for possible skin problems. Offer/encourage toileting prior to bedtime. Check resident approximately every two hours and provide incontinence care as needed. Focus: I have an ADL (activities of daily living) self care performance deficit r/t deconditioned s/p hospitalization , impaired mobility, weakness. Interventions: Toileting: I require one staff assist with toileting. On 9/11/24 at 12:59 P.M., the surveyors observed Resident #33 resting in bed with a catheter bag hanging off the side of the bed. On 9/12/24 at approximately 7:45 A.M., the surveyor observed Resident #33 in bed with a catheter bag hanging off the side of the bed. During an interview on 9/12/24 at 7:49 A.M., Nurse #2 said that Resident #33 had a catheter. During an interview on 9/12/24 at 8:00 A.M., Unit Manager #1 said that Resident #33 had previously resided on a different unit then was hospitalized . Unit Manager #1 said that he believed the catheter was implemented during Resident #33's hospitalization . During an interview on 9/12/24 at 8:05 A.M., Certified Nursing Aide (CNA) #3 said that Resident #33 has had a catheter since he/she was admitted to the unit (9/3/24). During an interview on 9/12/24 at 9:51 A.M., the Director of Nursing (DON) said that residents should have physicians orders and care plans in place for catheter care, management and monitoring. During an interview on 9/12/24 at 12:20 P.M., the Nurse Practitioner said that nurses have to put in orders for catheters and she was not aware that Resident #33 had no orders related to his/her catheter use or care.

Based on observation, record review and interview, the facility failed to implement the plan of care related to assistance with meals for one Resident, (#36), out of a total sample of 21 residents. Findings include: Review of the facility's Care Plans, Comprehensive Person Centered policy, dated March 2022 indicated: Policy statement: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. Resident #36 was admitted to the facility in June of 2022 with diagnoses including dementia and weakness. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #36 scored 5 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating severe cognitive impairment. The MDS also indicated Resident #36 required supervision/touching assistance with eating. On 9/10/24 at 7:58 A.M., the surveyor observed Resident #36 eating breakfast alone in his/her room. The Resident was served a waffle that was not cut and he/she was attempting to open a container of maple syrup with his/her hands. At 8:21 A.M., Resident #36 was eating with his/her hands and also still attempting to open the container of maple syrup. There were no staff in the area providing supervision and Resident #36 was not observable from the hallway. Review of Resident #33's care plans indicated: Focus: I have an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) Dementia, Impaired Mobility, Pain, Date Initiated: 06/30/2024 Interventions: Eating: I require set-up assistance [i.e., opening packages, cutting meat, arranging plate, etc] supervision with eating and drinking. Offer bedtime snack. On 9/11/24 at 7:59 A.M. and 8:10 A.M., the surveyor observed Resident #36 in bed, eating alone in his/her room. There were no staff providing supervision as indicated in his/her plan of care and Resident #36 was not observable from the hallway. During an interview on 9/11/24 11:44 A.M., Certified Nursing Aide (CNA) #1 said she was assigned to care for Resident #36. CNA #1 said that Resident #36 often eats in his/her room as he/she refuses to get out of bed. CNA #1 said that Resident #36 was independent with eating after his/her tray is set up. CNA #1 said that Resident #36 did not need to be supervised or physically assisted during meals. On 9/12/24 at 8:10 A.M., the surveyor observed Resident #12 eating his/her breakfast meal alone without staff supervision per the plan of care. Resident #36 was not observable from the hallway. Review of the CNA documentation from 8/1/24 through 9/10/24 indicated that Resident #36 received supervision or physical assistance with 41 out of 121 documented meals. During an interview on 9/12/24 at 9:51 A.M., the Director of Nursing (DON) said that care plans should be followed.

Based on observations, policy review, and interview the facility failed to ensure medications with short expirations dates were dated when opened. Findings include: Review of the facility policy titled 'Medication Labeling and Storage' revised February 2023, indicated the following but not limited to: *Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. *Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date. 1. During an inspection of the [NAME] unit on 9/12/24 at 6:35 A.M., the following medications were available for administration: - Two incruse Ellipta inhalers 62.5 (mcg) microgram inhalation powder opened and undated. - One Advair 100/50 mcg opened and undated. - One Advair 250/50 mcg opened and undated. - One albuterol sulfate 90 mcg opened and undated. - One Symbicort inhaler 80-4.5mcg opened and undated. - One fluticasone nasal spray 50 mcg opened and undated. During an interview on 9/12/24 at 6:45 A.M., Nurse #5 said the inhalers should be dated when opened and indicate a date to discard. During an interview on 9/12/24 at 9:47 A.M., the Director of Nursing said the inhalers are to be dated with an open date and an expiration date.

