Every finding on record at Cook Willow Health & Rehabilitation Center, Inc.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of two (2) sampled residents (Resident #1) reviewed for abuse, the facility failed to ensure the victim of a resident-to-resident altercation was afforded the choice to remain in his/her original room before staff initiated a room change following an incident in which Resident #2 threatened Resident #1 with a plastic knife. The facility further failed to ensure the room relocation promoted Resident #1's sense of safety and access within the facility when Resident #1 was moved four (4) rooms away from Resident #2 to a room located at the end of a corridor with no alternate route of exit/access, requiring Resident #1 to routinely pass Resident #2's room to access common areas of the facility. The findings include:1. Resident #1's diagnoses included muscle weakness, type II diabetes mellitus and absolute glaucoma (end stage glaucoma characterized by total irreversible blindness and eye pain).The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required substantial assistance for transfers and was dependent on staff for bed mobility.The Resident Care Plan (RCP) dated 2/16/26 identified Resident #1 had impaired Activities of Daily Living (ADLs) and mobility related to being newly admitted , weakness post hospitalization, a diagnosis of rhabdomyolysis (rare muscle injury that causes muscles to break down) and was at risk for impaired visual function related to glaucoma and a diagnosis of diabetes. Interventions included a partial assist of one (1) for bed mobility, transferred independently with a rolling walker and ambulated independently in the room and throughout the facility with a rolling walker.2. Resident #2's diagnoses included Alzheimer's disease, major depressive disorder with psychotic symptoms (when hallucinations or delusions occur alongside depressive symptoms) and generalized anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), and was independent with bed mobility, transfers and ambulation.The RCP dated 3/26/26 identified Resident #2 lacked safety awareness and had the potential to demonstrate manipulative behaviors related to poor impulse control, dementia, mental illness, ineffective coping skills and a history of substance use and had a history of making accusatory statements. Interventions included Resident #2 was to utilize plastic utensils for all meals, assessing and anticipating needs, assisting in developing more appropriate methods of coping and interacting, and if reasonable, staff discussing behavior and explaining/reinforcing why noted behavior is inappropriate and/or unacceptable.The facility Reportable Event (RE) dated 4/3/26 identified at 5:45 PM Resident #1 reported the dinner cart was outside of his/her room so he/she started yelling hello looking for help when Resident #2 walked over to Resident #1's side of the room and asked Resident #1 why he/she kept saying hello and told Resident #1 to use the call bell. Resident #2 then placed a plastic knife to Resident #1's neck and moved it across. The RE identified Resident #1 went into the hall and reported the alleged altercation to NA #1 who immediately removed Resident #1 from the area, notified the charge nurse (LPN #1) and Resident #2 was placed on one-to-one observation. No injury was noted to Resident #1, the APRN and the police were notified and Resident #2 was sent to the Emergency Department (ED) for evaluation.A late entry nurse's note by RN #1 dated 4/3/26 at 5:45 PM (created 4/6/26 at 8:45 PM) identified Resident #1 reported to staff that his/her roommate (Resident #2) approached him/her with a plastic knife and lightly ran the plastic knife across his/her throat and reported Resident #2 stated he/she was annoyed that Resident #1 was calling out for assistance as a staff member walked by the room. RN #1 identified Resident #1 was immediately removed from the room to the hallway and denied acute pain or other discomfort and no acute skin changes were noted to the throat area at that time. She reported Resident #1's affect was calm and Resident #1 remained in the hallway with staff in attendance.A late entry nurse's note by LPN #1 dated 4/3/26 at 9:30 PM (created 4/4/26 at 11:26 AM) identified Resident #1 was alert and oriented at baseline and at 5:45 PM, NA #1 identified Resident #1 reported Resident #2 placed a plastic knife to Resident #1's neck. No injuries were noted, Resident #1 was removed from the room by another staff member and the DON, APRN and police were notified of the altercation. Emotional support was provided to Resident #1 throughout the evening and a room change was offered to Resident #1, and he/she accepted and was subsequently moved at 7:00 PM and offered no complaints regarding the new room.A psychiatric APRN note dated 4/4/26 identified she was asked to see Resident #1 following the 4/3/26 altercation. Resident #1 was alert but slightly anxious and stated he/she was upset and worried about the other resident (Resident #2) returning from the Emergency Department (ED). The APRN offered antianxiety medication, but Resident #1 refused.Review of the facility census on 4/29/26 identified although Resident #2 was the aggressor, Resident #1's room remained the same since 6/13/24 and was not moved following the 4/3/26 altercation.Observation of Resident #1's room in proximity to Resident #2's room on 4/29/26 at 11:12 AM identified Resident #1 was moved to the end of a hallway that was 4 rooms down from Resident #2.Interview with Resident #1 on 4/29/26 at 11:16 AM identified prior to the 4/3/26 altercation Resident #2 had never been aggressive towards him/her but when he/she (Resident #1) started yelling that evening, Resident #1 immediately rushed over cursing, calling him/her names and then ran the plastic knife over his/her throat in a threatening manner and stated, If you don't shut up it will be worse next time. Resident #1 reported the behavior shocked and frightened him/her. Resident #1 identified following the altercation, staff approached him/her and reported they would be moving his/her room, and he/she agreed because he/she felt they had no choice but to move to feel safe and get away from Resident #2. Resident #1 reported he/she was angry that he/she did not get the choice to stay in the room and Resident #2 got his/her way and got the room to his/herself after threatening Resident #1, making him/her feel as if they were the issue and not Resident #2. Resident #1 identified he/she enjoyed ambulating out of the room, socializing with friends and going to the dining room for meals and reported since the room change, he/she had to walk past Resident #2's room to do any of those things which he/she continued to do, but felt nervous because Resident #2 was independent and could come out at any time. Resident #1 reported the Director of Social Services reapproached him/her numerous times since the altercation and offered room changes farther away from Resident #2, but he/she declined because he/she had no issue with the current roommate and was afraid of what kind of roommate he/she would be placed with if he/she were to move.Interview with Resident #2 on 4/29/26 at 12:16 PM identified on 4/3/26, Resident #1 was continuously yelling, hello which aggravated Resident #2, and he/she told Resident #1 to use the call bell and Resident #1 ignored him/her (Resident #2) so he/she went over to Resident #1 with a plastic knife, called Resident #1 names and then pushed the knife up against Resident #1's throat. Resident #2 reported he/she should have used the call bell and not touched Resident #1 but was just trying to, shut up Resident #1.Interview with LPN #1 on 4/29/26 at 12:00 PM identified following the altercation she spoke with the DON, and the DON directed her to move Resident #1 to a new room, so she asked Resident #1 if he/she was agreeable to the move and Resident #1 agreed. LPN #1 reported she did not give Resident #1 the option of staying in the room he/she was in at the time of the altercation LPN #1 identified that since the altercation, Resident #1 verbalized he/she was concerned and upset that Resident #2 had a private room and Resident #2 got what he/she wanted.Interview with the DON on 4/29/26 at 12:28 PM identified LPN #1 called her following the 4/3/26 altercation and although Resident #2 was the aggressor, she only had vacant private rooms on the short term unit available, so she contacted the Administrator and it was decided to keep Resident #2 in the room he/she was in, and she directed LPN #1 to move Resident #1 into a new room. Resident #1 agreed so she thought it was fine. The DON identified it did not occur to her that Resident #1's new room was at the end of a hallway and Resident #1 would be required to walk by Resident #2's room to access the remainder of the facility.Interview with the Director of Social Services on 4/29/26 at 1:27 PM identified Resident #1 should have remained in his/her room after the 4/3/26 altercation and the aggressor (Resident #2) should have been moved to a different room. She reported she understood why Resident #1 was frustrated with the room change.Re-interview with the DON on 4/29/26 at 1:45 PM identified Resident #1 should have been offered to remain in his/her original room and Resident #2 should have had the room change since the facility had two (2) private rooms on a different unit available at the time. Additionally, she reported she should have ensured the residents rooms were located on separate units.Review of the facility census dated 4/3/26 identified there were three (3) private rooms available on the East (short-term) unit that Resident #2 could have been moved to, which would have allowed Resident #1 to remain in his/her original room following the altercation.Review of the Abuse, Definitions and Procedure for Suspected Abuse policy dated 11/2021 directed, in part, the procedure for incidents of resident-to-resident abuse includes: the charge nurse and supervisor assess the victim of abuse for injury/harm, initiate proper treatment and investigate the incident to determine etiology and precipitating factors. Using this information, interventions are put into place to prevent further incidents and mitigate any negative consequences for the victim of such abuse. The plan of care for both the victim and the abuser is updated to reflect these interventions and a nurse's note is written.Review of the Residents' [NAME] of Rights policy (undated) directed, in part, you have the right to notice before your roommate is changed, you have the right to be treated equally with other residents in receiving care and services and regarding transfer and discharge regardless of the source of payment for your care and you have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment or involuntary seclusion.Although requested, a facility policy for room transfer following a resident-to-resident altercation was not available.

