Every finding on record at Complete Care at Glendale

Based on review of the clinical record, facility documentation/policies, and staff interviews, for one (1) of three (3) sampled residents (Resident #1) who required staff assistance for daily living skills, the facility failed to develop and implement a comprehensive care plan and physician orders to address the required use of a left arm sling following a humerus fracture. The findings included: Resident #1's diagnoses included fracture of the left humerus, chronic kidney disease, and type two diabetes. Review of the hospital discharge documents dated 11/21/25 identified Resident #1 was fitted for a left arm sling due to a humerus fracture. Review of physician's orders from 11/21/25 through 12/2/25 failed to identify an order for a left arm sling. The five (5) day Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13) and was dependent on staff for dressing and transfers in and out of the bed and chair. The Resident Care Plan (RCP) dated 11/27/25 identified Resident #1 had a self-care deficit and was at risk for falls. Interventions directed assistance of one (1) with dressing. The RCP failed to identify use of a sling and interventions for the left arm fracture. Review of the nurse aide care card failed to identify instructions for Resident #1 to wear a sling at all times to the left arm. Review of a complaint filed on 1/2/26 identified when the complainant visited Resident #1 on 12/3/25, Resident #1 did not have his/her left arm sling on. Interview with LPN #1 (the 7 AM to 3 PM charge nurse) on 2/3/26 at 1:29 PM identified she recalled Resident #1 had a sling that was to be worn all the time and that directions for sling use would have been either on the physician's order or the RCP. Interview with NA #1 (the 7AM to 3 PM nurse aide) on 2/3/26 at 1:47 PM identified she provided care for Resident #1 every time she worked. NA #1 identified Resident #1 wore the sling all the time except when he/she was being changed. NA #1 further identified she was aware of the directions for sling use because the therapist instructed her on the use of the sling and the directions were on the care card. NA #1 further identified that although Resident #1 did not actively take his/her sling off, it would come off sometimes with independent movement. Interview with the Certified Occupational Therapist Assistant (COTA) on 2/3/26 at 2:19 PM identified she was made aware of Resident #1's sling orders from the OT (Occupational Therapist) that did the initial evaluation. The COTA further identified the orders for the sling should have been on the physician's orders, RCP, and NA care card. Interview with the DON (Director of Nursing) on 2/3/26 at 2:30 PM identified directions for sling use should have either been on the physician's orders or on the RCP and that the facility failed to follow the Care Plan Policy. Review of the Facility Care Plan Policy identified in part the facility will develop and implement a care plan that includes instructions needed to provide effective and person-centered care of the residents that meets professional standards of quality care. The Policy further identified the care plan should contain any services and treatments to be administered by the facility staff. Although attempted, unable to reach the complainant.

Based on observations, facility documentation, facility policy, and interviews, the facility failed to ensure dry storage items were stored under sanitary conditions; and failed to ensure that the sanitizing solution was monitored for appropriate sanitizing levels; and failed to ensure food temperatures were monitored and logged for every meal; and failed to ensure that the nourishment refrigerator temperatures were checked and logged daily. The findings include:Observation on 1/11/26 at 8:24 AM during an initial tour of the kitchen with the Dietary Director in the dry food storage area identified a large, prepackaged bag that contained corn flake type cereal. The bag was not labeled or dated and there was a large tear in the bag (approximately 3 inches) with cereal open to the air. Additionally, a box of powered liquid thickener was observed fully opened at the top and had been placed in a plastic bag. The bag was open and nonsealable. Observation of the red sanitizing buckets identified that 2 of 3 buckets tested at 150 PPM. The Dietary Director identified these levels were low for the quaternary solution used by the facility and should have been tested between 200-400 PPM. Interview with the Dietary Director immediately following these observations identified he only started working at the facility 2 weeks prior and had identified issues with the kitchen, sanitization, and the debris around the grease trap. The Dietary Director failed to provide any additional information related to what these issues were. Following these observations, a request was made to review the sanitizing solution manufacturer directions, and the solution testing logs for 10/25, 11/25, 12/25 and 1/2026. Observations on 1/12/26 at 7:41 AM with the Dietary Director identified an open package of white sliced bread in the dry storage area. During this observation, 2 live flying insects, which appeared to be fruit flies, were observed within the dry storage area. Dietary Director reported that all dry food items within the kitchen should be stored securely with closed packaging.Following this observation, a request was made to review the food temperature logs for all meals from 10/25, 11/25, 12/25 and 1/2026. An additional request was also made to the Dietary Director to provide the sanitizing solution manufacturer directions, and the solution testing logs for 10/25, 11/25, 12/25 and 1/2026 previously requested. Observations on 1/12/26 at 1 PM of the two facility nourishment refrigerators identified temperature logs posted for 1/26. The logs failed to identify any documentation of the freezer temperatures and failed to identify the staff who completed the temperature checks. Interview on 1/13/26 at 7:05 AM with the Dietary Director identified he was unable to provide any documentation or instructions related to the sanitizing solution issues. The Dietary Director identified that the facility had not utilized any kind of system to track or document the sanitizing solution used throughout the kitchen and identified that this was something that he could implement in the future. Interview on 1/13/26 at 7:10 AM with Dietary [NAME] #1 and Dietary Aide #3 identified that the facility kitchen staff did not routinely test the sanitizing solution used in the kitchen or track the test strip results. Dietary [NAME] #1 identified that the previous dietary director had implemented the use of log sheets for a couple of months in 2025 however the sheets were only used sporadically by dietary staff and eventually they went away. Dietary [NAME] #1 identified she was a full time cook in the kitchen and regularly used the test strips when she used new sanitizing solution. Dietary [NAME] #1 identified that throughout 2025 there were several issues with the sanitizing solution testing being above 400 PPM so she was surprised that the levels were low during survey. Review of facility documentation and interview with the Dietary Director beginning at 1/13/26 at 11 AM identified issues with the prior nourishment refrigerator cleaning and temperature logs. The Dietary Director identified following taking over the role, he decided to utilize a new form beginning 1/26. The Dietary Director identified he did not realize the form did not include documentation of the freezer temperatures and he would correct this. The Dietary Director provided the nourishment refrigerator cleaning and temperature logs for 12/25. Review of the 12/25 temperature logs failed to identify any recorded temperatures from 12/23/25 - 12/29/25 or on 12/31/25. The Dietary Director identified that he was unable to locate any additional nourishment refrigerator cleaning or temperature logs for any other months in 2025. During this interview the Dietary Director also provided food temperature logs labeled Hot Food Temperature Log sheet for 1/26 for review. Review of the logs with the Dietary Director identified that the forms did not include any cold items, did not include any documentation related to the time or specific meal that the temperatures were recorded for, or the dietary staff who recorded the temperatures. The Dietary Director identified that in addition to the issues with the 1/26 food temperature logs, he was unable to locate any prior logs and could not provide any documentation of any food temperatures for 2025. Despite multiple requests, the facility failed to provide any documentation related to the quaternary solution used for sanitizing throughout the kitchen of the facility. Although requested, the facility failed to provide a policy on sanitizing solution use in the kitchen. Although requested, the facility failed to provide a policy on the resident nourishment refrigerators. Although requested, the facility failed to provide a policy on food temperature logs for residents' meals. The facility policy on food safety requirements directed that food would be stored, prepared, distributed, and served in accordance with professional standards for food service safety. The policy also directed that food safety practices would be followed throughout the facilities entire food handling process and elements of the process included:Storage of food in a manner that helped prevent deterioration or contamination of the food including the growth of organisms.Preparation of food including cooking, cooling, holding, and reheating.Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food.The policy also directed that refrigerated food storage included monitoring the function of refrigerated equipment daily and at routine intervals during all hours of operation. The policy further directed that when preparing food cooked food should be prepared until recommended temperatures for specific foods were reached and staff should monitor food temperatures to ensure proper hot and cold holding temperatures were maintained. The policy also directed that all equipment used in handling food should be clean and sanitized and handled in a manner to prevent contamination and staff should follow facility procedures for cleaning fixed cooking equipment. The facility policy on sanitation inspection directed that it was the policy of the facility to conduct inspections to ensure food service areas were clean, sanitary and in compliance with applicable state and federal regulations.

Based on observation, review of the clinical record, facility documentation, facility policies, and interview for 1 of 5 residents (Resident #121) reviewed for accidents, the facility failed to ensure a resident at risk for aspiration was supervised during a meal. The findings include: Resident #121, during admission to an acute care hospital on [DATE], had a Clinical Bedside Swallow Evaluation. The Clinical Bedside Swallow Evaluation identified Resident #121 had mild oral phase dysphagia complicated by prolonged oral transit time/bolus manipulation across trial consistencies. No overt signs and symptoms (s/s) or airway compromise was noted at this time and no retention in the oral cavity post-swallow. Recommendations included the following: diet: puree/IDDSI-4 and mildly thick liquids/IDDSI-2, liquid administration via: cup and straw, supervision: total assist with feeding, compensation/maneuvers: slow rate, small bites/sips and check for pocketing, environmental considerations: upright 90 degrees and upright 30 minutes after meals. Resident #121 was admitted to the facility in 12/2025 with diagnoses that included metabolic encephalopathy, neurocognitive disorder with Lewy Bodies, chronic systolic heart failure, type 2 diabetes mellitus, Parkinson's Disease, and dysphagia.The Speech Language Pathologist (SLP) Evaluation and Plan of Treatment dated 12/15/25 identified Resident #121 participated in a bedside swallowing evaluation which revealed moderate oral and severe pharyngeal stage dysphagia. Of note, the resident was positioned upright in bed and pushing against bed, head in lordosis position, significant difficulty with achieving head in midline position. The resident was unable to follow directions even with modeling, tactile, and verbal cues therefore the evaluation and oral mechanism exam was limited. The resident was dependent for feeding. Oral stage remarkable for reduced manipulation of bolus, mild to moderate residue requiring extra swallows and liquid wash to clear. Pharyngeal stage remarkable for moderately delayed swallow onset sporadically and sporadic absent swallow, wet cough noted for 40% of puree, 90% of nectar thick liquid, and delayed wet cough for 10% of honey thickened liquid. No significant change in signs and symptoms of aspiration with straw versus cup sips. However, of note, improved oral management and swallowing initiation timing with straw sips. However, the resident with intermittent recognition of straw resulting in inconsistent use. The resident was at high risk for aspiration across all consistencies, no significant change with temperature changes, verbal, and tactile cues. The resident was at high risk for malnutrition and dehydration. Discussed evaluation results and recommendations with the APRN, nursing, social worker, and two family members. The family declined alternative means of nutrition and hydration at this time, family considering palliative/hospice options. Recommended to continue puree diet, discontinue nectar thick liquid changed to honey thick liquid. The physician's order dated 12/15/25 directed for a cardiac, carbohydrate-controlled diet, dysphagia puree texture, honey consistency.The admission MDS dated [DATE] identified Resident #121 had had severely impaired cognition, required supervision or touching assistance with eating, had the following signs and symptoms of a swallowing disorder: holding food in mouth/cheeks or residual food in mouth after meals and coughing or choking during meals or when shallowing medications, and required the following nutritional approaches: a mechanically altered diet and a therapeutic diet.The SLP progress note dated 12/29/25 at 5:08 PM identified Resident #121 had demonstrated persistent signs and symptoms of aspiration across consistencies, over the treatment. However, slightly reduced signs and symptoms of aspiration from initial evaluation, no change with slow rate, small bites/sips, cued swallow, and unable to demonstrate a hard swallow. Resident #121 had increased cough this session and reduced oral intake. The resident was pushing away food reporting he/she was not hungry. Aspiration risk persists across consistencies, additional development of safe swallow strategies and training indicated. The family continues to decline alternate means of nutrition, the family was provided extensive education regarding aspiration risk, malnutrition risk, and clinical level of functioning, good comprehension and in agreement with current goals and plan of care.The care plan dated 1/5/26 identified Resident #121 exhibited or was at risk for impaired swallowing related to history of cerebral vascular accident (CVA), with interventions that included providing modified diet and liquid consistencies as ordered, encouraging small sip/bites and cue as needed, encouraging resident to alternate liquids and solids, monitoring for signs and symptoms of aspiration ie: coughing, watery eyes, choking, moist sounding voice, and if coughing occurs, no food/liquids until coughing resolves. The current nurse aide kardex identified Resident #121 required an extensive assist for self-feeding and directed to monitor adherence to fluid restriction; 2000ml daily, monitoring for signs and symptoms of aspiration, providing modified consistency diet and liquids as ordered, and if coughing occurs, no food/liquids until coughing resolves. Observation on 1/11/26 at 9:40 AM identified Resident #121 sitting up in bed coughing, which sounded wet.Observation on 1/11/26 at 11:45 AM through 12:00 PM identified Resident #121 was seated for lunch in the Parlor and was noted to have a consistent wet cough. Interview with LPN #1 on 1/11/26 at 12:00 PM identified that Resident #121 would sometimes cough during meals, as he/she was not tolerating food or drinks well due to Parkinson's which the SLP indicated was likely to worsen the dysphagia. LPN #1 indicated that Resident #121 was working with the SLP, was on a puree diet, honey thickened liquids, and the family had declined placement of a feeding tube. Subsequent to surveyor inquiry, the Change in Condition note dated 1/11/26 at 1:52 PM identified Resident #121 was noted to be coughing especially after eating or drinking, the resident was on puree diet and honey thick liquids, a congested cough was noted, and rhonchi lung sounds. The primary care provider was notified, a chest x-ray was ordered, and recommendations were made for Mucinex, nebulizer treatments, and supplemental oxygen therapy at 2 liters. Resident #121's blood pressure: 118/66, heart rate: 92, respiratory rate: 18, temperature: 97.3 , and pulse oximetry 92% on room air.The single view chest x-ray dated 1/11/26 at 3:16 PM identified modest right lower lobe and modest left lower lobe infiltrates and no venous congestion. Impression: modest bilateral lower lobe pneumonia. Observation on 1/12/26 at 12:06 PM identified Resident #121 alone in his/her room sitting up in a chair with a lunch tray and cranberry juice on the bedside table in front of the resident. A straw that contained residual of a red fluid like substance was hanging from his/her mouth. Observation with LPN #9 on 1/12/26 at 12:08 PM identified Resident #121 was alone in his/her room sitting up in a chair with a lunch tray and cranberry juice on the bedside table in front of him/her and a straw on his/her lap. LPN #9 indicated that Resident #121 should not have a lunch tray and drink placed in front of him/her; Resident #121 was not able to self-feed and required an assist with feeding. LPN #9 indicated that the SLP had identified that Resident #121 was likely to be aspirating during meals.Resident #121's meal ticket failed to identify he/she was at risk for aspiration.Interview with NA #5 on 1/12/26 at 12:15 PM identified that she had mixed Resident #121's cranberry juice with thickener to create a honey consistency and left the straw in the cup, accidentally. (NA #5 Clinical Competency Validations for Feeding the Resident and Obstructed Airway were identified as met on 12/22/25).During an interview with the Speech Language Pathologist (SLP #1) and the Directory of Rehabilitation on 1/12/26 at 12:28 PM, SLP #1 identified Resident #121 had been evaluated by SLP therapy services on 12/15/25, and a swallowing assessment and cognitive communication assessment were completed; at that time it was determined that Resident #121 was having moderate oral and severe pharyngal dysphagia, and he/she was having signs and symptoms of aspiration across all consistencies. SLP #1 indicated that she had discussed the evaluation results and her recommendations with the medical APRN, nursing staff, the social worker, and 2 family members. SLP #1 identified that Resident #121's family had declined alternate means of hydration and nutrition and at that time were considering palliative/hospice options. SLP #1 further indicated that Resident #121 was downgraded to honey thick liquids but kept puree diet consistency. SLP #1 indicated that Resident #121 had reached his/her maximum potential and benefit from SLP therapy services, and due to his/her progressive neuro-degenerative disease, the dysphagia would likely worsen, and anything that Resident #121 eats or drinks would be risky, but the nursing staff was educated with the compensatory strategies needed to assist Resident #121 with meals and the strategies were outlined in the care plan. SLP #1 indicated that residents identified for being at risk for aspiration have their compensatory strategies and aspiration monitoring outlined in the care plan, and that she does not believe that there was any notation on the resident's meal ticket to notify dietary staff when a resident had aspiration risk or required a specific level of meal supervision. SLP #1 identified that the plan moving forward was to continue Resident #121 with the current compensatory strategies and the current diet and liquid consistencies. Interview with APRN #1 on 1/13/26 at 12:12 PM identified that although she was not the facility's primary medical APRN, was covering and not familiar with Resident #121, she would expect a resident identified by speech for being at risk for aspiration would have an order for aspiration precautions. APRN #1 indicated she would enter a new order. Interview with NA #4 on 1/13/26 at 12:35 PM identified that she was not Resident #121's primary nurse aide, but she had occasionally provided care for the resident. NA #4 indicated that Resident #121 was on thickened liquids and a puree diet, and she was aware that he/she was an aspiration risk because she had been informed by the nurses, LPN #1 and LPN #9. NA #4 indicated that for residents requiring supervision with meals, she would push their tray table away from where the residents were seated or away from the bed to ensure the dietary aides didn't put the meal tray within their reach, and she would provide assistance with meals for the appropriate residents, depending on information provided by the nurse and the resident's care card. NA #4 identified that the last time she was assigned to Resident #121, he/she required supervision during the meal, was to be seated at 90 degrees, alternated bites and sips, and was aware that she needed to notify the nurse if Resident #121 had s/s of aspiration, including coughing. Interview with NA #6 on 1/13/26 at 12:40 PM identified that she was Resident #121's primary day shift nurse aide, and that prior to Sunday, when she noticed that the resident was coughing during breakfast, she would set him/her up for breakfast in his/her room but not remain in the room to supervise, as Resident #121 could feed him/herself. NA #6 indicated she would listen from another room in close proximity while feeding another resident. NA #6 indicated that on Sunday she noticed Resident #121 was coughing, so she remained with him/her during breakfast and notified LPN #1 at approximately 8:30 AM, and she was told to stop the feeding. LPN #1 came into evaluate Resident #121. NA #6 identified that she believed Resident #121 was at risk for aspiration because any resident on a thickener would be at risk. NA #6 indicated that education to alternate sips and bites for Resident #121 was not communicated to her, and that she did not feel that Resident #121 had the cognition to alternate sips and bites, while self-feeding. NA #6 indicated that Resident #121 went to the parlor for lunch on most days, and that room had nursing supervision. (NA #6 Clinical Competency Validations for Feeding the Resident and Obstructed Airway were identified as met on 12/30/25).Interview with Dietary Aide #2 on 1/13/26 at 12:50 PM identified that the dietary aides deliver the meal trays, and the nurse aides deliver the drinks to the residents. The SLP or nurses would notify the kitchen staff of any changes in diet or consistency, and that would be reflected on the meal ticket, but a resident at risk for aspiration would not be identified on the meal ticket. Dietary Aide #2 identified that she just remembers which residents are at risk and for aspiration, and she would drop their meal tray on their dresser or out of their reach, so the nurse aides could set them up and feed them. Dietary Aide #2 indicated that she was aware that Resident #121 was at risk for aspiration, but she could not recall if she was the dietary aide that placed the lunch tray in front of him/her, the day before. Dietary Aide #2 further indicated that a new process was put into place, starting today; meals for residents requiring feeding assistance would be delivered on a separate cart and the nurses and nurse aides would distribute the trays. Interview with the Dietary Director on 1/13/26 at 12:58 PM identified that the dietary aides pass meals to the residents and the nurse aides pass the drinks. The SLP would update new diet or consistency orders into the resident's electronic health record and that would automatically update the kitchen's ticketing system, additionally the SLP and RD also fill out diet request forms to communicate updates and verbally communicate changes. The Dietary Director indicated that he was unable to answer if residents at risk for aspiration should be identified on the meal ticket, and he would have to circle back with an answer. The Dietary Director indicated that a new process was put into place starting today; a master list was created of all residents with an aspiration risk, and a separate cart would go out with those resident's meals and be handed off directly to the nursing staff for delivery. Interview with the Regional Director of Dietary on 1/13/26 at 1:07 PM identified that he did not know the exact process at this facility, for communicating to dietary staff a resident that was on aspiration precautions. Interview with Dietary Aide #3 on 1/13/26 at 1:12 PM identified residents at risk for aspiration were not identified on the meal ticket, but she knew which residents were at risk because the nurses communicate that information to them, additionally she would notice a change in a diet or consistency order on a resident's meal ticket and then seek out clarification, however, she was not sure how a new dietary aide or dietary aide not familiar with the residents would know who was at risk for aspiration. Interview with the DNS and the Regional Director Resource Nurse (RN #8) on 1/14/26 at 10:04 AM identified that Resident #121's care plan identified him/her as requiring an extensive assist for self-feeding, and that it was the DNS's understanding that Resident #121 could manage the hand to mouth movements to self-feed but staff were expected to remain in the room to monitor for signs and symptoms of aspiration, provide cues, and remind the resident to alternate sips and bites per the interventions listed on the care plan; if Resident #121 started to cough, the meal should be stopped and nurse should be notified. The DNS further indicated that her understanding, based off conversations with the SLP and the interdisciplinary team, was that Resident #121 would remain someone who coughs while eating, the silent aspiration would not improve, and that the family agreed with the current plan of care. The DNS and RN #8 both indicated that it was their expectation that staff would be in the room while Resident #121 was eating. Interview with the Medical Director (MD #1) on 1/14/26 at 12:15 PM identified that while the nursing staff should attempt to supervise Resident #121 during meals due to his/her disease progression there was not much that could be done to stop him/her from aspirating. MD #1 indicated that since the family had declined artificial nutrition, the next step would be a conversation to discuss hospice. MD #1 further indicated that he thought there was an aspiration policy as he would expect the facility to have one in place. MD #1 identified that if a resident continues to aspirate and the family does not want artificial nutrition then a conversation about palliative care and hospices services should be discussed, hospice goals are designed to support the family and to allow the patient to be comfortable, even allowing the resident's diet to be liberalized as long as the family consents and understands the process. Although requested, an Aspiration policy was not provided. The Therapeutic Diet Orders policy directs the facility to provide all residents with food in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her rules and preferences. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to: inadequate nutrition, nutritional deficits, weight loss, medical conditions, and swallowing difficulty. The reason for therapeutic diet is to be documented in the medical record and/or indicated on the resident's comprehensive plan of care. All diet orders are to be communicated to the dietary department in accordance with facility procedures.The facility's Meal Supervision and Assistance policy directs that the resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary. The facility will utilize a systemic approach to ensure safety throughout the residence environment and among all staff. Compliance guidelines identified, in part, include: the facility will develop and implement an individualized plan of care based on the Resident Assessment Instrument to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time, the resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward, if the resident is served his or her meal in bed, use wedges and pillows to achieve an upright position, alternate food and liquids as desired and needed, in order to cleanse the mouth of food, be careful to provide portions of food easy for the resident to chew, feed slowly allowing plenty of time between bites, and encourage the resident to participate in his/her meal as much as possible.The Comprehensive Care Plans policy directs the facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will describe at a minimum the following: services that are to be furnished to attain or maintain the residence highest practicable physical, mental and psychosocial well-being, resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity as indicated. The comprehensive care plan will be prepared by the interdisciplinary team that includes but is not limited to: the attending physician or non-physician practitioner designee involved in the resident's care, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, the resident and the resident's representative, other staff or professionals and disciplines as determined by the residents needs or as requested by the resident. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #33) reviewed for pain management, the facility failed to ensure pain assessments per the physician's order. The findings include: Resident #33 was admitted to the facility in April 2022 with diagnoses that included headache, polyosteoarthritis, chronic pain, schizoaffective disorder, borderline personality disorder, and repeated falls. A physician's order dated 5/1/24 directed to administer Acetaminophen 325mg, 2 tablets by mouth, every 4 hours as needed for mild pain. A physician's order dated 5/13/25 directed to administer Topiramate (an anticonvulsant also used to prevent migraines) 100mg, 1 tablet by mouth, twice daily for migraines, The quarterly MDS dated [DATE] identified Resident #33 had intact cognition and reported pain that rarely interfered with therapy activities, occasionally effected sleep and day-to-day activities, and over the past 5 days his/her worst pain rating was 3 (on a scale of 0 through 10). The MDS further identified that Resident #33 had taken an opioid in the past 7 days and an indication for use was noted. The care plan dated 11/13/25 identified that Resident #33 was at risk for alterations in comfort related to chronic pain, bilateral shoulder osteoarthritis, neuropathy, neuritis, lower back pain, and a history of migraines with interventions that included completing pain assessments per protocol, utilizing the pain scale, and monitoring for non-verbal signs and symptoms of pain. Physician's orders for December 2025 (original date 1/19/22) directed pain monitoring every shift, (are you free of pain, if no indicate response), if new or change in pain, complete a pain evaluation. Additionally, physician's order for December 2025 (original date 10/3/25) directed to administer Tramadol HCL (medication for moderate to severe pain) 50 mg, 1 tablet every 6 hours as needed (prn) for moderate pain and 2 tablets every 6 hours prn for severe pain, and limit Acetaminophen to twice weekly. Review of the December 2025 MAR identified Resident #33 was free of pain on all shifts, all month despite receiving pain medication on 12/3, 12/6, 12/10, 12/11, 12/14, 12/15 twice, and 12/17/25. In different areas of the MAR, documentation included the following:On 12/3/25 at 9:37 PM, Tramadol 50mg was administered for a pain level of X (a numeric value was not identified).On 12/6/25 at 8:00 PM pain level was documented as X.On 12/10/25 at 12:10 PM pain level was documented as X.On 12/11/25 at 10:15 PM pain level was documented as X.On 12/15/25 at 7:35 AM pain level was documented as X.On 12/15/25 at 8:05 PM pain level was documented as X.On 12/17/25 at 8:06 pm pain level was documented as X. The nurse's notes dated 12/1/25 through 12/31/25 failed to identify the location of the pain when pain medication was administered except for 12/14/25 at 2:23 PM when Resident #33 he/she bumped his/her head against a chair and reported a pain level of 3. The January 2026 MAR dated 1/1/26 through 1/13/26 identified Resident #33 was free of pain or hurting on all shifts despite receiving pain medication on 1/5/26 at 9:06 PM for a pain level of X, on 1/6/26 at 4:03 AM for a pain level X, on 1/7/26 at 8:37 PM for a pain level X, on 1/12/26 at 8:02 PM for a pain level X, and on 1/8/26 at 10:36 PM for a pain level X. Interview with Resident #33 on 1/11/26 at 9:53 AM identified that he/she gets migraines, especially at night, and that there is a medication (could not recall the name) that he/she usually requests around 8:30 at night for the migraine, but the nurse doesn't always bring it.Interview with LPN #9 on 1/12/26 at 9:49 AM identified that Resident #33 had a history of migraines and had a comprehensive plan that was developed by the neurologist which included a few different treatments, but his/her migraine pain was also treated with a limited dose of Acetaminophen, as needed. LPN #9 further indicated that Resident #33 had leg pain because of prior leg surgery and the formation of scar tissue, and Tramadol was used to treat leg pain. LPN #9 identified that Resident #33 usually doesn't request pain medication during the day shift, when she works, but when she administers a pain medication she would complete a pain evaluation, which would include obtaining a pain rating on a scale of 0-10, the location of the pain, quality and description of the pain, and if the pain was a new or chronic pain. LPN #9 further identified she would document the evaluation in a progress note or administration note; if the reported pain was not a chronic pain, then she would also report the new onset of pain to the RN Supervisor and APRN.Review of the clinical record with the DNS and the Director of Resource Nurses (RN #8) on 1/14/26 at 9:46 AM failed to identify that pain evaluations were being completed prior to Resident #33 receiving Tramadol.During an interview with the DNS and RN #8 on 1/14/26 at 9:46 AM, RN #8 identified that the clinical record only contained documentation that the Tramadol had been effective, following administration. RN #8 indicated that he would expect to see a pain scale rating and location of the resident's pain, and if a resident was not able to communicate pain verbally, he would expect qualitative data to be used to complete a pain evaluation. RN #8 further indicated that he had updated the electronic Medication Administration Record to trigger the nurse to enter a numerical pain scale value when administering Tramadol.The facility's Pain Management policy directs the facility to utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. To help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated, evaluate the resident for pain and the cause upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs, and manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the residence goals and preferences. The policy further directs that the facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessments of a resident's pain. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team may necessitate gathering the following information, as applicable to the resident: history of pain and its treatment, asking the patient to rate the intensity of his her pain using numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident, reviewing the resident's current medical conditions, and identifying key characteristics of pain including duration of pain, frequency, location, timing, pattern, and radiation of pain.

