Every finding on record at Complete Care at Kimberly Hall-South

Based on observations, review of facility policy, and interviews, the facility failed to ensure sufficient dietary personnel were on duty to safely and effectively prepare and serve meals in accordance with scheduled mealtimes and resident needs and preferences. The findings include:1.Resident #47 had diagnoses that included anemia, high blood pressure, adjustment disorder with anxiety, and a history of alcohol abuse.Dietitian #1's note dated 4/21/26 identified the kitchen was aware of Resident #47's food preferences, including a preference for large portions, and would continue to honor these preferences and provide snacks between meals.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 had intact cognition and independent with eating and ambulation.The Resident Care Plan (RCP) dated 5/1/26 identified Resident #47 had a history of alcohol abuse, which may impact the resident's weight or appetite; was receiving a diuretic, placing the resident at risk for weight fluctuations; and had an elevated thyroid stimulating hormone (TSH), which may also affect weight. Interventions included offering menu alternatives, selective menus, and always available menus; providing large portions; providing snacks; and honoring food and beverage preferences as available.A physician's order dated 6/10/26 directed to provide a regular diet with regular texture, thin consistency, and large portions.Resident #47's meal ticket dated 6/19/26 identified that the resident should have been served 6 ounces of tomato soup, 1 package of saltine crackers, 11/2 grilled cheese sandwiches, cup of capri vegetable blend, cup of potato wedges, 2 ketchup packets, and 1/2 cup of apple crisp.Interview with Resident #47 on 6/29/26 at 12:33 PM identified he/she keeps meal tickets with each meal and writes notes about the meals delivered. Resident #47 stated he/she was very upset because on 6/19/26 the dinner arrived late at 7:40 PM, was cold, and did not match what was listed on the meal ticket. 2. Interview with Resident #101 on 6/29/26 at 2:30 PM identified all meals were consistently late. Resident #101 indicated Breakfast, scheduled at 8:45 AM, often arrives between 9:00 AM and 9:30 AM, and once as late as 10:00 AM; Lunch, scheduled at 12:45 PM, typically arrives around 1:30 PM, and some days as late as 1:45 PM; and Dinner, scheduled at 5:45 PM, was never delivered before 6:00 PM and often arrives between 6:30 PM and 7:00 PM. Resident #101 stated he/she was diabetic and needed meals on a schedule. Resident #101 stated on 6/19/26 dinner had not arrived by 7:00 PM, he/she was very hungry, asked nurse aides repeatedly where dinner was, and was informed nursing did not control the kitchen. Resident #101 stated dinner was delivered at 8:10 PM and consisted of a slice of deli turkey, a slice of cheese on a hamburger bun, a scoop of macaroni salad, and a dessert cup of ice cream.Interview with Resident #29 on 6/29/26 at 3:00 PM identified meals were always late. Resident #29 indicated Breakfast arrives as late as 10:30 AM; lunch typically arrives around 1:30 PM or as late as 2:00 PM, causing him/her to miss scheduled recreation. Resident #29 stated he/she normally goes to bed around 7:15 PM. Resident #29 identified on 6/19/26 he/she did not receive dinner until 7:50 PM, and the meal did not match the meal ticket. Resident #29 retained the 6/19/26 meal ticket and wrote on it that dinner was received at 7:50 PM. 3. A meeting with residents on 7/1/26 at 10:30 AM (Resident #3, #4, #11, #15, #21, #40, #53, #76, #84, and #98) identified that residents are expected to be in the dining room at 11:30 AM so staff can take their lunch orders; however, most times their orders are not taken for up to 11/2 hours, resulting in lunch being served late.Interview with Registered Nurse (RN) #4 on 7/2/26 at 6:33 AM identified he was the supervisor during the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts on 6/19/26. RN #4 stated that Licensed Practical Nurse (LPN) #5 paged overhead between approximately 6:30 PM and 7:00 PM on 6/19/26 reporting that dinner had not been received on E Wing and that the residents were hungry. RN #4 indicated he went to the kitchen to determine the reason dinner had not been delivered. RN #4 identified that there were only two staff present in the kitchen and that the department was short staffed due to callouts. RN #4 stated he remained in the kitchen and assisted with placing food on plates while the cook called out items from the meal slips. RN #4 indicated that the steam table was not used. RN #4 identified he brought the meal trays on a cart first to F Wing and then to E Wing. RN #4 indicated he did not notify the Director of Nursing Services (DNS) or the Administrator of the delayed meal service.Interviews with the DNS on 7/2/26 at 7:11 AM and 7:30 AM indicated she was not aware that residents did not receive their dinner until 7:00 PM or 8:00 PM on Friday, 6/19/26. The DNS identified dietary staff report to the Administrator, but indicated that if a situation affects residents, she expects the supervisor to notify her. The DNS further identified on 6/19/26 had RN #4 notified her that the dinner meals were delayed she would have contacted the Administrator and the regional dietary supervisor.Interview LPN #5 on 7/2/26 at 7:23 AM identified on 6/19/26 well after 7:00 PM she paged overhead that she was still waiting for supper for the residents on E Wing. LPN #5 identified it was well past the normal mealtime. LPN #5 indicated she had attempted to call the kitchen several times and there was no answer, so she paged overhead. LPN #5 stated she had four residents who required blood sugar testing at approximately 4:30 PM and did not recall whether insulin was needed at that time. LPN #5 indicated that if any diabetic residents exhibited symptoms, snacks and sandwiches were available in the refrigerator. LPN #5 identified on 6/19/26 RN #4 brought the food carts to the unit shortly after she paged but could not recall the exact time the residents received their meals.Interview with the Administrator on 7/2/26 at 8:00 AM indicated on 6/19/26 he was not notified that residents did not receive dinner until approximately 8:00 PM. The Administrator indicated if he had been notified of call outs and insufficient staffing, he would have authorized the use of paper products to ensure residents received their meals on time or would have contacted the corporate dietary department to request staff support from another facility. The Administrator identified the expected staffing in the kitchen for dinner service was one cook and three dietary aides. The Administrator stated on 6/19/26 he would have expected to be notified that staff had called out so the issue could have been addressed.Interview with the Dietary Director on 7/2/26 at 9:13 AM identified on 6/19/26 there was one cook (Cook #2) and two dietary aides scheduled for the dinner meal. The Dietary Director indicated on 6/19/26, Dietary Aide (DA) #3 was no call no show so it only left [NAME] #2 and DA #2 who was from a sister facility for the dinner meal. The Dietary Director identified she became aware on 6/20/26 that they were short staffed on 6/19/26 when staff told her dinner had been late and RN #4 had to assist in the kitchen. The Dietary Director indicated the dietary staff told her the dinner meals were served late on 6/19/26 but did not tell her how late they were and she did not ask. The Dietary Director identified on 6/19/26 she was notified that DA #3 had not arrived at work. The Dietary Director identified [NAME] #2 should have called her, and she would have returned to the facility to help ensure dinner was served on time.Interview with [NAME] #2 on 7/2/26 at 10:31 AM identified she and DA #2 were the only dietary staff working in the kitchen on 6/19/26 for the dinner service. [NAME] #2 stated for dinner service, one cook and two dietary aides are expected, and the dietary aides should be in the kitchen by 4:00 PM. [NAME] #2 indicated she realized the second dietary aide had not shown up by 4:30 PM, when dinner service was supposed to begin. [NAME] #2 identified she did not attempt to call DA #3 or the Dietary Director because she did not have their phone numbers. [NAME] #2 indicated on 6/19/26 at approximately 8:00 PM RN #4 came down to the kitchen and helped plate the meals. [NAME] #2 stated on 6/19/26 they did not finish serving the resident's their dinner meals until approximately 9:00 PM.Review of the facility Frequency of Meals Policy dated 7/1/24, indicated the facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals. The facility has three scheduled regular mealtimes per day comparable to normal mealtimes in the community, and three regular snack times scheduled.

Based on observation, review of facility policy, and interviews, the facility failed to ensure the resident meals were delivered timely. The findings include:Review of facility documentation, identified in part, steam cart delivery times for lunch were as follows:LUNCHBranford unit: 12:00 PMCornwall unit: 12:15 PMUnit F: 12:30 PMUnit E: 12:45 PMUnit D: 1:00 PMObservation on 6/30/26 at 12:23 PM identified the lunch steam table arrived at the [NAME] unit (16 residents) and the Dietary Director began plating lunch. Review of the facility steam cart delivery schedule identified the steam cart should arrive at the [NAME] unit at 12:00 PM ( 23 minutes late).Observation on 6/30/26 at 12:38 PM identified the lunch steam table arrived at the Cornwall Unit (20 residents) and the Dietary Director began plating lunch. Review of the facility steam cart delivery schedule identified the steam cart should arrive at the Cornwall unit at 12:15 PM (23 minutes late).Observation on 6/30/26 at 12:56 PM identified the lunch steam table arrived on the 2nd floor at nursing unit F (21 residents) and the Dietary Director and [NAME] #2 began plating lunch. Review of the facility steam cart delivery schedule identified the steam cart should arrive on the F unit at 12:30 PM (26 minutes late).Observation on 6/30/26 at 1:12 PM identified the lunch steam table arrived on the 2nd floor nursing at unit E (23 residents) and the Dietary Director and [NAME] #2 began plating lunch. Review of the facility steam cart delivery schedule identified the steam cart should arrive on the F unit at 12:45 PM (27 minutes late). At 1:18 PM the steam table ran out of rice, [NAME] #2 left to retrieve more rice from the kitchen and returned at 1:26 PM. At 1:27 PM the last 2 lunch trays were plated (42 minutes late).Observation on 6/30/26 at 1:32 PM identified the lunch steam table arrived on the 2nd floor nursing at unit D (25 residents) and the Dietary Director and [NAME] #2 began plating lunch. Review of the facility steam cart delivery schedule identified the steam cart should arrive on the D unit at 1:00 PM (32 minutes late) at 1:32 PM. At 1:37 PM the steam table ran out of peas, and the night shift cook was called to provide additional hot peas. At 1:50 PM the last lunch tray was plated (50 minutes late).Interview with Resident #101 on 6/29/26 at 2:30 PM identified all meals were consistently late. Resident #101 indicated Breakfast, scheduled at 8:45 AM, often arrived between 9:00 AM and 9:30 AM, and once as late as 10:00 AM; Lunch, scheduled at 12:45 PM, typically arrived around 1:30 PM, and some days as late as 1:45 PM; and Dinner, scheduled at 5:45 PM, was never delivered before 6:00 PM and often arrived between 6:30 PM and 7:00 PM. Resident #101 stated he/she was diabetic and needed meals on a schedule. Resident #101 stated on 6/19/26 dinner had not arrived by 7:00 PM, he/she was very hungry, asked nurse aides repeatedly where dinner was, and was informed nursing did not control the kitchen. Resident #101 stated dinner was delivered at 8:10 PM and consisted of a slice of deli turkey, a slice of cheese on a hamburger bun, a scoop of macaroni salad, and a dessert cup of ice cream.Interview with Resident #29 on 6/29/26 at 3:00 PM identified meals were always late. Resident #29 indicated Breakfast had arrived as late as 10:30 AM; lunch typically arrived around 1:30 PM or as late as 2:00 PM, causing residents to miss scheduled recreation. Resident #29 stated he/she normally went to bed around 7:15 PM but on 6/19/26 did not receive dinner until 7:50 PM, and the meal did not match the meal ticket. Resident #29 retained the 6/19/26 meal ticket and wrote on it that dinner was received at 7:50 PM.Interview with the Dietary Director on 6/30/26 at 2:50 PM indicated that lunch service was late on 6/30/26 because the dining room had to be served first, and dietary aides were still wrapping silverware. The Dietary Director identified that she was aware that the final lunch tray was prepared at 1:50 PM and that five lunch trays remained to be served at that time. She indicated she had been at the facility for three months and this was her first time working with a steam table. She indicated for the lunch service there was one and a half cooks plating food and two dietary aides passing plates and desserts. She stated she was unsure why meals were not delivered on time for any meal service.Interview with [NAME] #1 on 6/30/26 at 1:55 PM indicated she was a full time cook who normally served breakfast and lunch, but on 6/30/26 she was working as a dietary aide. [NAME] #1 identified that the kitchen needed additional staff to help ensure meals were delivered on time. She stated she had informed the Dietary Director that breakfast and lunch were served late most days. [NAME] #1 indicated the Dietary Director had not served or plated food from the steam table during her three months at the facility until 6/29/26 because the state survey was in the building. [NAME] #1 identified she typically served lunch by herself with two dietary aides passing meal trays. [NAME] #1 further identified they had more staff helping on 6/30/26 than usual and still were not able to complete lunch service until 1:50 PM.Review of the facility Frequency of Meals Policy dated 7/1/24, indicated the facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals. The facility has scheduled three regular mealtimes, comparable to normal mealtimes in the community, per day and has scheduled three regular snack times.