Based on tour of the Dietary Department, review of facility policy and staff interview, the facility failed to ensure perishable food items were dated upon opening and dishwasher temperatures were consistently monitored. The findings include:1. Tour of the Dietary Department on 9/4/25 at 9:40 AM with the Director of Food Services identified the following:a. The dry storage area was observed to contain the following items which were not labeled/dated when opened: a 10 pound (lb.) bag of acini pasta that was 9/10 full, a 10 lb. bag of penne pasta that was 1/3 full, a 10 lb. bag of ziti pasta that was 3/4 full, a 20 lb. bag of split peas that was 1/3 full, and a 2 lb. bag of bread crumbs that was 3/4 full.b. The walk-in cooler was observed to contain the following items which were not labeled/dated when opened: 1/4 of a 6 lb. roll of genoa salami, 1/8 of a 15 lb. section of virginia ham, and 1/8 of a 6 lb. roast beef (cooked rare).c. The walk-in freezer was observed to contain the following items which were not labeled/dated when opened: a 4 lb. bag of corn that was 1/4 full, a 5 lb. bag of sliced pepperoni that was 1/8 full, a 5 lb. bag of clams (not in shells) that was 1/8 full. Additionally, the following items were not dated when opened and had no expiration date because the items were removed from the original packages: 13 fish cakes wrapped with clear plastic wrap and a clear plastic bag with 6 seasoned white fish fillets.Interview with Director of Food Services at that time identified that food items were to be labeled with the date opened at the time of use/opening, and she was unable to identify the reason the items had not been labeled when opened.Subsequent to surveyor inquiry on 9/8/25 identified staff was inserviced on the food storage policy.Review of the Dietary Food & Drink Storage Policy directed, in part, dietary staff will date all perishable food items upon opening and monitor for expiration dates upon stocking. The policy further identified any food found unlabeled or out of date will be discarded immediately.2. Observation of the dishwashing process on 9/9/25 at 11:10 AM identified the stationary rack dual temperature machine performed the wash cycle at 160 F and then rinsed the dishes at 192 F which was within the appropriate temperature range.Review of the Dishwashing Temps Daily Log 2024 (wrong year within document title) on 9/9/25 at 11:15 AM identified columns for logging dishwasher temperatures (temps) for wash and rinse for all 3 meals (breakfast, lunch, and dinner) with additional columns for the date and staff initials. The first row of documentation on the log was dated 8/24/25 and failed to contain documentation of dishwasher temps for all 3 meals. The next 5 rows of documentation on the log dated 8/25/25-8/29/25 included documentation of dishwasher temps for breakfast and lunch but failed to include documentation for dinner. The next 2 rows of documentation on the log dated 8/30/25 and 8/31/25 failed to include documentation of dishwasher temps for all 3 meals. The next 9 rows of documentation on the log dated 9/1/25-9/9/25 included documentation of dishwasher temps for breakfast and lunch but failed to include documentation for dinner. Interview with Food Service Director on 9/10/25 at 2:15 PM identified she was aware of missing temperature documentation on the log sheet and that she had verbally spoken to the staff members involved. The Food Service Director identified there should not be any missing entries on the temp log. She further identified, she had not written the education down nor had the staff sign that they had been educated about their failure to document dishwasher temps on the log sheet. The Food Service Director identified she would initiate an inservice with written instructions, identified that the cooks were responsible for oversite of the kitchen and they should have ensured the dishwasher temps were documented as required. The Food Service Director was unable to identify the reason there were missing dishwasher temps nor why the cooks had not directed the dishwashers to document the temps.Subsequent to surveyor inquiry on 9/10/25, education was provided to the dietary staff on observing the dish machine temperatures and logging them properly according to facility policy.Review of the Dish Machine Wash/Rinse Policy directed, in part, kitchen personnel will check and log the temperature of the dishwasher at least once per meal period or shift. The policy directed the machine used high heat to sanitize and must reach the following temperatures: wash cycle 150 F to 165 F and final sanitizing rinse cycle 165 F to 180 F and any variations should be reported to the Food Service Director.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #7) reviewed for hospice services, the facility failed to ensure hospice provided nursing and social work documentation/communication regarding hospice visits. The findings include:Resident #7 was admitted to the facility in June 2018 with diagnoses that included severe dementia with psychotic disturbances, Type 2 diabetes and was receiving hospice services since October 2024.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a short/long term memory problem, had an upper and lower extremity impairment on one side, and was dependent for oral hygiene, toilet use, dressing and personal hygiene. Additionally, the MDS indicated Resident #7 was receiving hospice services.The Resident Care Plan dated 6/4/25 identified hospice care with interventions that included hospice visits, social service as needed for emotional support, and pastoral clergy for spiritual needs, provide maximum comfort for resident, and work cooperatively with hospice team to ensure resident's emotional, spiritual, intellectual, physical and social needs are met.A physician's order dated 9/8/25 directed to provide hospice service, comfort measures, do not resuscitate, do not hospitalize and registered nurse may pronounce death. A review of Resident #7's hospice documentation on 9/9/25 revealed that hospice services (nursing and social work) were not providing the facility with any written documentation of regular scheduled or unscheduled visits. The documentation provided by hospice staff for visits was on the Visit Description Log that included the hospice employee name, discipline, and visit type (scheduled/unscheduled) but failed to include any type of notes to identify what was provided and Resident #7's response. Furthermore, there was no copy of Resident #7's care plan by hospice in the clinical record. Interview with the Hospice Team Manager on 9/9/25 at 12:15 PM noted that the facility did not require the hospice team to leave notes after visits for Resident #7. The hospice team assigned to Resident #7 wrote notes in their system for Resident #7 but did not provide the facility with that documentation. According to Hospice Team Manager, the hospice nurse and/or social worker collaborate with facility supervisor verbally after visits but did not leave any written documentation of their visits. Interview with the Social Worker (SW) #2 on 9/9/25 at 1:50 PM identified that she was unaware that hospice was not providing written documentation of visits and was unaware that the facility did not require documentation. She indicated that periodically the hospice social worker would stop by her office and verbally communicate with her regarding Resident #7.Interview with APRN #1 on 9/9/25 at 2:05 PM identified that she was not aware that hospice was not providing written documentation of visits and documentation of recommendations to the facility. APRN #1 stated that her experiences with hospice services in long term care facilities had been written documentation from hospice was in the resident's clinical record. Interview with the DNS on 9/10/25 at 8:45 AM revealed that she was not aware that hospice was not providing documentation of their visits for Resident #7. The DNS indicated that verbal communication was not sufficient and that the facility needed written documentation regarding findings, recommendations and plan of care. In addition, the DNS indicated that she was accustomed to hospice services always providing documentation of any visits, was unsure of the reason they were not providing documentation to the facility, and it was nursing's responsibility to ensure documentation of visits was provided to the facility. Interview with RN #2 on 9/10/25 at 1:30 PM identified that she was unsure why hospice was not leaving documentation for visits for Resident #7. She indicated that she was never informed that the facility did not require notes from hospice as they used to leave notes but was aware that there had been changes in the nursing management team from the hospice vendor in the last year. Furthermore, RN #2 indicated that she did not have a copy of Resident #7's care plan from hospice nor have they ever provided it to her to incorporate it into Resident #7's care plan at the facility. A review of the Hospice Policy directed, in part, residents receiving hospice care are provided with compassionate, coordinated, and appropriate end of life care in accordance with federal and state regulations. The residents receive care that aligns with their goal, values and advance directives.