Based on observations, clinical record review, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #37) reviewed for unnecessary medications, the facility failed to ensure that a pharmacy recommendation was reviewed and addressed by the APRN/Physician. The findings include:Resident #37 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, hypertension, and dementia.The quarterly MDS dated [DATE] identified Resident #37 had severely impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder, and required supervision by facility staff with toileting, bathing, and dressing.The care plan dated 3/10/25 identified Resident #37 had altered cardiovascular status due to hypertension. Interventions included administering cardiac medications as ordered.A physician's order dated 5/15/25 directed for Metoprolol Tartrate (a medication for hypertension) 37.5 mg once daily.A pharmacy recommendation form dated 5/23/25 identified a recommendation to consider switching to Metoprolol Succinate (a long acting version of the medication). Review of the form failed to identify any physician or prescriber response addressing the recommendation.Review of the clinical record failed to identify any documentation that the 5/23/25 pharmacy recommendation was reviewed or addressed by Resident #37's APRN or physician.Interview with RN #8 (Regional Director of Resource Nurses) on 1/14/26 at 11:00 AM identified he was unable to locate any documentation at the 5/23/25 pharmacy recommendation was given to and reviewed by the provider. Interview with the DNS and RN #8 at 11:22 AM identified that the pharmacy recommendations were emailed to the DNS and the RN unit managers. The DNS identified that the unit manager would print the recommendation for the APRN and once the recommendation was reviewed, the DNS received the signed and completed recommendation, reviewed them and then provided them to medical records and the receptionist to upload to the resident's clinical record. The DNS identified that while she did spot check to ensure that the recommendations were reviewed, addressed, and signed off, she was unable to locate a few of them but did not quantify the number missing. Subsequent to surveyor inquiry and following this interview, the facility provided 2 undated signed pharmacy recommendation forms. The forms included the 5/23/25 form and a 10/15/25 pharmacy recommendation form. Review of the 5/23/25 form identified the provider disagreed with the recommendation to switch to a long acting version of Metoprolol without a rationale. Although requested, the facility failed to provide a policy related to pharmacy recommendations. The facility policy on pharmacy services directed that it was the policy of the facility to ensure that pharmaceutical services were provided to meet the needs of each resident and reflected the current standards of practice. The policy also directed that pharmaceutical services included the process of identifying, evaluating, and addressing medication related issues. The policy further directed that the licensed pharmacist would collaborate with the facility leadership and staff to coordinate pharmacy services within the facility.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #119) reviewed for discharge, the facility failed to ensure nursing staff documented when a resident left the facility against medical advice (AMA). The findings include: Resident #119 was admitted to the facility on [DATE] with diagnoses that included low back pain, diabetes, pneumonia, and abnormalities of gait and mobility.The nurse's note dated 8/29/25 at 9:57 PM identified Resident #119 arrived at the facility and was alert and oriented. Prior to admission Resident #119 had weakness and pain to the lower back and radiating to the left leg. Resident #119 denied shortness of breath and difficulty breathing. No edema noted to bilateral lower extremities. Resident #119 was on Levofloxacin 500mg every 48 hours for 5 days.Review of the census form identified Resident #119 had left the facility against medical advice (AMA) on 8/31/25.A nurse's note by the DNS dated 8/31/25 at 4:06 PM identified Resident #119 was expected to transfer to another room due to the resident's roommate testing positive for Covid-19. Resident #119, the resident's representative, the affected, and the new roommates were notified of the room change.Review of the voluntary discharge against medical advice form dated 8/31/25 identified Resident #119 signed the form on 8/31/25 at 5:30 PM and LPN #4 signed as the witness. A physician's order dated 8/31/25 directed to discharge against medical advice (AMA) with medications.Review of the nurse's note dated 8/31/25 at 5:14 PM through 9/1/25 at 1:25 AM failed to reflect documentation that Resident #119 had left the facility against medical advice (AMA) on 8/31/25 at 5:30 PM. Additionally, documentation failed to reflect that the resident representative was notified that Resident #119 had left the facility against medical advice (AMA). Interview and clinical record review with the Administrator on 1/12/26 at 8:46 AM identified the clinical record failed to reflect that Resident #119 had left the facility against medical advice. The Administrator indicated it is the expectation of the facility that nursing and social service staff would have documented that Resident #119 had left against medical advice. The Administrator indicated staff education would be provided to nursing and social services regarding documentation. Interview and clinical record review with the Director of Social Service on 1/12/25 at 8:54 AM identified she has been employed by the facility for approximately 4 years. The Director of Social Service indicated Resident #119 was admitted to the facility on a Friday, late in the evening, after her shift had ended. The Director of Social Service indicated Resident #119 left the facility against medical advice (AMA) on the following Sunday and she was not working. The Director of Social Service indicated the nursing department should have documented the residents discharge AMA in the clinical record.Interview and clinical record review with the DNS on 1/12/26 at 9:23 AM failed to provide documentation to reflect that Resident #119 had left the facility AMA. The DNS indicated on 8/31/25 at 5:36 PM she had notified APRN #2 that Resident #119 was leaving the facility AMA and obtained an order for the resident to leave with medications. The DNS indicated the expectation is that staff document in the clinical record when a resident leaves AMA.Although attempted, an interview with RN #4, and LPN #4 was not obtained.Review of the facility notification of change policy identified the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances that require a need to alter treatment. This may include transfer or discharge of the resident from the facility. Contact information of the resident's legal representative or family member must be recorded and periodically updated.Review of the facility transfer and discharge (including AMA) policy identified the facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. The facility will maintain evidence that the notice was sent to the Ombudsman. The facility will provide transfer/discharge notice to the resident/representative and Ombudsman as indicated. The social services director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices.Discharge against medical advice (AMA): Documentation of this notification should be entered in the nurse's notes by the nursing department. Notify adult protection services, or other entity as appropriate, if self-neglect is suspected. Document accordingly.

Based on observation, clinical reviews, facility documentation, facility policy and interviews for 1of 4 residents (Resident #12) reviewed for pressure ulcers, the facility failed to ensure hand hygiene was performed in accordance with infection control practices during wound care. The findings include:Resident #12 was admitted in 4/2025 with diagnoses that included Type II diabetes and atrial fibrillation and recent multidrug resistant organism (MDRO) of the urine.The quarterly MDS dated [DATE] identified Resident #12 was severely cognitively impaired and required one person assist for bed mobility, transfers, was dependent for toileting needs, had no unhealed pressure ulcers and was at risk for developing a pressure ulcer. The care plan dated 10/22/25 identified Resident #12 had an ADL deficit, actual moisture associated skin damage (MASD) and placed on enhanced barrier precautions after just completing treatment for a multidrug resistant organism in the urine. Interventions included dependent (two person) assist for bed mobility, transfers and conduct weekly wound assessments.Physician orders dated 1/6/26 directed cleansing of the left buttock with wound cleanser, apply skin prep to the peri wound then apply Santyl ointment (medication that removes damaged tissue to aid in wound healing) to wound bed, cover with calcium alginate (wound dressing that absorbs moisture) followed by a superabsorbent bordered foam dressing.Observation on 1/12/26 at 1:06 PM identified LPN #12 in Resident #12's room at the bedside wearing gloves and gown setting up wound supplies and barrier on the bedside table. LPN #12 instructed Resident #12 she was going to lower the head of the bed to begin wound care. Using her right hand, she operated the bed remote control and placed it by the rail. LPN #12 assisted the nurse aide in positioning the resident on the left side, exposing the left buttock. Using the left hand, LPN #12 then sprayed wound cleanser on a gauze pad held by the opposite hand, then reached toward the wound with the same right hand previously used to set up supplies and handle the remote control, without first removing gloves, performing hand hygiene and donning a new pair of gloves. The task was interrupted, hand hygiene performed, and a new pair of gloves were donned. LPN #12 proceeded to cleanse the wound to the left buttock with a gauze pad, discard the soiled gauze, remove both gloves then don a new pair of gloves without first performing hand hygiene. LPN #12 opened a skin barrier and reached for the peri wound. The task was interrupted. Interview with LPN #1 on 1/12/26 at 1:06 PM identified she should have removed the gloves, performed hand hygiene and put on a new pair of gloves between tasks, when beginning wound care and after cleansing of the wound but did not as an oversight as she was nervous.The task was subsequently completed by RN #3, the infection preventionist/wound nurse.Interview with RN #3 on 1/12/26 at 1:40 PM identified she was responsible for education for the use of personal protection equipment (PPE) and performing hand hygiene between dirty and clean tasks. RN #3 indicated staff compliance remained a challenge and that education was ongoing.Interview with the DNS on 1/13/26 at 3:44 PM identified she would expect hand hygiene to be performed between tasks and between removing and replacing gloves.A review of the facility policy for hand hygiene directs that all staff perform proper hand hygiene (using soap and water or alcohol-based hand rub) procedures to prevent the spread of infection to other personnel, residents and visitors. If the task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Hand hygiene is to be performed after handling contaminated objects, before and after removing PPE including gloves, before and after handling clean or soiled dressings, linens, etc., after handling items potentially contaminated with blood, body fluids, secretions or excretions and when moving from a contaminated body site to a clean body site.