Based on tours of the Dietary Department, observations, review of facility policy and interviews, the facility failed to ensure stored food was labeled and dated when opened, expired food was discarded, failed to ensure nourishment refrigerators were maintained in a clean sanitary manner, and failed to ensure the kitchen was maintained in a clean sanitary manner. The findings included:A tour of the Dietary Department on 6/29/26 at 7:45 AM with the Dietary Director identified: 1. The walk-in refrigerator was observed to contain the following opened food items that were undated when they were opened: a. One 3-liter container of egg salad (1/2 full) b. One pitcher of an unidentified red liquid (1/4 full) c. One half of a tomato d. 1/2 of two cut onions e. 1/2 of one cut tomato 2. The walk-in refrigerator was observed to contain the following opened items not labeled, not dated when it was opened, and did not contain an expiration date: a. an unidentified red liquid in a plastic pitcher not labeled or dated (1/4 full) 3. In the walk-in refrigerator, the Dietary Director identified the following opened food items stored in the refrigerator were expired: a. One 3-liter plastic container of baked beans, opened on 6/18/26, with an expiration date of 6/21/26, remained in the refrigerator 8 days past the expiration/discard date. b. One 3.5-liter plastic container of tangerines in syrup, opened on 6/22/26, with an expiration date of 6/25/26, remained in refrigerator 4 days past the expiration/discard date. c. One plastic container of unidentified cooked beef-colored meat, dated 6/23/26, with an expiration date of 6/26/26, remained in storage 3 days past the expiration/discard date. Interview with the Dietary Director on 6/29/26 at 7:50 AM identified all dietary staff are responsible for labeling and dating leftover foods and beverages before placing them in the walk-in refrigerator. The Director of Dietary indicated any food removed from its original container must be labeled and dated. The Dietary Director indicated she did not know why the observed food items including leftovers had not been labeled or dated. The Dietary Director identified the opened food items should have been discarded within 3 days after being opened and did not know why they had not been discarded. 4. Observation of the East Wing nourishment refrigerator on 7/2/26 at 9:30 AM with Dietary Director identified the following: a. One bowl of applesauce dated 6/25/26 (1/2 full) b. One bowl of applesauce dated 6/26/26 (1/4 full) c. One yogurt with an expiration date of 6/14/26 d. One pitcher containing a red liquid not labeled or dated (1/2 full) e. dried red liquid on the bottom shelf 5. Observation of the East Wing nourishment freezer on 7/2/26 at 9:30 AM with the Dietary Director identified the following: a. One frozen can of Arizona Iced Tea not labeled or dated b. One frozen water bottle containing a yellow liquid not labeled or dated c. One 12-ounce paper cup containing a frozen brown liquid not labeled or dated d. One bowl of applesauce covered with plastic wrap that was dated 6/6 (1/2 full) e. One opened bag containing four fish sticks opened not labeled or dated f. brown liquid on the bottom shelf 6. Observation of the Fairfield Unit nourishment refrigerator on 7/2/26 at 9:35 AM with the Dietary Director identified: a. One plastic bowl of pudding not labeled or dated b. 4 cups of orange juice not dated c. One pitcher containing red liquid not labeled or dated (1/4 full) d. One bowl of Jello in the freezer not labeled or dated e. One bottle of Snapple in the freezer not labeled or dated. Interviews with the Dietary Director on 7/2/26 at 9:33 AM and 9:40 AM identified that she is responsible for cleaning the nourishment refrigerators daily and the cook performs these duties in her absence. The Dietary Director indicated the nursing staff is responsible for labeling and dating all food and beverages placed in the nourishment refrigerators. The Dietary Director identified all opened food and beverages must be discarded by the third day. The Dietary Director indicated some of the observed items belonged to staff and nursing staff sometimes put the opened applesauce and juice containers in the refrigerator without labeling or dating them. The Dietary Director identified the unlabeled, undated, or expired food items should have been discarded. Review of the facility Labeling and Dating Policy undated, directed in part, educate all new hires and current employees on the importance of and guidelines for proper labeling and dating items. Proper labeling and dating will ensure that all foods are stored, rotated, and utilized in a first- in and first-out manner. Leftovers must be labeled, dated with the date they are prepared, and the use by date. Always defer to State and Local regulations as they supersede general guidelines. 7. On 7/7/26 at 9:01 AM, the Administrator notified the surveyor that a sprinkler had malfunctioned in the freezer, causing the fire alarm to be activated. 8. On 7/7/26 at 10:05 AM Building Fire Safety Inspections (BFSI) notified the surveyor that the local health department had closed the facility kitchen until the kitchen and freezer were completely sanitized following flooding caused by the sprinkler malfunction. 9. Observation on 7/7/2026 at 11:42 AM identified facility staff were serving beverages from the kitchen, despite the local health department's directive to keep the kitchen closed. 10. A tour of the kitchen on 7/7/2026 at 11:46 AM with the Administrator identified the following: a. The Ice machine door was in the open position, exposing the ice bin the kitchen environment b. buildup of dirt on the floor of the dry storage room c. One 21-gallon wheeled bin containing flour (1/5 full) without a cover had black specks observed in the flour. The floor beneath the flour bin was visibly soiled d. One dehumidifier mounted on the wall in the dry storage room. The dehumidifier drain hose discharged into a collection pan on the floor. Black substance was observed in the collection pan, on the floor surrounding the collection pan and dehumidifier, and on the wall behind the dehumidifier e. One light fixture in the chemical storage room without a protective cover f. The floor of the chemical storage room was noted with rust and visible dirt on the floor, and tiles on the wall were missing Interview with the Kitchen Manager and Director of Operations on 7/7/26 at 11:54 AM identified the dietary staff are responsible for maintaining the cleanliness of the kitchen, including sweeping, mopping, and cleaning food preparation and storage surfaces. The Kitchen Manager and Director of Operations identified the observed kitchen areas should have been cleaned but were unable to explain why they had not been cleaned. The Director of Operations was unable to explain why facility staff served juice after the kitchen closure. The Director of Operations stated staff should not have served beverages from the kitchen after the local health department directed the facility to close the kitchen. Interview with the Administrator on 7/7/2026 at 11: 59 AM identified a sprinkler in the facility's freezer activated around 9:00 AM and flooded the kitchen. The Administrator identified the local health department inspected the kitchen on 7/7/26 at approximately 9:45 AM and shut the kitchen down until it could be cleaned and sanitized. The Administrator indicated kitchen staff and nursing managers were notified that the kitchen was closed. The Administrator was unable to explain why beverages continued to be served after the kitchen was closed.

Based on interviews, review of the resident trust accounts, facility documentation, and facility policy for 6 of 6 residents (Resident #3, Resident #4, Resident #11, Resident #15, Resident #21, and Resident #84) reviewed for personal funds, the facility failed to ensure quarterly statements were provided to the residents. The findings include:1.Resident #3 had diagnoses that included diabetes, neurogenic bladder, and depression.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14 indicative of intact cognition. Interview with Resident #3 on 7/01/2026 at 10:40 AM identified he/she had funds in the resident trust account but had not received quarterly account statements.Interview with the Regional Business Office Coordinator on 7/02/2026 at 10:48 AM identified Resident #3 had funds in the resident trust account. She stated residents receive account statements quarterly and upon request. She indicated the statements are provided directly to residents, residents sign a copy acknowledging receipt, and the signed copy is maintained in the business office file. She identified Resident #3 could be provided with an account statement upon request; however, she was unable to provide documentation that the last four quarterly account statements were provided to Resident #3.Subsequent to surveyor inquiry, on 7/02/2026 the facility provided Resident #3 with a copy of his/her quarterly statement, and he/she signed the statement acknowledging receipt.2. Resident #4 had diagnoses that included hypertension, anxiety, and depression.The quarterly MDS assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.Interview with Resident #4 on 7/01/2026 at 10:40 AM identified he/she had funds in the resident trust account but had not received quarterly account statements.Interview with the Regional Business Office Coordinator on 7/02/2026 at 10:48 AM identified Resident #4 had funds in the resident trust account. She stated residents receive account statements quarterly and upon request. She indicated the statements are provided directly to residents, residents sign a copy acknowledging receipt, and the signed copy is maintained in the business office file. She identified Resident #4 could be provided with an account statement upon request; however, she was unable to provide documentation that the last four quarterly statements were provided to Resident #4.Subsequent to surveyor inquiry, on 7/02/2026 the facility provided Resident #4 with a copy of his/her quarterly statement, and he/she signed the statement acknowledging receipt.3. Resident #11 had diagnoses that included coronary artery disease, heart failure, and malnutrition.The quarterly MDS assessment dated [DATE] identified Resident #11 had a Brief Interview for Mental Status (BIMS) score of 14 indicative of intact cognition.Interview with Resident #11 on 6/29/2026 at 9:23 AM identified he/she had funds in the resident trust account but had not received quarterly account statements.Interview with the Regional Business Office Coordinator on 7/01/2026 at 12:50 PM identified Resident #11 had funds maintained in the resident trust account. She identified Resident #11 was not provided with quarterly statements because the facility serves as the resident's representative payee. She further identified that for residents for whom the facility is the representative payee, the Administrator reviews and signs the quarterly statements, after which the statements are filed rather than provided to the residents.Subsequent to surveyor inquiry, on 7/01/2026 the facility provided Resident #11 with a copy of his/her quarterly statement, and he/she signed the statement acknowledging receipt.4. Resident #15 had diagnoses that included diabetes, hypertension, and obstructive uropathy.The MDS assessment dated [DATE] identified Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15 indicative of intact cognition.Interview with Resident #15 on 7/01/2026 at 10:40 AM identified he/she had funds in the resident trust account but had not received quarterly account statements.Interview with the Regional Business Office Coordinator on 7/02/2026 at 10:48 AM identified Resident #15 had funds in the resident trust account. She stated residents receive account statements quarterly and upon request. She indicated the statements are provided directly to residents, residents sign a copy acknowledging receipt, and the signed copy is maintained in the business office file. She identified Resident #15 could be provided with an account statement upon request; however, she was unable to provide documentation that the last four quarterly statements were provided to Resident #15.Subsequent to surveyor inquiry, on 7/02/2026 the facility provided Resident #15 with a copy of his/her quarterly statement, and he/she signed the statement acknowledging receipt.5. Resident #21 had diagnoses that included coronary artery disease, heart failure, and hypertension.The quarterly MDS assessment dated [DATE] identified Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 indicative of intact cognition.Interview with Resident #21 on 7/01/2026 at 10:40 AM identified he/she had funds in the resident trust account but had not received quarterly account statements.Interview with the Regional Business Office Coordinator on 7/02/2026 at 10:48 AM identified Resident #21 had funds in the resident trust account. She stated residents receive account statements quarterly and upon request. She indicated the statements are provided directly to residents, residents sign a copy acknowledging receipt, and the signed copy is maintained in the business office file. She identified Resident #21 could be provided with an account statement upon request; however, she was unable to provide documentation that the last four quarterly statements were provided to Resident #21.Subsequent to surveyor inquiry, on 7/02/2026 the facility provided Resident #21 with a copy of his/her quarterly statement, and he/she signed the statement acknowledging receipt. 6. Resident #84 had diagnoses that included coronary artery disease, heart failure, and hypertension.The quarterly MDS assessment dated [DATE] identified Resident #84 had a Brief Interview of Mental Status (BIMS) score of 12 indicative of moderately impaired cognition.Interview with Resident #84 on 7/01/2026 at 10:40 AM identified he/she had funds in the resident trust account but had not received quarterly account statements.Interview with the Regional Business Office Coordinator on 7/02/2026 at 10:48 AM identified Resident #84 had funds in the resident trust account. She stated residents receive account statements quarterly and upon request. She indicated the statements are provided directly to residents, residents sign a copy acknowledging receipt, and the signed copy is maintained in the business office file. She identified Resident #84 could be provided with an account statement upon request; however, she was unable to provide documentation that the last four quarterly statements were provided to Resident #84.Subsequent to surveyor inquiry, on 7/02/2026 the facility provided Resident #84 with a copy of his/her quarterly statement, and he/she signed the statement acknowledging receipt.Review of facility Resident Personal Funds Policy, dated July 2025, directed in part, the individual financial record must be available to the resident through quarterly statements and upon request.

Based on observation, review of facility documentation, review of facility policy, and interviews reviewed for infection control practices, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was worn when handling soiled linens. The findings include:Observation on 7/1/2026 at 1:25 PM identified Housekeeper #1 transferred clean linens from the washer into a bin and then loaded soiled linens into the washer without wearing the required personal protective equipment (PPE), including a gown and gloves.Interview with Housekeeper #1 on 7/1/2026 at 1:28 PM identified she was aware that appropriate PPE, including a gown and gloves, was required when handling soiled linens. Housekeeper #1 stated she did not wear the required PPE because she forgot. Housekeeper #1 identified she typically does not work in the laundry room but was completing laundry tasks because a resident asked her to wash some of their clothing, and she wanted to assist the resident.Interview with the Director of Environmental Services on 7/1/26 at 1:30 PM identified that although not all housekeeping staff routinely work in laundry, some staff are trained to do perform laundry tasks. The Director of Environmental Services stated she was unsure whether Housekeeper #1 had received the appropriate training. She further statedAlthough requested, documentation demonstrating Housekeeper #1's orientation and/or training to perform laundry tasks was not provided.Review of the facility Laundry Handling and Processing Policy, dated 2/1/25, directed in part, when handling soiled linens, the correct PPE to wear is a gown and gloves and that soiled laundry should never be carried against employee's bodies.

Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 sampled resident (Resident #8) reviewed for positioning, the facility failed to ensure a device was applied for foot contractures. The findings include:Resident #8 had diagnoses that included myelopathy, idiopathic peripheral autonomic neuropathy, and polyneuropathy.The physician's order dated 1/22/26 directed the application of bilateral Multi Podus boots ( a device used to protect immobile feet and ankles to prevent skin breakdown reduces pressure on the heel and prevents deformities such as plantar flexion contractures or foot drop) to both legs/feet for up to 8 hours as tolerated following morning care, with removal before evening care. The order also directed that skin checks be completed before applying the boots and after removing them.The quarterly MDS dated [DATE] identified Resident #8 had intact cognition, impairment of the lower extremities on both sides, was non ambulatory, and dependent on staff for all activities of daily living (ADLs), including bed mobility and transfers.The Resident Care Plan (RCP) dated 4/12/26 identified Resident #8 required assistance with activities of daily living (ADLs), including bathing, grooming, personal hygiene, dressing, bed mobility, transfers, locomotion, and toileting related to myelopathy. Interventions included applying bilateral Multi Podus boots for up to 8 hours as tolerated, applying the boots after morning (AM) care, removing the boots before evening (PM) care, and completing pre- and post-application skin checks.Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) dated 1/22/26 through 6/29/26 failed to identify that Multi Podus boots were scheduled to be applied after morning (AM) care and removed during evening (PM) care.Review of the nurse's notes dated 1/22/26 through 6/29/26 failed to identify that Resident #8 had refused to wear the bilateral Multi Podus boots.Observations on 6/29/26 at 10:08 AM and again at 2:00 PM identified Resident #8 was lying in bed. Two leg/foot splints were observed in a stationary chair positioned at the foot of the resident's bed. The splints were covered by a Hoyer lift pad and a pile of the resident's clothing.Observation on 7/1/26 at 12:45 PM identified Resident #8 was lying in bed. Two leg/foot splints remained in the stationary chair positioned at the foot of the resident's bed and were covered by a Hoyer lift pad and the resident's clothing.Interview with Licensed Practical Nurse (LPN) #4 on 7/1/26 at 12:46 PM identified she thought Resident #8 wore the leg/foot splints only at night. LPN #4 stated after reviewing Resident #8's clinical record, she identified the physician's order directed the splints to be applied for eight hours following morning care and removed at bedtime (HS) care. LPN #4 indicated she did not know why Resident #8 was not wearing the splints at the time of the observation and stated that Nurse Aide (NA) #4 had not informed her that the resident had refused to wear them. LPN #4 identified that the splints should have been applied to Resident #8 following morning care.Interview with Nurse Aide (NA) #4 on 7/1/26 at 12:48 PM identified he was responsible for providing care to Resident #8. NA #4 stated he had worked at the facility for five years and does not read resident care cards because he receives report from the nurse at the beginning of each shift regarding any changes in residents' conditions. NA #4 indicated on 7/1/26 at approximately 10:00 AM he provided care to Resident #8, including washing and dressing the resident. NA #4 stated that Resident #8 did not have splint. NA #4 identified he was unaware that splints were in Resident #8's room and that therapy had not informed him that the resident required splints.Interview with the Director of Rehab on 7/2/26 at 12:03 PM identified Resident #8 had contractures of the bilateral feet, and Multi Podus boots were ordered to prevent further contracture progression. The Director of Rehab identified therapy initiates the orders for Multi Podus boots. The Director of Rehab indicated that nurse aides are responsible for applying Resident #8's Multi Podus boots after morning care and removing them during evening care. The Director of Rehab identified that licensed nursing staff are responsible for signing off that the Multi Podus boots were applied after morning care and removed during evening care.Interview with the Director of Nursing Services (DNS) on 7/2/26 at 12:11 PM identified the therapy department provides the unit manager with new orders for splints or braces, and the unit manager is responsible for entering those orders into the physician order section of the electronic medical record. The DNS indicated nurse aides may apply the Multi Podus boots and are responsible for reporting any changes in skin integrity to the nurses. The DNS identified that nursing staff are responsible for ensuring the Multi Podus boots are applied as ordered and for documenting the application on the Treatment Administration Record (TAR) according to the physician's orders. Additionally, the DNS stated that residents with Multi Podus boots or splints have these interventions addressed on the resident's care plan.Interview and clinical record review with Registered Nurse (RN) #5, the Corporate RN Clinical Nurse, on 7/2/26 at 12:41 PM identified nurse aides may apply the Multi Podus boots, and nursing staff are responsible for ensuring the boots are applied and removed as ordered and for documenting the application and removal on the Treatment Administration Record (TAR). During a clinical record review conducted with RN #5 and the Director of Nursing Services (DNS), RN #5 stated that when Resident #8 returned from the hospital in January 2026, the readmission nurse did not enter the Multi Podus boot order correctly into the electronic medical record. RN #5 indicated the incorrectly entered order did not trigger a notification for nursing staff to apply and remove the Multi Podus boots. RN #5 further stated that the next shift nurse was responsible for verifying that orders were entered correctly. RN #5 identified on 1/22/26, therapy entered the Multi Podus boot order; however, the order did not populate onto the TAR. RN #5 further identified nurses are responsible for verifying the order should have selected the scheduling and detail fields to ensure the order appeared for nursing staff and prompted documentation of application and removal. RN #5 stated Resident #8 should have had the Multi Podus boots applied and removed per the physician's order.Subsequent to the surveyor inquiry, a Physical Therapy Evaluation dated 7/3/26 identified that Resident #8 had previously been able to tolerate wearing bilateral Multi Podus boots for up to 8 hours per day to prevent contractures and to increase range of motion and functional mobility. At the time of the evaluation, Resident #8 was wearing Multi Podus boots for 2 hours per day and could tolerate only 2 hours. A new goal was established for Resident #8 to increase tolerance of bilateral Multi Podus boots up to 8 hours per day to prevent contracture formation and improve range of motion and functional mobility. Physical Therapy will pick up Resident #8 daily for a duration of 83 days to address this goal.Review of facility Use of Assistive Devices Policy dated 9/1/25, directed in part, to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. Refusals of use, or problems with the device, will be documented in the medical record.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #29) reviewed for choices, the facility failed to provide showers as scheduled per the resident's preference. The findings include:Resident #29 had diagnoses that included polyarthritis, depression, anxiety, and impaired mobility.The physician's orders dated 9/20/23 directed weekly showers with skin checks every Wednesday on the evening shift.The quarterly MDS dated [DATE] identified Resident #29 had intact cognition, was frequently incontinent of bowel and bladder, required moderate assistance with personal hygiene and showers, and touching assistance with shower transfers.The Resident Care Plan (RCP) dated 5/6/26 identified Resident #29 had impaired mobility and was at risk for falls. Interventions directed staff to provide the assistance of one with transfers, remain in proximity of the resident when using the toilet, and supervise the resident at all times during showers.Review of the nursing notes dated 6/10/26 through 6/29/26, failed to reflect that Resident #29 refused showers during this period.Interview with Resident #29 on 6/29/26 at 11:17 AM identified he/she had not received a shower in the previous three weeks because the shower bench was broken. Resident #29 stated his/her head felt itchy and that he/she wanted a shower to wash his/her hair. Resident #29 indicated staff told him/her a replacement shower bench had been ordered but had not yet arrived.Interview with Nurse Aide (NA) #6 on 7/1/26 at 10:11 AM identified the shower chair had been broken for approximately three weeks. NA #6 stated during that time, residents who could stand received showers, while residents who required the shower chair received bed baths. NA #6 identified Resident #29 was scheduled to receive showers on Wednesdays during the 3:00 PM to 11:00 PM shift and NA #5 was Resident #29's regular 3:00 PM to 11:00 PM nurse aide. NA #6 stated that staff documented both showers and bed baths in the Shower section of the ADL flowsheets by placing a check mark to indicate care was completed and the documentation did not distinguish whether the resident received a shower or a bed bath.Interview with NA #7 on 7/1/26 at 10:17 AM identified the shower chair had been broken for approximately one month. NA #7 indicated there were two shower chairs, one of which was broken and one that remained available for use. NA #7 indicated maintenance had ordered replacement shower chairs, which were expected to arrive soon. NA #7 stated if Resident #29 had requested a shower, she would have provided one.Interview with NA #5 on 7/1/26 at 11:10 AM identified she was responsible for providing Resident #29's showers on Wednesday evenings. NA #5 indicated approximately three weeks earlier, she and the nurse notified maintenance that the shower chair was broken, and she had no way to provide showers to residents who required the chair. NA # 5, identified during the previous three weeks Resident #29 had not received a shower because the shower chair was broken. NA #5 indicated she asked staff on other units whether they had a shower chair she could borrow, but they did not. NA #5 further indicated the previous day she and Licensed Practical Nurse (LPN) #5 spoke with the Assistant Director of Maintenance regarding the broken shower chair. NA #5 indicated the Assistant Director of Maintenance reported the Director of Maintenance had not informed him that a replacement shower chair needed to be ordered or brought to the facility.Interview with the Assistant Director of Maintenance on 7/1/26 at 11:30 AM identified he first became aware of the broken shower chair on the East Unit the previous evening when NA #5 and LPN #5 informed him as he was leaving for the day. The Assistant Director of Maintenance indicated LPN #5 told him the broken shower chair had been reported to the Director of Maintenance approximately three weeks earlier and staff were still awaiting a replacement. The Assistant Director of Maintenance identified after reviewing the maintenance work orders system, there was a work order dated 6/1/26 documenting that the East Wing shower chair was broken. The Assistant Director of Maintenance indicated he did not know what action the Director of Maintenance had taken in response to the workorder.Interview with the Administrator on 7/1/26 at 11:35 AM indicated he had just become aware of the broken shower chair on the East Wing. The Administrator identified after investigating, Resident #29 informed him it was the shower bench that was broken. The Administrator identified that he obtained a shower bench from another unit and brought it to the East Wing so Resident #29 could receive a shower.Interview with the Director of Nursing Services (DNS) on 7/1/26 at 11:45 AM identified residents receive showers once or twice weekly based on their preferences. The DNS indicated shower schedules are assigned according to bed assignment. The DNS identified the expectation is residents receive showers on their scheduled day and time. The DNS indicated if a resident refused a shower or received a bed bath instead of a shower, the nurse was expected to document it. The DNS indicated she was not aware Resident #29 had not received a shower during the previous three weeks because the shower bench was broken. The DNS identified she became aware today that Resident #29 had not received showers.Interview with LPN #5 on 7/2/26 at 7:30 AM identified on Tuesday, 6/30/26, NA #5 informed her the shower bench was broken and that Resident #29 only accepted showers on Wednesdays using the shower bench. LPN #5 indicated NA #5 informed her a couple of days ago that Resident #29 had not received a shower during the previous three weeks because the shower bench was broken. LPN #5 indicated the Assistant Director of Maintenance was on the unit and informed them he was not aware of the broken shower bench because the Director of Maintenance had not informed him. LPN #5 further indicated the Assistant Director of Maintenance instructed her to enter a maintenance work order into the computer for the next day because he was leaving for the day. LPN #5 identified she entered the work order as instructed.Review of facility Resident Shower Policy, directed in part, the facility assists residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues per the current standards of practice. Residents will be provided with showers per request or per facility schedule protocols and based upon resident safety.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews, for 1 of 2 residents (Resident #47) reviewed for food and nutrition services, the facility failed to provide a nutritious, appealing, and palatable meal in accordance with the resident's preferences. The findings include:Resident #47 had diagnoses that included anemia, high blood pressure, adjustment disorder with anxiety, and history of alcohol abuse. Dietitian #1's note dated 4/21/26 identified the kitchen was aware of Resident #47's food preferences, including a preference for large portions, and will continue to honor these preferences and provide snacks between meals.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 had intact cognition and was independent with eating and ambulation.The Resident Care Plan (RCP) dated 5/1/26 identified Resident #47 had a history of alcohol abuse, which may impact the resident's weight or appetite; was on a diuretic, placing the resident at risk for weight fluctuations; and had an elevated thyroid-stimulating hormone (TSH), which may also affect weight. Interventions included offering menu alternatives, selective menus, and always available menus; providing large portions, providing snacks, and honoring food and beverage preferences as available.The physician's order dated 6/10/26 directed to provide a regular diet with regular texture, thin consistency and large portions.Review of Resident #47's dinner meal ticket dated 6/28/26 identified the resident was to receive 3 chicken tenders with honey mustard, 2/3 cup of broccoli florets, 2/3 cup of tater tots with ketchup, 1 dinner roll with margarine, and 1/2 cup of pear crisp. Interview and observation with Resident #47 on 6/29/26 at 12:33 PM identified he/she keeps their meal tickets and writes notes on them based on what they receive for dinner. Resident #47 stated that on Sunday, 6/28/26, although the meal ticket was dated 9/1/2026, he/she received 1 hard boiled egg, mashed potatoes, and cauliflower. Resident #47 identified on 6/28/26 he/she did not request another meal because he/she felt it would not make a difference, because mistakes like that often happen. Resident #47 stated he/she was very upset by this mistake and did not feel it was enough food for dinner, nor did it appear appetizing, nor was it consistent with his/her food preferences.Interview with the Kitchen Director on 7/1/26 at 9:30 AM identified on 6/28/2026, Resident #47 should have been served the meal identified on the resident's meal ticket, which included chicken tenders, broccoli, tater tots, and pear crisp. The Kitchen Director stated Resident #47 should not have received a hard-boiled egg, mashed potatoes, and cauliflower as substitutions for the scheduled meal. The Kitchen Director identified a dinner meal consisting of one hard-boiled egg, mashed potatoes, cauliflower, and pear crisp did not provide adequate protein. The Kitchen Director indicated the facility utilizes a rotating menu and stated that although the meal ticket for Resident #47 was dated 9/1/26, the system may occasionally experience a date glitch; however, the menu items remain unchanged. The Kitchen Director stated the meal served to Resident #47 was most likely provided on Sunday, 6/28/26, because the meal items served corresponded with the items listed on the meal ticket.Interview with Dietitian #1 on 7/1/26 at 10:45 AM identified Resident #47 did not have any dietary restrictions, and she was not aware of the resident ever requesting hard boiled eggs. Dietitian #1 identified one hard boiled egg, mashed potatoes, and cauliflower was not enough protein for a dinner meal. Dietitian #1 further identified if Resident #47 was served hard boiled eggs as a substitute for 3 chicken tenders, at least 2 hard boiled eggs should have been provided. Dietitian #1 stated the hard-boiled egg, mashed potatoes, and cauliflower served to Resident #47 were all white-colored foods and meals should include foods of various colors.Interview with [NAME] #3 on 7/1/26 at 10:28 AM identified he did not recall whether he served Resident #47 hard boiled eggs on 6/28/26 for dinner. [NAME] #1 stated at least two residents were served hard boiled eggs that evening. [NAME] #1 identified hard boiled eggs were on the serving table and are usually offered for dinner on Sunday evenings.Resident Council meeting with a state surveyor on 7/1/2026 at 10:30 AM identified residents reported meals were sometimes not consistent with the posted menu. Residents further reported that hard-boiled eggs had been served as a dinner meal in the past.Review of the facility Food Preparation Guidelines policy dated 7/1/24, directed in part, food should be prepared in an attractive manner, with variation in color and texture, and when providing alternatives, they should be appealing, similar in nutritional value, and consistent with resident preferences.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for falls, the facility failed to complete and document neurological checks after an unwitnessed fall per facility policy. The findings include: Resident #2 was admitted to the facility with diagnoses that included encephalopathy, dementia and adult failure to thrive. The nursing admission assessment dated [DATE] identified Resident #2 was verbally incomprehensible, was only orientated to person, required extensive assistance with activities of daily living (ADL'S). The admission minimum data set MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8) and had one fall with no injury since admission. The care plan dated 4/5/24 identified Resident #2 was at risk for falls secondary to dementia with forgetfulness and impulsive behavior. Interventions included to assist Resident #2 to organize belongings for a clutter free environment, therapy/rehab services as indicated and approved by hospice, after meals recline Resident #2 in chair for comfort and bring Resident #2 to a common area to observe when restless. A nursing change in condition note dated 4/23/24 at 12:41 AM identified Resident #2 had an unwitnessed fall and was found on his/her buttocks with a skin tear on his/her left arm. It identified the plan was to notify a provider of any change in condition, fall precautions per facility protocol, assess pain per protocol and monitor with neuro checks per protocol. A physician's order dated 4/23/24 directed to notify a provider of any change in condition, fall precautions per facility protocol, assess pain per protocol and monitor with neuro checks per protocol. Review of the accident & incident form dated 4/23/24 and medical record failed to identify neurological checks were completed. A nursing change in condition note dated 4/24/24 at 1:57 AM identified Resident #2 had an unwitnessed fall, was found on the floor sitting on his/her buttocks by the bed and could not recall what happened. It identified the plan was to notify a provider of any change in condition, fall precautions per facility protocol, assess pain per protocol and monitor with neuro checks per protocol. A physician's order dated 4/24/24 directed to notify a provider of any change in condition, fall precautions per facility protocol, assess pain per protocol and monitor with neuro checks per protocol. Review of the accident & incident form dated 4/23/24 and medical record failed to identify neurological checks were completed. Although requested, the DNS was unable to produce Resident #2's neurological checks for 4/23/24 and 4/24/24. Review of the neurological assessment policy directed neurological assessment are completed to assess neurological status after an un-witnessed fall. Neurological assessments will be completed as follows: every fifteen minutes for the first hour, every thirty minutes for the next two hours, every hour for the next two hours, every shift for the next seventy two hours and then as the primary healthcare provider orders.