Based on review of the clinical record, facility documentation, facility policy and staff interviews for 1 of 4 residents reviewed for accidents (Resident #28), the facility failed to provide transfer assistance per the physician's order which resulted in a fall with an injury. The findings include: Resident #28's diagnoses included non-traumatic subarachnoid hemorrhage (bleeding in the brain), muscle weakness, difficulty in walking, unsteadiness on feet and repeated falls. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 was cognitively intact and required partial/moderate assistance with transfers, and substantial/maximal assistance with toileting and bed mobility. The MDS indicated Resident #28 had not had any falls since admission/entry, reentry or on the prior assessment.A plan of care progress note (a note written after a resident care plan conference was held) dated 5/15/25 at 12:37 PM identified Resident #28 had a resident care conference held with the interdisciplinary team (IDT) and the responsible party was in attendance. The progress note indicated Resident #28 was at risk for falls related to a history of a fall with injury, had decreased mobility and was a transfer assist of 2 with a rolling walker (RW). Additionally, the progress note identified Resident #28 was on a skilled Physical Therapy (PT) maintenance program and that the care plan and kardex updates had been completed. Review of the Resident Care Conference form dated 5/15/25 identified Resident #28 was a fall risk and an assist of 2 with a rolling walker (RW) for transfers.The Resident Care Plan (RCP) dated 5/16/25 identified Resident #72 had impaired mobility due to weakness and was at risk for falls related to gait and balance problems. Interventions included assistance of 2 with a RW for transfers and ambulation and to anticipate and meet the resident's needs. A physician's order dated 5/19/25 directed Resident #28 was to be transferred with an assist of 2 with a RW and a pivot assist device may be used to transfer the resident off the toilet. A therapy progress note dated 8/5/25 at 9:43 AM identified Resident #28 was seen for a quarterly screen and required extensive assistance for toileting, bed mobility and an assist of two staff for transfers. The progress note indicated Resident #28 was participating in a PT maintenance program. A nursing progress note dated 8/15/25 at 10:45 AM and written by the DNS identified Resident #28 was found on the floor at his/her bedside with a large, raised hematoma to the left forehead area. The Advanced Practice Registered Nurse (APRN) was notified, and Resident #28 was transferred by ambulance to the hospital emergency department for a trauma evaluation. A facility Reportable Event form (RE) completed by Licensed Practical Nurse (LPN) #1 on 8/15/25 (no time noted) identified Resident #28 had a witnessed fall during a transfer on 8/15/25 at 10:45 AM, sustained a hematoma to the left side of his/her head and had complaints of pain after the fall. The RE indicated the Resident #28 was sent by ambulance to the hospital emergency department for further evaluation. Review of hospital documentation dated 8/15/25 identified Resident #28 was evaluated in the emergency department after a fall and had sustained a traumatic hematoma to the forehead. The documentation noted Resident #28 was to have ice applied to the area of swelling and receive pain relievers as needed. Nursing notes dated 8/16/25 through 8/17/25 identified Resident #28 received Acetaminophen once, Tramadol twice and an ice pack once for discomfort. Review of the kardex/Nurse Aide (NA) care card dated as printed on 8/20/25 indicated that Resident #28 was an assist of 2 for transfers with a RW. (The DNS and Physical Therapist indicated although the Nurse Aide care card was printed on 8/20/25, it was in effect on 8/15/25). Interview, review of the clinical record and facility documents with the DNS on 9/9/25 at 1:05 PM identified Resident #28 had a witnessed fall during a transfer with injuries (hematoma, facial swelling, and bruising) on 8/15/25. The DNS indicated although the Resident #28 was an assist of 2 with a RW for transfers, NA #4 did not follow the plan of care and transferred the resident alone, which caused the resident to fall and sustain injuries. The DNS was unsure why NA #4 had transferred the resident with an assist of 1 (despite a 5/19/25 physician's order for transfers with an assist of 2 with a RW) and identified after the incident NA #4 was terminated and education was conducted with the facility's NA staff regarding completing all transfers per the resident's plan of care. Interview with NA #4 on 9/9/25 and 1:55 PM identified she had made a mistake and transferred Resident #28 by herself on 8/15/25 and the resident subsequently fell and was injured. NA #4 indicated prior to transferring the resident from the bed to the wheelchair she failed to reference Resident #28's kardex/NA care card and thought the resident was a stand pivot assist of 1 for transfers. NA #4 identified she should have referenced Resident #28's kardex/NA care card, obtained help from another nursing staff and followed the resident's plan of care before transferring the resident. NA #4 further indicated she did not utilize a gait belt because she didn't have a gait belt with her to use or the RW when transferring Resident #28 on 8/15/25 and during the transfer she was unable to stop the resident from falling, witnessed the resident fall and hit his/her head on the floor. Interview with the physical therapist (PT) #1 on 9/10/25 at 10:10 AM identified due to weakness in Resident #28's legs, the risks of transferring the resident with an assist of 1 were that he/she would lose balance or strength during the transfer and fall. PT #1 indicated NA # 4 should have followed Resident #28's plan of care and physician's orders and had another staff to assist her with transferring the resident. PT #1 indicated by not transferring Resident #28 with 2 staff, she caused the resident to fall and sustain injuries on 8/15/25. PT #1 identified she was familiar with Resident #28 because the resident was on a PT maintenance program at the time of the fall. In addition, PT #1 identified Resident #28 had no changes in his/her functional abilities prior to the fall and was a transfer assist of 2 with a RW for a long period of time. Interview with Resident #28 on 9/10/25 at 10:19 AM identified he/she still had a painful bump under his/her hairline on the left side of his/her head and it bothered him/her that the lump was still there. Resident #28 indicated although the large amount of bruising to his/her head and face had resolved, she was unhappy a bruised area remained under her left eye. Resident #28 identified since the fall on 8/15/25, he/she also had episodes of dizziness when turning his/her head to the left and he/she was seen by the APRN for it. Although Resident #28 was unable to recall the details of his/her fall on 8/15/25, he/she indicated he/she insists there are 2 staff with a RW to transfer him/her at all times. Interview with LPN #1 on 9/10/25 at 11:42 AM identified she was the charge nurse when Resident #28 fell on 8/15/25 and when she was called to the resident's room, she found Resident #28 on the floor with only NA #4 in the room. LPN #1 indicated NA #4 had transferred Resident #28 by herself and should not have. LPN #1 identified NA #4 should have referenced the resident's kardex/NA care card and asked for assistance from another nursing staff prior to the transfer. Additionally, LPN #1 identified she did not observe a gait belt or a RW on or in the area of Resident #28 after the fall. Review of the facility policy, Resident Transfer, undated, directed staff should ensure the safe and effective transfer of residents from bed to chair while preventing injury and complying with safety standards. The policy directed staff should follow the residents care plan or physician's orders and should never transfer a resident alone if the assessment indicated more than one person is needed. The policy further directed to use gait belts when appropriate.