Based on observation, record review and interviews, the facility failed to ensure that one Resident (#64) was free from significant medication errors out of a total sample of 21 residents. Specifically, the nurses did not administer the wrong dispensed dosage of Trazadone (an antidepressant). Findings include: Review of the facility policy titled 'Administering Medications' revised April 2019, indicated the following but not limited to: -If a dosage is believed to be inappropriate or excessive for a resident or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences the person preparing or administering the medication will contact the prescriber the residents attending physician or the facilities medical director to discuss the concerns. -The individual administering the medication checks the label three times to verify the right resident right medication right dosage right time right method route of administration before giving the medication. Resident #64 was admitted to the facility in July 2024 with diagnoses including dementia and psychotic disorder. Review of Resident #64's Minimum Data Set (MDS) dated [DATE], indicated the Resident had impaired short term and long term memory on the Brief Interview for Mental Status (BIMS). During a medication observation pass on 9/11/24 at 9:41 A.M., Nurse #4 said to the surveyor the medication card containing Trazadone (an antidepressant) 50 milligram tablet half tablets was not the correct dosage per the physician orders. Nurse #4 said she was going to call the pharmacy for clarification and did not administer the half tablets. Review of the medication blister pack, the following was observed two missing pills out of 30 tablets that had been dispensed by the pharmacy. The label read as following: -Trazadone HCl tab 50 milligrams. Give one quarter tablet (12.5mg) by mouth two times a day for anxiety. Review of the medical record failed to indicate that the physician had been notified of the wrong medication that had been dispensed to the facility. Review of Resident #64's current Medication Administration Record (MAR) indicated the medication trazadone had been administered the last two days. During an interview on 9/11/24 at 9:45 A.M., Nurse #4 said the two missing medications from the blister pack would be an indication that the medication had been administered. During an interview on 9/12/24 at 9:44 A.M., the Director of Nursing (DON) said the pharmacy had acknowledged the medication that had been dispensed to the facility was the wrong dosage. The DON said that the nurses should use their judgment during medication pass to prevent administering wrong dosages.

Based on record review, policy review and interview the facility failed to ensure a plan of care was developed for Trauma Informed Care, with individualized interventions, for one Resident (#7) who had a history of trauma out of a total sample of 21 residents. Specifically, for Resident #7, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. Findings include: Review of the facility policy titled Trauma Informed and Culturally Competent Care, dated 8/2022, indicated the following: Purpose: -To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. -To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Definitions: - Trigger is a psychological stimulus and prompts recall of a previous traumatic event, even if the stimuli itself is not traumatic or frightening. Resident Care Planning: -Develop and individualized care plan that addresses past trauma in collaboration with the resident and family, as appropriate. -Identify and decrease exposure to triggers that may re-traumatize the resident. -Recognize the relationship between past trauma and current health concerns (e.g. substance abuse, eating disorders, anxiety, and depression). Resident #7 was admitted to the facility in March 2019, with diagnoses including traumatic Post-Traumatic Stress Disorder (PTSD), major depressive disorder and anxiety. Review of Resident #7's most recent Minimum Data Set (MDS) assessment, dated 6/19/24, indicated that Resident #7 had a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15 indicating he/she is cognitively intact. Further review of the MDS indicated Resident #7 has an active diagnosis of PTSD and requires partial/moderate to dependent assistance for daily activities. Review of the care plan on 9/11/24 at 2:02 P.M., last revised 3/31/20, indicated Resident #7 has a diagnosis of PTSD. Further review indicated interventions including the following: -Accept my current level of function, be consistent, positive, honest and nonjudgmental while working with me. -After every outburst, discuss with me how my anger escalates. -Allow me to use displacement when angry by providing things that I can manipulate or destroy (example: clay). -Encourage me to accept forgiveness from myself and others. -Encourage me to express my anger verbally rather than physically. -Help me to regain control and identify sources of emotions so that I may manage outbursts. -Offer me medications for prevention or treatment of post-traumatic stress disorder as needed; Evaluate responses to these medications. -Provide me a safe comfortable space when I am overwhelmed or stressed. -Remind me that setbacks on the process of treatment are not failures but an expected part of therapy. -When Stress/Anxiety arises allow me to vent/share feelings. Review of Resident #7's care plan failed to indicate the development of a comprehensive trauma informed care plan with identified triggers and interventions for his/her diagnosis of PTSD. During an interview on 9/12/24 at 8:45 A.M., Unit Manager #1 said if a resident is identified with a PTSD diagnosis, there should be a care plan developed with specific triggers for staff to better care for the resident. During an interview on 9/12/24 at 9:34 A.M., Social Worker #1 said residents with PTSD should be formally assessed and a care plan developed with his/her strengths and weaknesses as well as identified triggers. During an interview on 9/12/24 at 9:55 A.M., the Director of Nursing said if PTSD is identified following a trauma informed assessment, a patient centered care plan will be developed with triggers identified.