Based on observations, facility documentation, facility policy, and interviews, the facility failed to ensure that the kitchen was free of flying insects. The findings include: Observations on 1/11/26 at 8:24 AM during an initial tour of the kitchen with the Dietary Director identified 2 live flying insects at the interior entryway of the kitchen area. The insects appeared to be fruit flies. Additional observations of the grease trap area, also located near the interior entryway of the kitchen area, identified a significant amount of food debris and multiple dead winged insects directly on top of the grease trap, the gap between the wall and the grease trap, and along the wall surface directly next to the grease trap. The winged insects also appeared to be fruit flies. Interview with the Dietary Director immediately following these observations identified he only started working at the facility 2 weeks prior and had identified issues with the kitchen, sanitization, and the debris around the grease trap but had not noticed any active pest activity during that time. The Dietary Director failed to provide any additional information related to what these issues were. Observations on 1/12/26 at 7:41 AM with the Dietary Director identified an open package of white sliced bread in the dry storage area. During this observation, 2 live flying insects, which appeared to be fruit flies, were observed within the dry storage area. Dietary Director reported that all dry food items within the kitchen should be stored securely with closed packaging.Interview on 1/12/26 at 10:55 AM with the Regional Facilities Director identified he has only just been notified of the issue with flying insects by the Dietary Director during the survey. The Regional Facilities Director identified he would be placing traps and had already requested pest control come into the facility that day. He would also be addressing issues related to food items being sealed and cleanliness in the kitchen. Observations on 1/13/26 at 7:05 AM with the Dietary Director identified 3 live flying insects which appeared to be fruit flies flying near the range hood. Interview on 1/13/26 at 7:10 AM with Dietary [NAME] #1 and Dietary Aide #3 identified that there had been issues with fruit fly activity in the kitchen for several months, with heavy activity in the summer months. Dietary [NAME] #1 and Dietary Aide #3 identified since the weather change the insect activity had decreased but they were still present throughout the kitchen area. Review of pest control service reports provided by the facility identified that the kitchen area was treated for crawling insects on 10/27/25, 11/30/25, and 12/30/25.Although requested, the facility failed to provide any documentation that pest control services related to the flying insects had been completed on 1/12, 1/13, or 1/14/26.The facility policy on the pest control program directed that the facility would maintain an effective pest control program that eradicated and contained most common household pests and rodents. The policy further directed that the facility would maintain a report system of issues that might arise in between scheduled visits with the outside pest service provider and treat as indicated, and that the facility would utilize a variety of methods and controlling certain seasonal pests which would involve indoor and outdoor methods that were deemed appropriate by the outside pest service and state and federal regulations.The facility policy on sanitation inspection directed that it was the policy of the facility to conduct inspections to ensure food service areas were clean, sanitary and in compliance with applicable state and federal regulations. The policy further directed that all food service areas would be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #7, 117 and 119) reviewed for hospitalization and/or discharge, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified in a timely manner when the residents were was transferred and admitted to the hospital and when a resident had left against medical advice (AMA). The findings include: 1. Resident #7 was admitted to the facility in February 2021 with diagnoses that included epilepsy, traumatic brain injury, and acute embolism. Review of the census form identified Resident #7 was transferred to the hospital and admitted on [DATE]. A nurse's note dated 6/9/25 at 8:26 PM identified Resident #7 was readmitted to the facility at 7:00 PM alert, nonverbal, and calm. Review of a notification details form dated 10/2/25 identified the routine monthly resident transfers dated between 6/1/25 – 6/30/25 were sent to the Office of the State Long-term Ombudsman (4 months late). Review of an action summary report dated 10/2/25 failed to reflect Resident #7's transfer to the hospital on 6/3/25 and failed to reflect notification to the Office of the State Long-term Ombudsman of the hospital transfer. Interview with the Business Office Manager on 1/13/26 at 8:35 AM identified she was not aware she was required to notify the Office of the State Long-term Ombudsman when residents were transferred to the hospital. The Business Office Manager indicated that in October 2025, she submitted a resident discharge lists for June 2025, July 2025, August 2025, and September 2025 to the Office of the State Long-term Ombudsman. The Business Office Manager indicated she did not include residents who had been transferred to the hospital. 2. Resident #117 was admitted to the facility in May 2025 with diagnoses that included congestive heart failure (CHF), stage 5 chronic kidney disease, and bladder cancer. The 5-day MDS dated [DATE] identified Resident #117 had intact cognition. Review of the clinical record identified Resident #117 was transferred to the hospital on 6/22/25 and returned on 6/26/25. Additionally, Resident #117 was transferred to the hospital on 6/29/25 and returned on 7/5/25. Review of facility documentation identified the Office of the State Long-Term Care Ombudsman was not notified of the resident's hospitalizations of 6/22/25 or 6/29/25 until 10/2/25. Interview with the Business office Manager (BOM) on 1/12/26 at 9:50 AM identified there was confusion related to a new process she had been instructed to complete related to the Ombudsman's office and confused the process with replacing the Ombudsman notifications. The BOM identified that she realized that she should be reporting transfers/discharges monthly and reported the hospitalizations of 6/22/25 and 6/29/25 to the Office of the State Long-Term Care Ombudsman via the portal on 10/2/25. The facility policy on transfers and discharges directed that the facility would provide transfer/discharge notice to the resident/representative and Ombudsman as indicated. 3. Resident #119 was admitted to the facility on [DATE] with diagnoses that included low back pain, diabetes, pneumonia, and abnormalities of gait and mobility. Review of the census form identified Resident #119 had left the facility against medical advice (AMA) on 8/31/25. A nurse's note by the DNS dated 8/31/25 at 4:06 PM identified Resident #119 was expected to transfer to another room because the resident's roommate tested positive for Covid-19. Resident #119 and his/her resident's representative and the new roommates were notified of the room change. Review of the voluntary discharge against medical advice form dated 8/31/25 identified Resident #119 signed the form on 8/31/25 at 5:30 PM and LPN #4 signed as the witness. Review of the nurse's note dated 8/31/25 at 5:14 PM through 9/1/25 at 1:25 AM failed to reflect documentation that Resident #119 had left the facility against medical advice (AMA) on 8/31/25 at 5:30 PM. Additionally, documentation failed to reflect that the resident representative was notified that Resident #119 had left the facility against medical advice (AMA). Review of the action summary report dated 10/2/25 identified Resident #119 left against medical advice, or discontinued care on 8/31/25 at 6:09 PM. The action summary report failed to reflect the Office of the State Long-term Ombudsman had been notified that Resident #119 left on 8/31/25 against medical advice in a timely manner. Review of the notification details form dated 10/2/25 identified the routine monthly resident transfers for 8/1/25 – 8/31/25 were sent to the Office of the State Long-term Ombudsman (2 months late). Interview with the Business Office Manager on 1/12/26 at 9:35 AM identified she has been employed with the facility for approximately 2 years. The Business Office Manager indicated last year in 2025 she attended a webinar regarding notice of intent to discharge. The Business Office Manager indicated that the monthly resident discharge notifications to the Office of the State Long-term Ombudsman were discontinued and the new form, notice of intent to discharge, was to be sent to the Office of the State Long-term Ombudsman daily. The Business Office Manager indicated in October 2025, she submitted the resident discharge lists for June 2025, July 2025, August 2025, and September 2025 to the Office of the State Long-term Ombudsman. Interview with the Administrator on 1/12/26 at 9:50 AM identified she was not aware that notification to the Office of the State Long-term Ombudsman of resident discharges and hospital transfers were not timely and/or done. The Administrator indicated the issue was brought to her attention by the Ombudsman. The Administrator indicated the Business Office Manager is responsible for submitting the list of resident discharges and transfers to hospital to the Office of the State Long-term Ombudsman on a monthly basis. The Administrator indicated she will educate the Business Office Manager to submit a list of all discharges which will include all hospital transfers on a monthly basis. Review of the facility transfer and discharge (including AMA) policy identified the facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. The facility will maintain evidence that the notice was sent to the Ombudsman. The facility will provide transfer/discharge notice to the resident/representative and Ombudsman as indicated. The social services director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. Discharge against medical advice (AMA): Documentation of this notification should be entered in the nurse's notes by the nursing department. Notify adult protection services, or other entity as appropriate, if self-neglect is suspected, and document accordingly.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for abuse, the facility failed to revise the care plan with interventions to reduce future injury after the resident sustained an injury of unknown origin. The findings include:Resident #1 was admitted to the facility in 6/2022 with diagnoses that included atherosclerosis of the native arteries, peripheral vascular disease (PVD) and dementia.The annual MDS dated [DATE] identified Resident #1 was moderately cognitively impaired, independent with bed mobility and required one person assist with transfers, toileting and locomotion using a wheelchair/walker. The care plan dated 11/18/25 identified Resident #1 had impaired cognition, was independent with transfers and ambulation with a walker, received antiplatelet therapy (medication used for PVD management that may increase risk for bleeding) and was at risk for skin breakdown. Interventions included to cue, supervise as needed, monitor for adverse reactions to antiplatelet therapy and observe skin for signs of breakdown.a. A weekly skin assessment dated [DATE] identified no skin injury/wound(s) were noted.Nure's note dated 12/24/25 at 2:30 AM identified Resident #1 sustained a skin tear to the right shin without pain. The note did not identify a documented measurement, description or origin of the injury. The physician was notified, and treatment was initiated for the skin tear per facility wound care protocol.b. A weekly skin assessment dated [DATE] identified no skin injury/wound(s) were noted.Nurse's note dated 1/7/26 at 2:38 AM identified an area of discoloration to the lower right back and right outer thigh area that was observed by the nurse aide during rounds. No pain or discomfort was noted. There was no documented measurement, description or origin of the injury. The physician was notified, with no new orders.Skin injury report dated 1/7/26 at 2:45 AM identified Resident #1 had an area of discoloration described as a bruise to right lower back and right thigh. Resident #1 was alert, confused and ambulated independently. Resident #1 reported that he/she probably bumped into it with no other information regarding where the injury occurred and no documented measurement or description.A reportable event form dated 1/7/26 identified a skin discoloration to the right hip and thigh described as a bruise with no further documented measurement, description, origin of the injury or any interventions to prevent further injuries. The care plan dated 1/8/26 identified skin discoloration to the right hip and buttocks without interventions to prevent further injury.Nurse's note dated 1/12/26 at 8:33 PM identified that Resident #1 had discoloration to the right lower back and thigh. Resident #14 denied pain, known injury or mistreatment and the finding was not suspicious in nature. Resident #1 took prescribed medication which may have contributed to bruising and had dementia with poor safety awareness. Resident #14 self- transferred in and out of bed and on/off toilet independently, did not consistently use a walker and probably bumped it. Resident #14 had a history of falls with the last known fall to have occurred on 11/28/25. The incident was reviewed by the interdisciplinary team, and the care plan was updated. Care plan dated 1/12/26 identified skin discoloration to the right hip and buttocks with interventions to monitor the discolored areas for increase and report findings to the APRN. The care plan did not include interventions to reduc future injury.Interview with RN #3 on 1 13 26 at 8:19 AM identified she was responsible for wound management at the facility. On 1/8/26, she assessed the area and noted discoloration to the right hip and buttocks which was not consistent with a pressure injury. RN #3 indicated she updated the care plan to include the skin discoloration but did not include any interventions. Interview and clinical record review with the Director of Rehabilitation on 1/13/26 at 9:19 AM identified Resident #1 was independent with ambulation but based on current functional level, would not be able to get up on his/her own after a fall. The Rehabilitation Director indicated residents would be referred for screening by nursing when a resident sustained an injury of unknown origin. The Director of Rehabilitation further identified Resident #1 was last seen in October 2025 for services and she had not received a referral for a screen to determine if anything environmental could have caused repeated injuries.Interview, clinical record and facility documentation review with the DNS on 1/13/26 at 1:22 PM identified for any injury of unknown origin, the resident would be interviewed if possible. If unable to explain the injury due to cognitive impairment, staff statements were relied upon and the care plan updated. The DNS identified a reportable event form had not been completed for the skin tear because completing a form for every skin tear in the facility with no known cause would be excessive.Subsequent interview, clinical record and facility documentation review with the DNS on 1/13/26 3:21 PM identified Resident #1's bruising was discussed at a risk management meeting, but she could not recall an outcome of the discussions, and she did not have documentation supporting preventative measures had been put in place to reduce future injury.Interview with RN #6, the MDS coordinator on 1/14/26 at 6:56 AM identified the interdisciplinary team was responsible for the revision of the care plan for any change of condition. RN #6 identified on 1/12/26, 5 days after the discovery of the skin discoloration, she updated the care plan to include the skin discoloration but did not include preventative interventions to reduce the risk of future injury as she did not know what they would be. RN #6 further identified interventions would need to be discussed.The policy for Care Plan Revisions Upon Status Change directs that the care plan will be revised as necessary when a resident experiences a status change. Upon identification of a change in status, the interdisciplinary team will discuss the resident condition and collaborate on intervention options. The team discussion will be documented in the progress notes, and the care plan will be updated with new or modified interventions that reflect the resident's needs.The policy for Abuse, Neglect and Exploitation defines possible indicators of abuse as any physical mark such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body and any physical injury of unknown source. Allegations must be reported to the overseeing state agency immediately, but not later than two hours after an allegation is made if the allegation involves abuse or results in serious bodily injury. Or 24 hours if events do not involve abuse or serious bodily injury. Connecticut Public Health Code directs that all reportable events, which have occurred in the facility, shall be reviewed monthly by the administrator and director of nurses. All situations which have potential for risk shall be identified. A determination shall be made as to what preventative measures shall be implemented by the facility staff.

Number of residents sampled: Number of residents cited: Based on observation, review of the clinical record, facility policies, and interviews for 1 of 5 residents (Resident #121) reviewed for accidents, the facility failed to ensure an RN assessment was completed timely following a change in the residents condition and failed to ensure antibiotics were administered timely after an x ray identified pneumonia. The findings include:Resident #121 was admitted to the facility in 12/2025 with diagnoses that included metabolic encephalopathy, neurocognitive disorder with Lewy Bodies, type 2 diabetes mellitus, Parkinson's Disease, and dysphagia.The physician's orders dated 12/15/25 directed for a cardiac, carbohydrate-controlled diet, dysphagia puree texture, honey consistency and directed for the administration of Albuterol Sulfate Inhalation Solution (2.5mg/3ml) 0.083% (a bronchodilator which works to relax the muscles of the airway to make breathing easier) 3ml inhale orally, via nebulizer every 6 hours, for shortness of breath or wheezing. The admission MDS dated [DATE] identified Resident #121 had had severely impaired cognition, required supervision or touching assistance with eating, had the following signs and symptoms of a swallowing disorder: holding food in mouth/cheeks or residual food in mouth after meals and coughing or choking during meals or when shallowing medications, and required the following nutritional approaches: a mechanically altered diet and a therapeutic diet.The care plan dated 1/5/26 identified Resident #121 exhibited or was at risk for impaired swallowing related to history or cerebral vascular accident (CVA), with interventions that included providing modified diet and liquid consistencies as ordered, encouraging small sip/bites and cue as needed, encouraging resident to alternate liquids and solids, monitoring for signs and symptoms of aspiration ie: coughing, watery eyes, choking, moist sounding voice, and if coughing occurs, no food/liquids until coughing resolves. The nurse aide kardex identified Resident #121 required an extensive assist for self-feeding and directed to monitor adherence to fluid restriction; 2000ml daily, monitoring for signs and symptoms of aspiration, providing modified consistency diet and liquids as ordered, and if coughing occurs, no food/liquids until coughing resolves. Observation on 1/11/26 at 9:40 AM identified Resident #121 sitting up in bed coughing, the cough was noted to sound wet.Observation on 1/11/26 at 11:45 AM through 12:00 PM identified Resident #121 was seated for lunch in the parlor and was noted to have a consistent wet cough. Interview with LPN #1 on 1/11/26 at 12:00 PM identified that Resident #121 would sometimes cough during meals, as he/she was not tolerating food or drinks well, due to his/her Parkinson's which the SLP had educated that the disease process was likely to worsen the dysphagia. LPN #1 indicated that Resident #121 was working with the SLP, was on a puree diet, honey thickened liquids, and the family had declined placement of a feeding tube. The Medication Administration Record (MAR) dated 1/11/26 at 12:28 PM identified Albuterol Sulfate Inhalation Solution (2.5mg/3ml) 0.083% was administered, via nebulizer. a. The LPN's Change in Condition note dated 1/11/26 at 1:52 PM identified Resident #121 was noted to be coughing especially after eating or drinking, the resident was on puree diet and honey thick liquids, a congested cough was noted, and rhonchi lung sounds. The primary care provider was notified, and a chest x-ray was ordered. Recommendations included Mucinex, nebulizer treatments, and supplemental oxygen therapy at 2 liters. Resident #121's blood pressure: 118/66, heart rate: 92, respiratory rate: 18, temperature: 97.3 , and pulse oximetry 92% on room air.The change in condition follow-up note, written by the LPN, dated 1/11/26 at 9:48 PM identified there was no change in condition, Resident #121 was observed coughing, frequently-gargling, positive for pneumonia, on honey thickened liquids, on a puree diet and intravenous (IV) antibiotics. The LPN's change in condition follow-up note dated 1/12/26 at 7:35 AM identified Resident #121's condition was improved. Resident #121 was coughing, oxygen saturation was below 80% (normal range 95-100%), he/she was started on 2 liters of oxygen, bloodwork was done, and the resident has pneumonia. Will start IV antibiotics today. With nasal cannula, Resident #121's oxygen level was above 95%. Resident #121 was resting in bed with the head of the bed up, call bell was within reach.Review of the nurse's notes dated 1/11/26 through 1/12/26 failed to identify an RN assessment of the resident's condition had been completed after the residents change in respiratory status including the diagnosis of pneumonia. Review of the clinical record with the 7:00 AM - 3:00 PM RN Supervisor (RN #2) and the Infection Control Nurse (RN #3) on 1/12/26 at 10:59 AM failed to identify that an RN assessment was completed following Resident #121's change in condition, on 1/11/26. During an interview with RN #2 and RN #3 on 1/12/26 at 10:59 AM, RN #2 identified that LPN #1 had come to her sometime during the afternoon on 1/11/26 to notify her that he had placed a call to the medical APRN and that a chest x-ray was ordered for Resident #121 due to his/her congested cough. RN #2 could not recall the time that she was notified of Resident #121's change in condition, and she would look further into the documentation to see if an RN assessment had been completed. RN #3 indicated that she had just learned of Resident #121's cough and treatment plan, earlier this morning, and had planned to follow-up and complete an assessment, this morning. RN #3 further indicated that while the medical provider and family were notified of the change of condition, she would also have expected an RN assessment to have been completed and documented, as soon as the congested cough was identified and the first PRN nebulizer treatments was administered on 1/11/26 at 12:28 PM. Review of the clinical record with the DNS and the Regional Director Resource Nurse (RN #8) on 1/14/26 at 10:00 AM failed to identify that a timely RN assessment was completed following Resident #121's change in condition, on 1/11/26.During an interview with the DNS and RN #8 on 1/14/26 at 10:00 AM, the DNS identified that she would have expected an RN assessment to have been completed on Resident #121 once the congested cough was identified because this was an observed change in his/her condition. b. Radiology Results Report dated 1/11/26 at 3:16 PM identified a single view chest x-ray was completed on Resident #121 on 1/11/26 at 2:42 PM. The findings identified normal heart size and configuration. The mediastinum was normal without adenopathy. There were modest right lower lobe and modest left lower lobe infiltrates. There was no venous congestion. The osseous structures were unremarkable. Impressions: modest bilateral lower lobe pneumonia. Electronically signed by the physician on 1/11/26 at 3:16 PM. A physician's order dated 1/11/26 (and discontinued on 1/12/26) directed to administer Cefpodoxime Proxetel 200mg (antibiotic used to treat respiratory bacterial infections) give 1 tablet by mouth, every 12 hours for pneumonia, for 7 days.The Medication Administration Record (MAR) dated 1/11/26 failed to identify Resident #121 received Cefpodoxime Proxetel 200mg.A physician's order dated 1/12/26 directed to administer Ceftriaxone Sodium Intravenous Solution 1 gram (gm) (antibiotic used to treat bacterial infections such as pneumonia) use 1 gm intravenously once daily for pneumonia, for 5 days.The Medication Administration Record (MAR) dated 1/12/26 failed to identify Resident #121 received Ceftriaxone Sodium Intravenous Solution 1gm.Clinical record review with the 7:00 AM - 3:00 PM nurse (LPN #9) on 1/12/26 at 9:40 AM identified that the medical provider had ordered Ceftriaxone on 1/12/26 around 1:00 AM and Resident #121's first dose of IV Ceftriaxone was scheduled for 1/12/26 at 6:00 AM.Interview with LPN #9 on 1/12/26 at 9:40 AM identified that Resident #121 had a chest x-ray that was reviewed by the medical provider on 1/11/26 at 3:15 PM, and the resident had IV Ceftriaxone scheduled for administration on 1/12/26 at 6:00 AM. LPN #9 identified that the Ceftriaxone should have been administered, but she could not speak to why it had not been administered by the 11:00 PM - 7:00 AM nurse.Subsequent to surveyor inquiry, the RN note dated 1/12/26 at 9:55 AM identified that the APRN was updated that Resident #121 had not yet received IV Ceftriaxone. A new order directed to change time of administration to 10:00 AM and give the Ceftriaxone. IV Ceftriaxone started running without difficulty and was tolerated well.Review of the clinical record with the 7:00 AM - 3:00 PM RN Supervisor (RN #2) and the Infection Control Nurse (RN #3) on 1/12/26 at 10:59 AM failed to identify Resident #121 received antibiotics in a timely manner.During an interview with RN #2 and RN #3 on 1/12/26 at 10:59 AM, RN #3 identified that LPN #9 had notified her, just prior to 10:00 AM, that Resident #121's antibiotics had not been started. RN #3 indicated that she notified the resident representative and the medical APRN of the delay, and the Ceftriaxone was administered on 1/12/26 at 10:00 AM. RN #3 identified that the medical APRN's original order was for Cefpodoxime Proxetil 200 mg, 1 tablet by mouth every 12 hours, and that antibiotic was not available at the facility. When the pharmacy delivered the order in the evening, Resident #121 was not able to swallow the tablet so an order for IV Ceftriaxone was obtained and an peripheral IV line was placed on 1/11/26 at 11:12 PM. RN #3 further indicated that IV Ceftriaxone was available in the facility's emergency box and should have been administered after obtaining IV access, ideally before midnight. RN #3 identified that Resident #121 received his/her first dose of antibiotics on 1/12/26 at 10:00 AM, when LPN #9 brought the concern to her attention, subsequent to surveyor inquiry. Review of the clinical record with the DNS and the Regional Director Resource Nurse (RN #8) on 1/14/26 at 10:00 AM failed to identify Resident #121 received antibiotics for the treatment of pneumonia, in a timely manner.During an interview with the DNS and RN #8 on 1/14/26 at 10:00 AM, the DNS identified that, during her investigation of why the administration of Resident #121's antibiotics were delayed, the 11:00 PM - 7:00 AM LPN indicated she could not find the saline to reconstitute the Ceftriaxone. The DNS indicated that the RN Supervisor was notified and took the LPN's word for it that the saline was not available. The APRN was notified, but she did not want to modify the order to IM (intramuscular). The DNS could not identify if the saline unavailability and delay of the antibiotic administration was communicated to the 7:00AM - 3:00PM (LPN #9) nurse during shift report, as none of this information had been documented in the clinical record, and she was relying on information from interviews obtained during her investigation. The DNS identified that the saline must have been available at the facility because LPN #9 was able to administer the medication as soon as it was identified that the antibiotic had not been given. The DNS indicated that she would have expected Resident #121 to have received the IV Ceftriaxone following the insertion of the peripheral line and would have expected the RN Supervisor to look for the saline, not take the LPN's word for it that it was not available. The DNS further identified that she would expect the reason for the delay in the antibiotic administration to be documented in Resident #121's clinical record. The Verbal Orders policy directs that physician orders may be received by telephone, by a licensed or registered health care specialist who is legally authorized to do so and to follow through with orders by making appropriate contact or notification.The Medication Administration policy directs medications are to be administered by licensed staff, as ordered by the physician and in accordance with professional standards of practice; ensuring that the six rights of medication administration are followed: the right resident, drug, dosage, route, time, and documentation. The policy further directs that medications are to be administered within 60 minutes prior to or after scheduled times unless otherwise ordered by the physician.