Based on staff interviews, review of the clinical record and facility policy for 1 of 1 sampled resident (Resident #54) reviewed for death, the facility failed to ensure a comprehensive assessment was completed at the time of death. The findings include: Resident #54's diagnoses included hemophagocytic lymph histiocytosis, chronic obstructive pulmonary disease, unspecified atrial fibrillation and, diastolic (congestive) heart failure, and anemia.An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 was cognitively intact and was dependent on staff for all transfers and personal care activities. Additionally, the MDS identified that Resident #54 required set-up assistance for eating.A Resident Care Plan dated 7/1/25 noted Resident #54 had altered respiratory status and difficulty breathing related to a right lower infiltrate from 6/30/25. Interventions included administering medications (specifically bronchodilation inhaled agents) as ordered and monitoring for effectiveness and side effects.A physician's order dated 7/4/25 directed Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do Not Hospitalize (DNH), Register Nurse Pronouncement (RNP), and comfort measures only (CMO).Nursing notes dated 7/7/25 at 6:08 AM and written by Registered Nurse (RN) #5 identified that Resident #54 was observed not to be breathing, without a heartbeat and RN #5 pronounced death at 5:47 AM (the assessment failed to include a lack of blood pressure and pupillary response). The next of kin and the funeral home were notified of Resident #54's death, however the assessment at the time of death failed to include a lack of blood pressure.In an interview and clinical record review with the Director of Nursing Services on 9/12/25 at 8:25 AM, it was identified that the RNP assessment completed by RN #5 was not comprehensive to include a lack of blood pressure.In an interview, clinical record, and facility policy review with the Assistant Director of Nursing Services (ADNS) on 9/12/25 at 9:40 AM, the ADNS indicated that the RNP assessment needed to include the absence of a heartbeat or breath sounds, both verified for a full minute, and a lack of blood pressure. The ADNS indicated that the RNP assessment policy was overseen by the interdisciplinary team and that nursing staff have access to review this policy, with no known reason for not following the policy as written.Interview and clinical record review on 9/12/25 at 10:41 AM with Registered Nurse #5 identified that he was aware of the facility policy and believed he had followed this. He identified that he verified that Resident #54 was not breathing, had no pulse, and that Resident #54's pupils were fixed and dilated. RN #5 identified his note from 7/7/25 failed to include blood pressure, stating this was taken earlier in the evening, and that he believed he had included all necessary additional information in this note. RN #5 further identified he had become concerned about his inability to immediately access the state portal to report the death, potentially leading to the missing details in his note, and that he was responsible for performing a complete assessment upon death.The facility policy for Registered Nurse pronouncement of death directs that the RN record the clinical findings and notify the physician, as well as that the assessment findings at the time of pronouncement include the following: absence of pulse, respirations, blood pressure, heart sounds, pupillary response (fixed and dilated), and the time the assessment was conducted.

Based on review of the clinical record, facility policy and interviews for 1 of 2 sampled residents (Resident #1) reviewed for accidents, the facility failed to ensure the care plan was revised when Resident #1 was removing the wanderguard bracelet (sensor used to assist in preventing exiting through doorways outside). The findings include:Resident #1 was admitted to the facility in December 2023 with diagnoses that included Alzheimer's dementia, history of viral hepatitis and seizure disorder. Physician's orders dated 6/12/25 directed to check function of wanderguard every night and check placement of wanderguard once a shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and was independent with activities of daily living (ADLs).The Resident Care Plan dated 6/24/25 identified elopement as an area of concern including having a history of removing the wanderguard bracelet. Interventions included to check wanderguard function daily, check placement once a shift, offer diversional activities, place in wanderguard book, psychiatric consults as needed, approach in non-threatening manner, and medicate for anxiety as needed. Nursing notes dated 6/25/25 at 6:36 AM identified that Resident #1's wanderguard was not in place and that the resident had stated that he/she had to take it off because his/her ankle swells. The nursing note indicated that a new bracelet with same sensor was applied to Resident #1's right ankle but failed to identify how Resident #1 was able to remove the wanderguard bracelet. An elopement assessment dated [DATE] identified Resident #1 was an elopement risk. The 6/28/25 elopement assessment did not differ from previous elopement assessments completed on 3/23/25 and 4/3/25 that identified Resident #1 was an elopement risk. Nursing notes dated 7/21/25 at 6:13 AM identified that Resident #1 continued to refuse wanderguard replacement after multiple attempts as resident stated he/she does not need it anymore. The nursing note failed to identify when the wanderguard was removed and how Resident #1 removed the wanderguard bracelet. A follow up nursing note by the Assistant Director of Nurse's (ADNS) on 7/21/25 at 7:04 AM identified that Resident #1 allowed the wanderguard to be reapplied to left ankle after Resident #1 was educated on the rationale for the need of the wanderguard bracelet. An interview with the ADNS on 9/12/25 at 9:30 AM identified that he was unaware how Resident #1 removed the wanderguard on 6/25/25 and 7/21/25 and was unsure if it was investigated on how it was removed. Furthermore, the ADNS stated that the care plan was not revised to include the removals of the wanderguard on 6/25/25 and 7/21/25 and it is nursing and the Care Plan Coordinator's responsibility to ensure the care plan was updated with new interventions. The ADNS was unaware of the reason the care plan was not revised to reflect the wanderguard removals and new interventions to prevent the removals attempted.An interview with Registered Nurse (RN) #2 on 9/12/25 at 9:45 AM indicated that she was responsible along with nursing to update the care plans with new interventions. RN #2 indicated that Resident #1's care plan should have been revised with new interventions when he/she removed the wanderguard on 2 occasions. RN #2 stated that she was unsure why it was not updated as it was an oversight, but she may have been on vacation when the 7/21/25 incident occurred. Additionally, RN #2 stated she was unaware how Resident #1 was removing his/her wanderguard. An interview with Resident #1 on 9/12/25 at 10:10 AM indicated that he/she had removed the wanderguard on more than one occasion. Resident #1 stated that he/she removed the wanderguard using nail clippers because he/she just did not want to wear it. Review of the Resident Care Plan Policy dated December 1998 directed, in part, that the Resident Care Coordinator shall be responsible for conducting spot check reviews of written care plan to correct any deficiencies in documentation or lack of updating by any discipline.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #56) reviewed for abuse, the facility failed to ensure timely investigation of an allegation of mistreatment. The findings include: Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #56) reviewed for abuse, the facility failed to ensure timely investigation of an allegation of mistreatment. The findings include: Resident #56's diagnoses included cerebral infarction, dementia, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen (14/15), indicating alert and oriented, and required moderate assistance for showers. The Resident Care Plan (RCP) dated 7/9/2025 identified Resident #56 had impaired ADLs (activities of daily living) and mobility related to acute right side cerebral infarction. Interventions directed to provide assistance with ADLs. Interview with Person #1 on 9/4/2025 at 10:15 AM identified on 8/1/2025, Resident #56 reported to Person #1 that during his/her shower, he/she was inappropriately touched by the staff member on the groin. Person #1 stated he/she reported the allegations to the ADON. Although requested, the facility was unable to provide documentation regarding an investigation conducted regarding the allegation of mistreatment. Interview with ADON on 9/4/2025 at 10:25 AM identified on an unknown date, Person #1 had reported that Resident #56 alleged he/she was inappropriately touched during the shower. The ADON stated that Person #1 did not report any specific type of touching, such as foundling, roughness, or pain. The ADON stated Resident #56 was confused during that timeframe, and although Person #1 reported the allegation, Person #1 verbally indicated he/she did not believe the event had occurred. The ADON stated he did not report or investigate the allegation of abuse, due to Person #1 had requested staff not speak with Resident #56 about the allegation because Resident #56 would think Person #1 had told on him/her and Person #1 did not believe the allegation. Although requested, the facility was unable to provide documentation regarding an investigation was performed for the allegation made on 8/1/2025. Interview with the DON on 9/4/2025 at 2:30 PM identified she was not aware of the allegation of mistreatment. The DON stated all allegations of abuse must be investigated properly, and this allegation should have been reported by the ADON and then investigated in a timely manner. Review of the Abuse Policy dated 11/2021 directed in part, any complaint of, observation of, or suspicion of resident abuse, mistreatment, or neglect is to be thoroughly investigated. The investigation will include an accident report, obtaining statements from potential witnesses, completion of necessary evaluations (i.e., skin/body checks, pain evaluation), and maintaining a timeline of events. Facility investigations will be completed with seventy-two (72) hours.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #56) reviewed for abuse, the facility failed to ensure staff reported an allegation of mistreatment timely, and failed to ensure the State Agency was notified timely of an allegation of mistreatment. The findings include: Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #56) reviewed for abuse, the facility failed to ensure staff reported an allegation of mistreatment timely, and failed to ensure the State Agency was notified timely of an allegation of mistreatment. The findings include: Resident #56's diagnoses included cerebral infarction, dementia, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen (14/15), indicating alert and oriented, and required moderate assistance for showers. The Resident Care Plan (RCP) dated 7/9/2025 identified Resident #56 had impaired ADLs (activities of daily living) and mobility related to acute right side cerebral infarction. Interventions directed to provide assistance with ADLs. Interview with Person #1 on 9/4/2025 at 10:15 AM identified on 8/1/2025, Resident #56 reported to Person #1 that during his/her shower, he/she was inappropriately touched by the staff member on the groin. Person #1 stated he/she reported the allegations to the ADON. Interview with ADON on 9/4/2025 at 10:25 AM identified on an unknown date, Person #1 had reported that Resident #56 alleged he/she was inappropriately touched during the shower. The ADON stated that Person #1 did not report any specific type of touching, such as foundling, roughness, or pain. The ADON stated Resident #56 was confused during that timeframe, and although Person #1 reported the allegation, Person #1 verbally indicated he/she did not believe the event had occurred. The ADON stated he did not report or investigate the allegation of abuse, due to Person #1 had requested staff not speak with Resident #56 about the allegation because Resident #56 would think Person #1 had told on him/her and Person #1 did not believe the allegation. Review of CT's Department of Health's FLIS Events Report Tracking System identified the facility failed to submit a reportable event for the allegation made on 8/1/2025. Interview with the DON on 9/4/2025 at 2:30 PM identified she was not aware of the allegation of mistreatment. The DON stated all abuse allegations must be reported immediately, investigated promptly, and reported to the State Agency within two hours of discovery. The DON stated the ADON should have notified her of the allegation, and Resident #56's allegation of inappropriate touching during a shower should have been investigated in a timely manner, and the State Agency should have been notified. Review of the Abuse Policy dated 11/2021 directed in part, any complaint of, observation of, or suspicion of resident abuse, mistreatment, or neglect is to be thoroughly investigated and reported. The facility will follow State Health Department guidelines and other regulatory agencies for reporting requirements. Facility investigations will be completed with seventy-two (72) hours. All incident reports must be completed immediately after the incident has occurred (all abuse, alleged or confirmed), and the facility will follow State Health Department guidelines and other regulatory agencies for reporting requirements.