Based on observation, interview and record review the facility failed to provide appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. The facility failed to initiate an order for [REDACTED]. Findings include: Resident #43 was admitted to the facility in 11/2015 with a history of [MEDICAL CONDITIONS], anxiety, and major [MEDICAL CONDITION]. Review of Resident #43's care plans initiated on 11/2015 indicated a focus of: a potential for alteration in mood state related to a [DIAGNOSES REDACTED]. Resident has been hospitalized since 4/2014 and prior, was living in a group home due to his [MEDICAL CONDITION]. Resident has psych history since [DIAGNOSES REDACTED]. Intervention initiated 11/2015 indicated Resident #43 should receive behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.) Review of the Nurse Practitioner notes of 8/24/17 indicated that Resident #43 was seen for [MEDICAL CONDITION] and [MEDICAL CONDITION]. The assessment and plan indicated that she observed subtle, but gradually worsening [MEDICAL CONDITION]. Patient has been exhibiting impulsiveness, unrealistic mobility expectations (such as requesting to be allowed to leave the facility to do mountain climbing), verbal inappropriateness/outbursts, delusions, and manic episodes. Retrospectively, subtle psychological/behavior changes were observed in the last few weeks. She wrote an order for [REDACTED].>Review of the medical record indicated that there was a physician order [REDACTED]. Review of the psychiatric communication book indicated that there was a note dated 8/24/17 to see Resident #43 for a psychiatric consult: [MEDICAL CONDITIONS], impulsiveness, verbal inappropriateness and outbursts. Review of the nurses notes indicated that on 8/25/17 Resident #43 continues to show change in mentation, he/she was verbally inappropriate with staff and suspicious of medications, refused 0600 medications and continues to be difficult for any nursing interventions. Nurse Practitioner is aware and placed a new order for a psychiatric consult. There were no nurse's notes from 8/1/17 to 8/24/17 to indicate what the above mentioned changes in mentation consisted of. The medical record failed to contain evidence that a psychiatric consult was performed. Review of the nurses notes indicated the following changes in mood state: 8/28/17 Resident continues to question medication and would not accept them without questioning everything first. Patient requesting another batch to be made and then said forget it I don't want them. 8/30/17 Resident pulled out his/her gastrostomy tube (for feeding). 8/31/17 Resident refused to have the feeding connected. 9/7/17 Resident refused afternoon medications. Patient was naked in wheelchair yelling/swearing at staff. 9/14/17 [DEVICE] feed was started at 8:30 P.M. and patient accepted but at 9:30 P.M., pressed his/her call light to have it stopped. Resident was reinformed the importance of keeping it running in that it is his only source of nutrition. He/she continued to refuse keeping it running and insisted that it be shut off. 9/17/17 At 5:00 A.M., resident disconnected his/her tubefeed and called nurse to have pump turned off. 9/29/17 Increased confusion noted and has been escalating each day yelling on phone today about his/her parents and writing emails to his/her sister very angry email has remained unclothed this shift with no indication of any intention to dress. 11/7/17 Resident's sister is concerned about his/her mental status. She reported today to this writer that he/she reported to her that he/she is hearing voices. Resident was screaming at his/her sister on the phone today. This writer later witnessed this resident having a full dialog conversation with what seemed like voices. The medical record failed to include any psychiatric services from the date the psychiatric consult was ordered 8/24/17 until 11/7/17 when the patients sister voiced concern with his/her mental status. The Resident was seen by psychiatric services on 11/7/17 with no medication changes recommended and to document any hallucination or delusion and notify psychiatric services as they occur. 11/8/17 Patient began yelling and hallucinating. Patient said Is he going to escort me out of here? when the patient was alone in the room with the nurse and experienced auditory hallucinations. Patient reassured he/she was safe and instructed to call this writer if hallucination continued. 11/9/17 Resident displayed with auditory hallucinations with escalation at times. 