Based on observation, review of the clinical record, facility policies, and interviews for 1 of 4 residents (Resident #12) reviewed for pressure ulcers, the facility failed to complete a nutritional assessment for a resident with a newly re-opened pressure injury in a timely manner, and for 2 of 4 residents (Residents #60 and 121) reviewed for pressure ulcers, the facility failed to ensure a specialty mattress was set in accordance with a physician's order, and for Resident #121, the facility failed to ensure a comprehensive pressure ulcer assessment was completed on admission. The findings include: Resident #12 was admitted in 4/2025 with diagnoses that included Type II diabetes and atrial fibrillation. The quarterly MDS dated [DATE] identified Resident #12 had severely impaired cognition, required one person assist for bed mobility, transfers, was dependent for toileting needs, had no unhealed pressure ulcers and was at risk for developing a pressure ulcer. The care plan dated 10/22/25 identified Resident #12 had was at risk for malnutrition and skin breakdown. Interventions included provide supplements as ordered and observe for signs and symptoms of skin breakdown. A wound consult dated 12/2/25 identified Resident #12 had a previously opened stage II pressure injury to the left buttocks that was resolved. Recommendations included continuing current skin care and breakdown prevention and discontinue supplements. Physician's order dated 12/2/25 directed to cleanse skin to buttocks and apply Calazime ointment every shift. A dietary progress note dated 12/29/25 identified a stage II pressure wound on the left buttock resolved 12/2/25, with moisture associated skin damage, (MASD) to the buttocks remaining. Recommendations included to discontinue Pro-stat (protein supplementation beneficial for wound healing) related to resolved pressure injury. Nurse's note dated 12/29/25 at 8:00 AM identified Resident #1 was seen by the certified wound nurse for a skin assessment of the buttocks. Resident #1 had MASD with open excoriations present to the left and right buttock. Skin was blanchable. Physician's order dated 12/2/25 directed to cleanse skin to bilateral buttocks and apply Calazime ointment every shift and cleanse wound with wound cleanser, pat dry, apply calcium followed by calcium alginate and cover with foam dressing in the evening. A wound consult dated 12/30/25 identified Resident #12 was being evaluated for an unstageable pressure wound on the left buttock measuring 5cm x 4.5cm x 3cm, 100% eschar (black necrotic tissue). The area was debrided, ultrasound mist therapy applied and new daily wound treatments initiated. A wound tracking dated 12/30/25 did not include the newly identified pressure ulcer to the left buttock. Risk management meeting minutes dated 12/31/25 identified Resident #12 had an in-house acquired deep tissue injury to the left buttock. A wound consult dated 1/6/26 identified weekly evaluation and treatment for an unstageable pressure wound to the left buttocks measuring 5.5 x 4 x 0.4cm. The area was partially debrided, then non-contact ultrasound therapy was provided with new wound treatment recommendations. A wound tracking dated 1/6/26 identified Resident #12 was being treated for a facility acquired unstageable pressure ulcer to the left buttock. A dietary progress note dated 1/12/26 at 1:05 PM, completed twelve days after the discovery of the newly reopened pressure wound on 12/30/25, identified Resident #12 had a previously resolved wound as of last assessment and was now being evaluated for a pressure wound to the left buttock per 1/6/26 wound note. Recommendations include Pro-stat AWC daily to promote wound healing. Interview with Dietitian #1 on 1/13/26 at 9:54 AM identified she routinely monitored residents with wounds and completed nutritional assessments of newly identified or recurrent wounds. Dietitian #1 indicated she obtained information through morning report, reviewing wound notes and by a weekly wound tracking report provided by the wound nurse. Dietitian #1 further identified she did not assess Resident #12 before 1/12/26 and would typically review a wound within one month of identification, as she was onsite three days weekly. Dietitian #1 was unable to recall being present at morning report or risk management when Resident #12's newly re-opened wound was discussed prior to 1/6/26. Interview with the Regional Dietitian on 1/13/26 at 11:06 AM identified Resident #12's newly identified wound should have been assessed by the dietitian as soon as possible after its discovery. Interview with APRN #1 on 1/13/26 at 12:07 PM identified that while she did not provide routine services for Resident #12, any resident with a pressure-related wound should be nutritionally assessed no more than five days after the discovery of a new wound. Interview with the DNS on 1/13/26 at 1:10 PM DNS identified new wounds were communicated during morning report, in a weekly wound report and at-risk management meetings. The DNS further identified that although there was no specific policy, a nutritional assessment should be completed for any resident with a new wound discussed at risk management within a week. Interview with RN #3 on 1/13/26 at 2:56 PM identified she was responsible for wound management at the facility. RN #3 indicated she completed a weekly wound tracking report listing all the residents with wounds in the facility and disseminated electronically to the interdisciplinary team. On 12/30/25, RN #3 completed rounds with the wound specialist where Resident #12's new wound was identified. RN #3 identified she completed the weekly wound tracking after rounds but did not include information regarding Resident #12's new wound as an oversight. RN #3 further identified, however, that she was present when Resident #12's wound was discussed during morning report and later at a scheduled risk management meeting on 12/31/25 confirming Dietitian #1 was present during both meetings. Dietary staff punch detail dated 12/30/25 through 1/12/26 identified a nutritionist was on-site six days, including on 12/31/25, before a nutritional assessment with new recommendations had been completed on 1/12/26. A review of the facility policy for Nutritional Management directs that a comprehensive assessment will be completed within 72 hours of admission, annually and upon a significant change of condition and follow-up assessments as needed. Components of the assessment may include any physical and medical conditions and monitored/revised on an ongoing basis. 2. Resident #60 was admitted to the facility in 10/2022 with diagnoses that included Parkinson's Disease, difficulty in walking, spinal stenosis, and adult failure to thrive. The quarterly MDS dated [DATE] identified Resident #60 had intact cognition, required substantial/maximal assistance with rolling left and right, sitting to lying, sitting to standing, and toilet transfers, was at risk for developing pressure ulcers/injuries, and required a pressure reducing device for the chair and bed. A physician's order dated 6/26/25 directed to provide a low air loss mattress to the bed set to 160 lbs. and check settings and functions every shift. The care plan dated 1/7/26 identified Resident #60 was at risk for skin breakdown related to limited mobility, incontinence, fragile skin, anticoagulation use, and failure to thrive. Interventions included a low air loss mattress to the bed set to 160 lbs. and to observe skin daily for any localized skin problems. Observation on 1/11/26 at 8:30 AM identified the specialty mattress was set to 400 lbs. and a sticker on the face of the pump unit directed the mattress to be set at 160 lbs. Observation with RN #6 on 1/11/26 at 9:49 AM identified the specialty mattress was set to 400 lbs. RN #6 adjusted the setting to 160 lbs. Interview with RN #6 on 1/11/26 at 9:50 AM identified that Resident #60's specialty mattress was not set to the setting that was directed by the sticker on the pump unit, and that Resident #60's specialty mattress setting was observed all the way up. RN #6 identified that it was the responsibility of the charge nurse to check the specialty mattress settings every shift, but she occasionally would make rounds on the unit and check specialty mattress settings. Interview with LPN #1 on 1/11/26 at 9:51 AM identified that he was the nurse assigned to Resident #60 from 7:00 AM - 3:00 PM and that his/her specialty mattress setting should be set according to the physician's order. LPN #1 indicated it was the responsibility of the charge nurse to ensure specialty mattresses are functioning and set correctly, each shift. LPN #1 identified that he had not yet checked Resident #60's mattress settings for the day shift but had done so during his shift the day before and was not aware that the specialty mattress had been set to 400 lbs. Interview with the Wound Nurse (RN #3) on 1/12/26 at 8:03 AM identified that Resident #60 currently did not have a pressure ulcer but had a history of a stage 3 pressure ulcer to his/her back. RN #3 indicated that Resident #60 had a history of kyphosis (excessive outward curvature of the spine) which put him/her at risk for developing pressure injuries to that area so as a preventative measure the specialty mattress remained in place as an intervention. RN #3 further indicated that it was the responsibility of the charge nurse to evaluate the specialty mattress function and settings every shift; in addition, she completed audits of all specialty mattress settings, every Monday. RN #3 identified that it was important to ensure specialty mattresses are set in accordance with the physician's order because a mattress that was too firm defeats the purpose of the interventions and won't relieve pressure. 3. Resident #121 was admitted to the facility in 12/2025 with diagnoses that included metabolic encephalopathy, neurocognitive disorder with Lewy Bodies, chronic systolic heart failure, and type 2 diabetes mellitus. The Nursing admission assessment dated [DATE] at 1:23 PM identified that Resident #121 had a pressure injury/ulcer to the coccyx, MASD to the groin, and his/her right and left heels were dry and scaly. The Nursing admission Assessment failed to identify wound measurements and/or staging of the coccyx pressure injury/ulcer. The Braden score identified Resident #121 was at high risk for developing pressure injuries. The nurse's note dated 12/16/25 at 10:13 AM identified Resident #121 had been seen by the wound specialist for a weekly wound assessment. A stage 4 pressure wound to the sacrum/coccyx that measured 1.5 x 1.4 x 0.4, wound bed is 25% granulation, 75% non-ran/necrosis, edges were macerated, moderate serosanguinous drainage, surrounding skin color and temperature were within defined limits. The wound was cleansed and treatment applied, tolerated well. Refer to wound physician note for full visit details. The admission MDS dated [DATE] identified Resident #121 had had severely impaired cognition, required substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting, was dependent with sitting to standing and toilet transfers, had 1 stage 4 pressure ulcer, and required the following pressure ulcer/injury treatments: pressure reducing device for bed and chair, nutrition or hydration intervention to manage skin problems, and pressure ulcer/injury care. A physician's order dated 12/17/25 directed to provide a low air loss mattress to the bed, one time only for 1 day, bed safety check and hand check set up, and end every shift setting 170, check settings and functions every shift The care plan dated 1/5/26 identified Resident #121 was at risk for skin breakdown related to impaired mobility, incontinence, increased risk for wound worsening related to poor oral intake and decline, actual coccyx pressure ulcer. Interventions included a low air loss mattress set to 170 lbs. and weekly skin checks by licensed nurse. Observation on 1/11/26 at 8:30 AM identified Resident #121's specialty mattress was set to 350, a sticker on the face of the pump unit identified the mattress setting should be set to 130 (physician's order directs for setting of 170). Observation with RN #6 on 1/11/26 at 9:48 AM identified Resident #121's specialty mattress was set to 350; RN #6 adjusted the setting to 130. Interview with RN #6 on 1/11/26 at 9:50 AM identified that Resident #121's specialty mattress was not set to the setting that was indicated by the sticker on the pump unit, and that Resident #121's specialty mattress had been set at 350. RN #6 identified that it was the responsibility of the charge nurse to check the specialty mattress settings every shift, but she occasionally would make rounds on the unit and check specialty mattress settings. Interview with LPN #1 on 1/11/26 at 9:51 AM identified that he was the nurse assigned to Resident #121 from 7:00 AM - 3:00 PM and that his/her specialty mattress setting should be set to the physician's order, and he would have to confirm Resident #121's mattress setting with the physician's order. LPN #1 indicated that it was the responsibility of the charge nurse to ensure specialty mattresses were functioning and set correctly, each shift. LPN #1 identified that he had not yet checked Resident #121's mattress settings for the day shift but had done so the day before and was not aware that the specialty mattress was set to 350. Interview with the Wound Nurse (RN #3) on 1/12/26 at 8:03 AM identified that Resident #121 was admitted with a stage 4 pressure ulcer, which was almost healed, but that Resident #121 was very deconditioned. RN #3 further indicated that it was the responsibility of the charge nurse to evaluate the specialty mattress function and settings every shift and in addition she completed audits of the specialty mattress settings every Monday. RN #3 identified that it was important to ensure specialty mattresses were set in accordance with the physician's order because a mattress that was too firm defeats the purpose of the interventions and won't relieve pressure. Clinical record review with the Wound Nurse (RN #3) and the Regional Clinical Resource Nurse (RN #5) on 1/3/26 at 12:50 PM failed to identify a comprehensive assessment, including wound measurements and staging, was completed on admission, 12/12/25, or prior to 12/16/25 (4 days), of Resident #121's pressure ulcer to the coccyx. During an interview with RN #3 and RN #5 on 1/3/26 at 12:50 PM, RN #3 identified that she was not in the facility when Resident #121 was admitted on [DATE], but she had rounded with the Wound Specialist on 12/16/25 and documented a comprehensive wound assessment. RN #3 indicated that prior to her wound assessment, which was completed during wound rounds, there was no documentation in Resident #121's clinical record that the coccyx pressure ulcer had been measured or staged. RN #3 further indicated that pressure ulcers that were present on admission should be measured, staged, and documented by the admitting nurse. During an interview with the DNS and the Regional Director of Resource Nurses (RN #8) on 1/14/26 at 9:59 AM, the DNS identified that it was the responsibility of the nurse to confirm specialty mattress settings were set according to the physician's order and should be documented in the clinical record. The DNS indicated that the Wound Nurse also completed weekly audits of the specialty mattress settings, and RN #8 identified that the physician's order and the specialty mattress setting should match. The DNS indicated that it was the expectation that documentation of a pressure ulcer that was present on admission would be documented in the clinical record and would include a description, measurements, and staging of the pressure injury, and it was the responsibility of the RN Supervisor to ensure that assessment was completed. The Use of Support Surfaces policy directs support services will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. Support surfaces will be chosen by matching the potential therapeutic benefit with the resident's specific situation. Considerations for utilizing specialized support services: medical condition, size and weight, mobility and activity levels, need for moisture control or shear reduction, presence of pressure injuries including severity and location, risk for developing a pressure injury or at high risk for additional pressure injuries, pain or discomfort, bottoms out on current surface. Except for the facility's standard mattresses and wheelchair cushions support services will be utilized in accordance with the physician's order. The Pressure Injury Prevention and Management policy directs the facility to establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have pressure injury present. Pressure injuries will be differentiated from non-pressure injuries, such as arterial, venous, diabetic, moisture or incontinence related skin damage. Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate if present, presence of pain, signs of infection, wound bed, wound edge and surrounding tissues characteristics. The Documentation of Wound Treatments policy directs the facility to complete accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and change in treatment. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. The following elements are documented as part of a complete wound assessment: type of wound and anatomical location, stage of the wound, if pressure injury or the degree of skin loss if non-pressure, measurements including height, width, depth, undermining, and tunneling, and description of wound characteristics.