Based on observations, review of clinical records, facility policy and interviews for 1 of 2 sampled residents (Resident #4) reviewed for an indwelling urinary catheter, the facility failed to ensure the drainage bag was not touching the floor. The findings include:Resident #4 was admitted to the facility in January 2024 with diagnoses that included obstructive uropathy and tubulo-interstitial nephritis (inflammation of the tubes and tissue of the kidney).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was cognitively intact and was totally dependent on staff for assistance with activities of daily living (ADLS). Additionally, the MDS identified Resident #4 had an indwelling urinary catheter. The Resident Care Plan dated 6/19/25 identified a urinary catheter as a concern with interventions that included changing the catheter bag as needed, keep below the level of the bladder, document any pain/discomfort and monitor for signs of infection.A physician's order dated 7/9/25 directed to change catheter monthly on the 28th of each month, provide meatal hygiene once a day, and catheter care once a shift.Observations on 9/8/25 at 11:10 AM, 9/9/25 at 1:00 PM and 9/10/25 at 12:30 PM identified Resident #4's urinary catheter drainage bag was attached to the back of his/her wheelchair with the drainage bag touching the floor.An Interview with Registered Nurse (RN) #1 on 9/10/25 at 1:00 PM identified that a urinary catheter drainage bag should not be touching the floor due to infection control concerns as the floor was not a clean surface. RN #1 indicated that it was the nurse aides (NA) responsibility to ensure that the drainage bag was never touching the floor.Interview and observation with NA #1 on 9/10/25 at 1:10 PM identified Resident #4's was sitting in his/her wheelchair in the bedroom with the urinary catheter drainage bag touching the floor. NA #1 indicated that the urinary drainage bag should not be touching the floor as it was an infection control issue. NA #1 stated that Resident #4 was not on her assignment but would adjust the urinary drainage bag immediately.An interview with the Infection Preventionist (ICN) on 9/10/25 at 1:15 PM identified that urinary drainage bags should not touch the floor. The ICN indicated that Resident #4's urinary drainage bag was not touching the floor earlier and that it must be related to how it was placed on the back of the wheelchair. Furthermore, the ICN indicated that he would assess how the urinary drainage bag was being attached to the back of the wheelchair to ensure that it does not touch the floor.Interview with NA #3 on 9/10/25 at 2:00 PM indicated that Resident #4 was on her assignment on 9/10/25 and that she provided catheter care to the resident. NA #3 did not recall the urinary drainage bag touching the floor and was aware that it should not be touching the floor.A review of the policy Foley Catheter Care and Use dated September 2001, directed, in part, that the collection bag and/or tubing are not allowed to touch the floor or other contaminated objects such as the wheels of chairs.

Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 3 (Resident #2, Resident #53 and Resident #55) sampled closed records reviewed, the facility failed to ensure the ombudsman was notified of the resident discharges. The findings include 1.Resident #2's diagnoses included urinary tract infection (UTI), myocardial infarction (heart attack), and benign prostatic hyperplasia. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was cognitively intact, had an indwelling catheter, required setup or clean-up assistance with eating, and was dependent for bed mobility and transfers.The Resident Care Plan (RCP) dated 3/10/25 identified Resident #2 had an indwelling catheter upon admission. Interventions included changing the catheter bag as needed, monitor/document pain/discomfort due to the catheter, and monitor/record/report to physician signs/symptoms of UTI (pain, burning, blood tinged urine, urine cloudiness, foul smelling urine). a. A nursing note dated 3/21/25 at 10:20 AM identified Resident #2 was sent to the hospital for evaluation and treatment for respiratory distress, abnormal blood work, and abdominal pain. A nursing note dated 3/25/25 at 9:53 PM identified Resident #2 was readmitted to the facility from the hospital with a diagnosis of severe sepsis related to a UTI complicated by obstructive pyelonephritis. b. A nursing note dated 5/19/25 at 3:16 PM identified Resident #2 was transferred to the hospital for a cystoscopy procedure. A nursing note dated 5/19/25 at 3:32 PM identified Resident #2's responsible party notified the facility Resident #2 was admitted to the hospital following a shaking episode in the recovery room after his/her cystoscopy procedure. A nursing note dated 6/9/25 at 9:46 PM identified Resident #2 was re-admitted to the facility from the hospital at 8:45 PM with a diagnosis of sepsis due to UTI with septic shock, new onset of atrial fibrillation, myocardial infarction, right thumb cellulitis, and pulmonary infiltrates. c. A nursing note dated 6/22/25 at 2:05 PM identified Resident #2 was sent to the hospital for evaluation and treatment related to Resident #2's complaints of nausea with no appetite, coughing, wheezing, shaking, diminished lung sounds, and a temperature of 101.8 degrees Fahrenheit. A nursing note dated 6/23/25 at 1:02 AM identified Resident #2 was admitted to the hospital with a diagnosis of UTI. A nursing note dated 6/26/25 at 9:55 PM identified Resident #2 was readmitted to the facility from the hospital at 5:30 PM with a diagnoses of UTI with sepsis and parainfluenza. 2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, cellulitis of the left lower limb and acute osteomyelitis. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #53 was severely cognitively impaired and required substantial/maximal assistance with bed mobility and was dependent with toileting and transfers. A nursing progress note dated 6/24/25 at 1:36 PM identified Resident #53 was having difficulty speaking, had garbled speech and was unable to follow commands at 12:40 PM. A Registered Nurse (RN) assessment was completed, and the Advanced Practice Registered Nurse (APRN) was notified. Resident #53 was transferred by ambulance to the hospital emergency department for further evaluation. A social service progress note dated 6/26/25 at 2:27 PM identified Resident #53 remained hospitalized , was transferred to another hospital and a bed hold policy was mailed to the resident's responsible party. Review of the facility census list for Resident #53 identified the resident was transferred to the hospital on 6/24/25 and was discharged from the facility on 7/1/25. 3. Resident #55 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease with dyskinesia, fracture of the left clavicle, and a history of falling. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 was moderately cognitively impaired and required substantial/maximal assistance with bed mobility and toileting and was dependent with transfers. The Resident Care Plan (RCP) dated 6/20/25 identified Resident #55 was admitted to the facility for short term rehabilitation and had a self-care performance deficit. Interventions included the resident would have a physical and occupational therapy evaluation and staff were to provide the resident with the necessary assistance for transfers, toileting, eating and bed mobility. An APRN progress note dated 6/25/25 at 9:50 AM identified Resident #55 had improved and was scheduled to be discharged from the facility on 6/27/25. A social service progress note dated 6/26/25 at 12:03 PM identified Resident #55's discharge was planned for 6/27/25 and the residents responsible party was the primary caregiver and did not want a home care referral at this time. A nursing progress note dated 6/27/25 at 5:18 PM identified Resident #55 was discharged home with his/her responsible party at 1:30 PM. Review of the facility census list for Resident #55 identified the resident was admitted to the facility on [DATE] and was discharged from the facility on 6/27/25. Interview with Social Worker (SW) #2 on 9/10/25 at 1:30 PM identified she did not send notifications of discharges and transfers to the Ombudsman, and it was the Director of Nurses (DNS) who was responsible. Interview with the DNS on 9/10/25 at 1:32 PM identified she did not send notifications regarding discharges