11/16/17 Audible hallucination seen angered at times during the day demanding extra flushes stated at separate times today reason given, found naked with privacy curtain pulled all around, music on, denies pain but was overheard yelling at someone that the staff was unable to see. 11/20/17 Resident placed on 15 minute checks due to suicidal ideation. There was no evidence in the medical record that the facility had notified psychiatric services of the hallucinations and/or delusions Resident #43 had between 11/7/17 and 11/20/17 until Resident #43 was placed on 15 minute checks for suicidal ideation. 11/21/17 Seen by psychiatric social worker due to increased delusions. Painted a picture of a person he/she identified as him/herself hanging on a tree. Resident has a bag packed next to his/her bed in case he/she needs to leave the facility. Reports his/her sister is in the building watching him and talking to him. She is not present during these times. Showed the writer a list of things to paint such as being suffocated, having to be a spy, being in the battery war for [AGE] years and having to kill people to protect others. He/she reported that he/she felt he/she needed help and agreed to meet with the mental health counselor. There were no nurses notes from 11/22/17 to 11/30/17. A psychiatric services progress note indicated the Resident was seen for psychiatric therapy services on 11/29/17 to decrease symptoms, achieve and maintain stability and improve daily living. Will continue to meet for 1:1 therapy to work on minimizing symptoms of [MEDICAL CONDITION], improving coping skills and maximizing quality of life within the facility During an interview with Nurse #5 on 11/30/17 at 10:00 A.M., she said that Resident #43 has behaviors and hallucinations, mostly at night that he/she is falling off a cliff. She said that with Resident #43's history she would have expected weekly visits from psych services. Nurse #5 was only able to find evidence that services were provided in 5/2016 and then not again until 11/7/17. She was not able to find evidence that a psychiatric consult had been obtained despite the physician ordering one on 8/24/17. During an interview with Social Worker (SW #1) on 11/30/17, at 10:28 A.M. she said that due to Resident #43's psychiatric history that the facility psychiatric services should be very much involved. SW #1 was not able to find any evidence that the psychiatric consult that had been ordered 8/24/17had been completed. There is no evidence in the clinical record to indicate that psychiatric services had assisted in developing a behavior plan and no evidence that interventions to assist staff in managing this residents behaviors had been discussed with facility staff.

Based on record review and interviews, for one of five sampled residents (Resident #1), the Facility failed to ensure that Resident #1, whose plan of care did not include the use of a restraint, was not placed in an area where he/she was not able to move freely in his/her wheelchair, which resulted in Resident #1 being restrained. On 9/26/14, between 12:00 P.M. and 1:00 P.M., Resident #1 sat in the back corner of the dayroom in his/her wheelchair with a table in front of him/her, an armchair blocking him/her on one side, and additional chairs near Resident #1, which did not allow Resident #1 to leave the area if he/she chose. - CNA #1 and CNA #2 said on a few occasions, they positioned furniture in front of and at both sides of Resident #1, who was seated in a wheelchair, to prevent Resident #1 from leaving the dayroom. Findings include: The Admission record indicated the staff admitted Resident #1 to the Facility in June 2014 and his/her [DIAGNOSES REDACTED]. The plan of care related to Resident #1's behaviors, dated 7/1/14, included for Resident #1 to sit at table located away from other residents related to his/her hitting residents, offer hands-on activities, and for staff to use a chair alarm. Resident #1's plan of care did not include the use of a restraint. The Admission Minimum Data Set (MDS) assessment, completed on 7/7/14, indicated Resident #1 had cognitive impairment and required the assistance from two staff for ambulating and one staff for locomotion on the unit. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 11:15 P.M., on 10/28/14. The Surveyor interviewed CNA #2 at 11:35 A.M., on 10/28/14. CNA #1 and CNA #2 said sometimes Resident #1 continuously stood from the wheelchair or moved his/her wheelchair in the day room, which was not safe. CNA #1 and CNA #2 said Resident #1 hit other residents when moving in the wheelchair independently or bumped into the wall. CNA #1 and CNA #2 said on a few occasions, when there was no activity in the dayroom and a lot of residents in the day room, they moved Resident #1 close to a table and moved furniture (arm chairs) close to Resident #1's wheelchair to prevent Resident #1 from leaving the dayroom. CNA #1 and CNA #2 said although Resident #1 was strong and could move the table to leave, leaving the dayroom would be difficult for Resident #1 when staff placed the chairs near him/her. The Surveyor interviewed Nurse #1 at 11:00 A.M., on 10/28/14. The Surveyor interviewed Nurse #3 at 3:05 P.M., on 10/28/14. The Surveyor interviewed Nurse #4 at 3:30 P.M., on 10/28/14. The Surveyor interviewed Nurse #5 at 5:30 A.M., on 10/30/14. The Surveyor interviewed CNA #4 at 2:10 P.M., on 10/28/14. The Surveyor interviewed CNA #9 at 3:45 P.M., on 10/28/14. The Surveyor interviewed the Activity Director at 1:00 P.M., on 10/28/14. The Surveyor interviewed Activity Aide #1 at 1:45 P.M., on 10/28/14. Nurse #1, Nurse #3, Nurse #4, Nurse #5, CNA #4, CNA #9, the Activity Director, and Activity Aide #1 said they never saw Resident #1 confined in the dayroom with tables/chairs and they never confined Resident #1. CNA #1 and CNA #2 said on 9/26/14, after Resident #1's lunch, he/she kept standing from the wheelchair and tried to leave the dayroom. CNA #1 said CNA #2 was scheduled to go to lunch, which left her and the nurse on the unit. CNA #1 and CNA #2 said they moved the chairs around Resident #1 to keep him/her seated, prevent him/her from leaving the dayroom in the wheelchair, and keep him/her safe. CNA #1 said she remained in the dayroom. CNA #1 said an activity was scheduled at 2:00 P.M. CNA #1 said shortly after, CNA #2 returned to the unit, the Ombudsman came to the dayroom and told them they were not allowed to restrain Resident #1. The Surveyor interviewed the Ombudsman at 11:00 A.M., on 10/27/14. The Ombudsman said on 9/26/14, between 12:00 P.M. and 1:00 P.M., Resident #1 sat in the back corner of the dayroom in his/her wheelchair with a table in front of him/her, an armchair blocking him/her on one side, and additional chairs near Resident #1, which did not allow Resident #1 to leave the area if he/she chose. The Ombudsman said Resident #1 stood several times and was not able to ambulate due to the furniture around him/her, and sat back down in the wheelchair. The Ombudsman said two CNAs were serving meals and assisting other residents in the dining room. The Ombudsman said one of the CNAs told her Resident #1 would leave the area if not confined. The Ombudsman said she told the CNAs they had restrained Resident #1, by preventing him/her from leaving the dayroom. The Ombudsman said one of the CNAs immediately removed the chairs around Resident #1's wheelchair. The Ombudsman said the Activity Director was also in the dayroom and reported the incident to the Director of Nurses (DON). The Ombudsman said the DON said the staff were not following Resident #1's plan of care. Nurse #3, who was assigned to Resident #1 during the day shift on 9/26/14, said he was not aware Resident #1 was restrained in the dayroom. The Activity Director and Activity Aide #1 said on 9/26/14, they were not in the dayroom, when Resident #1 ate meals. The Restraint Policy, dated 4/28/09, indicated that any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of moment or normal access to one's body was a physical restraint. The Policy indicated using devices in conjunction with a chair, such as trays and tables that a resident cannot remove easily and prevented the resident from rising was a physical restraint. The Policy indicated the staff were not to use restraints for staff convenience. The Surveyor interviewed the DON at 8:25 A.M., on 10/28/14. The DON said she immediately went to Resident #1's unit and spoke to the staff. The DON said she told CNA #1 and CNA #2 they restrained Resident #1, which was against the Facility Policy. The DON said she educated CNA #1 and CNA #2 regarding the Facility Restraint Policy. The DON said she interviewed staff on all three shifts regarding Resident #1's plan of care and seating in the dayroom and the other staff denied restraining Resident #1. Although Resident #1 had dementia and a [MEDICAL CONDITION], a reasonable person who was restrained in a manner which prevented his/her moving as desired and at will, would experience psychological harm or distress as a result.