Based on review of clinical records, interviews, facility documentation and facility policy for one (1) of three (3) residents (Resident #1) reviewed for a change of condition, the facility failed to notify the resident's family of a critical lab value result. The findings included: Resident #1 was admitted to the facility in March of 2025 with diagnoses that included cervicalgia, other spondylosis, and subluxation of the T2/T3 thoracic vertebra. The comprehensive Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 11), required set-up assistance with eating and oral hygiene, and required supervision with personal hygiene. The Resident Care Plan (RCP) dated 3/18/25 identified a risk for malnutrition related to hyponatremia, dehydration, intravenous fluids, variable oral intake, mechanically altered diet, and oral nutritional supplements. Interventions directed to monitor for signs of dehydration and monitor weights and labs as available. Lab results dated 4/16/25 at 2:53 PM identified a critical serum sodium level of 99. Nursing notes dated 4/16/25 at 3:54 PM identified Resident #1 was seen by MD #1 and APRN #1, new orders for a KUB (kidney, ureter, bladder x-ray) and an ultrasound to bilateral upper extremities, and that Person #1 was aware of all new orders, however failed to indicate Person #1 was informed of the critical sodium level of 99. Nursing notes dated 4/16/25 at 6:55 PM identified a peripheral intravenous line was inserted into Resident #1's left hand and that a one (1) liter normal saline infusion was initiated at 50 milliliters per hour, however failed to indicate Person #1 was informed of the critical sodium level of 99. Nursing notes dated 4/17/25 at 3:50 PM identified a STAT BMP (basal metabolic panel) was ordered for Resident #1, intravenous hydration was completed, and Person #1 was aware of all new orders. Review of the Notification of Changes policy directed to promptly inform the resident, consult with the resident's physician, and notify, consistent with his/her authority, the resident's representative when there was a change requiring such notification which included circumstances that required a need to alter treatment, such as a new treatment or discontinuation of current treatment due to adverse consequences, acute condition, or exacerbation of a chronic condition. ,

Based on review of clinical records, interviews, facility documentation and facility policy for one (1) of three (3) residents (Resident #1) reviewed for a change of condition, the facility failed to ensure follow-up labs were drawn in a timely manner for a resident with critical lab values. The findings included: Resident #1 was admitted to the facility with diagnoses that included cervicalgia, other spondylosis, and subluxation of the T2/T3 thoracic vertebra. The comprehensive Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 11), required set-up assistance with eating and oral hygiene, and required supervision with personal hygiene. The Resident Care Plan (RCP) dated 3/18/25 identified a risk for malnutrition related to hyponatremia, dehydration, intravenous fluids, variable oral intake, mechanically altered diet, and oral nutritional supplements. Interventions directed to monitor for signs of dehydration and monitor weights and labs as available. Review of the hospital discharge records dated 3/12/25 identified Resident #1 was hyponatremic with a serum sodium level of 128, was treated with gentle fluid hydration, and his/her sodium level improved to 131 prior to discharge. Lab results dated 4/16/25 identified a critical serum sodium level of 99. Provider's orders dated 4/16/25 at 3:49 PM directed a Basic Metabolic Panel (BMP) (blood test that measures levels in the blood to assess metabolism, kidney function, blood sugar, and electrolyte balance) with a requested service date of 4/17/25. Review of the clinical record identified the order was canceled the morning of 4/17/25 and replaced with an order for a STAT (immediate) BMP at 11:15 AM. The BMP results dated 4/17/25 identified Resident #1's blood was drawn on 4/17/25 at 9:26 PM, was received by the lab for processing on 4/18/25 at 12:54 AM, and resulted on 4/18/25 at 2:02 AM with a critical serum sodium level of 103. APRN #2's (On-Call APRN) note dated 4/18/25 at 2:34 AM identified he/she was informed of Resident #1's abnormal sodium result of 103, Resident #1 was unarousable upon exam, Resident #1's condition was critical and directed Resident #1 be sent to the hospital. The 4/18/25 hospital record identified Resident #1 was diagnosed with hyponatremia, hypokalemia, hypomagnesemia, acute respiratory failure with hypoxia, hypovolemia, altered mental status, and was admitted into the critical care unit. An interview with APRN #1 on 5/13/25 at 11:20 AM identified an order for a BMP (which included a serum sodium level) was initially ordered on 4/16/25 at 3:49 PM, with a service date of 4/17/25. APRN #1 further indicated the lab results should have been available by the time he/she arrived at the facility on the morning of 4/17/25 and after identifying the labs were not drawn, placed a new order at 11:15 AM for a STAT BMP. APRN #1 indicated he/she immediately informed LPN #1, who was assigned to care for Resident #1 during the 7:00 AM to 3:00 PM shift on 4/17/25, of the STAT order. The order was entered into the lab portal at 12:45 PM (one hour and thirty minutes after the order was entered). Interview with MD #1 on 5/13/25 at 12:09 PM identified he/she was aware of the critical sodium level of 99 on 4/16/25 and ordered one (1) liter of normal saline to be administered at 50 milliliters per hour, Lasix 40 milligrams daily for treatment of hyponatremia, and a follow-up lab draw for 4/17/25 to re check Resident #1's sodium level. MD #1 further indicated the follow up sodium level of 103 was not an adequate response to the interventions ordered and required transfer to the hospital. A confirmation for the lab order dated 4/16/25 (with a service date of 4/17/25) was requested, however, the facility was unable to provide verification that the lab was ordered. Interview with APRN #1 on 5/13/25 at 4:00 PM identified he/she was not informed of any issue with the initial BMP order (entered on 4/16/25) and was never told lab orders needed to be entered as STAT to be drawn on a non-routine lab day (4/17/25). Interview with LPN #1 on 5/14/25 at 9:42 AM identified an order entered as STAT should be carried out immediately after completing essential in progress tasks. The process to enter a STAT lab order required the order to be entered into the electronic lab portal and to place a phone call to the lab service provider to directly notify the lab of the STAT order. Interview with the Director of Nurses (DON) on 5/14/25 at 10:30 AM identified the facility failed to process the BMP ordered by APRN #1 on 4/16/25. The DON further identified that both the charge nurse and nurse supervisor were responsible for checking pending orders in the electronic medical record (EMR) which is where the lab order would have been entered by the provider for facility processing. Interview with Person #1 (lab service provider) on 5/14/25 at 2:48 PM identified labs ordered for non-routine lab draw days (4/17/25) would need to be entered STAT for the lab to be scheduled and drawn and that the lab technician would be dispatched to fulfill the order within eight (8) hours after the order was placed. Person #1 further indicated that if a lab order needed to be drawn more expediently, the facility should have entered specifications in the comment field of the order screen. Person #1 identified the comment field for the lab order dated 4/17/25 was blank.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to maintain nourishment refrigerators in a clean and sanitary manner including labeling, dating and discarding food items as per the policy. The findings include: A tour of the resident's nourishment refrigerators with the Director of Dietary on [DATE] at 7:40 AM identified the following. Nourishment refrigerator #1. Brown liquid on the bottom in the freezer and the refrigerator had dried liquid on the bottom shelf and splatter marks on the inside walls. Ice cream partially eaten not labeled or dated in the freezer. Minestrone soup dated [DATE], not labeled with a name. Small container with sausage cubes and toothpicks in each piece of meat dated [DATE] not labeled with a name. A sandwich baggy with 4 cheese cubes dated [DATE] not labeled with a name. A chicken sandwich on a plate with saran wrap not labeled with a name or dated. A peanut butter and jelly sandwich in saran wrap with hard bread dated [DATE]. A sandwich baggy with 5 cubes of cheese dated [DATE] not labeled with a name. A sandwich baggy with 13 cubes of cheese dated [DATE] not labeled with a name. A sandwich baggy with 16 cubes of cheese dated [DATE] not labeled with a name. Brown pudding in a bowl with a lid not labeled with a name or dated. A cup of applesauce with a lid not labeled with a name or dated. Inside the bottom drawer was a brown paper bag dated [DATE] with a small round cheesecake with no date, and cheese sticks, 2 expired on [DATE], 1 expired on [DATE], and 1 expired on [DATE]. In the bottom drawer was a bag of 8 tangerines not labeled with a name or dated. Nourishment refrigerator #2. Crumbs on the shelves in the refrigerator and liquid spots in the refrigerator. The freezer had a reddish-brown liquid frozen on the bottom. The seal of the freezer was torn and missing pieces. In the freezer was a frozen yogurt labeled with a name but not dated. In the freezer was a reusable metal 40 ml water bottle not labeled with a name or dated. In the freezer was a red liquid in an Arizona bottle half full not labeled with a name or dated. In the freezer was a half-eaten ice cream caramel cookie crunch not labeled with a name or dated. In the refrigerator was a pitcher of liquid not labeled with a name or dated. There was a ,d+[DATE] sandwich that was wrapped in paper towels and was hard to touch, not labeled with a name or dated. Soup in a bowl with lid dated [DATE] not labeled. An interview with the Director of Dietary on [DATE] at 8:20 AM indicated that it was the kitchen and housekeeping's responsibility to keep the nourishment refrigerators and freezers clean. The Director of Dietary indicated she usually cleans them daily, but she was off on Friday, Saturday, and Sunday and identified that it was the cook's responsibility when she was off. The Director of Dietary did not know why the freezers and refrigerators were not kept clean and indicated all items in the nourishment refrigerator were to get discarded after 3 days. The Director of Dietary indicated all staff and visitors know that all items must be labeled and dated before placing them in the refrigerator or freezer and there was a sign on the front of both refrigerators to remind the staff and visitors. The Director of Dietary indicated in refrigerator #1 that she did not know how she missed the brown paper bag in the bottom drawer with the expired cheese sticks. The Director of Dietary indicated in refrigerator #2 in the freezer the yogurt and water bottle belonged to staff and staff are aware they are not allowed to use the resident's nourishment refrigerator. The Director of Dietary indicated the water pitcher with juice was from the nourishment cart and nursing should have dated it before placing it in the refrigerator. Review of the policy on resident refrigerators identified items not labeled and dated will be discarded. Items older than 3 days will also be discarded. Review of the facility food brought in for residents identified food brought into resident's by family or visitors will be handled and stored in a safe and sanitary manner to ensure the safe consumption of food brought in. Storing food brought in that requires refrigeration shall be labeled with the resident's name and date that the food was brought in. Food must be stored in a closed container to prevent contamination. Food with be held in the refrigerator for 3 days following the date on the label and will be discarded by staff.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #74) reviewed for positioning, the facility failed to ensure positioning in wheelchair per policy. The findings include: Resident #74 was admitted to the facility with diagnoses that included muscle weakness, difficulty in walking and dementia. An Occupational Therapy note dated 12/7/23 identified Resident #74 was a fall risk and dependent on staff to put on and take off footwear. Resident #74 utilized a wheelchair and could sit unsupported for 30 seconds with his/her feet flat on floor but was unable to stand unsupported with an assistive device. The quarterly MDS dated [DATE] identified Resident #74 had severely impaired cognition, was always incontinent of bowel and bladder and required maximum assistance for transfers from bed to chair and toilet transfers. Resident #74 was independent with self-propelling in a standard wheelchair at least 150 feet in hallway and 50 feet when making 2 turns. Resident #74 was non ambulatory. A physician's order dated 1/10/24 directed a pressure redistribution cushion to chair. The care plan dated 1/18/24 identified the resident was at risk for skin breakdown due to limited mobility. Interventions included applying pressure redistribution surfaces to chair as per guidelines. Resident #74 uses a sit to stand lift for transfers. Resident #74 self-propels in wheelchair so keep room free from clutter. Observation on 1/22/24 at 10:10 AM identified Resident #74 was self-propelling down the hallway in a standard wheelchair using only his/her arms. The resident's legs were unable to reach the floor and observed extended outward and dangling about 4-5 inches above the floor. The wheelchair was without the benefit of leg rests. Interview with Resident #74 on 1/22/24 at 10:11 AM indicated he/she does not have leg rests but was requesting if someone could get some. Resident #74 indicated he/she was not comfortable in the wheelchair because his/her legs did not reach the floor because of a new cushion. Interview with NA #1 on 1/22/24 at 10:12 AM indicated she provided morning care for Resident #74 and the resident required a stand pivot with one assist out of bed to the standard wheelchair. NA #1 indicated Resident #74 did not have leg rests in his/her room for the wheelchair. NA #1 searched the room and the closet and indicated no leg rests could be found and identified she did not know how long they have been missing. NA #1 indicated she did not inform anyone about the missing leg rests. Interview with NA #2 on 1/22/24 at 10:15 AM indicated that the central supply person had received several new wheelchair cushions, and the central supply person went around giving residents new cushions. NA #2 indicated the central supply person gave Resident #74 a new cushion last Friday, but the new cushion was higher than the last cushion Resident #74 had. Interview with the Director of the Rehabilitation Department (PT #1), on 1/22/24 at 10:18 AM indicated that everyone was responsible for assigning cushions to wheelchairs. PT #1 indicated that sometimes it is the rehab department, sometimes nursing and sometimes the central supply person. PT #1 indicated Resident #74 self-propels sometimes with his/her arms and sometimes with his/her legs. PT #1 indicated Resident #74 sometimes uses leg rests for going outside and Resident #74 sometimes attempts to stand independently and was a fall risk. PT #1 indicated if there were leg rests on Resident #74's wheelchair, it could be more dangerous if Resident #74 attempted to stand up with the leg rests on the wheelchair. In an observation of Resident #74 while in the wheelchair, PT #1 indicated that Resident #74's feet do not touch the floor and were about 4 inches from the floor. PT #1 indicated Resident #74 was sitting on a higher cushion than he remembers. PT #1 indicated he could lower the wheelchair to use the same cushion or change the cushion so Resident #74's feet would reach the floor. PT #1 indicated he could also add leg rests. In an interview with Resident #74 on 1/22/24 at 10:20 AM he/she informed PT #1 that he/she was not comfortable with the positioning in the wheelchair. Resident #74 indicated he/she would like to try changing the cushion and have leg rests. Interview with LPN #1 on 1/22/24 at 10:30 AM indicated Resident #74 only uses his/her arms to self-propel in the wheelchair and does not use his/her legs. Interview with PT #1 on 1/22/24 at 10:35 AM identified the measurement from Resident #74's feet to the floor was 4.5 inches and the new cushion on the wheelchair was 2.5 inches high. PT #1 indicated the old cushion was only about a half inch high. PT #1 indicated he could lower the wheelchair and change cushion and give Resident #74 leg rests. PT #1 with OT #1 searched Resident #74's room and indicated there were no leg rests in the room and did not know how long they were not available. In an interview on 1/22/24 at 10:45 AM, Resident #74 reported to PT #1 and OT #1 he/she wanted leg rests. After surveyor inquiry, a physician's order dated 1/22/24 directed occupational therapy evaluation and treatment as recommended. Observation on 1/24/24 at 8:36 AM identified Resident #74 was sitting in his/her wheelchair eating breakfast with a one-inch cushion and bilateral leg rests on the wheelchair with his/her legs resting on the leg rests. Interview with the Staff Development Nurse, (RN #1) on 1/24/24 at 8:45 AM indicated nursing staff are educated on a web-based system with paper posttest. RN #1 indicated the nursing staff must have competencies. RN #1 indicated if a resident cannot self-propel with their legs, then the wheelchair must have leg rests. Interview with LPN #1 on 1/24/24 at 9:00 AM indicated therapy was in with Resident #74 this morning and gave Resident #74 a smaller cushion which was not as high for the wheelchair and leg rests to make him/her more comfortable. Interview with Director of Rehabilitation (PT #1), on 1/25/24 at 10:45 AM indicated on 1/22/24 he lowered Resident #74's wheelchair, added leg rests and changed the cushion. PT #1 indicated Resident #74 was picked up by OT for positioning and was now on case load. Review of the facility use of a wheelchair policy identified the purpose was to provide mobility for non-ambulatory residents with safety and comfort. A wheelchair should be the proper size: if too large the resident will not maintain good body alignment and if too small skin irritation will result due to pressure. Do not remove leg rests unless resident uses feet on floor to enable mobility. Pad seat of the chair with a pressure reducing cushion. Ensure cushion has a cover. Assist resident into wheelchair and lower leg rests and place resident's feet on the footrests. Position feet and legs in proper body alignment.