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for hospice, the facility failed to administer prescribed morphine during the dying process, for a prolonged period of time, after an ineffecive dose was administered. The findings include: Resident #2 was admitted to the facility with diagnoses that included encephalopathy, dementia and adult failure to thrive. A provider order dated 3/28/24 directed do not resuscitate. A provider order dated 4/5/24 directed morphine .25 ml by mouth every two (2) hours as needed for pain. The admission minimum data set (MDS) assessment dated [DATE] identified Resident #2 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8) and received hospice care while a resident. The Resident Care Plan (RCP) dated 4/23/24 identified hospice services began 4/11/24 due to an end stage diagnosis of dementia and failure to thrive. Interventions included to assess for pain, restlessness, agitation and other signs of discomfort, medicate as ordered and evaluate effectiveness and provide non-pharmacological approaches to aid in decreasing comfort. The RCP further directed to provide emotional and social support to the patient and family to address anticipatory grief and end of life wishes. The RCP identified Resident #2 was at risk for alterations in comfort. Interventions included to medicate Resident #2 as ordered for pain, monitor for effectiveness, monitor for side effects and report to the physician as indicated. A nursing note by RN #2 dated 4/28/24 at 12:00 PM identified the unit nurse called her stating Resident #2 was sleeping and did not respond when called. Resident #2's family member was informed of Resident #2's status, did not want him/her to be hospitalized and would go in to the facility to see him/her. Review of the mediation administration record (MAR) dated 4/28/24 identified morphine .25 ml was administered by LPN #1 at 9:45 AM and was documented as ineffective. The medical record failed to identify what interventions were done, if any, for Resident #2's ineffective morphine dose. The vital signs dated 4/28/24 at 1:40 PM identified Resident #2's heart rate was 123 beats per minute (BPM) (normal range is 60-100 BPM), respirations were 22 breaths per minute (normal range is 12-20 breaths per minute), and oxygenation of 81% on room air (normal range is 95-100%). A physician's order dated 4/28/24 at 3:15 PM directed morphine .25 ml by mouth every one (1) hour as needed for pain. A nursing note by RN #2 dated 4/28/24 at 3:22 PM identified Resident #2's family members questioned the unit nurse several times about his/her morphine medication, which was every two hours as needed. They requested it be increased to every hour. Review of the MAR on 4/28/24 identified morphine .25 ml was administered by RN #1 at 3:45 PM (effectiveness was unknown, 6 hours after the last dose of morphine was administered), 5:00 PM (effectiveness was unknown), 6:00 PM (effective) and 7:00 PM (effective). A nursing note by LPN #1 dated 4/28/24 at 3:53 PM identified Resident #2 was responsive to physical stimuli and noted with labored breathing. Oxygen was administered at 2 liters/minute and family asked if oxygen could be removed and LPN #1 explained it should be kept on due to oxygen levels. Resident #2's family members were at the bedside and constantly requesting Morphine. Resident #2 was resting with no signs of pain/discomfort. An RN death pronouncement dated 4/28/24 identified Resident #2's date and time of death was 4/28/24 at 7:27 PM. Interview with Person #1 (Resident #2's family member and health care representative) on 5/1/25 at 12:30 PM identified she went to visit Resident #1 at approximately 10:00 AM on 4/28/24 and Resident #2 was agitated, air hungry, had rapid/shallow respirations and was sweating. She identified the nurse told her Resident #2 just received morphine, so Person #1 requested the morphine dose be changed to hourly. Person #1 identified the nurse told her she would contact the physician, and no further doses of morphine were administered. Person #1 identified that at around 2:00 PM, the nurse went into Resident #2's room and asked if everyone was okay, but did not assess Resident #2. Person #1 identified that at 3:00 PM, she went out of the room to find a nurse and requested Resident #2 receive a dose of morphine. She further identified that due to a change of shift, the nurse did not return to the room until 3:40 PM and the nurse indicated she had to complete her medication pass for the other residents on the unit before administering Resident #2's morphine. Person #1 requested the supervisor and the supervisor identified the morphine dose had been changed from every two (2) hours to every one (1) hour. The supervisor took over medication administration for Resident #2 and Resident #2 received a morphine dose at 3:45 PM (approximately six (6) hours after the previous administration). Interview with LPN #1 (administered morphine on 4/28/24 at 9:45 AM) on 5/1/25 at 12:42 PM identified she could not remember Resident #2. However, LPN #1 identified if an as needed medication is administered and ineffective, she would notify the physician, the hospice team and document in the medical record. She was unable to speak to why there were no follow up interventions to Resident #2's ineffective morphine dose at 9:45 AM and why no further doses were administered. Review of the coordination of hospice services policy directed that the plan of care will include directives for managing pain and other uncomfortable symptoms and will be revised and updated as necessary. Review of the pain management policy directed that facility staff will observe nonverbal indicator which may indicated the presence of pain such as change in vital signs (increased heart rate, respirations and/or blood pressure) and perspiration. It identified to reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work the minimize or manage side effects. Facility staff will notify the practitioner if the resident's pain is not controlled by the current treatment regimen.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for wounds, the facility failed to ensure staff developed a comprehensive care plan to include an alteration in skin integrity. The findings include: Resident #2's diagnoses included hemiplegia and hemiparesis (paralysis and weakness of one side), diabetes, chronic kidney disease stage 4, and heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 2 had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment and required total care for ALDs, rolling, and was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 1/29/2025 identified a risk for impairment to skin integrity secondary to generalized weakness, impaired mobility, incontinence and diabetes. Interventions directed use of pressure relieving devices in bed and/or chair, observe/document/report to MD/APRN as needed, and turn and reposition four (4) times per shift. Review of admission note dated 1/9/2025 identified a moisture associated skin damage (MASD) to left buttock and scrotum. Nursing note dated 1/9/2025 at 8:26 PM identified the MASD, and a three (3) centimeter (cm) skin tear on the left arm. Review of initial specialty physician wound evaluation and management summary dated 1/22/2025 identified Resident #2 had a left lower buttock Stage 3 pressure ulcer, a left upper buttock stage 2 pressure ulcer, and a right buttock stage 2 pressure ulcer. Nursing change in condition note dated 1/28/2025 (no time) identified a small open area noted on the left side of the G-Tube, measured 0.9 by 0.7 by 0.1 centimeters (cm). the APRN was notified at 7:22 PM with orders to leave the abdominal skin opening open to air and notify of any change in condition. Nursing note dated 1/29/2025 at 8:44 PM identified wound doctor to see wound on buttocks. Skin integrity report dated 1/29/2025 and wound evaluation and management summary report dated 1/29/2025 identified an unstageable wound to left sacrum. Additional record review failed to identify a care plan was developed related to actual alteration in skin integrity. Interview, clinical record and facility documentation review with DNS and RN #2 on 4/3/2025 at 12:11 PM identified although Resident #2 had a care plan in place for a risk for alteration in skin integrity, Resident #2's care plan did not include the actual alteration in skin integrity. Interview identified the care plan should have been updated to reflect the actual alterations in skin integrity. Review of facility Comprehensive Care Plans Policy directed in part, to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical needs. A comprehensive care plan will describe at a minimum the services that are to be furnished. Facility documentation review identified staff education was initiated on 2/20/2025 and included when a resident has a skin alteration, a care plan must be updated with the new area and new interventions. Audits were initiated on 2/18/2025 and a QAPI meeting was held on 2/18/2025. Based on review of facility documentation, past non-compliance was identified.

Based on clinical record review, interviews, and review of facility documentation for one (1) of three (3) residents (Resident #1) reviewed for dialysis, the facility failed to adequately assess an Arteriovenous Fistula (AVF) (a surgical connection made between an artery and a vein accessed by needles to administer hemodialysis treatment) dialysis access site that was bleeding status post hemodialysis treatment to ensure bleeding had stopped, subsequently the resident had a significant bleed and was sent to the hospital and diagnosed with hemorrhagic shock requiring four (4) units of blood resulting in a finding of Immediate Jeopardy. The findings included: Resident #1's diagnoses included end stage renal disease and Type 2 diabetes mellitus. Review of Resident #1's Care Plan dated [DATE] identified the risk for injury or risk of complications related to renal dialysis with interventions that directed to observe for active bleeding and monitor hemodialysis access site for excessive redness, swelling, pain at site, signs and symptoms of infection, and excessive bleeding from the site, and to report to physician as indicated. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of twelve (12), indicative of moderately impaired cognition. The MDS further identified Resident #1 required substantial assistance with bathing and personal hygiene and received hemodialysis treatments. A physician's order dated [DATE] at 4:39 PM identified that the resident attends dialysis three (3) times weekly at 8:30 AM. The order directed to monitor the AVF site for signs and symptoms of infection, edema, bleeding and upon return from dialysis; to notify the primary care physician and dialysis unit if there are signs and symptoms of infection, and if the AVF site is bleeding, to apply pressure for fifteen (15) minutes and notify MD/Physician if bleeding does not stop. Review of nurse's notes dated [DATE] at 11:01 PM identified LPN #1 was alerted that Resident #1's left upper arm AVF was bleeding by the Nurse Aide (NA), the supervisor was then notified and assisted with applying a pressure dressing. The note further identified the bleeding had become worse around 9:30 PM, a call was made to the supervisor who assisted in sending the resident to the hospital, and 911 was called. Emergency Medical Technician's (EMT's) applied a more effective pressure dressing and took the resident via stretcher to the hospital. Review of an ambulance run sheet date [DATE] at 9:45 PM identified that upon entry into Resident #1's room the resident was noted with several layers of bandages on the arm, all soaked with blood. The soaked bandages were removed and direct pressure was applied and the bleeding was controlled. The resident was being wheeled to the ambulance from the facility when a sudden change in mental status was noted and the resident became apneic (lack of breathing), and pulseless. The cardiac pads were applied and two (2) compressions were given and on the third (3rd) compression the resident yelled out, the resident returned to a normal sinus rhythm (normal cardiac rhythm). Review of hospital discharge records dated [DATE] identified Resident #1 arrived at the hospital in hemorrhagic shock (acute decrease in the body's supply of blood) with a blood pressure of ,d+[DATE] (normal blood pressure ,d+[DATE]) and received four (4) units of packed red blood cells and one (1) unit of frozen fresh plasma (FFP)(a blood transfusion). Interview with the Certified Clinical Hemodialysis Technician (CCHT) on [DATE] 1:52 PM identified that Resident #1 completed dialysis treatment at 3:06 PM, the AVF had clotted and there was no bleeding prior to the discharge back to the Skilled Nursing Facility. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 11:07 AM identified that when the resident returned from hemodialysis sometime after 3:00 PM, he looked at the dressed AVF site and no visible signs of bleeding were evident. Around 8:00 PM Nurse Aide (NA) #1 informed him that Resident #1's AVF was bleeding. LPN #1 identified that he requested RN #1's assistance with the resident, and assisted RN #1 by holding the bandages in place as RN #1 secured the dressing to the resident's arm. LPN #1 identified that no additional pressure (manual) was applied to the access, that they just let the absorbent pads do the job. LPN #1 further identified that bleeding had ceased after the dressing was changed, and after performing two (2) ten (10) minute checks on the resident, LPN #1 had determined the bleeding had stopped as the dressing remained clean, dry and intact. However, LPN #1 indicated he/she didn't check the access site under the dressing to ensure the bleeding had actually stopped as he/she did not want to disturb the area and cause it to bleed again. LPN #1 indicated the standard of practice for access bleeds was to apply a pressure dressing to the access site without applying additional pressure to the area and that if the bandage applied was tight enough it should be sufficient to stop the bleeding. LPN #1 further identified he/she was notified at approximately 9:30 PM that Resident #1's access was noted to be bleeding through the dressing. LPN #1 informed RN #1 of the situation, and indicated the bandages were soaked with blood, that the resident had blood dripping down his arm, and that blood was on the bedsheet (approximately the size of a one (1) dollar bill). LPN #1 further identified RN #1 had assisted with Resident #1's had placed manual pressure on the access area until emergency medical technicians arrived. (This interview was read back to LPN #1 on [DATE] at 12:00 PM and verified to be accurate). Interview with RN #1 on [DATE] at 11:39 PM identified he/she was informed after dinner that Resident #1's access was bleeding and observed Resident #1's bandages were somewhat bloodied , but not saturated. RN #1 indicated he/she removed the dressing from dialysis from earlier in the day which were soaked in blood, and placed an Abdominal Pad (ABD pad- a long, thick and absorbent (multi layered) dressing used to cover wounds) dressing vertically over the wrapped gauze around it and the arm to secure the dressing, and applied tape to hold the gauze in place. RN #1 further identified he/she did not apply manual pressure to the access and that the gauze itself acted as a pressure dressing. RN #1 indicated he/she checked on Resident #1 twenty (20) minutes after the pressure dressing was applied and determined that the bleeding had stopped, because the dressing and tape were clean, dry and intact. She did not check under the dressings bandage and visualize the access site to ensure the bleeding had stopped. Around 30 minutes after she last checked the resident she was informed Resident #1's access site was again bleeding, she saw that the dressing was soaked with blood. RN #1 applied additional 4x4 gauze pads and an ABD pad on top of the previous dressing, secured them in place, applied a towel on top of the dressing and applied manual pressure to the access site until emergency medical technicians arrived. (Interview read back to RN #1 at the conclusion of the interview on [DATE] and verified as accurate). An untimed written statement provided by the facility dated [DATE] (2 weeks after the incident) written by RN #1 identified that RN #1 was notified by LPN #1 that the resident was bleeding at the AVF site. She placed three (3) four (4) by four (4) dressings and an ABD pad over the dressings placed at hemodialysis early in the day and wrapped the area in cling wrap. She applied manual pressure for 10 minutes, and at the end of 10 minutes she lifted up the end of the tape and didn't see any bleeding so she informed the charge nurse the bleeding had stopped and left the unit. She returned twenty (20) minutes later and the dressing was free from breakthrough bleeding. Thirty (30) minutes later she was called to the unit because LPN#1 had noted some blood on the dressing, however, it was not saturated. RN #1 placed ,d+[DATE] gauze dressings on the area and held pressure until emergency services arrived. Interview with Emergency Medical Technician (EMT) #1 on [DATE] at 10:23 AM identified he/she entered Resident #1's room as three (3) staff members were changing his/her sheets, and that Resident #1 had a big, bulky bandage on his/her left upper arm that was saturated with blood. EMT #1 indicated he/she removed the bloody dressing and applied a new pressure dressing to the access site and noted the arterial (lower cannulation site) was bleeding and the venous (upper cannulation site) was scabbed over. EMT #1 further identified the bleeding stopped once the pressure dressing was applied and that the dressing remained clean, dry, and intact throughout transport to the hospital. Interview with the Medical Director (MD) on [DATE] at 3:27 PM identified if an AVF access starts to bleed at the facility, staff is to apply pressure with gauze over the access site for five (5) to seven (7) minutes and may leave the resident unattended for a few minutes if the bleed was small, a breakthrough bleed. However, if the access failed to clot, the MD indicated the resident should be sent out to the hospital for further evaluation. The MD further indicated to properly assess if the access (AVF) bleeding has stopped, the nurse should remove the dressing to check the actual needle (puncture) insertion sites rather than assess by the cleanliness of the dressing to see if the access site is still bleeding. Interview with the Director of Nurses (DNS) on [DATE] at 12:20 PM identified that there are currently 47 residents in the facility receiving hemodialysis treatment. The DNS further identified that it was inappropriate for staff to leave Resident #1 after applying the first pressure dressing, that staff should have removed the dressings and checked the access site to ensure the bleeding had stopped prior to leaving the resident. Further, the physician should have been called when the resident's access first bled on evening of [DATE], approximately five (5) hours after he/she returned from dialysis treatment. Interview with the Staff Development Nurse (SDN) on [DATE] at 12:45 PM identified the facility does not provide dialysis access training during the nurse's orientation, however the nurse could receive training while precepted if there was an actual bleeding event while he/she was working. The SDN further identified the facility did not have a specific guideline, timeframe, or training checklist to ensure staff receives training on what to do for bleeding hemodialysis accesses. Review of the hemodialysis policy identified the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician's orders, the comprehensive person-centered care plans, and resident's goals and preferences to meet the special medical nursing, mental and psychosocial needs of residents receiving hemodialysis.