and transfers to the Ombudsman, and she would need to find out who was responsible. Another interview with the DNS on 9/12/25 at 8:50 AM identified the Administrator was putting the discharge and transfer notifications into the ombudsman portal and all of the required notifications would be completed shortly. The DNS indicated upon surveyor inquiry it was discovered the required resident discharge and transfer notifications were not being made to the Ombudsman by the prior DNS since late 2023 and subsequent to surveyor inquiry, the Administrator was ensuring their error was corrected. The DNS identified she had only been in her current position for 4 weeks and was not aware it was her responsibility to notify the Ombudsman regarding discharges and transfers. An interview with the Administrator on 9/12/25 at 9:40 AM identified the last time the Ombudsman was notified of a resident discharge or transfer at the facility was in 8/2023. The Administrator indicated it was the responsibility of the DNS to notify the Ombudsman and she was not aware the required notifications were not being completed or why the prior DNS did not do them. The Administrator identified she would be changing the task responsibility of Ombudsman notifications of facility discharges and transfers to the social worker. Another interview with the Administrator on 9/12/25 at 11:02 AM identified she had completed the 2023-2025 ombudsman notifications for resident discharges and transfers at the facility and documentation was provided. Review of facility policy, Policy for Notification of Discharge or Transfer to Long-Term Care Ombudsman, undated, directed in compliance with federal and state regulations, the facility must send a copy of the notice of discharge or transfer to a representative of the Office of the State Long-Term Care Ombudsman.

Based on the tour of the Dietary Department, staff interview, facility documentation and policy, the facility failed to ensure the Dietary department consistently labeled canned food to reflect their age or shelf life, failed to discard dented cans and failed to ensure proper hair covering for a beard. The findings included: Tour of the Dietary Department on 1/31/24 at 10:37 AM during the initial walk through of the kitchen with the Cook Supervisor identified the following: a. The dry storage room had the following food items with no expiration dates: 2 cans of dark red kidney beans (104 oz per can ), 4 cans of white beans (104 oz per can), 2 cans of white beans (14 oz per can), 8 cans of diced tomatoes (104 oz per can ), 15 cans of beets (104 oz per can), 4 cans of baked beans(104 oz per can), 6 cans of corn (104 oz per can), 9 cans of roasted red peppers (22 oz per can), 8 cans of corned beef Hash (104 oz per can), and one opened bag of cornbread stuffing. b. The following cans were dented and were on the shelf within the usable stock: 1 can mandarin oranges(4 oz), 1 can of jellied cranberry sauce (5 oz), 2 cans of corned beef hash (104 oz per can) and 1 can of new england style beaked beans (4 oz). c. The walk-in freezer was noted to contain a homemade Chocolate Creme Pie (#6) and a Boston Creme Pie (#7) and with no expiration date. e. The walk-in refrigerator was observed to contain blueberries, strawberries, and grapes that were observed in open cartons with no open date or expiration date. f. Observation on 1/31/24 at 11:39 AM identified Cook #1 was stirring macaroni salad, had a beard without the benefit of a beard covering. Interview on 1/31/24 at 11:39 AM with the Cook Supervisor indicated Cook #1's beard was not appropriately covered. g. Observation on 2/2/24 at 9:50 AM identified of Cook #1 with his bread uncovered while preparing food. Interview with Cook Supervisor at that time identified that Cook #1 had trimmed his beard since 1/31/24 and he thought it was short enough to not warrant a beard covering. Interview on 1/31/24 at 11:20 AM with the Cook Supervisor indicated that she and staff were responsible for dating the products after removing them from the original package and opening them. She additionally stated the kitchen supervisor was responsible for checking the dented cans at least once per week and staff was responsible for notifying the supervisor if they drop and dent a can. Subsequent to surveyors' inquiry, the Cook supervisor provided expiration dates for the canned items listed in exhibit A. Facility policy indicated Dietary employees are required to wear hair restraints to cover any loose hair. Policy additionally indicated beards longer than 1 inch requires a guard or net. The facility was unable to provide a policy regarding labeling and dating of foods, however, the facility policy indicated that Dietary would monitor for expiration dates upon restocking. Facility policy additionally indicated that deeply dented cans should be discarded.

Based on observations, review of the clinical record, review of facility documentation, facility policy, and interviews for 3 of 3 residents, (Resident #7, Resident #27, and Resident #253) reviewed for oxygen therapy, the facility failed to appropriately label nasal cannula oxygen tubing (Resident #7), and failed to follow a physician's order related to oxygen administration (Resident #27 and Resident #253). The findings include: 1. Resident #7's diagnoses included respiratory failure with hypoxia, sleep apnea, and Chronic Obstructive Pulmonary Disease (COPD). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 was cognitively intact and required moderate assistance for bed mobility and transfers, and required maximum assistance for personal hygiene. Additionally, the MDS identified Resident #7 utilized oxygen therapy. The Resident Care Plan dated 12/26/23 identified Resident #7 had COPD and asthma and required supplemental oxygen. Interventions included oxygen administration as ordered by the physician, monitoring for signs and symptoms of respiratory distress, and reporting to the physician. The physician's orders dated 1/6/24 through 2/6/24 directed oxygen administration via nasal cannula at 2 L/min (liters per minute) as needed for shortness of breath, and to change and date the oxygen tubing every Sunday on the 11:00 PM to 7:00 AM shift. Observations on 1/31/24 at 11:55 AM, on 2/1/24 at 10:55 AM, and on 2/2/24 at 11:49 AM identified Resident #7 utilizing oxygen at 2.0 L/min via a nasal cannula, the nasal cannula was not labeled or dated. Interview with LPN #2 on 2/2/24 at 12:12 PM identified that the oxygen tubing was changed and labeled with the date and nurses initials every Sunday on the 11:00 PM to 7:00 AM shift, per the facility policy. She identified that Resident #7's oxygen tubing was not labeled, and she was unsure of the reason, but if a NA's (Nurses Aid) changed the tubing due to soiling, the nurse should have been alerted. Subsequent to surveyor inquiry, LPN #2 indicated she would replace the nasal cannula oxygen tubing, ensuring it was labeled and dated appropriately. Review of the Cleaning, Maintaining and Changing of 02/Nebulizer Equipment policy dated 12/2018 directed, in part, that once a week 02 equipment (cannulas, hand-held nebulizers, humidifier bottles, masks and extension tubing) will be changed and labeled with the date and initials by the 11:00 PM to 7:00 AM nurse. 