Based on review of facility documentation and policy for 1 of 5 personnel files reviewed, the facility failed to conduct a required background for an LPN, according to policy, prior to hire. The findings include: LPN #2's hire date was 1/17/22. Review of LPN #2's personnel file identified that LPN #2 consented to a background check on 1/6/22, however, the file did not contain the state required ABCMS background check, including fingerprinting. Interview with the Director of HR on 1/26/24 at 1:00 PM identified LPN #2 did not have the required background check prior to hire. The Director of HR identified that she did not know why the background check was not done as it was prior to her employment at the facility. Review of the facility policy on background checks identified all offers of employment are contingent upon clear results of a thorough background check. Background checks will include social security verification, prior employment verification, personal and professional references, criminal history and state specific background checks, i.e. facilities operating in states that require state specific background check processes shall be adhered to per state guidelines.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 9 residents (Resident #40) reviewed for PASSAR, the facility failed to submit a PASSAR when a resident received a new diagnosis. The findings include: 1. Resident #40 was admitted to the facility initially on 5/12/14 with a diagnosis that included mild or situational depression, myocardial infarction, and urinary tract infection. A PASARR Level 1 dated 5/1/14 identified Resident #40 had a diagnosis of mild or situational depression with no major mental illness and no diagnosis of dementia. The outcome from the assessment indicated a 120 day short term approval. Resident #40 was readmitted to the facility on [DATE] with diagnoses that included anxiety disorder, congestive heart disease, depression, and cerebral infarction. The care plan dated 3/25/23 identified Resident #40 was at risk for distressed and fluctuating mood symptoms related to diagnosis of depression. Interventions included to monitor for signs and symptoms of worsening sadness and depression. The annual MDS dated [DATE] identified Resident #40 had severely impaired cognition, a diagnosis of dementia, anxiety disorder, depression other than bipolar, and psychotic disorder other than schizophrenia, and received antidepressants 7 days a week. The social worker annual assessment dated [DATE] identified Resident #40 was not considered by the state level 2 PASARR process to have a serios mental illness and/or intellectual disability or a related condition. Interview with the MDS Coordinator, (RN #5) on 1/24/24 at 9:49 AM identified Resident #40 had an MDS dated [DATE] that indicated no for a diagnosis for PASSAR. RN #5 indicated Resident #40 was admitted without a diagnosis of dementia but in October of 2022 was given a diagnosis of dementia. Interview with SW #1 on 1/24/24 at 10:15 AM indicated social services was responsible to update the PASSAR when there was a new psychiatric diagnosis or if someone came in as a Level 2 and needed updates based on how many days the resident was approved for. SW #1 indicated after the surveyor requested the PASSAR for Resident #40, SW #1 indicated she reviewed the medical record and had noticed Resident #40 had a diagnosis of major depression after admitted d 5/12/14, but that diagnosis was not on the admission PASSAR. SW #1 indicated at that time a new PASSAR should have been done with the new diagnosis and it wasn't done. SW #1 indicated Resident #40 had a 120 day approval and there was not another PASARR completed at that time. SW #1 indicated it also did not get picked up when the prior social worker, SW #2, had done an audit of all PASSAR's for all residents that were in the facility in beginning of 2022. SW #1 indicated when she started in early 2022, the SW #2 had completed an audit of all PASSAR's in the facility a couple of months before she left and informed her that all the PASSAR's were up to date and were all set. SW #1 indicated she assumed, moving forward, she only had to review the PASSAR's on admission and when psychiatry identified a new psychiatric new diagnosis. SW #1 indicated it was missed and was an oversight. SW #1 indicated that she submitted a new PASSAR on 1/23/24 and today she received the outcome of the PASSAR as a Level 1 exempt due to the new diagnosis of dementia in 2022. SW #1 indicated she and the other social workers at the facility had started an audit yesterday of all PASSAR's in the facility to make sure the diagnosis on the PASSAR matches the diagnosis list in the medical record and would update PASARR if needed. Review of the facility preadmission screening for mental illness and/or intellectual development disability policy identified facility staff will ensure that appropriate pre-admission screening for mental illness and intellectual disability was conducted per federal and state regulations. Individuals identified with mental illness, or intellectual or developmental disability will be provided with appropriate services. The facility staff will ensure upon admission the pre-admission screening and resident PASARR has been completed. If a PASSAR is incomplete or incorrect, social services will coordinate with appropriate needs and services and any recommendations with be incorporated into the plan of care. Completed PASSAR's will be kept in the medical record. Social Services will coordinate any updates as needed and per the federal and state regulations. 46040

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #29) reviewed for pressure ulcers, the facility failed to ensure that a low air loss mattress was applied timely for a resident admitted at risk of skin breakdown, and failed to ensure that an RN assessment was completed on a newly identified skin issue. The findings include: Review of the hospital discharge summary dated 11/23/23 identified Resident #29 was discharged from the hospital to the facility with a wound vac in place at the right hip due to an abscess requiring surgical intervention. Resident #29 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, osteomyelitis of the right femur, and insulin dependent diabetes. The care plan dated 11/23/23 identified Resident #29 was at risk for skin breakdown due to decreased mobility, incontinence, and actual skin breakdown related to a right hip pressure wound with wound vac. Interventions included completing weekly wound assessments to include measurements and description of the wound status. The Braden Scale (used to determine risk of pressure ulcer development) dated 11/23/23 identified that Resident #29 had a high risk of developing pressure ulcers. The admission MDS dated [DATE] identified Resident #29 had severely impaired cognition, was always incontinent of bowel, frequently incontinent of bladder and required maximum assistance with bathing, eating, and toileting. The MDS further identified Resident #29 was at risk for development of pressure ulcers. A physician's order dated 12/5/23 directed to apply a low air loss mattress with a setting of 160 lbs. The order further directed to check settings and function every shift. Review of the clinical record failed to identify that a low air loss mattress had been placed prior to 12/5/23, 12 days after admission. A nurse's note dated 12/17/23 at 2:43 AM by LPN #4 identified that Resident #29 had a change of condition evaluation due to newly identified skin issue. LPN #4 identified Resident #29 had a 2 cm x 3 cm pressure injury with blackened skin at the sacrum. The note further identified the APRN and Person #1, Resident #29's resident representative, were notified. Review of the clinical record failed to identify an RN assessment was completed following the development of the newly identified skin issue on 12/17/23. A wound care physician's note dated 12/19/23 identified Resident #29 was seen for follow up evaluation of a right hip post-surgical wound, and an initial evaluation of an unstageable full thickness pressure injury to the sacrum. The sacral wound measured 4.5 cm x 5.5 cm and the depth of the wound was unstageable due to the presence of nonviable tissue and necrosis. The treatment plan included a daily dressing of calcium alginate with silver, gauze island, and border dressing daily. The care plan dated 1/22/24 identified Resident #29 was at risk for skin breakdown due to decreased mobility, incontinence, and actual skin breakdown related to a right hip pressure wound with wound vac and a newly developed sacral pressure ulcer. Interventions included the use of a low air loss mattress and to check the function and settings every shift. Interview with Person #1 on 1/22/24 at 10:24 AM identified that Resident #29 had a pressure ulcer that developed after admission to the facility. Person #1 identified that Resident #29 originally came to the facility for care of a right hip wound and developed an area on his/her back side a couple of weeks after admission. Person #1 identified that he/she was upset about the new pressure ulcer, as he/she felt the facility should have had interventions in place due to Resident #29's history with wounds. Interview with LPN #2 on 1/25/24 at 1:45 PM identified she was unsure when the low air loss mattress was placed, but there had been issues with the settings related to firmness that happened 'a few months ago' and that maintenance recommended the setting of 160 lbs. LPN #2 identified she reached out to maintenance about the mattress a couple of days after the mattress was placed, but by verbal request, and that the placement and documentation of maintenance assisting would not have any documentation. Interview and review of the clinical record with RN #3 on 1/26/24 at 11:13 AM identified that Resident #29 was admitted to the facility with a wound vac to the right hip. RN #3 identified that Resident #29 was initially scheduled to see an outside wound care physician, but at some point, that changed and subsequently the facility wound care physician saw Resident #29 for an initial evaluation on the morning of 12/5/23. RN #3 identified that during the initial evaluation, she saw that Resident #29 had a low air mattress in place, but the mattress felt too soft and so the weight was increased to 160 lbs. to increase the firmness. RN #3 identified she was unaware how long Resident #29 had the mattress in place, who placed it, or why it would have been placed without a physician's order prior to 12/5/23. RN #3 identified that the facility had a system to request low air loss mattresses and she would research to see if a request had been made for the mattress to determine when it was applied to Resident #29's bed. RN #3 also identified that Resident #29 should have had an RN assessment following the newly identified pressure ulcer on 12/17/23 by LPN #4. RN #3 further identified LPN #4 would not be able to make the determination if a wound was related to a pressure injury, and that an RN assessment would be necessary to determine this. RN #3 identified that she was typically notified of newly identified skin issues by the nursing staff via 'a sticky note on my desk', text, or 24-hour report sheets, and she would often complete an RN assessments of new wounds, but that a nursing supervisor could also assess any new skin issues. RN #3 also identified she did review charts of residents with newly identified skin issues. Interview with the DNS on 1/26/24 at 11:42 AM identified that for any newly identified skin issues, an RN assessment should be completed. The DNS identified an LPN would not be able to make an assessment if a skin issue was related to a possible pressure injury, and that would need to be determined by an RN. The DNS identified she did not complete an RN assessment of Resident #29's wound on 12/17/23 and she was unsure why a RN had not assessed Resident #29's wound until 12/19/23 as this was not the facility policy. Interview with the Regional Clinical Manager on 1/26/24 at 11:59 AM identified that the low air loss mattress for Resident #29 was not located in the facility system, and he was unable to determine when the mattress was applied. Although requested, the facility failed to provide a policy on Braden Scale assessments, a policy on newly identified skin issues or a policy on low air loss mattresses. The facility policy on nursing assessments directed that LPNs may assist an RN to collect data for nursing assessments, but assessments would be reviewed, coordinated, and certified as complete by RN within 24 hours of the assessment. The policy further directed that nursing assessments included a change of condition.

Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #83) reviewed for psychiatric medication side effects, the facility failed to ensure a status change Level 1 PASRR screen was completed. The findings include: Resident #83 was admitted to the facility on [DATE] with diagnoses that included neoplasm of the brain, anxiety, and major depressive disorder. Review of the Notice of PASRR Level 1 Outcome report dated 5/27/21 identified Resident #83 had situational low level behavioral health symptoms, a diagnosis of major depression with no indicators identified that would signify the need for further evaluation, at that time. The report further identified that if Resident #83's symptoms/behaviors did not improve or resolve within 30 - 60 days of the screen, then the nursing facility must submit an updated status change Level 1 screen to reevaluate the need for a PASSR Level 2 behavioral health evaluation. The annual MDS dated [DATE] identified Resident #83 had intact cognition, had an active diagnosis of depression, and had taken an antidepressant during the last 7 days. The care plan dated 12/15/23 identified Resident #83 exhibited or was at risk for distressed fluctuating mood symptoms related to anxiety or fear. Interventions included observing for signs of delirium, including delusions and hallucinations; notifying the physician as needed, and referencing the delirium care plan for additional interventions. The care plan further identified Resident # 83 was at risk for complications related to the antidepressant, needed daily, to manage his/her mood. Interventions included observation of Lexapro side effects, completion of the behavior monitoring flow sheet, monitoring for changes in mental status and functional level, and reporting changes to the physician, as indicated. Interview with SW #3 on 1/26/24 at 10:52 AM identified that since Resident #83's admission on 4/22/21, 4 Level of Care evaluations had been completed, but an updated status change Level 1 screen, per the recommendation on the 5/26/21 PASAR Level 1 Outcome report, had not been submitted. SW #3 indicated that since Resident #83's behavioral health symptoms/behaviors did not improve or resolved within 30 - 60 days of the initial screen, the facility should have submitted another Level 1 PASRR screen. Interview with the Director of Social Service (SW #1) on 1/26/24 at 11:00 AM identified that another Level 1 PASRR screen should have been submitted for Resident #83. SW #1 further identified that another Level 1 PASRR screen will be submitted for Resident #83 and that an audit of all facility PASRR outcome reports will be conducted to ensure there are no additional residents that had missed a screening or evaluation. The facility's Pre-Admission Screening for Mental Illness and/or Intellectual/Developmental Disability policy directs facility staff to ensure that appropriate pre-admission screening for mental illness and/or intellectual/developmental disability is conducted per the federal/state regulations. Social Services will review the PASRR to determine appropriate needs/services and any recommendations will be incorporated into the plan of care.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure that a resident who had significant cognitive impairment did not leave the facility unescorted. Resident #1 was located by the police approximately 2 hours and 40 minutes after he/she was last seen by a staff and was transported to the hospital and treated for hypothermia. This resulted in a finding of Immediate Jeopardy. Resident #1 was admitted with diagnoses that included dementia, Parkinson's, anxiety, and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of six (6) indicative of severely impaired cognition, was independent with ambulation and activities of daily living. A care plan dated 11/27/2023 identified Resident #1 has a decline in cognitive function and impaired thought processes, short-and long-term memory loss, and impaired decision-making with interventions that directed to evaluate responses from Brief Interview for Mental Status assessment or staff assessment for mental status and address as indicated. A psychiatric evaluation dated 12/11/23 identified that Resident #1 had memory impairment, psychosis, confusion, poor coordination, and difficulty with decision making. A review of the facility's reportable event and investigation summary dated 12/12/2023 at 5:38 P.M. identified that Resident #1 had exited the facility. Resident #1 was last seen walking in the hallway around 2:50 PM by NA #4. Resident #1 was located with the assistance of the police department less than 0.3 miles from the facility at approximately 6:30 PM. Resident #1 was appropriately dressed in a coat and hat. Review of the police report dated 12/15/2023 at 9:04 A.M. identified on 12/12/2023 at approximately 6:03 P.M. officers were dispatched to the facility and met with the DNS who stated it was unlike Resident #1 to wander from the facility, but he/she would be confused and unsure how to get back to the facility. While searching the area, dispatch received a call regarding an elderly male that was found in a driveway. The caller was from a residence on a street that was located approximately half a mile from the facility. Police officers made contact with the resident and identified it was Resident #1. Resident #1 complained of being cold, however, did not report any injuries. Resident #1 was transported to the hospital for evaluation via ambulance. A review of the Hospital emergency room history and physical dated 12/13/2023 identified Resident #1 was brought into the emergency room by ambulance from a stranger's home, the resident has a history of dementia, and eloped from the skilled nursing facility. Resident #1 was found outside in freezing temperatures. Resident #1 was noted to be hypothermic with a body temperature of 34.3 degrees Celsius (93.7 degrees Fahrenheit) (normal body temperature is 98.6 degrees F) related to environmental exposure. Resident #1 required intravenous fluids and a Bair Hugger (a convective temperature management system used in a hospital setting to maintain a resident's core body temperature). Resident #1 was discharged back to the facility on [DATE]. A review of the outdoor temperatures identified on 12/12/2023 from 4:00 P.M. 6:00 PM the temperatures ranged from 36 to 41 degrees Fahrenheit, and the sun set at 4:23 PM (Resident #1 was seen by Dietary Aide #1 at 2:50 PM and was found at 6:30 PM, the resident was outside for at least 2 hours and 40 minutes). Review of Dietary Aide #1's orientation record indicated she was educated on managing elopement on 11/9/23, prior to the elopement on 12/12/23. Managing Elopement identified that if an employee observes a resident leaving the premises, he/she should attempt to prevent departure in a courteous manner, get help from other staff members in the immediate vicinity. Interview with Dietary Aide #1 on 1/4/2024 at 11:55 A.M. identified that on 12/12/2023 at approximately 3:50 P.M. as she pulled into the facility's parking lot, she observed a male standing in the facility's parking lot. Dietary Aide #1 identified that she thought the male appeared to be a resident and was concerned because it was getting dark outside. Dietary Aide #1 indicated she punched in for her shift, forgot about the male she saw in the parking lot, and did not communicate to any staff at the facility that she had seen a male who may have been a resident in the parking lot. Dietary Aide #1 identified at approximately 5:30 P.M. on 12/12/2023 while she was passing the dinner trays, when she arrived at Resident #1's room, he/she was not there. Dietary Aide #1 indicated she then went to the nurse station to report Resident #1 was not in his/her room. Dietary Aide #1 identified at that time she heard the nursing staff discussing they could not find Resident #1. Dietary Aide #1 identified on 12/12/2023 at approximately 5:30 P.M. she reported to the nurse on the unit that she had seen a man who appeared to be a resident in the parking lot when she pulled in at 3:50 P.M. Interview with NA #2 on 1/4/2024 at 11:00 A.M. identified that she was assigned to care for Resident #1 from 3:00 P.M. to 11:00 P.M. on 12/12/2023. NA #2 stated at the start of her shift she made rounds and Resident #1 was not in his/her room. NA #2 identified she did not return to Resident #1's room again. NA #2 indicated Resident #1 does not spend long periods of time out of his/her room but does walk throughout the facility. NA #2 identified at approximately 5:00 P.M., LPN #2 asked her if she had seen Resident #1 and she told LPN #2 she had not. NA #2 identified this is when she became aware that Resident #1 could not be located within the facility and at that point staff started searching for Resident #1. Interview with LPN #2 on 1/4/2024 at 12:50 P.M. identified she worked on 12/12/2023 from 3:00 P.M. to 11:00 P.M., and Resident #1 was on her assignment. LPN #2 identified at approximately 3:30 P.M. during her shift rounds she went to Resident #1's room, the bathroom door was closed, and at that time she thought Resident #1 was using the bathroom. LPN #2 indicated she had not gone back to Resident #1's room to see if he/she was out of the bathroom until approximately 5:00 P.M. LPN #2 identified at approximately 5:00 P.M. she went back to Resident #1's room to administer his/her medications and Resident #1 was not in his/her room. LPN #2 identified at that time she thought it was unusual and became concerned that Resident #1 was not in his/her room. LPN #2 identified that staff were looking for Resident #1, however, h/she could not be located within the facility. LPN #2 indicated she then notified RN #3 (the 3:00 PM to 11:00 PM nursing supervisor) that Resident #1 could not be found in the facility. LPN #2 identified she and other staff continued searching for Resident #1 outside on the grounds of the facility, however Resident #1 was not located. Interview with the Administrator, DNS, and RN #2 (Regional Nurse) on 1/4/2024 at 1:15 P.M. identified that Resident #1 would not be allowed outside the facility unattended. Once the resident was identified to be missing the facility followed their policy with a search both inside and outside the facility and when the resident could not be located the police were called, the police located the resident approximately 0.3 miles from the facility at approximately 6:30 PM and the resident was transferred to the hospital. The DON identified that after the investigation it was unclear how the resident had exited the building. Multiple attempts to interview RN #3 and NA #4 were unsuccessful. Review of the Elopement policy dated 3/2021 identified that the facility strives to prevent resident elopement. An elopement is identified as a resident leaving the premises without staff knowledge. If an employee observes a resident leaving the premises, he/she should attempt to prevent departure in a courteous manner, get help from other staff members in the immediate vicinity, if necessary; and instruct the other staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises and a search will be conducted lasting no longer than 30 minutes before the police are called. Review of the Emergency Preparedness Plan and Internal Disaster Plan for Elopement/Missing Resident, revised on 5/2021, identified in part there will be a designated person in charge to coordinate search from the front desk or predetermined location, a facility and grounds search is initiated 5-7 minutes required for search, if the resident is not located during the initial search notify the local police (911), Administrator, DNS, resident responsible party, and the physician. Immediate Jeopardy past non-compliance was identified during the onsite visit of 1/4/23 as the facility initiated corrective actions to prevent reoccurrence immediately after the incident on 12/12/23. The facility re-assessed Resident #1 for wandering and a wander guard was applied to Resident #1. Resident #1's plan of care was updated and reviewed with the interdisciplinary team. The facility audited all the exit doors to ensure alarms were functioning appropriately, conducted elopement assessments on all ambulatory residents, with no additional residents identified at risk. Staff were re-educated on the facility elopement prevention and management policy, and additional education on actions to take if you observe a resident in the parking lot unattended you must assist them back inside and report it to the supervisor. The facility then initiated audits and a QAPI process to ensure education was effective.

Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of six (6) residents, (Resident #2 and Resident #6) who were reviewed for abuse, the facility failed to ensure residents were free from physical abuse resulting in injury. The findings include: 1) Resident #2 had diagnoses that included type II diabetes and atherosclerotic heart disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was without cognitive impairment, required extensive two (2) person assist with Activities of Daily living (ADL), bed mobility, transfers, and personal care. A care plan dated 6/22/23 identified Resident #2 exhibited or was at risk for fluctuating moods related to sadness/depression with interventions that included to observe for symptoms of worsening sadness, depression, anxiety, fear, anger, agitation and refer to the behavioral health specialist as needed. 2) Resident #1 had diagnoses that included cerebral infarction, bipolar disorder, and psychophysiological insomnia (a type of sleep disorder). The admission MDS assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, did not display any hallucinations or delusions, required one(1) person assist with bed mobility, two (2) persons with transfer and limited one (1) person assist with walking in his/her room with a walker. A care plan dated 6/14/23 identified Resident #1 had a Pre-Admission Screening and Resident Review (PASRR) level of determination secondary to a serious mental illness of bipolar disorder and psychotropic medication use with interventions that directed to administer antidepressant medications as ordered, monitor for side effects, and arrange for a PASRR re-evaluation if there is a significant change in status. a) A Reportable Event dated 6/27/23 identified at 12:15 AM, Resident #1 struck his/her roommate Resident #2 in the head with a telephone causing a laceration. The residents were immediately separated. The police, Advanced Practice Registered Nurse, (APRN) were notified and both residents were sent to the hospital for evaluation. The Emergency Department (ED) note dated 6/27/23 at 2:03AM identified Resident #1 woke his/her roommate, Resident #2 by hitting him/her over the head with a landline phone. Resident #1 reported h/she wanted to kill his roommate and assaulted staff when they tried to separate Resident #1 from Resident #2 however, Resident #1 stated s/he had no recollection of the events, Resident # 1 was psychiatrically cleared, and returned to the facility. An incident/ Accident Staff/ Resident/ Witness Statement dated 6/27/23 written by Nurse Aide NA #2 identified she was in the hall with a co-worker when she thought she heard a fall. She went to the room (where Resident #1 and resident #2 resided) and observed Resident #1 with a phone in his/her hands and hit Resident #2 multiple times in the head. NA #2 attempted to take the phone away and Resident #1 began to hit her leg multiple times. An intra- agency Patient Referral Report dated 6/27/27 identified Resident #2 was evaluated at the emergency department after a head injury, laceration of the forehead. The Head CT scan (imaging that identifies abnormalities) showed no injury. The laceration was repaired with 8 sutures. An interview with Licensed Practical Nurse, LPN #1 on 7/13/23 at 10:32 AM identified she was working on the 11:00 PM to 7:00 AM shift on 6/27/23 to 6/28/23, rounds had just been completed and Resident #1 and Resident #2 were both in bed, quiet and sleeping with the lights out. LPN #1 further identified that sometime after 12:00 AM, LPN #1 was in the hall with another aide, (NA #2), when she heard someone yell for help. They ran to the room where she observed Resident #1 hitting Resident #2 on the head with the phone saying s/he was going to kill (Resident #2). The supervisor was notified, and staff separated the two residents by wheeling Resident #2 out of the room and down the hall. The police were called, and LPN #1 heard Resident #1 tell the police s/he was trying to kilI Resident #2. LPN #1 stated there were no previous issues reported by staff or by Resident #2 prior to the incident. Interview with the Director of Nursing on 7/13/23 at 12:48 PM identified Resident #1 had no known prior violent behaviors and there were no known issues between Resident #1 and Resident #2 prior to the incident. The two residents were placed in separate living quarters following return from the hospital and Resident #2 was subsequently discharged as planned the following day. Multiple attempts to interview NA #2 and the nursing supervisor were unsuccessful. 3) Resident #6 had diagnoses that included type II diabetes and dementia. The quarterly MDS assessment dated [DATE] identified Resident #6 had moderate cognitive impairment and was independent with Activities of Daily Living, (ADL's), requiring one person assist with dressing and personal care. A care plan dated 6/19/23 identified Resident #6 tremor impaired cognition and required some assist with ADL's due to tremors with interventions that directed to observe for changes in cognitive status and refer to rehabilitation therapy if a decline in ADL's was noted. 4) Resident #5 had diagnoses that included dementia with other behavioral disturbance. The Admission MDS assessment dated [DATE] identified Resident #5 had severe cognitive impairment and required extensive one person assist with ambulation on and off the unit using a walker or wheelchair. A care plan dated 6/18/23 identified Resident #5 had impaired cognition related to dementia, was resistive to care and could have combative behaviors with interventions that directed to allow time to express feelings and explain all care before initiating and evaluate the need for a psychiatric/behavioral health consult if indicated. a) A Reportable Event dated 6/28/23 identified on 6/26/23 at approximately 3:30 PM, Resident #5 was observed by rehab staff (the Director of Rehabilitation and Occupational Therapist, OT #1) to have followed Resident #6 into the rehabilitation room in his/her wheelchair and struck Resident #6 on his/her left upper thigh. The residents were immediately separated and Resident #6 sustained no injuries. The Advanced Practice Registered Nurse (APRN) was notified and local police. Resident #5 reportedly mistook Resident #6 as his/her spouse. The care plan was updated to ensure rehab sessions and activities be attended separately. Resident #5 was subsequently discharged on [DATE] as previously planned. Interview with the Director of Rehabilitation on 7/13/23 at 1:21 PM identified on 6/26/23 he observed Resident #5 follow Resident #6 into the rehabilitation therapy room and it appeared as if she knew him/her. Resident #5 stated You're going to find that blond. Resident #6 did not respond, and attempted to stand to stand when Resident #5 slapped him/her across the thigh. The Director of Rehabilitation immediately separated the two residents and notified the Director of Nursing. Interview with OT #1 on 7/13/23 2:00 PM identified she was in the therapy room when she observed Resident #5 following Resident #6 saying something about chasing skirts and believed Resident #5 thought Resident #6 was his/her spouse. Resident #6 did not respond to Resident #5, and when Resident #6 went to stand, Resident #5 struck him/her. An interview with the Director of Nursing (DNS) on 7/13/23 at 2:10 PM identified the incident was witnessed and that Resident #5 singled Resident #6 out thinking s/he was his/her spouse. A review of the facility policy for Abuse directed each resident had the right to be free from abuse including the willful infliction of injury resulting in physical harm.

Based on clinical record reviews, review of facility documentation, and interviews for two of three sampled residents (Resident #58 and #450) who were at risk for falls, the facility failed to provide the appropriate supervision and/or assistive devices to prevent a fall with injury. The findings include: 1. Resident #58's [DIAGNOSES REDACTED]. The significant change Minimum Data Set assessment dated [DATE] identified Resident #58 rarely and/or never made daily decisions related to poor cognition and short and long term memory deficits, required extensive two (2) person assistance with transfers in and/or out of the chair and bed, the resident's balance during transitions from surface to surface was not steady and the resident was only able to stabilize with staff assistance for transfers, was non-ambulatory, and had a history of [REDACTED]. The Resident Care Plan dated 11/20/17 identified the resident was at risk for falls. Interventions directed when out of bed in the wheelchair keep the resident in eye sight, when in bed place all necessary personal items within reach, maintain a clutter-free environment in the resident's room, place the call bell within reach at all times, place a protective cover over the chair cushion to prevent the resident from sliding out of her wheelchair, and offer a nap to the resident after toileting in the afternoon. The Situation Background Assessment Recommendation (SBAR) dated 2/3/18 at 1:17 PM identified the cushion had moved and the resident was lying on his/her right side in front of the wheelchair and the supervisor was called. The Reportable Event Form dated 2/3/18 at 1:15 PM identified Resident #58 was found on the floor in front of his/her wheelchair, and the cushion had moved on the wheelchair. The facility's investigation identified the wheelchair cushion slid forward causing Resident #58 to slide to the floor. In a written statement by the 7AM-3PM nurse aide identified Resident #58 was very active from the previous shift and she had gotten Resident #58 out of bed first thing in the shift which was earlier than usual time. The nurse's note dated 2/3/18 at 1:35 PM identified the 7AM-3PM nursing supervisor was called to assess the resident after a fall. The note identified the resident was found sitting on the floor with no visible signs of injuries, the resident had no complaints of pain and was assisted back in the chair. The nurse's note dated 2/3/18 at 23:00 PM identified after being transferred back to bed, Resident #58 complained of pain in the right hip and right lower back and subsequent to notification the physician ordered an x-ray. The nurse's note dated 2/3/18 at 6:22 PM identified Resident #58 was transferred to the hospital after the x-ray results were positive for a [MEDICAL CONDITION]. The nurse's note dated 2/6/178 at 11:35 AM identified Resident #58 was readmitted to the facility. Interview and review of clinical record with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 3/26/18 at 1:45 PM identified that Resident #58 had poor endurance in the wheelchair, was restless at times moving his/her hips when in the wheelchair, and would go back to bed for a nap after lunch. Interview with one of the 7AM-3PM nurse aides, Nurse Aide (NA) #1, on 3/26/18 at 1:55 PM identified Resident #58 was restless at times, would move his/her bottom back and forth when in the wheelchair, would always lean on something in front of him/her, and she had informed the nurses. NA #1 stated on 2/3/18 she got Resident #58 out of bed earlier than usual because the resident was restlessness and Resident #58 should have gone back to bed earlier since the resident was up early. NA #1 stated she was following the resident's usual routine and did not consider putting Resident #58 back to bed earlier. NA #1 identified on 2/3/18 Resident #58 was found by a visitor who alerted staff that the resident was on the floor. Interview with NA #3 on 3/26/18 at 2:10 PM identified Resident #58 would often put his/her head down when in the wheelchair, and usually would get up late in the morning because the resident would get tired and often lean forward in the wheelchair. NA #3 stated Resident #58 would go back to bed after lunch for a nap because he/she did not tolerate sitting in the wheelchair for a long time. During an interview and review of the clinical record with the Director of Nursing (DON) and Regional Nurse #1 on 3/27/18 at 9:35 AM the DON stated on 2/3/18 the cushion and Resident #58 slid out of the wheelchair. Interview and review of the clinical record and facility documentation with the DON and Regional Nurse #1 on 3/27/18 at 11:05 AM identified Resident #58 had a prior fall from the wheelchair on 10/28/17 and the intervention was to keep Resident #58 in eye sight when in the wheelchair. Interview and review of the clinical record with Social Worker #1 and the Unit Manager, RN #3 on 3/27/18 at 12:28 PM identified Resident #58 leaned forward in the wheelchair at times, and when seated at a table, the resident would put his/her head on the table. RN #3 stated after the 2/3/18 fall, the care plan was revised to include a dycem cushion on the wheelchair seat. Review of facility Falls Management Policy directed in part, fall risk will be assessed and appropriate interventions determined to reduce risk and minimize injury. 2. Resident #450's [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The 14-day Minimum Data Set assessment dated [DATE] identified that Resident #450 had difficulty focusing attention, was easily distracted, had difficulty recalling items, focusing attention, and keeping track of what was being said, required extensive two (2) person assistance with transfers in and/or out of the bed and chair, total assistance of two (2) staff for toileting, the resident's balance during transitions from surface to surface was not steady and the resident was only able to stabilize with staff assistance, and the resident had one fall since with no injury in the past ninety (90) days. The Physical Therapy note dated 4/3/17 identified Resident #450 had difficulty with transfers, and required maximum assistance with transfers from bed to wheelchair. The Physical Therapy notes dated 4/5/17 identified Resident #450 was a fall risk, reported dizziness during treatment and had a blood pressure of 89/57. The Care Plan Meeting note dated 4/6/17 at 1:26 PM identified that Resident #450's family was present and the purpose of the meeting was to review the resident's progress and discharge planning. The note identified Resident #450 continued to need much assistance with activities of daily living. When ambulating the resident tended to lan to one side, thus needing two (2) to assist at times with the rolling walker and wheelchair follow. Resident #450 was a moderate to maximum assistance with transfers. The note identified the family was made aware the resident may not progress to his/her previous baseline and the family requested a referral to a rehabilitation hospital. The Resident Care Plan dated 4/6/17 identified a fall risk related to impaired mobility. Interventions directed to place the call light within reach and to remind and encourage the resident to use the call light when attempting to reach for something and for transfers. The nurse's note dated 4/7/17 at 10:33 AM identified the resident was alert, confused and around 8:00 AM the resident fell and complained of left side pain. The note at 10:42 AM identified Resident #450 had sustained a skin tear on the left forearm, a treatment was applied and the healthcare agent was notified at 9:30 AM. The Reportable Event Form dated 4/7/17 identified that at 8:15 AM Resident #450 was found on the floor in the bathroom. The report identified Resident #450 was trying to grab for the wheelchair, the wheelchair moved, and the resident fell off the toilet landing on his/her side hitting his/her head. Resident #450 complained of pain on the left side and had a purpura area on the left forearm. The facility's investigation identified a Student Practical Nurse had taken Resident #450 to the bathroom, left the resident alone in the bathroom with the wheelchair close by, and was standing outside the bathroom door when the fall occurred. The nurse's note dated 4/7/17 at 4:07 PM identified Resident #450 had an unplanned transfer to the hospital related to abnormal bloodwork. Review of the hospital clinical record history and physical dated 4/7/17 identified Resident #450 was admitted with multiple left rib fractures of 7th, 8th and 9th which were non-displaced and displaced fractures of the right 10th and 11th posterior ribs, the resident did not sustain a pneumothorax. The hospital record identified resident's condition declined, developed pneumonia [MEDICAL CONDITION], requiring intubation and transfer to the intensive care until until 4/14/17 when the resident was extubated and the advanced directive was changed to comfort measures only. Interview with the Nursing Instructor on 1/30/18 at 12:05 PM identified the Student Practical Nurse took Resident #450 to the bathroom, left the resident alone in the bathroom with the wheelchair, shut the door for privacy, and waited on the other side of the door. Review of the clinical record with the Nursing Instructor identified Resident #450 was confused with cognitive impairments and a fall risk, and the Nursing Instructor stated Resident #450 should not have been left alone in the bathroom. Interview with the 7AM-3PM Unit Manager, Registered Nurse (RN) #1 on 1/31/18 at 10:31 AM identified if a resident was confused they should not be left alone in the bathroom. RN #1 stated Resident #450 fell on [DATE] and sustained a skin tear when the student nurse left the resident alone in the bathroom. RN #1 identified Resident #450 should not have been left alone in the bathroom. Interview with the Student Practical Nurse on 1/31/18 at 11:49 AM identified she transferred Resident #450 onto the toilet, showed the resident how to use the call bell, left the wheelchair in the bathroom and then closed the bathroom door almost all the way. The Student Practical Nurse stated although Resident #450 was confused she left the resident alone in the bathroom. The Student Practical Nurse stated even though she stood behind the almost closed door, she was not able to see Resident #450 on the toilet. The Student Practical Nurse identified she heard a commotion, looked in the bathroom and observed Resident #450 on the floor. The Student Practical Nurse identified that although she locked the wheels the wheelchair must have moved. Interview with the Director of Nursing (DON) on 1/31/18 at 12:10 PM identified she did not remember Resident #450 well and did not remember if the resident could be left alone in the bathroom. The DON stated that residents who are confused, identified as a fall risk, have a history of prior falls, need assistance with transfers, and have cognitive impairment such as Resident #450, should not be left alone in the bathroom. Review of facility Falls Management Police directed in part, residents at risk for falls will receive appropriate interventions to reduce risk and minimize injury.

Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one of six residents (Resident # 16) reviewed for accidents, the facility failed to ensure the resident was transferred safely to prevent an injury. The findings include: Resident # 16 's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident # 16 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment and required extensive assist of one staff for transfers. The Resident Care Plan (RCP) dated 7/5/15 identified risk for falls and a risk for decline in ADLs and transfers. Interventions directed to reinforce precautions for fall risk, provide verbal cues for safety, and to provide one staff assistance for transfers when using a rolling walker. A physician's orders [REDACTED]. The nurse's note dated 10/11/15 recorded at 13:48 identified a witnessed fall occurred with Resident # 16 and indicated while the resident was taken to the shower room to be weighed, the resident sat in a chair scale and the the scale moved. Resident # 16 fell when the chair moved and complained of left knee pain. A physician's orders [REDACTED]. An x-ray of the left knee dated 10/11/15 results noted no fracture or dislocation seen. A physician's orders [REDACTED]. Additional review of the left knee x-ray dated 10/25/15 results noted an acute impacted tibia medial plateau fracture. A physician's orders [REDACTED]. The Accident and Incident Report dated 10/26/15 identified on 10/11/15 Resident # 16 was taken to the shower room to be weighed, while being reseated in the chair, the scale moved and the resident sat on the floor sustaining a left elbow skin tear. The report also indicated the resident complained of pain to the left knee. The facility's investigation identified NA # 1's statement to the facility identified while NA # 1 was obtaining the resident's weight, NA # 1 turned to sit Resident # 16 back down into the chair the scale moved and the resident was lowered to the floor. Interview and review of NA # 1's statement with NA # 1 on 3/14/16 at 12:59 P.M. identified when she/he attempted to sit Resident # 16 back down on the scale, the scale moved and the resident fell to the floor. During an interview, review of NA # 1's statement, and observation of the scale on the unit in the shower room and re-enactment of the incident with NA # 1 on 3/15/16 at 9:26 A.M. identified when Resident # 16 stood on the scale ( one that was not a chair scale as identified in the facility investigation on 10/26/15) for NA # 1 to obtain his/her weight. NA # 1 further indicated once she/he obtained the resident's weight she/he attempted to sit the resident back down and the resident fell . Observation on 3/15/16 of the scale identified a metal scale base covered with a textured rubber material, with a ramp for wheelchair access and a grab bar on one side for the resident to hold while on scale. Additional observation of the scale identified two wheels in a fixed position off the floor near the bottom of the metal grab bar. The scale was noted to be heavy and difficult for the surveyor to move when attempted to push. NA # 1 further indicated he/she brought Resident # 16 into the room in a wheelchair, locked the breaks, Resident # 16 stood and stepped onto the scale, and when Resident # 16 went to sit back down the scale moved and Resident # 16 sat on the floor. During an interview and review of the x-ray report dated 3/15/16 at 10:08 A.M. with radiologist MD # 2, the radiologist indicated the acute impacted tibia medial plateau fracture would be caused by a load on a person's leg in a straight position and indicated the fracture could be caused by an up and down force to the bone. MD # 2 further indicated the load must have been from the top to the bottom of the bone, from the femur impacting and pressing down on the tibia like a hammer hitting a nail. During an interview and observation with the Director of Maintenance on 3/15/16 at 11:40 AM, the Director of Maintenance indicated the wheels on the scale are stationary, can only be used when maintenance moves the scale, and the scale is heavy and hard to move.