Based on clinical record review, facility documentation, polic review and interviews the facility failed to ensure that staff was educated and aware of what to do when a hemodialysis resident with an Ateriovenous Fistula (AVF) was noted to be bleeding from the AVF. The findings include: Resident #1's diagnoses included end stage renal disease and Type 2 diabetes mellitus. Review of Resident #1's Care Plan dated [DATE] identified the risk for injury or risk of complications related to renal dialysis with interventions that directed to observe for active bleeding and monitor hemodialysis access site for excessive redness, swelling, pain at site, signs and symptoms of infection, and excessive bleeding from the site, and to report to physician as indicated. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of twelve (12), indicative of moderately impaired cognition. The MDS further identified Resident #1 required substantial assistance with bathing and personal hygiene and received hemodialysis treatments. A physician's order dated [DATE] at 4:39 PM identified that the resident attends dialysis three (3) times weekly at 8:30 AM. The order directed to monitor the AVF site for signs and symptoms of infection, edema, bleeding and upon return from dialysis; to notify the primary care physician and dialysis unit if there are signs and symptoms of infection, and if the AVF site is bleeding, to apply pressure for fifteen (15) minutes and notify MD/Physician if bleeding does not stop. Review of nurse's notes dated [DATE] at 11:01 PM identified LPN #1 was alerted that Resident #1's left upper arm AVF was bleeding by the Nurse Aide (NA), the supervisor was then notified and assisted with applying a pressure dressing. The note further identified the bleeding had become worse around 9:30 PM, a call was made to the supervisor who assisted in sending the resident to the hospital, and 911 was called. Emergency Medical Technician's (EMT's) applied a more effective pressure dressing and took the resident via stretcher to the hospital. Review of an ambulance run sheet date [DATE] at 9:45 PM identified that upon entry into Resident #1's room the resident was noted with several layers of bandages on the arm, all soaked with blood. The soaked bandages were removed and direct pressure was applied and the bleeding was controlled. The resident was being wheeled to the ambulance from the facility when a sudden change in mental status was noted and the resident became apneic (lack of breathing), and pulseless. The cardiac pads were applied and two (2) compressions were given and on the third (3rd) compression the resident yelled out, the resident returned to a normal sinus rhythm (normal cardiac rhythm). Review of hospital discharge records dated [DATE] identified Resident #1 arrived at the hospital in hemorrhagic shock (acute decrease in the body's supply of blood) with a blood pressure of ,d+[DATE] (normal blood pressure ,d+[DATE]) and received four (4) units of packed red blood cells and one (1) unit of frozen fresh plasma (FFP)(a blood transfusion). Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 11:07 AM identified that when the resident returned from hemodialysis sometime after 3:00 PM, he looked at the dressed AVF site and no visible signs of bleeding were evident. Around 8:00 PM Nurse Aide (NA) #1 informed him that Resident #1's AVF was bleeding. LPN #1 identified that he requested RN #1's assistance with the resident, and assisted RN #1 by holding the bandages in place as RN #1 secured the dressing to the resident's arm. LPN #1 identified that no additional pressure (manual) was applied to the access, that they just let the absorbent pads do the job. LPN #1 further identified that bleeding had ceased after the dressing was changed, and after performing two (2) ten (10) minute checks on the resident, LPN #1 had determined the bleeding had stopped as the dressing remained clean, dry and intact. However, LPN #1 indicated he/she didn't check the access site under the dressing to ensure the bleeding had actually stopped as he/she did not want to disturb the area and cause it to bleed again. LPN #1 indicated the standard of practice for access bleeds was to apply a pressure dressing to the access site without applying additional pressure to the area and that if the bandage applied was tight enough it should be sufficient to stop the bleeding. LPN #1 further identified he/she was notified at approximately 9:30 PM that Resident #1's access was noted to be bleeding through the dressing. LPN #1 informed RN #1 of the situation, and indicated the bandages were soaked with blood, that the resident had blood dripping down his arm, and that blood was on the bedsheet (approximately the size of a one (1) dollar bill). LPN #1 further identified RN #1 had assisted with Resident #1's had placed manual pressure on the access area until emergency medical technicians arrived. (This interview was read back to LPN #1 on [DATE] at 12:00 PM and verified to be accurate). Interview with RN #1 on [DATE] at 11:39 PM identified he/she was informed after dinner that Resident #1's access was bleeding and observed Resident #1's bandages were somewhat bloodied , but not saturated. RN #1 indicated he/she removed the dressing from dialysis from earlier in the day which were soaked in blood, and placed an Abdominal Pad (ABD pad- a long, thick and absorbent (multi layered) dressing used to cover wounds) dressing vertically over the wrapped gauze around it and the arm to secure the dressing, and applied tape to hold the gauze in place. RN #1 further identified he/she did not apply manual pressure to the access and that the gauze itself acted as a pressure dressing. RN #1 indicated he/she checked on Resident #1 twenty (20) minutes after the pressure dressing was applied and determined that the bleeding had stopped, because the dressing and tape were clean, dry and intact. She did not check under the dressings bandage and visualize the access site to ensure the bleeding had stopped. Around 30 minutes after she last checked the resident she was informed Resident #1's access site was again bleeding, she saw that the dressing was soaked with blood. RN #1 applied additional 4x4 gauze pads and an ABD pad on top of the previous dressing, secured them in place, applied a towel on top of the dressing and applied manual pressure to the access site until emergency medical technicians arrived. (Interview read back to RN #1 at the conclusion of the interview on [DATE] and verified as accurate). An untimed written statement provided by the facility dated [DATE] (2 weeks after the incident) written by RN #1 identified that RN #1 was notified by LPN #1 that the resident was bleeding at the AVF site. She placed three (3) four (4) by four (4) dressings and an ABD pad over the dressings placed at hemodialysis early in the day and wrapped the area in cling wrap. She applied manual pressure for 10 minutes, and at the end of 10 minutes she lifted up the end of the tape and didn't see any bleeding so she informed the charge nurse the bleeding had stopped and left the unit. She returned twenty (20) minutes later and the dressing was free from breakthrough bleeding. Thirty (30) minutes later she was called to the unit because LPN#1 had noted some blood on the dressing, however, it was not saturated. RN #1 placed ,d+[DATE] gauze dressings on the area and held pressure until emergency services arrived. Interview with LPN #2 on [DATE] at 12:30 PM failed to identify when asked what to do when a dialysis resident had a bleeding AVF. LPN #2 indicated that he/she was to apply a clamp and dressing to an arteriovenous fistula (located in the resident's arm) if it was bleeding, and when questioned about the process of applying the clamp and dressing to the bleeding AVF, LPN #2 identified he/she was unsure of what to do. Of further note, LPN #2 was the only nurse working on the F wing during first shift that housed twenty (20) residents receiving dialysis, seven (7) of which had AVF accesses. Interview with the Staff Development Nurse (SDN) on [DATE] at 12:45 PM identified that there are 47 hemodialysis patients that reside in the skilled nursing facility, as there is a dialysis den. The standard of practice for a bleeding AVF access was for nurses to reinforce the current dressing, apply no additional manual pressure to the access site, to notify dialysis staff if the clinic was still open, and then notify the APRN (Advanced Practice Registered Nurse) and Medical Director of the issue. The SDN failed to provide training documents to verify staff received training on what to do for bleeding dialysis accesses/sites, however indicated staff was to follow first-aid instructions and place a reinforcement bandage over the access and secure with a stretch bandage. The SDN indicated the facility does not provide dialysis access training during the nurse's orientation, however the nurse could receive training while precepted if there was an actual bleeding event while he/she was working. The SDN further identified the facility did not have a specific guideline, timeframe, or training checklist to ensure staff receives training on what to do for bleeding accesses. Review of the hemodialysis policy identified the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician's orders, the comprehensive person-centered care plans, and resident's goals and preferences to meet the special medical nursing, mental and psychosocial needs of residents receiving hemodialysis.

Based on review of clinical records, interview, and review of facility documentation reviewed for one (1) of three (3) residents reviewed for incontinent care, the facility failed to perform hand hygiene in accordance with facility policy. The findings included: Resident #1's diagnoses included Type 2 diabetes mellitus without complications and a urinary tract infection. Review of Resident #1's Care Plan dated 11/18/24 identified risk for decreased ability to perform activities of daily living (ADL's) including toileting with interventions that directed to provide the resident with extensive assist of one (1) for toileting hygiene. Review of the Comprehensive Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of twelve (12), indicative of moderate cognitive impairment. The MDS further identified Resident #1 was dependent with toileting hygiene and was frequently incontinent of bowel and bladder. Observation performed on 1/14/25 at 2:45 PM identified NA #1 preparing Resident #1 for incontinent care. NA #1 had prepared the area, gathered the needed supplies, and applied gloves prior to removing the incontinent brief and cleaning the resident with a hygienic spray and moist washcloth. NA #1 then removed his/her gloves and applied a new set of gloves prior to applying barrier cream to the resident, however failed to perform hand hygiene prior to applying new gloves. NA #1 then removed his/her gloves after applying the barrier cream and applied new gloves, again failing to perform hand hygiene prior to applying the new gloves. NA #1 then applied a new, clean brief to Resident #1, lowered his/her [NAME], covered him/her with the bed sheet and blanket, and ensured his/her comfort prior to removing his/her gloves and performing hand hygiene. Interview with NA #1 on 1/14/25 at 2:50 PM identified the facility standard of practice was to perform hand hygiene each time gloves were removed during incontinence care and that he/she forgot to do so. Review of the Glove policy directed gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin and to wash hands after removing gloves.