Based on observation, record review and interview, the facility failed to provide the necessary care and services in order to control the pain of 1 Resident (#5) in a sample of 17 residents. Findings include: For Resident #5, the facility failed to administer pain medication 1/2 hour before physical therapy treatment which impacted the Resident's participation and progress. Resident #5 was admitted to the nursing facility in 3/2013, with [DIAGNOSES REDACTED]. The Admission Minimum Data Set, dated dated [DATE], documents the Resident as having moderate impairments in cognition with a score of 9 out of 15 on the Brief Interview of Mental Status (BIMS). The Resident has range of motion limitations of both upper and lower extremities on one side. Pain is documented as a 9 out of 10 (on a scale of 1 to 10 with 10 being excruciating pain) which limits the Resident's day to day activities and makes it hard to sleep. The Resident describes the pain as constant. The Resident was receiving physical therapy 5 times per week. A 3/15/13 physical therapy progress note documents that the Resident had decreased bilateral lower extremity range of motion due to pain. The note further documents that the Resident complained of left elbow pain with a pain rating of 10 out of 10 at times. On 3/15/13 a physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 3/29/13 the Resident was seen by Nurse Practitioner #1 for a palliative care consult. The Nurse Practitioner documented that the Resident had knee pain; chronic OA ([MEDICAL CONDITION]) which is the Residents primary pain compliant and reports it impacts his/her tolerance of therapy. The recommendation was to schedule [MEDICATION NAME] 2.5 milligrams 30 minutes prior to therapies to maximize patient tolerance and adequately test his/her abilities to restore function. A physician's orders [REDACTED]. A Physical Therapy Progress Report, dated 4/19/13 documents under a section for identifying impairments limiting progress and/or barriers to improvement as: - decreased lower extremity strength. - decreased weight bearing left upper extremity. - decreased lower extremity range of motion. - increased pain. - decreased motivation. On 4/26/13 the Resident was discharged from physical therapy. The discharge summary documents: patient is limited from further progress by pain, limitations in range of motion bilateral lower extremities. On 5/1/13 at 9:00 A.M. a medication pass observation was conducted with Medication Nurse #1. As he/she opened the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No scheduled time had been documented for the [MEDICATION NAME] 2.5 milligrams to be given 30 minutes before physical therapy. Medication Nurse #1 was observed to enter PRN under the time of administration area for this medication. When interviewed on 5/1/13 at 9:10 A.M., Medication Nurse #1 stated that the medication was a PRN as physical therapy happened at different times each day. Despite both the Surveyor and Medication Nurse #1 looking at the original order (which did not contain a PRN direction), Medication Nurse #1 re-stated that it was meant as a PRN. Review of the 3/2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. PRN had been crossed off and 7-3 written in. Although the Resident had received physical therapy on 3/30/13 at 12:00 P.M., no [MEDICATION NAME] had been given 30 minutes before as ordered. The 4/2013 medication administration was reviewed and the 2.5 milligrams of [MEDICATION NAME] had not been administered the entire month. In the section where the time of administration would be documented, someone had again written PRN. Resident #5 had received 15 doses of the PRN [MEDICATION NAME] 5 milligrams in 4/2013, however, the medication was administered between 8:00 A.M. and 9:00 A.M. with two doses given between 11:00 A.M. and 12:00 P.M. Review of the physical therapy progress notes for 4/2013 noted that therapy was provided to the Resident for 18 days, with 3 sessions between 3:00 P.M. and 4:00 P.M. and 13 sessions between 4:00 P.M. and 5:00 P.M. The remaining two had occurred at 11:00 A.M. and 12:00 P.M. Neither the PRN 5 milligram dose, nor the 2.5 milligram dose of [MEDICATION NAME] had been given 30 minutes before physical therapy sessions. On 5/1/13, an order was obtained to discontinue the order for [MEDICATION NAME] 2.5 milligrams 30 minutes before physical therapy secondary to physical therapy discontinued a of 4/26/13.