2. Resident #27's diagnoses included respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and dependence on supplemental oxygen. The Admission MDS assessment dated [DATE] identified Resident #27 was cognitively intact and had impaired lower extremity function. Additionally, the MDS identified Resident #27 required set up assistance with eating, required maximum assistance with toileting, required partial assistance with upper body dressing and personal hygiene. The MDS further identified Resident #27 utilized oxygen therapy. The Resident Care Plan dated 1/19/24 identified Resident #27 had pneumonia. Interventions included oxygen therapy as ordered, medications administered as ordered and monitor/document for side effects and effectiveness, and to monitor vital signs as ordered. A physician's order dated 1/19/24 directed oxygen administration via nasal cannula at 2 L/min (liters per minute) continuously. A nurse's note dated 2/1/24 at 12:59 AM indicated that oxygen via nasal cannula was held on Resident #27 and not in place due to the oxygen saturation (the amount of oxygen in the blood) reading of 94% (despite a physician's order for continuous oxygen at 2L/min). Observation on 2/1/24 at 10:46 AM identified Resident #27 in bed with his/her eyes closed. The oxygen nasal cannula was not in place and was in a bag on the concentrator to the right of the bed, not within reach of Resident #27 (despite a physician's order for continuous oxygen at 2L/min). Observation on 2/1/24 at 1:36 PM identified Resident #27 in his/her wheelchair with no nasal cannula on, and the oxygen concentrator was no longer in the room. Interview and review of the clinical record with RN #1 and LPN #2 on 2/2/24 at 12:16 PM indicated that per the physician's order, Resident #27 should have been receiving oxygen at 2 L/min continuously via nasal cannula. Neither nurse was aware of the reason Resident #27 was not wearing the ordered oxygen, but if he/she refused, there should have been a nursing note and the APRN and/or physician should have been notified. LPN #2 reviewed the clinical record and failed to locate a nursing note indicating that Resident #27 had refused oxygen or a physician's order to titrate (increased or decreased) oxygen. Although RN #1 and LPN #2 were unsure of the reason for the lack of oxygen they felt it could have been a mistake in admission orders on readmission from the hospital. Interview with MD #1 on 2/2/24 at 1:36 PM indicated that he would expect the nursing staff to notify him if a resident was not utilizing an active order or refusing an ordered treatment or medication. He would then re-evaluate the order as needed based on the facility report, clinical data, and/or assessment. Subsequent to surveyor interview, a new physician's order was obtained on 2/2/24 at 12:30 PM directing oxygen at 2 L/min via nasal cannula as needed for Shortness of Breath (SOB). 3. Resident # 253's diagnoses included respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and sleep apnea. A physician's order dated 1/25/24 directed oxygen administration via nasal cannula at 2 L/min (liters per minute) continuously. The Admission MDS assessment dated [DATE] identified Resident #253 was cognitively intact, had no upper/lower extremity limitations, and required partial assistance with personal hygiene, dressing, toileting, and oral hygiene. Additionally, the MDS identified Resident #253 utilized oxygen therapy. Observation on 2/1/24 at 10:56 AM identified Resident #253 in the Rehab gym exercising with weights without the benefit of oxygen (despite a physician's order directing oxygen at 2 L/min continuously). Interview with Resident #253 on 2/1/24 at 12:06 PM identified that staff was attempting to wean him/her off of oxygen prior to his/her discharge home, and that the removal of the oxygen by therapy was planned. Resident #253 reported that he/she was short of breath without oxygen, but that he/she was starting to feel better once the oxygen was reapplied after therapy. A physician's order dated 2/1/24 at 8:00 PM (after surveyor's observation) directed that staff may titrate oxygen via nasal cannula to maintain oxygen saturation greater than 95% twice daily. The Resident Care Plan dated 2/4/24 identified Resident #253 had COPD. Interventions included oxygen therapy as ordered by the physician, the head of the bed to be elevated during episodes of difficulty breathing, and monitoring for signs and symptoms of acute respiratory failure. Subsequent to surveyor inquiry, the physician's order dated 1/25/24 directing that Resident #253 remain on oxygen via nasal cannula at 2 L/min continuously, was discontinued on 2/5/24 at 10:10 AM. Interview with PT #1 on 2/5/24 at 10:13 AM identified that therapy had attempted an oxygen titration but had not yet documented their assessment in the progress notes because Resident #253's Managed Care (insurance) policy does not require notes until 2/7/24. She reported they had completed PT/OT evaluations, but that would not identify any oxygen therapy except for what the resident was admitted with. She indicated they would not initiate any oxygen changes in therapy unless nursing first obtained a physician's order, but reported they had a different charting system because they are an outside vendor, and she did not know how to use the facility's electronic charting system. She reported therapy gives a verbal hand off to nursing after each visit, and nursing documents as needed. Review of the Physical Therapy notes dated 1/26/24 and Occupational Therapy notes dated 1/30/24 provided by the outside vendor failed to document oxygen trials or titration with Resident #253. Interview with RN #3 on 2/5/24 at 10:17 AM identified that she was not able to locate any notes in the facility record related to oxygen or the titration of the oxygen. She indicated that nursing should be documenting their observations and the therapy reports, and was unsure of the reason there was no documentation. Further, she identified that there were two active oxygen orders in place, one for continuous oxygen and one for oxygen titration. Interview with the DNS on 2/5/24 at 11:02 AM identified that a physician's order for oxygen titration should be entered prior to staff removing the oxygen or attempting the titration. She did not know the reason there were two orders for both continuous oxygen and a titration, but indicated she would investigate it. At 11:51 AM, the DNS identified that the nurse who entered the oxygen titration order was new to the facility, and that she would educate her on updating orders for the future. Review of the Use of Oxygen policy dated 12/1998 directed, in part, that oxygen is used only on the order of a physician. Although requested, an oxygen titration policy was not provided.

Based on review of the clinical record, facility policy, and interview for the only sampled resident, (Resident #50), reviewed for bladder and bowel incontinence, the facility failed to correctly code bladder continence and failed to complete a bowel assessment on readmission following a hospitalization . The findings include: Resident #50's diagnoses included a right hip fracture, repeated falls, and dementia. Review of the Nursing Admission assessment dated [DATE] identified Resident #50 had multiple daily episodes of urinary incontinence with little to no control, and a bowel evaluation that identified the resident was occasionally incontinent of bowel. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 was moderately cognitively impaired, required assistance with activities of daily living, and was frequently incontinent of urine and occasionally incontinent of bowel. The Resident Care Plan dated 10/25/23 identified Resident #50 was at risk for bowel and bladder incontinence. Interventions included to be alert for continence changes, signs and symptoms of infection, stress incontinence, and to notify the physician as indicated. Review of Nurse Aid (NA) daily urinary flow sheets for October 2023, November 2023, and through December 15, 2023, indicated that Resident #50 was mostly continent of bladder during the day in October and November and mostly incontinent of bladder at night. Additionally, Resident #50 was noted to be mostly continent of bowel in November and mostly incontinent of bowel through December 15, 2023. A physician's order dated 12/15/23 directed Resident #50 to be sent to the hospital. Review of the Nursing Readmission assessment dated [DATE] identified a bladder assessment indicating Resident #50 was completely continent of urine (a significant improvement), and the bowel assessment was left blank. Review of the quarterly MDS assessment dated [DATE] identified Resident #50 was severely cognitively impaired, required assistance with activities of daily living, and was always incontinent of both bowel and bladder. The Resident Care Plan dated 1/1/24 failed to identify changes from the care plan dated 10/25/23. An interview with the Director of Nursing (DNS) on 2/6/24 at 10:16 AM identified that the facility policy for bladder and bowel assessments indicated an assessment should be conducted on admission, readmission, and quarterly. The DNS was unsure why the resident was coded as fully continent of urine on the readmission nursing assessment and was unable to locate that a bowel assessment had been conducted following readmission on 12/19/23. Review of the facility Bladder Assessment policy directed, in part, that a comprehensive bladder assessment will be done upon admission, annually, upon readmission with a significant change.