Based on review of clinical records, interviews, and review of facility documentation for one (1) of three (3) residents reviewed for accidents, the facility failed to safely transfer a resident while using a Hoyer Lift. The findings included: Resident #1 had diagnoses that included transient ischemic attack, cerebral infarction, difficulty walking, syncope and collapse. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of eight (8) indicative of moderate cognitive impairment. The MDS further identified Resident #1 was dependent with chair to bed-to-chair transfers. Review of Resident #1's Care Plan dated 8/20/24 identified the risk for decreased ability to perform activities of daily living (ADL's) and directed assist of two (2) bed mobility, toileting, dressing, bathing, and for transfers using a mechanical lift. Review of the Facility Licensing and Investigations Section Reportable Event Form dated 8/27/24 identified Resident #1 was transferred from his/her bed to his/her wheelchair by two (2) aides utilizing a Hoyer Lift, however, the Hoyer Lift tilted and hit the resident in the face/head following the transfer, causing an abrasion to the top of his/her scalp. Interview with RN #1 on 1/14/25 at 1:34 PM identified he/she received report from two (2) nurse's aides on 8/27/24 that Resident #1 sustained an injury during their bed to wheelchair transfer. RN #1 further indicated the two (2) nurse's aides had transferred Resident #1 from his/her bed utilizing a Hoyer Lift into his/her wheelchair, however after the resident was transferred into his/her wheelchair, the Hoyer Lift had tilted over and the overhead bar (which secured the seat sling supporting the resident to the Hoyer Lift during transfer) hit the resident in the head and caused a small abrasion. RN #1 identified the resident was assessed and his/her wound was attended to. Interview with the Regional Resource Nurse (RRN) on 1/14/25 at 1:40 PM failed to identify what caused the Hoyer Lift to tilt after Resident #1 was transferred from his/her bed into his/her wheelchair on 8/27/25. Interview with the Director of Nurses (DON) on 1/14/25 at 5:13 PM identified staff were trained on how to use the Hoyer Lift, that transfers were a two (2) person assist process with one (1) person guiding the resident during the mechanical transfer process while the other person moved the lift. Although identified it was the responsibility of both staff members to ensure residents were transferred safely, she was unsure of what had occurred during the transfer that caused the Hoyer to tilt and hit the resident in the head.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #8 and 66) reviewed for non-pressure skin condition, the facility failed to notify the provider or resident representative of a change in condition and allegation of abuse. The findings include: 1. Resident #8 was admitted to the facility in January 2023 with diagnoses that included dementia and end stage renal disease requiring dialysis. The nursing admission assessment dated [DATE] identified a healed abrasion to the mid forehead. The physician's admission history and physician dated 1/24/23 did not reflect an area to the forehead. The quarterly MDS dated [DATE] identified Resident #8 had severely impaired cognition. a. Review of the provider notes and nurse's notes dated 1/1/24 to 5/12/24 did not reflect the area to the to the resident's forehead. Review of the skin weekly skin checks performed by a licensed nurse dated 4/3/24 to 5/8/24 did not reflect any new or current skin injury or wounds. A physician's order dated 4/18/24 directed to obtain a wound consult and treatment as indicated and weekly showers with skin checks on Wednesdays 3:00 PM to 11:00 PM shift. The nurse's note written by LPN #7 dated 5/13/24 at 5:32 AM identified that Resident #8 picked the scab on the mid forehead, and she cleansed it with normal saline and left open to air. Review of the nurse's notes dated 5/13/24 to 7/1/24 failed to reflect an RN assessment of the area on the resident's mid forehead had been done, or that the APRN/MD and resident representative were made aware of the area on the resident's mid forehead. Interview with the second floor Unit Manager (RN #3) on 11/19/24 at 7:30 AM indicated that when a resident has a change in condition there would be an RN assessment and the resident representative and APRN or physician would be notified. After review of the clinical record, RN #3 indicated that she did not see any documentation that on 5/13/24 there was an RN assessment of the scab that had been picked on the mid forehead nor that the APRN or physician and resident representative were notified. Interview with RN #3 on 11/19/24 at 8:47 AM indicated that on the admission assessment dated [DATE] there was a healed abrasion to the mid forehead and not until 5/13/24 there was an LPN who noted Resident #8 had picked the scab to the forehead causing it to bleed. RN #3 indicated that her expectation was that Resident #8 would have had an RN assessment, and the nurse would have notified the resident representative and the APRN or physician. b. Review of the weekly skin checks performed by a licensed nurse dated 10/2/24 to 11/11/24 did not identify any new or current skin injury or wounds. Review of the nursing notes and the APRN/MD notes dated 10/2/24 to 11/17/24 did not identify an open or scabbed are noted to Resident #8's forehead. A physician's order dated 10/13/24 directed to give a weekly bed bath due to dialysis permacath with skin checks on Wednesdays 3:00 PM to 11:00 PM shift. Observation on 11/17/24 at 9:06 AM noted a scabbed area approximately nickel size with some fresh dry blood and some hard dried blood noted on the resident's mid forehead. Resident #8 was not able to indicate what had happened. Interview with LPN #6 on 11/17/24 at 11:07 AM observed Resident #8 had an area to the forehead and indicated that she had not seen that prior and did not receive anything regarding this area to the mid forehead during the change of shift-to-shift report. After clinical record review, LPN #6 indicated that the area on the mid forehead must be new because she could not find anything in the documentation under a change of condition assessment or in a progress note. LPN #6 indicated that her expectation was there would be a documented RN assessment and the APRN and resident representative would be notified. Review of the nurse's notes dated 11/17/24 to 11/19/24 did not identify there was an RN assessment or that the APRN/MD and resident representative were updated. Interview with DNS and Director of Clinical Operations (RN #5) on 11/19/24 at 10:05 AM indicated staff are aware that the area on Resident #8's forehead opens and closes but only had seen a nurses note dated 5/13/24 written by an LPN and there was not documentation that the resident representative and the APRN or physician were notified. Additionally, RN #5 indicated that on 11/17/24 when surveyor and LPN #6 observed the bleeding and partially scabbed area to Resident #8's forehead there was not an RN assessment and the resident representative and APRN or physician were not notified. RN #5 and the DNS indicated that the expectation was when there is any change of condition that the LPN notifies the RN, the RN does an assessment and documents the assessment and notifies the resident representative and provider. RN #5 indicated that he would have an RN do an assessment and notify the resident representative and APRN. Interview with second floor Unit Manager (RN #3) on 11/19/24 at 10:59 AM indicated she was responsible to do weekly wound measurements and documentation of pressure and non-pressure areas. RN #3 indicated that there was no documentation for the 5/13/24 and the 11/17/24 skin areas or that the APRN or physician and resident representative were notified. RN #3 indicated that she will do an RN assessment today and document it and notify the resident representative and the APRN today. Review of the Skin Assessment Policy identified it was the policy to perform a full body skin assessment as art of the systemic approach to pressure injury prevention and management. A full body head to toe skin assessment will be conducted by a licensed or registered nurse upon admission or readmission and weekly thereafter and if there is a change in condition. Documentation of skin assessment includes the date, time, nurses name and title. The documentation will include the observation, type of wound, measurements, color, wound bed, drainage, odor, and if there was pain noted. Review of the Skin Integrity for Skin Tears Policy identified it was the policy to provide proper treatment and care to maintain skin integrity. The facility will utilize a systemic approach for the prevention and management of skin tears, including assessment, care planning, monitoring, and modification of interventions as appropriate. The licensed nurse will conduct skin assessments according to facility policy. When a skin tear is discovered, the nurse will complete an accident and incident report. The following information shall be documented: the residents name, the employee who discovered the skin tear, the site and description of the skin tear, the date and time the skin tear was discovered, the name of the employee who provided care to the resident 24 hours previously, site care rendered and evaluation of the incident, the names of any witnesses, the date and time the physician and resident representative were notified , and any other information relevant to the incident. The attending physician will assume responsibility for the overall care and treatment of the resident's medical condition. The attending physician will be notified of the presence, progression towards healing, or lack of healing of any skin tears, assessments of residents, and reporting any changes in condition to the physician. Interventions will be modified in the resident's plan of care as needed. Considerations for needed modifications include changes in medical condition or factors affecting the risk for skin tears, new onset or recurrent skin tears, lack of progression towards healing, resident is non-compliance, and changes in the resident's goals and preferences. 2. Resident #66 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic obstructive pulmonary disease, and stage 2 chronic kidney disease. The annual MDS dated [DATE] identified Resident #66 had intact cognition, was frequently incontinent of bowel and bladder, was dependent for rolling left to right and chair/bed-to-chair transfers and required a maximal assist with bathing and toileting hygiene. The care plan dated 11/8/24 identified Resident #66 exhibits verbal behaviors related to, accusatory statements, at times. Interventions included to evaluate the nature and circumstances of the verbal behavior with the resident and/or resident representative and to provide social service visits to provide support, as needed. During an interview with Resident #66 and SW #2 on 11/18/24 at 9:05 AM, Resident #66 identified that about 2 weeks ago, a nurse aide came into his/her room and woke him/her up by grabbing the top of his/her shirt. Resident #66 identified that when he/she asked the nurse aide what she was doing, the nurse aide indicated that she was there to wash him/her up. Resident #66 indicated that when the nurse aide was washing the upper part of his/her body he/she said something to the nurse aide but could not recall what was said, and the nurse aide told him/her to be quiet, shoved a washcloth in his/her mouth, and laughed. Resident #66 could not specifically recall the nurse aide's name but was able to provide a physical description; Resident #66 denied reporting this incident to any facility staff members prior to this interview. Review of the 11/18/24 through 11/19/24 nurse's notes failed to identify Resident #66's Conservator was notified of the abuse allegation. Review of the 11/18/24 through 11/19/24 social service notes failed to identify Resident #66's Conservator was notified of the abuse allegation. Interview with Resident #66's Conservator (Person #1) on 11/19/24 at 9:15 AM identified that she had not been notified of Resident #66's allegation that a nurse aide put a washcloth in his/her mouth. Person #1 further identified that she had not received an email or a voicemail regarding the allegation and her voicemail box was not full. Interview with SW #2 on 11/19/24 at 9:53 AM identified that she did not notify Person #1 of Resident #66's allegation, but that she would inquire if the DNS or Nursing Supervisor made the notification to the responsible party. Interview and clinical record review with the DNS on 11/19/24 at 10:56 AM indicated that the Nursing Supervisor (RN #3) had notified Person #1 of Resident #66's allegation on 11/18/24, but review of the progress notes dated 11/18/24 through 11/19/24 failed to identify documentation that Person #1 was notified. The DNS indicated that following an allegation of abuse, she would expect the responsible party to be notified and documentation of the notification to be in the clinical record. Interview with RN #3 on 11/19/24 at 11:16 AM identified that she left a message in Person #1's confidential mailbox on 11/18/24 at around 3:00 PM. RN #3 indicated that she did not document the responsible party notification in Resident #66's clinical record, most likely because somebody called her away to go do something else. RN #3 indicated that she should have documented, in the progress notes, that she attempted to contact Person #1 and left a voicemail, and it is her usual practice to document such notifications in the progress notes. The facility's Notification of Changes policy directs the facility to promptly inform the resident, consult's the resident's physician, and notifies, consistent with his or her authority, the resident representative when there is change requiring notification. Circumstances requiring notification include: accidents, significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status, circumstances that require a need to alter treatment, a transfer or discharge from the facility, a change in room or roommate assignment, and a change in resident rights. 47457

Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #66) reviewed for Advance Directive, the facility failed to ensure resident care conferences (RCC) were completed quarterly. The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic obstructive pulmonary disease, and stage 2 chronic kidney disease. The admission MDS dated [DATE] identified Resident #66 was admitted from a short-term general hospital and had moderately impaired cognition. The care plan dated 11/17/23 identified Resident #66 was at risk for limited meaningful engagement related to self-isolation. Interventions included providing opportunities for choice during care/activities to provide a sense of control. The social service notes dated 11/4/23 through 11/19/24 failed to identity quarterly care conferences were completed from 11/4/23 through 7/17/24; quarterly care conferences were completed on 7/18/24, 8/1/24, and 11/7/24. Interview with Resident #66 on 11/17/24 at 10:20AM identified that he/she recalled attending one care plan meeting but could not remember if he/she had been invited to other care conferences and chose not to attend. Interview with Resident #66's Conservator (Person #1) on 11/19/24 at 9:15 AM identified that, since becoming Resident #66's Conservator on 3/11/24, she had been invited to Resident #66's RCC's and believed that she had participated in one care conference. Person #1 further identified that she and the facility social worker were also in contact, as needed, via email and telephone. Interview and clinical record review with SW #2 on 11/19/24 at 9:53 AM failed to identify documentation of quarterly resident care conferences from Resident #66's admission on 11/4/23 through 7/18/24. SW #2 identified that while official resident care conferences did not occur quarterly, she had frequent conversations and meetings with Resident #66. SW #2 indicated that the MDS coordinator is responsible for scheduling RCC's. Interview and clinical record review with the MDS Coordinator (RN #4) on 11/19/24 at 10:40 AM identified that Resident #66 was initially admitted for a short-term stay so social services would have been responsible for completing his/her initial RCC and that one of the social workers could better speak to why Resident #66's initial resident care conference was missed. RN #4 indicated that Resident #66 had MDS assessments completed at the end of January and April, so he/she should have been scheduled to have an RCC at the end of January or the beginning of February and then again at the end of April or the beginning of May. RN #4 indicated that it appeared that Resident #66's initial RCC and quarterly RCC's following the January and April MDS assessments were missed, and she was unsure how that could have happened. Interview with the DNS on 11/19/24 at 10:56 AM identified that she would expect the first resident care conference to be completed 72 hours after admission, and that would be completed by social services, if the resident was admitted as short-term. The DNS further identified that she would expect resident care conferences to be completed quarterly, after the initial RCC and the MDS Coordinator was responsible for scheduling those meetings. The facility's Resident, Family, Care Plan Conferences policy directs the facility to assure the resident and/or family/representatives are part of the interdisciplinary team and participate in the development and ongoing review of the person-centered interdisciplinary plan of care. The conferences will be scheduled based on identified needs and regulatory standards. If the resident and resident representatives do not participate in the development of the plan, an explanation will be included in the resident's medical record. The policy directs the procedure as follows: notify resident and family/legal representative of the next scheduled care conference, notify the appropriate interdisciplinary team members, review the interdisciplinary plan of care and the anticipated goals and interventions, ask the resident/resident representative to express their preferences about care, review the CAA's summary sheet, and summarize the outcome of the meeting and document attendance.