2. For Resident #13, the facility failed to provide adequate supervision to prevent accidents. Resident #13 was admitted to the facility in 7/2007. [DIAGNOSES REDACTED]. On 4/23/12, the Quarterly MDS of 1/25/12 was reviewed. The resident was identified as having been severely cognitively impaired, requiring total care in all activities of daily living except supervision for eating. The resident was always incontinent of bowel and bladder, with no recent falls, and utilized a physical restraint, identified as a chair that prevents rising. On 4/23/12, review of the medical record indicated a physician's orders [REDACTED]. The order was for the use of a lap tray on the wheelchair secondary to an unsteady gait and no safety awareness. Removal of the tray was to take place when the resident was in bed and during mealtime. On 4/23/12, review of a nurse's notes dated 2/6/12 indicated: "At 6:10 P.M. after supper, the lap tray was replaced and (the straps were) tied in a bow snuggly as per nursing assistant. The nursing assistant stated that she left all the residents in the common room to put a resident to bed. Writer (of this nurse's note) walked into the common room where she found Resident #13 on the floor surrounded by other residents. The resident sustained [REDACTED]. The resident was unable to explain what happened. It appeared that one of the other residents had untied the ropes making it easy for the lap tray to come off in an attempt to assist the resident out of the chair, unaware of the limitations of Resident #13. Resident #13 was assisted into the wheelchair by two staff and first aid was given to stop the bleeding from the wound...." On 4/23/12, the Resident Event Report Worksheet was reviewed and confirmed the above documentation. Statements were obtained from three staff members. These statements also confirmed the above. Further review of the Event Report indicated that no staff were in the dining room at the time of the accident, as the staff were in resident rooms attending to other residents, i.e. toileting after supper. During interview on 4/23/12 at 1:00 P.M., Nurse #1 said that at no time should these rooms be left unsupervised. The facility failed to provide supervision in the resident dining room where several confused residents were gathered. This resulted in Resident #13 being released from a restraint, sustaining an unwitnessed fall and head injury. Based on observations, staff interviews, and record review, the facility failed to ensure adequate supervision for the prevention of falls for 2 residents (#11 and #13) in a sample of 17 residents. Findings include: 1. For Resident #11, the facility failed to ensure adequate supervision in the community room to prevent a fall on 4/17/12 at 1:50 P.M. Resident #11 was admitted to the facility in 4/2012 for rehabilitation after a left [PROCEDURE] (removal of the breast due to cancer). The resident's other [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS), dated [DATE], indicated that Resident #11 had short term memory loss with moderate cognitive impairment. The MDS indicated that the resident required physical assistance of one person with transfers and limited assistance with ambulation. The plan of care for the prevention of falls, dated 4/11/12, indicated that Resident #11 required chair and bed pressure alarms at all times and extensive assistance by one person with transfers and ambulation. Review of the Physical Therapy Evaluation, dated 4/12/12, indicated that Resident #11 was at risk for falls due to confusion and poor safety awareness. The Evaluation further indicated that the resident was unaware of need for assistance to get out of bed and/or the chair. During an interview on 4/17/12 at 11:30 A.M., the Ombudsman said there was little or no supervision of residents in the common rooms on either the first or second floor. On 4/17/12 at 1:52 P.M., Resident #11 was observed sitting on the floor with Nurse #3 holding a bloody gauze pad on the resident's head. During an interview on 4/17/12 at 2:15 P.M., Nurse #3 said she heard a bang and saw Resident #11 sitting on the floor under the table, bleeding from a laceration on the back of his/her head. Nurse #3 said she assessed the resident, notified the physician, and transferred the resident to the hospital emergency room for an evaluation. Nurse #3 said she was unaware that the resident had returned from physical therapy at the time of the fall. Nurse #3 said the resident's wheelchair was folded next to the table and a pressure alarm was present on the wheelchair. Nurse #3 said she did not hear the resident's alarm sound prior to his/her fall. During an interview on 4/17/12 at 2:20 P.M., the Assistant Director of Nurses (ADON) said he was notified by Nurse #3 of Resident #11's fall. The ADON said at the time of Resident #11's fall, he was told that there was no nursing personnel in the common room. The ADON said residents in the common room were to be supervised at all times. The ADON said he was told by the Physical Therapy Aide (PTA) that after she was unable to find either a Certified Nurse Aide (CNA) or a nurse, she left the resident sitting in his/her wheelchair with the chair alarm in place at a table in the common area. During an interview on 4/17/12 at 2:45 P.M., the PTA said she did not tell either a CNA or a nurse that the resident had returned from physical therapy. The PTA said she left Resident #11 sitting on a wheelchair in the common room next to the nurses' station. The PTA said she was unsure if she had locked the brakes on the resident's wheelchair before leaving the resident. The PTA said there was no nursing personnel in the common room when she left the nursing unit. Review of the Event/Incident Report, dated 4/17/12, indicated that Resident #11 was left unsupervised in the common room, fell to the floor, sustained a laceration to the back of the head, and required 7 staples to close the wound at the hospital. The ADON and Nurse #3 said Resident #11 was left in the common room unsupervised.