Based on review of the clinical record, facility documentation, facility policy and procedures, observations and interviews for one of three residents reviewed for accidents (R #6), the facility failed to utilize an appropriate device and/or provide appropriate supervision to prevent an injury.The findings included: Resident #6's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident was severely impaired for decision-making skills, requiring total assistance from staff for all activities of daily living and had an unsteady sitting balance during transfers between bed, chair and/or wheelchair. a. The RCP updated and/or initiated on 4/30/13 4/25/13 identified a focus on the resident requiring assistance with ADL care that included bed mobility and transfers. Interventions included total lift for all transfers. A review of facility documentation dated 7/14/13 at 10:35 A.M. identified that during a transfer with NA #2 and NA #3, the resident's head and torso fell out of the mechanical lift sling and/or pad which led to the resident striking his/her head against the bedframe resulting in a laceration to the back of the head. On 8/2/13 at 9:45 A.M. at and 12:42 P.M. interviews and review of facility documentation with NA #2 and NA #3 indicated that prior to the transfer, the resident was placed on a pad with divided legs (DL) and/or a split pad that was criss crossed around the resident's legs prior to attaching the pad to the lift for transfer. The aides further indicated that during the transfer NA #2 operated the lift and NA #3 was responsible for stabilizing the resident's body (i.e. head, torso, and feet) along with guiding the resident's body into his/her wheelchair while standing at the foot of the resident's bed. The aides further noted that in the process somehow the resident fell and/or slipped out of the DL and/or split pad backwards striking his/her head against the bed frame resulting in an opened, bleeding laceration to the scalp as the resident's lower extremities remained attached to the DL pad on the lift. On 8/2/13 at 10:22 A.M. an interview with NA #4 indicated that although she wasn't part of the transfer on 7/14/13 she went to R #6's room after hearing a scream and discovered NA #2 and #3 holding the resident while pushing him/her back into bed. NA #4 further noted that the resident had large amounts of blood coming from the head and that the resident's body was halfway out of the lifting device with his/her legs still in the sling. On 8/2/13 at 1:10 P.M. an interview and review of the clinical record with the Staff Development Nurse (RN#1) identified that on 7/8/13 the resident had been re-assessed by nursing and was changed from a divided leg sling (DL) to a full body (FB) sling even though both NA #2, and NA #3 indicated upon interview that a DL and/or split pad sling was utilized for transferring R #6 on 7/14/13. Subsequent to the resident striking his/her head, R #6 was transferred to the ER (emergency room ) for an evaluation and following treatment, the resident was returned to the facility and was noted as having 6 staples to the back of the head to close his/her wound. b. On 8/2/13 at 9:45 A.M. and 12:42 P.M. interviews with NA #2 indicated that a purple full body mesh pad, split at the legs was utilized during the transfer even though NA #3 indicated that that a green strapped pad that was split for criss crossing it around the resident's legs was utilized during the transfer. Although there was a constrast in the description of the color of the pad utilized by the aides during the transfer, they were both in agreement that the pad utilized for the transfer was divided and/or split at the leg. A review of a nursing assessment dated [DATE] identified that the pad the aides were to have utilzied for the resident on 7/14/13 was a purple full body pad without the split and/or divided leg. On 8/2/13 at 1:00 P.M. and 1:15 P.M. while inspecting the lift pads in the laundry room with RN #1 who indicated upon interview that although the aides received education in utilizing the mechanical lift, they were confusing the color of the borders of the pads with the color of the entire pad which were bluish and/or purple in color with trimmed borders of navy blue, purple, and green which noted the size of the pad to be utilized on the resident (i.e. navy blue =small, purple= medium, green=large). She further noted that on 7/8/13 the resident was assessed to utilized a purple pad and/or sling without a split and/or divided legs. A review of the clinical record as well and the nurse's aide care card for R #6 lacked documentation to reflect the type of mechanical lift as well as the size, color and style (i.e. full body or divide leg and/or split leg) of the lift pad and/or sling required for transferring the resident were provided to the staff for guidance. In addition, subsequent to the event of 7/14/13, R #6 was changed from a two person assist to a three person assist with transfers. On 8/2/13 at 10:00 A.M. R #6 was observed being transferred from his/her bed to a wheelchair by NA #2, NA #4 and NA #5 in the presence of RN #1. It was noted that a purple full body (no split) pad was utilized. The resident required assistance from NA #5 to stabilize his/her upper body in an upright seated position to prevent the resident from leaning out of the right side of the pad. The mechanical lift was being operated by NA # 2 and it was further noted that as the lift moved towards the resident's wheelchair, NA #4 was there to assist NA #5 in guiding the resident into his/her wheelchair appropriately.

Based on clinical record reviews, and interviews for two of six sampled residents reviewed for pressure sores (R#145, 80), the facility failed to develop and/or initiate interventions to prevent heel breakdown in a resident at high risk for heel ulcers, and/or failed to identify, and/or assess, and/or obtain treatment orders for a pressure sore until the wound was identified as a stage 3. The findings include: 1. Resident #145 was admitted to the facility after having surgery for [REDACTED]. The resident's other [DIAGNOSES REDACTED]. The hospital discharge summary dated 3/21/13 indicated that vascular studies were conducted on the resident's right leg to ensure patency of the graft after the resident sustained [REDACTED]. The discharge summary indicated that a right knee immobilizer was to be utilized for transfers. The nursing admission assessment dated [DATE] identified the presence of a left foot wound. No wounds or skin issues were identified for the right foot. The admission MDS dated [DATE] identified that the resident was without cognitive impairment, required the assistance of 2 staff for transfers and ambulation, and had no pressure sores. The 14 day MDS dated [DATE] was the same as the admission MDS. The care plan dated 3/31/13 indicated that the resident was at risk for skin breakdown. Interventions included "encourage to off load heels". No other interventions were identified related to reducing pressure on the resident's heels/feet. The psychiatric consultant's notes dated 4/18/13 indicated that the resident was upset and anxious regarding his/her leg pain. A change in condition assessment dated [DATE] indicated that a deep tissue injury/pressure ulcer measuring 0.6 by 1.2 cm was found on the right outer heel. The resident was experiencing pain with a rate of 5 on the pain scale. A podus boot was obtained and applied. Review of the March and April treatment kardexes noted that although daily diabetic foot checks were to be done on the March kardex, none were signed off as having been completed. Further review noted that the order/nursing measure had not been carried over to the April kardex. Interview and review of the clinical record with the DNS on 8/1/13 at 12:15 PM and 3:16 PM failed to provide documentation that the resident's heels had been offloaded, that interventions to prevent breakdown had been initiated upon admission, and/or that assessments of the resident's feet had been done daily as indicated on the March treatment kardex. Further review failed to provide documentation that the care plan had been updated to reflect the pressure sore development and/or that new interventions had been initiated other than 2 notes indicating that a boot was in place on the right foot. The DNS indicated that the "encourage offloading" intervention on the care plan meant that staff should encourage the residents, but that no specific devices or procedures were in place to prevent breakdown. The DNS indicated that offloading should be indicated on the treatment kardex and signed off as completed by the nurse's. 2. Resident #80's [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] did not identify any skin impairment to the coccyx. A Braden skin assessment identified the resident was at moderate risk for pressure sore development. The admission Minimum Data Set ((MDS) dated [DATE] identified R#80 was totally dependent for bed mobility and transfers, required extensive assistance with dressing, toileting and personal hygiene and was always incontinent of urine and occasionally incontinent of stool. The care plan dated 1/22/13 identified a right buttock skin abrasion/tear as a problem with interventions that included observe skin condition with ADLs and evaluate area daily including surrounding tissue. An updated care plan dated 2/7/13 identified a stage 3 pressure ulcer to the coccyx with interventions that included provide wound treatment as ordered and weekly wound assessments. Review of the clinical record identified the resident was sent to the emergency room with rectal bleeding on 2/2/13 at 11:56 PM. Transfer paperwork completed by the facility on 2/2/13 indicated the resident had a superficial area on the coccyx. The resident returned from the emergency roiagnom on [DATE] at 7:26AM. Nursing progress notes lacked re-assessment of the wound on the coccyx upon re-entry. The resident was sent back to the hospital on [DATE] at 10:38AM and returned at 4PM. On 2/5/13 at 6:30 PM a late entry nursing progress note identified the presence of a stage 3 pressure ulcer to the coccyx which measured 4.8cm x 2.2cm x<0.1cm. An interview and review of the clinical record with the DNS on 8/2/13 at 9:15AM failed to provide documentation that any nursing assessments and/or interventions were done from the time the area was identified on 2/2/13 until 2/4/13. In addition, physician orders [REDACTED].

Based on clinical record review, and interview for one of three sampled residents reviewed for pressure sores (R#145), the facility failed to develop a comprehensive care plan that specified interventions related to the resident's high risk factors for development of pressure sores to the lower extremities resulting in development of a pressure sore to the heel. The findings include: Resident #145 was admitted to the facility after having surgery for [REDACTED]. The resident's other [DIAGNOSES REDACTED]. The hospital discharge summary dated 3/21/13 indicated that vascular studies were conducted on the resident's right leg to ensure patency of the graft after the resident sustained [REDACTED]. The discharge summary indicated that a right knee immobilizer was to be utilized for transfers. The nursing admission assessment dated [DATE] identified the presence of a left foot wound. No wounds or skin issues were identified for the right foot. The admission MDS dated [DATE] identified that the resident was without cognitive impairment, required the assistance of 2 staff for transfers and ambulation, and had no pressure sores. The 14 day MDS dated [DATE] was the same as the admission MDS. The care plan dated 3/31/13 indicated that the resident was at risk for skin breakdown. Interventions included "encourage to off load heels". No other interventions were identified related to reducing pressure on the resident's heels/feet. The psychiatric consultant's notes dated 4/18/13 indicated that the resident was upset and anxious regarding his/her leg pain. A change in condition assessment dated [DATE] indicated that a deep tissue injury/pressure ulcer measuring 0.6 by 1.2 cm was found on the right outer heel. The resident was experiencing pain with a rate of 5 on the pain scale. A podus boot was obtained and applied. Review of the March and April treatment kardexes noted that although daily diabetic foot checks were to be done on the March kardex, none were signed off as having been completed. Further review noted that the order/nursing measure had not been carried over to the April kardex. Interview and review of the clinical record with the DNS on 8/1/13 at 12:15 PM and 3:16 PM failed to provide documentation that the resident's heels had been offloaded, that interventions to prevent breakdown had been initiated upon admission, and/or that assessments of the resident's feet had been done daily as indicated on the March treatment kardex. Further review failed to provide documentation that the care plan had been updated to reflect the pressure sore development and/or that new interventions had been initiated other than 2 notes indicating that a boot was in place on the right foot. The DNS indicated that the "encourage offloading" intervention on the care plan meant that staff should encourage the residents, but that no specific devices or procedures were in place to prevent breakdown. The DNS indicated that offloading should be indicated on the treatment kardex and signed off as completed by the nurse's.

Based on clinical record review and staff interview for 1 of 3 sampled residents who developed pressure ulcers, (R#276) the facility failed to ensure interventions were in place for a resident at risk for skin break down. The findings include: Resident #276 was admitted to the facility 1/29/12 following left hip joint replacement. Additional [DIAGNOSES REDACTED]. Review of the Discharge Inter-Agency Patient Referral Report (W-10) dated 1/27/12 identified to maintain total hip precautions and an abduction pillow between legs at night. The nursing admission assessment dated [DATE] identified the resident had impairment to the left side of the lower extremities, bilateral [MEDICAL CONDITION] to the lower extremities, requiring assistance to change position, and a surgical incision to the left hip measuring 17 cm in length. In addition the Braden scale assessment dated [DATE] identified R #276 a mild risk for skin breakdown. The interim admission care plan dated 2/7/12 identified at risk for skin breakdown as evidenced by limited mobility. Interventions included to assist with repositioning, monitor skin for symptoms of breakdown, pressure redistribution surface for bed, and weekly skin observations by a licensed staff. However, no interventions were implemented to address heel elevation in the prevention of pressure ulcers. An interim care plan dated 2/16/12 identified actual skin breakdown related to shearing/ friction, recent surgery and limited mobility. Additionally, a deep tissue injury (DTI) was noted to the right heel and a stage 2 to the left heel and a stage 2 to the left mid sole. Interventions was updated to include float heels while in bed. Review of the ADL flow records from 1/30/12 thru 2/9/12 identified R #276 on 27 shifts out of 36, required extensive staff assistance of one or two persons for bed mobility. Review of nurse's notes from time of admission 1/29/12 thru 2/10/12 failed to identify that R#276 heel's were being elevated. Physician orders [REDACTED]. Review of physician progress notes [REDACTED]. physician progress notes [REDACTED]. physician progress notes [REDACTED]. The resident was placed on fluid restriction for 5 days and I&O monitored. physician progress notes [REDACTED]. Upon assessment R #276 was noted with bilateral heal wounds. The left heel noted as a stage 2 measuring 6.0 cm by 8.0 cm opened blister, with a dark pink bed, and a small intact blister present on the left midsole. A treatment was ordered and Quell boots were applied when the resident was not walking. Review of nurse's note dated 2/09/12 at 7:02 PM identified R #276 complained of pain to the left lower extremity. Review of weekly skin integrity report dated 2/10/12 identified a facility acquired stage 2 pressure ulcer to the left heel measuring 6.0 cm by 8.0 cm with serosanguineous drainage. Additionally, a blister was identified to the left mid sole. Additionally, a skin integrity report dated 2/10/12 for the right heel identified a DTI measuring 1.2 cm by 2.4 cm, an intact blood blister with a purple center. Interview and Review of R #276 's clinical record and the Treatment kardex's with the DNS on 9/13/12 at 11:30 AM from January and February, 2012, failed to identify that R #276's heels were elevated until 2/10/12 when the Resident was noted to have stage 2 pressure ulcers to the bilateral heels, and the resident was prescribed to wear Quell boots at all times except when ambulating. Additionally, the DNS indicated that although the facility does not have a hip precautions policy, the expectation is when a resident comes into the facility with a hip replacement the residents heels should be floated to decrease pressure and the risk of skin breakdown.

Based on interview and review of facility documentation, for one resident reviewed for potential dehydration (Resident # 334), the facility failed to ensure monitoring was in place to ensure proper hydration was maintained to prevent dehydration. The findings include: Resident #334's [DIAGNOSES REDACTED]. An assessment dated [DATE] identifed intact cognition and limited assistance with activities of daily living. The care plan dated 6/27/11 identified at risk for gasterointestinal symptoms related to [MEDICAL CONDITION]. Interventions include to monitor ostomy drainage and report changes to the physician. Nursing notes dated 7/20/11 12:00 noon identified resident complained of having 12 loose stools on the 11-7pm shift. On 7/22/11, 6:00 pm nurse notes indicate the resident had hallucinations and was transferred to hospital for evaluation. Review of the hospital documentation dated 7/23/11 identified a [DIAGNOSES REDACTED]. Interview with the dietician on 7/28/11 at 12:30pm identified that intake and output monitoring had not been recommended upon the initial nutritional assesment, although she was aware of a history of dehydration. Further interview identified a follow up chart review was not conducted because "she was not admitted to the hospital and I did not have a order for a consult". Interview with Advanced Practice Registered Nurse (APRN) #1 on 7/28/11 at 1:00 pm identified he/she had multiple conversations with the physician and the " watery stool was not new". Further noting the drainage from the wound vac had been less than usual. Interview and review of the hydation policy with the Director of Nursing on 7/28/11 at 1:00 pm identified although monitoring of intake and output is to be done for three days of admission and with risk of dehydration and/or a [DIAGNOSES REDACTED]. Interview with the Licensed Practical Nurse (LPN) # 2 on 7/28/11 at 2:00 pm noted a care plan to address both risk and actual [DIAGNOSES REDACTED]. The facility failed to ensure that a plan was developed and implemented to ensure the resident maintained adequate hydration.

Based on observation, clinical record review, review of facility policy, and interviews for one of five residents reviewed for smoking (Resident #338) and/or for 2 of 3 residents reviewed with injuries (Residents # 52 and #55), the facility failed to ensure the environment remained free from hazards an/or failed to ensure measures were in place to prevent an injury. The findings include: a. Resident #338 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition, no behaviors and extensive assistance with activities of daily living. An assessment and agreement to smoke dated 7/26/11 indicated Resident #338 was assessed to be an independent smoker and understood the facility's smoking policy. A care plan dated 7/26/11 indicated the resident prefers to smoke. Interventions included to assess the resident's ability to smoke independently and to monitor compliance to the smoking policy. Observation of Resident #338 on 7/27/11 at 12:30 PM indicated Resident #338 was in his/her room. Interview with Resident #338 at that time indicated the resident's cigarettes and lighter were on the bedside stand. Interview with Licensed Practical Nurse (LPN) #1 on 7/27/11 at 12:45 PM indicated the resident had not requested to smoke that day and she did not know how or when the resident obtained a lighter. Review of the facility policy for smoking indicated smoking supplies will be labeled with the patient's name, maintained by staff and stored in a suitable cabinet kept at the nursing station. The policy further indicated if the resident is deemed cognitively and physically able to secure all smoking materials, the facility may allow him/her to maintain his/her own tobacco products in a locked compartment. Patients are not allowed to maintain their own lighter, fluid or matches. Subsequently, the lighter was removed from the resident's possession and the resident was reeducated on the smoking policy. b. Resident #52 had [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] indicated the resident had long term and short term memory impairment, severely impaired cognition, required total assistance with activities of daily living(ADL) and a [DIAGNOSES REDACTED]. Facility accident/incident report dated 5/24/11 reflected that a Nurse Aide (NA) reported to licensed staff that Resident #52 was found to have swelling to the left shoulder and left upper arm with pain on movement. Facility investigation report dated 5/24/11 indicated that the resident required a mechanical lift for all transfers, at times the resident had movements that kept him/her straight in the lift and tended to shift towards the left. An x- ray report dated 5/24/11 indicated a fracture to the left shoulder through the surgical neck of the humerus. Observation on 7/27/11 at 11:40 AM noted that NA #1 held onto the left side of the pad during the transfer. When questioned about the position during the transfer he/she replied that the staff "never know which side the resident will shift to" during the transfer. Interview with Physician (MD) #1 on 7/27/11 at 2:15PM reflected that the fracture to the humerus was not a pathological fracture and was not a result of osteoporosis. Interview with the Director of Nursing on 7/27/11 at 2:42 PM reflected that the facility had concluded that the fracture may have been a result of ongoing osteoporosis and movement upon transfer by a mechanical lift. The facility failed to ensure that the resident remained free from injury and/or that interventions were in place prior to the incident occuring. c. Resident #55's [DIAGNOSES REDACTED]. An assessment dated [DATE] indicated the resident required extensive assistance with bed mobility, transfer and dressing and required one person physicial assist. Review of Resident #55's clinical record indicated that the resident had skin tear on 1/5/11, 4/23/11, 6/24/11 and 7/19/11. Resident #55 was observed during survey process from 7/25/11 through 7/28/11 with dressing to left lower leg and a review of nurses notes for that period also indicated that resident had a skin tear to left leg with the dressing intact. During an interview on 7/28/11 at 10:05 AM, Resident #55 stated that he/she obtained a skin tear while nurses aides were transfering him/her. During an interview with Director of Nursing Service (DNS) on 7/28/11 at 10:20 AM he/she stated that resident obtained a skin tear when staff was getting him/her out of bed in the morning. Interview with Nurses Aide (NA) #1 on 7/28/11 identified that the resident usually required assistance with one staff but at times resident gets tired and may require two person assistance but if resident become tired he/she would ask for assistance. An interview with NA #2 indicated that Resident #55 sustained a skin tear approximately a week ago during a transfer on the back of his/her foot and it was reported to the charge nurse. A review of facility documentation indicated that staff continually observe and monitor patients for changes and implement revisions to the plan of care as needed. A review of resident care plan with Licensed Practical Nurse (LPN) #2 and Register Nurse (RN) #2 failed to ientifiy that a preventitive careplan was in place for resident with fragile skin and/or that a careplan was initiated after resident sustained [REDACTED].