47457 Based on review of the clinical record, facility policy, and interviews for 2 of 2 residents (Resident #66 and 70) reviewed for Advance Directives, the facility failed to review code status, with the resident and resident's representative according to facility policy. The findings include: 1. Resident #66 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic obstructive pulmonary disease, and stage 2 chronic kidney disease. The care plan dated [DATE], (revised [DATE], [DATE], [DATE], and [DATE]), identified Resident #66 had an established advance directive CPR (Cardiopulmonary resuscitation). Interventions included activating resident's advance directive, as indicated, providing resident/health care decision maker with sufficient information to make an informed decision, and reviewing contents and providing opportunity to update and/or make changes to Advance Directive with resident and/or healthcare decision maker quarterly and as needed. The admission MDS dated [DATE] identified Resident #66 was admitted from a short-term general hospital and had moderately impaired cognition. A physician's order dated [DATE] directed Full Code (a medical directive that instructs a patient's health care team to perform lifesaving procedures in the event of a medical emergency, such as cardiac or respiratory arrest). The Decree/Appointment of Conservator/Voluntary Representation document dated [DATE] identified Person #1 as Resident #66's conservator of the person and estate. The document directs that the conservator of the person shall have the authority over the Petitioner's personal needs in the following areas: personal care, comfort, safety and maintenance, medial or other professional care, subject to C.G.S section 45a-656(d), residence, subject to C.G.S section 45a-656b, and personal effects. The undated and unsigned Resident/Patient Health Care Instructions document identified an X for the following goals: No, do not attempt CPR; allow death to occur naturally (DNR). Transfer to hospital for any condition requiring hospital-level care. All medical tests acceptable (treatment planned for diagnosed condition). Two sticky notes attached to the Resident/Patient Health Care Instructions document dated [DATE] identified, refused to continue and will not sign-multiple excuses and dated [DATE] identified, reapproached and still refuses. A social service (SS) note dated [DATE] at 12:13 PM identified social services called and also emailed patient's COP/E in order to sign off on patient's code status wishes. Awaiting a response so the code status to be returned. No issues noted at this time, SS will remain involved as needed. During an interview with the DNS and SW #2 on [DATE] at 2:00 PM, SW #2 identified that earlier in the day, she had left a voicemail and sent email to Person #1 to discuss Resident #66's advance directive choices. Subsequent to surveyor inquiry a Resident/Patient Health Care Instructions document, signed by Resident #66 but not dated, identified Resident #66's initials for the following goals: No, do not attempt CPR; allow death to occur naturally (DNR). Transfer to hospital for any condition requiring hospital-level care. Limited (noninvasive, low risk) medical tests only. Antibiotics acceptable. No artificial ventilation. No artificially administered fluids and nutrition. Other life sustaining treatments acceptable if recommended for an acute episode, but not indefinitely. The social service note dated [DATE] at 11:31 AM identified code status updated from the COP/E to reflect patient's new wishes for his/her code status. Orders and care plan updated. Interview and clinical record review with SW #2 on [DATE] at 7:51 AM identified that she had heard back from Person #1 and now Resident #66 was a DNR, per his/her wishes. SW #2 indicated that she was not sure why there was a gap in completing Resident #66's Resident/Patient Health Care Instructions document, but that she had challenges getting in contact with Person #1, and Person #1 had not attended the quarterly care conferences. SW #2 further indicated that it was not brought to her attention that Resident #66 had indicated that she wanted to be a DNR on admission, and that his/her Resident/Patient Health Care Instructions document had not been signed. SW #2 identified that upon Resident #66's admission, he/she was responsible for self, and ideally the advance directive documentation should be signed at the time of admission. SW #2 identified that she would have to obtain additional information to confirm who would be responsible for reapproaching a resident that initially refused to sign the Resident/Patient Health Care Instructions document. SW #2 identified that she would have assisted with getting the form signed if she was aware that Resident #66 had indicated that he/she would like to be a DNR. Upon clinical record review, it was identified that Resident #66's quarterly Care Conferences had not been completed from [DATE] through [DATE], but SW #2 indicated that she had discussed code status with Resident #66 during other meetings, prior to being conserved. SW #2 further indicated that code status was also discussed during Resident #66's [DATE], [DATE], and [DATE] quarterly care conferences; review of the [DATE], [DATE], and [DATE] attendance signature sheets identified Resident #66 did not attend the [DATE] or [DATE] conferences but attended the [DATE] conference. Interview with Person #1 on [DATE] at 9:15 AM identified that while she believes she did discuss life support choices and advance directives with Resident #66 and the facility, she could not recall the outcome of the conversations, and she did not have documentation of those conversations. Person #1 indicated that she could not remember when it was brought to her attention that Resident #66's wishes were to be a DNR, but on [DATE] she signed Resident #66's advance directive documentation. Interview with the DNS and the Director of Clinical Operations on [DATE] at 10:51 AM identified that the expectation is that advance directive education would be reviewed with the resident and/or resident representative and documentation would be completed within the first 24 hours. The DNS further identified that advance directives would also be reviewed or updated, at the request of the resident and/or resident representative and during the resident's quarterly care conference. The Director of Clinical Operations identified that in this case where Resident #66 had refused to sign the documentation of his/her wishes, he would expect that a conversation would have occurred in order to understand the reasons for refusals; and that upon conservatorship he would have expected advance directive documents to have been reviewed and signed. The facility's Residents' Rights Regarding Treatment and Advance Directives policy directs the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. The policy further directs the facility to provide the resident or resident representative information, in a manner that is easy to understand about the right to refuse medical or surgical treatment and formulate an advance directive, the facility will periodically assess the resident for decision making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities, the facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant health care decisions, the facility will define and clarify medical issues and present them to the resident or legal representative as appropriate, during the care planning process the facility will identify, clarify and review with the resident or legal representative whether they desire to make any changes related to any advanced directives. 2. Resident #70 was admitted to the facility on [DATE] with diagnoses that included stroke, hemiplegia, and aphasia. Review the clinical record identified a signed advance directive form dated [DATE] for Resident #70 which directed do not resuscitate, do not intubate, and RN to pronounce in the event of death (DNR/DNI/RNP). The name and signature on the advance directive form did not belong to Resident #70, and further review of the clinical record failed to identify any resident representative or emergency contact with the name and signature identified on the form. A physician's order dated [DATE] directed Resident #70 had advance directives that included DNR/DNI/RNP. The annual MDS dated [DATE] identified Resident #70 had severely impaired cognition, was always incontinent of bowel and bladder and was dependent on staff assistance with dressing, toileting, and bathing. The care plan dated [DATE] identified Resident #70 has established advance directives that included DNR/DNI/RNP. Interventions included to review the contents and provide the opportunity to update and/or make changes to the advance directives with the resident or healthcare decision maker quarterly and as needed. Review of the clinical record failed to identify that the facility had reviewed advance directives with any of Resident #70's listed resident representatives since admission. Interview with RN #3 (unit manager) on [DATE] at 6:45 AM identified that the signature on Resident #70's advance directive form from [DATE] was a family member of the resident. RN #3 identified Resident #70 had other court appointed resident representatives and she was unable to locate any additional documentation to identify that Resident #70's advance directives with any additional resident representatives since admission to the facility. Interview with Social Worker #1 on [DATE] at 3:10 PM identified that after surveyor inquiry regarding with RN #3, she attempted to contact Resident #70's resident representatives to review the advance directives in place to determine if any changes needed to be made. Social Worker #1 identified she was not aware that the signed advance directives on file from Resident #70's admission had not been reviewed with any resident representative on record. The facility policy on advance directives directed that during the care planning process, the facility would clarify and review, with the resident or legal representative, whether they desire to make any changes to the advance directives. The policy further directed that decisions regarding advance directives and treatment would periodically be reviewed as periodically review as part of the comprehensive care planning process.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 68) reviewed for activities of daily living (ADLs), the facility failed to ensure that the resident's choices related to care were honored. The findings include: Resident # 68 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, neuralgia, and neurogenic bowel. The quarterly MDS dated [DATE] identified Resident # 68 had intact cognition, was always incontinent of bowel and bladder and was dependent on staff to assist with toileting, bathing and transfers. A physician's order dated 4/26/24 directed to Resident #68 was to be assisted back to bed by 8 PM each day per resident request. Review of the record identified the order was originally entered into the electronic record by RN #3. The care plan dated 5/3/24 identified it was important to Resident #68 to have the opportunity to engage in daily routines relative to preferences. Interventions included Resident #68 choosing his/her own bedtime. Interview with Resident #68 on 11/17/24 at 9:45 AM identified he/she had several issues with NA #1 who worked during the 3-11 PM shift, providing care. Resident #68 identified that NA #1 was very talkative and demanding when providing care, and many times did not answer his/her call light timely when NA #1 was assigned to him/her. Resident #68 also identified that NA #1 would often leave the unit multiple times a shift which the facility was aware of, and that Resident #68 had a physician's order to be assisted to bed by 8 PM, but due to the issues with NA #1 leaving the unit or not being available, he/she often had to wait, often until 10 PM. Resident #68 identified due to all of these issues; he/she had refused to allow NA #1 to care for him/her multiple times. Resident #68 identified that despite his/her refusals to allow NA #1 to provide care, several facility staff had spoken with him/her and asked him/her to allow NA #1 to assist with his/her car due to multiple reasons, including staffing assignments in the facility being based on seniority and Resident #68's care requirements that included 2 staff members to assist with transfers. Resident #68 identified he/she eventually allowed NA #1 to provide care with transfers, however Resident #68 identified he/she really did not want NA #1 involved in any of his/her care. Resident #68 identified he/she had told multiple people over the last year of his/her request to not have NA #1 provide care but could not remember all of the staff he/she discussed the matter with. Resident #68 denied any issues related to abuse but reiterated that he/she did not want NA #1 providing care for him/her due to their personalities not meshing. Review of NA #1's personal file failed to identify any documentation related to Resident #68's reporting of issues related to care or interactions with NA #1. Review of the resident grievance records for 2023 and 2024 failed to identify any grievances filed on behalf of Resident #68 related to NA #1. Interview with RN #3 on 11/19/24 at 9:45 AM identified that she was not aware of any issues related to Resident #68 requesting that NA #1 not be assigned to provide care. RN #3 identified that she was aware of issues related to staff complaining about NA #1 but that she had not received any complaints from Resident #68 related to NA #1. RN #3 failed to provide any specific issues related to NA #1 and care, but identified she was aware of some issues related to staff complaints regarding NA #1. RN #3 identified that she did enter the order related to Resident #68 being assisted to bed by 8 PM, but identified she did not remember why the order was placed. Interview with LPN #1 on 11/19/24 at 10:45 AM identified that Resident #68 had requested to be assisted to bed and had complained to her regarding the issue, and that she reported this to RN #3 who then placed the order for the physician to sign in April 2024. LPN #1 identified Resident #68 had notified her that he/she did not care for NA #1 and had personality conflicts with her, and had issues with being assisted to bed timely. LPN #1 identified that while she was aware that Resident #68 did not want NA #1 to provide care, she was not aware what the facility had done to address the situation other than putting the order in place. LPN #1 identified that everyone knows he/she doesn't like NA #1 and that LPN #3 and LPN #4 were the primary nurses on the 3-11 PM shift and would know more regarding the situation. LPN #1 also identified that LPN #3 had been trying to work on issues with NA #1 related to remaining on the unit and work assignments, but had not been successful. LPN #1 failed to elaborate any further on what the issues were. Interview with LPN #4 on 11/19/24 at 11:29 AM identified that Resident #68 had issues in the past with NA #1, but was okay with NA #1 working with him/her, as long as NA #1 was not in Resident #68's room by herself. LPN #4 identified that Resident #68 expected to be assisted to bed right away, but due to the need for a hoyer lift and 2 staff to transfer, at times Resident #68 had to wait until staff were available. LPN #4 identified that Resident #68 did not like NA #1 personally, and that was the issue with care. LPN #4 also identified that NA #1 was routinely assigned as Resident #68's primary nurse aide, but the staff on the unit worked as a team. When asked why, if Resident #68 had continually voiced that he/she did not want NA #1 to provide care or be assigned to him/her, was NA #1 still being assigned to the resident, LPN #4 reiterated that the staff on the unit worked as a team so even if NA #1 was assigned to Resident #68, it would not always be her addressing his care needs. LPN #4 identified that when Resident #68 initially requested for NA #1 not to be assigned or to provide care to him/her, multiple staff spoke with Resident #68 and identified that NA #1 would at least need to assist with transfers. LPN #4 identified that Resident #68 then allowed this. LPN #4 identified his understanding was as long as NA #1 did not go into Resident #68's room alone there was no issue with her providing care with another staff member. When asked who this information was reported to, LPN #4 identified it was common knowledge for all the staff, including RN #3, the Administrator who Resident #68 spoke with regularly, and the DNS. LPN #4 identified he had recently been out of work from 7/24-11/24, and the issue had been going on prior to his leave but was unable to identify how long Resident #68 had voiced issues with NA #1. Interview with the DNS on 11/19/24 at 11:40 AM identified she was aware with issues related to NA #1 remaining on task, leaving the unit multiple times during the shift, and not assisting other facility staff on the unit when needed. The DNS identified that she had spoken with NA #1 but did not place any documentation in NA #1's personnel file. The DNS identified she was not aware of any issues with Resident #68 reporting he/she did not want NA #1 assigned to him/her or to provide care and that she was only hearing of this at the time of this interview. The DNS identified that there were no issues with seniority at the facility that would prevent NA #1 from being reassigned to another unit, and that Resident #68 was cognitively intact and had the choice to decide who he/she wanted to provide care, unless there was an emergency that could potentially cause Resident #68 harm. The DNS identified that she was unsure why staff had not reported this information to her previously, and that she would address the matter right away. Interview with the Administrator on 11/19/24 at 12:00 PM identified he was not aware of any issues related to Resident #68 and NA #1, and Resident #68 had not requested or spoken with him regarding NA #1 not providing care. Subsequent to surveyor inquiry, the DNS notified Resident #68 and this surveyor on 11/19/24 at 12:20 PM that NA #1 would no longer be working on Resident #68's unit, would no longer be assigned to Resident #68, and that this change would be permanent. Although attempted, an interview with LPN #3 was not obtained. The facility policy on resident rights directed that residents of the facility had the right to be treated with respect and dignity, including the right to receive services of the facility with reasonable accommodation of the resident's needs and preferences. The policy further directed that residents of the facility had the right to, and the facility must promote and facilitate, the resident's right to self determination through support of the resident's choices, including the right to choose health care and providers of health care services, and that the resident had the right to make choices about the aspects of his/her life in the facility that were significant to the resident.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #8) reviewed for non-pressure skin condition, the facility failed to document an RN assessment when the resident was identified with a scabbed area on the forehead, and for 1 resident (Resident #68) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure that a low air loss mattress was set per the physician's orders. The findings include: 1. Resident #8 was admitted to the facility in January 2023 with diagnoses that included dementia and end stage renal disease requiring dialysis. The nursing admission assessment dated [DATE] identified a healed abrasion to the mid forehead. The physician's admission history and physician dated 1/24/23 did not reflect an area to the forehead. The quarterly MDS dated [DATE] identified Resident #8 had severely impaired cognition. a. Review of the provider notes and nurse's notes dated 1/1/24 to 5/12/24 did not reflect the area to the to the resident's forehead. Review of the skin weekly skin checks performed by a licensed nurse dated 4/3/24 to 5/8/24 did not reflect any new or current skin injury or wounds. A physician's order dated 4/18/24 directed to obtain a wound consult and treatment as indicated and weekly showers with skin checks on Wednesdays 3:00 PM to 11:00 PM shift. The nurse's note written by LPN #7 dated 5/13/24 at 5:32 AM identified that Resident #8 picked the scab on the mid forehead, and she cleansed it with normal saline and left open to air. Review of the nurse's notes dated 5/13/24 to 7/1/24 failed to reflect an RN assessment of the area on the resident's mid forehead had been done. Interview with the second floor Unit Manager (RN #3) on 11/19/24 at 7:30 AM indicated that when a resident has a change in condition there would be an RN assessment. After review of the clinical record, RN #3 indicated that she did not see any documentation that on 5/13/24 there was an RN assessment of the scab that had been picked on the mid forehead. Interview with RN #3 on 11/19/24 at 8:47 AM indicated that on the admission assessment dated [DATE] there was a healed abrasion to the mid forehead and not until 5/13/24 there was an LPN who noted Resident #8 had picked the scab to the forehead causing it to bleed. RN #3 indicated that her expectation was that Resident #8 would have had an RN assessment b. Review of the weekly skin checks performed by a licensed nurse dated 10/2/24 to 11/11/24 did not identify any new or current skin injury or wounds. Review of the nursing notes and the APRN/MD notes dated 10/2/24 to 11/17/24 did not identify an open or scabbed are noted to Resident #8's forehead. Observation on 11/17/24 at 9:06 AM noted a scabbed area approximately nickel size with some fresh dry blood and some hard dried blood noted on the resident's mid forehead. Resident #8 was not able to indicate what had happened. Interview with LPN #6 on 11/17/24 at 11:07 AM observed Resident #8 had an area to the forehead and indicated that she had not seen that prior and did not receive anything regarding this area to the mid forehead during the change of shift-to-shift report. After clinical record review, LPN #6 indicated that the area on the mid forehead must be new because she could not find anything in the documentation under a change of condition assessment or in a progress note. LPN #6 indicated that her expectation was there would be a documented RN assessment. Review of the nurse's notes dated 11/17/24 to 11/19/24 did not identify there was an RN assessment of the area on the resident's mid forehead. Interview with DNS and Director of Clinical Operations (RN #5) on 11/19/24 at 10:05 AM indicated staff are aware that the area on Resident #8's forehead opens and closes but only had seen a nurses note dated 5/13/24 written by an LPN. Additionally, RN #5 indicated that on 11/17/24 when surveyor and LPN #6 observed the bleeding and partially scabbed area to Resident #8's forehead there was not an RN assessment. RN #5 and the DNS indicated that the expectation was when there is any change of condition that the LPN notifies the RN, the RN does an assessment and documents the assessment. Interview with LPN #2 on 11/19/24 at 10:41 AM indicated she was the full-time charge nurse on the unit with Resident #8. LPN #2 indicated that the area on Resident #8's forehead opens and gets scabbed over and heals and then Resident #8 picks at it and opens it again and then it heals. LPN #2 indicated this has occurred many times since his/her admission. LPN #2 indicated that she does not know how many times the area to the forehead had opened and then healed. LPN #2 indicated that Resident #8 had not been seen by the facility wound physician and there were no weekly wound assessments completed by the RN unit manager RN #3 so she could not clearly identify when the area had opened and closed. Interview with second floor Unit Manager (RN #3) on 11/19/24 at 10:59 AM indicated she was responsible to do weekly wound measurements and documentation of pressure and non-pressure areas. RN #3 indicated that there was no documentation for the 5/13/24 and the 11/17/24 skin areas. Interview with second floor Unit Manager (RN #3) on 11/19/24 at 10:59 AM indicated she was responsible to do weekly wound measurements and documentation of pressure and non-pressure areas. RN #3 indicated that was responsible to do the weekly wound rounds with the wound physician that comes to the facility. RN #3 indicated that she is aware of the area on Resident #8's forehead that has opened and healed many times. RN #3 indicated that she has not followed Resident #8's forehead on a weekly basis from when it opens until when it heals. RN #3 indicated that she does not know why she has not followed it and done weekly documentation, because reflecting now she believes she should have followed it. RN #3 indicated that she recalls in the past once there was a treatment for bacitracin to the area. RN #3 indicated that LPN #6 did not notify her on 11/17/24 during the 7:00 AM to 3:00 PM shift that Resident #8 had a change of condition with an open area or scabbed area to the forehead and needed an RN assessment. Review of the Skin Assessment Policy identified it was the policy to perform a full body skin assessment as art of the systemic approach to pressure injury prevention and management. A full body head to toe skin assessment will be conducted by a licensed or registered nurse upon admission or readmission and weekly thereafter and if there is a change in condition. Documentation of skin assessment includes the date, time, nurses name and title. The documentation will include the observation, type of wound, measurements, color, wound bed, drainage, odor, and if there was pain noted. Review of the Skin Integrity for Skin Tears Policy identified it was the policy to provide proper treatment and care to maintain skin integrity. The facility will utilize a systemic approach for the prevention and management of skin tears, including assessment, care planning, monitoring, and modification of interventions as appropriate. The licensed nurse will conduct skin assessments according to facility policy. When a skin tear is discovered, the nurse will complete an accident and incident report. The following information shall be documented: the residents name, the employee who discovered the skin tear, the site and description of the skin tear, the date and time the skin tear was discovered, the name of the employee who provided care to the resident 24 hours previously, site care rendered and evaluation of the incident, the names of any witnesses, the date and time the physician and resident representative were notified , and any other information relevant to the incident. The attending physician will assume responsibility for the overall care and treatment of the resident's medical condition. The attending physician will be notified of the presence, progression towards healing, or lack of healing of any skin tears, assessments of residents, and reporting any changes in condition to the physician. Interventions will be modified in the resident's plan of care as needed. Considerations for needed modifications include changes in medical condition or factors affecting the risk for skin tears, new onset or recurrent skin tears, lack of progression towards healing, resident is non-compliance, and changes in the resident's goals and preferences. 2. Resident #68 was admitted to the facility on [DATE] with diagnoses that included neuralgia, and neurogenic bowel. The annual MDS dated [DATE] identified Resident #68 had intact cognition, was always incontinent of bowel and bladder and was dependent on staff to assist with toileting, bathing and transfers. The MDS also identified Resident #68 was at risk for developing pressure ulcers. A physician's order dated 9/25/24 directed to set the specialty air mattress to Resident #68's weight (318 lbs.) and to check settings and function every shift. The care plan dated 9/26/24 identified Resident #68 had a low air loss (LAL) mattress. Interventions included to set per resident weight (318 lbs.) and check settings and functions every shift. Review of the clinical record identified Resident #68 had a weight of 323.6 lbs. on 11/4/24. Observation and interview with Resident #68 on 11/17/24 at 9:45 AM identified Resident #68's specialty air mattress was set to 220 lbs., 103.6 lbs. under Resident #68's last recorded weight. Resident #68 identified he/she could not remember how long the mattress had been in place, but that he/she did not weigh 220 lbs. and that the mattress was not set to his/her weight. Resident #68 also identified he/she would not be able to tell if there was an issue with the mattress due to his/her medical conditions. Observations of Resident #68's specialty mattress on 11/18/24 at 2:00 PM and 11/19/24 at 9:40 AM identified Resident #68's specialty air mattress was set to 220 lbs. Observation and interview with RN #3 on 11/19/24 at 9:45 AM identified Resident #68's air mattress was set to 220 lbs., which was more than 100 lbs. below Resident #68's most recent weight. RN #3 identified she was unsure why Resident #68's bed was set incorrectly and would look into the issue. During this observation, RN #3 changed the setting of Resident #68's specialty mattress to 290 lbs., the next weight setting, and identified she did not want to set it to the next setting, 350 lbs., as this would be over Resident #68's current weight. Interview with LPN #1 on 11/19/24 at 10:45 AM identified that she was typically assigned to care for Resident #68 on day shift and that she had been notified by RN #3 that Resident #68's specialty mattress setting was incorrect. LPN #1 identified that going forward she would make sure she was more careful in checking the setting was correct and would notify the nursing staff on the unit to make sure to check the physician's order against the mattress setting. Interview with the DNS on 11/19/24 at 11:40 AM identified the facility had recently changed over the specialty mattresses used for residents of the facility from a leased contract with a vendor to specialty mattresses purchased by the facility for residents. The DNS identified that the change happened in 9/2024, and she believed that the difference in the mattress settings-the prior mattresses were set to a specific number (i.e. 1, 2,3,4 etc.), while the new mattress settings were weight dependent-was the cause of the issue. The DNS identified that she would have expected the nursing staff to follow the physician's order, and going forward the staff would be educated to ensure that the specialty mattress was set currently. The facility policy on support surfaces directed that these surfaces included specialty mattresses. The policy further directed that support surfaces would be utilized in accordance with a physician's order, and that powered surfaces or those requiring air would be checked by the licensed nurse each shift and as needed for proper function and/or inflation. 46040

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #13) who was reviewed for an allegation of abuse, the facility failed to ensure that the resident remained free from abuse. The findings include: Resident #13's [DIAGNOSES REDACTED]. The significant change Minimum Data Set assessment dated [DATE] identified Resident #13 had severe cognitive impairments, exhibited no behavioral symptoms and required extensive one person assistance with bed mobility, transfers in and/or out of the bed and chair, personal hygiene and toilet use, was non-ambulatory and utilized a wheelchair for mobility. The Resident Care Plan reviewed in March 2016 identified the potential for increased anxiety related to receiving care. Interventions included to provide emotional support and reassure resident of his/her safety. The nurse's note dated 3/16/16 at 9:29 PM identified the resident was found in his/her room attempting to self-transfer from the wheelchair into bed, the resident was observed to be sitting on the floor with the upper body still holding onto the wheelchair. The resident's upper body was lowered to the floor and the nursing supervisor was notified. The nursing supervisor's assessment identified no apparent injuries and the resident was transferred back to bed via a mechanical lift with assistance from charge nurse, Licensed Practical Nurse (LPN) #1, and the nurse aide. The nurse's note dated 3/17/16 at 7:20 PM identified an additional incident had occurred the previous evening on 3/16/16 after a fall while the resident was transferred back to bed. The 3-11PM Nurse Aide (NA) #2 was witnessed by LPN #1 making threatening gestures towards the resident, telling the resident to shut up. The note identified NA #2 made three (3) different gestures all witnessed by the charge nurse and the charge nurse reported the incident to the supervisor. The Supervisor's assessment identified the resident showed no signs of distress and the appropriate parties were notified. The Reportable Event Form dated 3/17/16 identified on 3/16/16 at 9:20 PM LPN #1 witnessed NA #2 raise her hand towards Resident #13 while providing care. The report identified all parties were informed, Resident #13 did not appear to sustain any injuries and did not exhibit any behavioral changes. The report identified NA #2 was suspended pending the investigation. Review of NA #2's personnel file identified a termination dated of 3/28/16. In an interview on 7/26/16 at 3:40 PM, LPN #1 identified she assisted NA #2 with transferring Resident #13 back to bed after a fall on 3/16/16. LPN #1 stated when the resident was back in bed, the resident became anxious and restless and started to scream at which point NA #2 raised the resident's shoe over the resident ' s head and told the resident to shut up. LPN #1 identified the resident initially stopped screaming and then started again, at which time NA #2 clenched her fist towards the resident's face and grabbed Resident #13 by the cheeks and said I told you to shut up. LPN #1 identified the incident happened quickly and that she had previously felt intimidated by NA #2 behavior therefore she was hesitant to stop her but did not leave the room. LPN #1 stated after NA #2 left the resident's room she reassured the resident first and then reported the incident to the Nursing Supervisor, Registered Nurse (RN) #1. In an interview on 7/27/16 at 12:42 PM, RN #1 identified on the evening of 3/16/16 she was notified by LPN #1 that Resident #13 had fallen. RN #1 stated after assessing the resident she informed LPN #1 to transfer the resident back to bed and then went to another unit. RN #1 identified shortly after leaving the unit, LPN #1 requested that she return and LPN #1 informed her that NA #2 shouted at Resident #13 and had grabbed the resident by the chin. RN #1 identified when she instructed NA #2 to leave the premises because of the abuse allegation, NA #2 response was argumentative and defensive before she left the facility. Efforts to contact NA #2 were unsuccessful. Review of facility policy on abuse prohibition identified abuse as the willful infliction of physical pain or mental anguish by a caretaker of services which are necessary to maintain physical or mental health.

Based on clinical record review, observation and interview for two of six sampled residents (Resident # 49 and # 68) observed for smoking, the facility failed to ensure the residents were appropriately supervised to prevent an accident and/or for 1 of 1 sampled residents, (R# 230), at risk for elopement, the facility failed to ensure assistive devices were in place to prevent an elopement. The findings include: 1. Observation on 11/28/12 at 2:10 PM of the smoking area noted 2 residents (Resident #49 and Resident #68) were outside of the building smoking and were utilizing smoking aprons. Two staff members were present inside the building. The surveyor stood in back of the seated nurse aide and noted that she could only visualize half of one of the resident ' s face and the other resident was not able to be visualized. Interview at 2:13 PM on 11/28/12 with the DNS, Administrator and the Corporate Nurse identified that the staff are educated regarding the need to be in the direct area of the residents' during smoking and the residents have to be visualized during the entire smoke break. The DNS further identified that the staff were immediately reeducated regarding the facility smoking policy and the need to be directly supervising the resident during smoking. A review of the facility smoking policy identified that the observer must be in the direct area of the smoker, within eye contact, and able to respond to emergency situations. 2. Resident #230's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] identified moderately impaired cognition, extensive assistance for transfers, supervision for locomotion on and off the unit, and wheelchair use for primary mode of transportation. The resident care plan dated 11/7/11 identified at risk for elopement related to dementia and cognitive loss with interventions which included to assess risk factors and utilize a security (wanderguard) bracelet. The elopement risk screen and evaluation dated 1/8/10 identified Resident # 230 was exit seeking, agitated, poor decision making skills, has attempted to leave the facility in past without notifying staff, and wanders throughout the building. Facility documentation dated 2/1/12 identified Resident # 230 was found outside on the sidewalk face down still in the wheelchair. Additionally, the documentation identified right forehead swelling and Resident # 230 complained of facial pain. Nurse's notes dated 2/1/12 at 3:39PM identified Resident # 230 was assessed and found to have a 5centimeter (cm) x 1cm hematoma to the right orbital area, and an abrasion to the bridge of the nose approximately 2cm x 0.4cm. The physician was notified and directed to send the resident to the hospital and diagnosed with [REDACTED].# 230 had a decline in status and the wanderguard device was removed per nursing judgment. Additionally, the former DNS identified that after the residents condition improved, an elopement reassessment was not completed and/or the wanderguard reinstituted. Interview with DNS on 12/5/12 at 10:20AM identified that although Resident # 230 was wandering around the building; the resident was not exit seeking and therefore was not reassessed for elopement. A review of the facility elopement policy identified residents at risk for elopement will be assessed; care planned for and utilize a security (wanderguard) bracelet. Subsequent to Resident # 230's elopement and fall of 2/1/12 a wanderguard was reapplied to the resident.