Based on observation and staff interview for 1 of 1 sampled resident (Resident #36) reviewed for Activities of Daily Living (ADLs), the facility failed to provide personal hygiene for nails and removal of facial hair. The findings include: Resident #36's diagnosis included peripheral vascular disease, dementia, and arthritis. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #36 was severely cognitively impaired, required extensive supervision and assist of 1 for dressing, eating, and personal hygiene, extensive assist of 2 for bed mobility, and toileting, dependent with assist of 2 for transfers. The Resident Care Plan dated 1/27/24 identified Resident #36 required assistance/was dependent for activities of daily living in personal hygiene with interventions that included to supervise ADLs, assist Resident #36 with bathing, hygiene and dressing. Observation on 1/31/24 at 12:00 PM and 2/1/24 at 8:51 AM identified Resident #36's fingernails were long, soiled beneath the nails and had chipped nail polish. Additionally, Resident #36 had a substantial amount of facial hair growth. Interview and observation of Resident #36 with Licensed Practical Nurse (LPN) #1 on 2/2/24 at 10:35 AM identified that Resident #36 nails needed to be cut and his/her facial hair needed to be trimmed. Interview with Nurse Aide (NA) #1 on 2/2/24 at 11:05 AM identified that she did not have the resources to trim Resident #36's fingernails (which she identified resources to mean nail clippers) and was not aware of the facility policy for trimming resident's nails. Registered Nurse (RN) #1 who was present at the end of the interview with NA #1 identified that the policy was for the residents to be well groomed and that nail clippers were available at the nurse's station. Observation with RN #1 identified 10 pairs of nail clippers were located at the nurse's station. Facility policy regarding AM care indicated shaving was essential part of daily AM care for males. Shave the ladies when indicated Facility policy regarding AM care directed to notice if the nails were in need of grooming. Nails should be included in the regular bath day. If they haven't been, take the initiative and soak those nails. On 2/5/24, subsequent to surveyor inquiry, Resident #36 was noted to have a shaved face and clean, trimmed nails.

Based on observations, review of the clinical record, staff interviews and facility policy for 1 of 5 residents(Resident #18) reviewed for psychotropic medications, for 1 of 2 residents (Resident #39) reviewed for pressure ulcers and for 1 of 1 sampled resident (Resident #50) reviewed for elopement, the facility failed to revise the resident care plan. The findings include: 1. Resident #18 was admitted to the facility on [DATE] with a diagnosis including dementia, anxiety, and irregular heart rhythm. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 was moderately cognitively impaired and required partial or moderate assistance to roll left and right on the bed and substantial or maximal assistance to transfer from the bed to a chair. The MDS also identified Resident #18 did not exhibit physical or verbal behaviors directed towards others or self and that Resident #18 had not received any antianxiety or antidepressant medication. A physicians order dated 3/29/23 directed to administer Trazodone (a medication for depression) 25 milligrams (mg) every 6 hours as needed for anxiety for 14 days. The Resident Care Plan dated 6/5/23 identified Resident #18 was receiving a psychotropic medication (Tramadol) related to pain management. Interventions included to consult with pharmacy and provider to consider dosage reduction when clinically appropriate. A physicians order dated 12/6/23 directed to administer 25 mg of Trazodone twice a day and 50 mg in the afternoon. The Medication Administration Record (MAR) identified Resident #18 received 25 mg of Trazodone at 9:00 AM and 1:00 PM and 50 mg of Trazodone at 5:00 PM from 1/1/24 to 1/23/24. A physicians order dated 1/24/24 directed to administer 50 mg of Trazodone once in the day and once in the evening. The MAR identified Resident #18 received 50 mg of Trazodone at 5:00 PM and 9:00 PM from 1/24/24 to 1/30/24. On 1/31/24 at 11:30 AM, Resident #18 was observed to be sleeping in a wheelchair and did not arouse to surveyor speaking during the screening process. On 2/5/24 at 10:24 AM, Resident #18 was observed sleeping in bed and aroused to surveyor speaking. Resident #18 was able to answer that they had eaten breakfast and then fell back asleep during the conversation. On 2/5/24 at 10:30 AM, an interview with the Nursing Supervisor (RN #1) indicated that new medications such as antidepressant and other psychotropics would be included in the care plan, but was unable to locate a care plan for the use of Trazodone. She further identified that all team members were responsible for updating the care plan. RN #1 also indicated that the MDS Coordinator (RN #3) also gets updated on resident changes through the facility morning report and that RN #3 would also update the RCP. On 2/5/24 at 1:30 PM an interview and clinical record review with RN #3 indicated that sometimes a care plan for antidepressant medication use would be combined with other psychotropic medication use. The clinical record identified that there was a care plan present for the psychotropic medication Tramadol (a medication for pain) but not for Trazodone ( a medication for depression). RN #3 indicated that medication orders would sometimes contain information on symptom or side effect monitoring and interventions. Subsequent to surveyor inquiry, the RCP was updated on 2/5/24 to include the use of an antidepressant, however, the updated RCP incorrectly identified Tramadol as the antidepressant instead of Trazodone. 2. Resident #39 was admitted on [DATE] with a diagnoses including dementia, generalized muscle weakness, and muscle contracture of the left leg. The Resident Care Plan dated 8/11/23 identified Resident #39 had a potential to have altered skin related to decreased mobility and incontinence. Interventions included providing a pressure relieving mattress and other devices, keeping skin clean and dry, and assisting to reposition as needed. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #39 had short term and long term memory problems. Resident #39 was dependent for toileting, dressing, putting on and taking off footwear, and transferring from bed to a chair. The MDS also indicated that Resident #39 was at risk for developing pressure injuries but did not have any unhealed pressure ulcers. Nursing notes dated 9/25/23 indicated that an open area to Resident #39's coccyx measuring 0.2 centimeters (cm) by 0.2 cm by 0.1 cm was noted during care and that the wound bed had yellow slough. The nursing note also indicated that an Algicell Silver dressing and protein liquid were ordered. The September 2023 Treatment Administration Record (TAR) identified Resident #39 received an Algicell Silver dressing on 9/25/23 and 9/28/23. A wound physician initial evaluation dated 10/9/23 indicated that Resident #39 had a Stage 2 pressure ulcer to the sacrum. The recommended treatment plan included placing an Alginate Calcium dressing and changing it daily. A wound physician's follow up evaluation dated 11/6/23 indicated that the Stage 2 pressure ulcer to Resident #39's sacrum resolved on 11/6/23. A wound physician evaluation dated 1/5/24 indicated that Resident #39 had an unstageable deep tissue injury to the left heel. The recommended treatment was application of a daily skin protectant. A wound physician evaluation dated 1/15/24 identified that Resident #39 continued to have an unstageable pressure ulcer to the left heel and recommended the addition of an Alginate Calcium dressing with silver daily. The January 2024 TAR indicated that Resident #39 received daily skin protectant from 1/1/24 to 1/30/24 and an Alginate Calcium dressing with silver on 1/18/24 and 1/21/24. An interview and RCP review on 2/2/24 at 1:38 PM with RN #3 identified that the last time the RCP was reviewed was on 8/11/23 and 12/8/23 and the RCP was not revised to include the development of pressure ulcers on 9/25/23 or 10/9/23. RN #3 also indicated that the RCP was expected to be updated with any changes or additions when a resident experiences changes including in diet, diagnosis, mood, and skin. RN #3 indicated that the nurse that found a new pressure ulcer would also update the RCP and that it may have been an oversight. On 2/5/24 at 10:30 AM an interview with the Nursing Supervisor (RN #1) indicated that new wounds would be included in the resident's care plan. RN #1 also indicated that all team members were responsible for updating the care plan but that there are a lot of new nurses who may not know they need to update the care plan or might not get to it during the work day. Subsequent to surveyor inquiry, the care plan was updated on 2/2/24 and identified that Resident #39 had an actual impairment to their skin related to a deep tissue injury to the left heel. Interventions included keeping a foam heel protector in place at all times and follow facility protocols for treatment of injury. 3. Resident #50 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, repeated falls and ataxia. The Resident Care Plan (RCP) dated 10/17/23 identified a problem with elopement as evidenced by wandering, exit seeking and impaired judgement. Interventions included Redirect exit seeking behavior, wander guard left ankle, check daily at night for functioning and every shift for placement. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 was moderately cognitively impaired and required supervision touching assistance with bed to chair to bed transfers without limitation in range of motion. The MDS further identified Resident #50 had falls prior to admission, had wandering behavior and utilized a wander guard/elopement alarm daily. Treatment Administration Record (TAR) dated 12/1/23 to 12/31/23 indicated wander guard to the left ankle to check functioning of the wander guard every night check placement every shift for exit seeking with discontinued dated 12/16/23. On 2/4/24 at 10:15 AM review of the NA care card with NA #6 identified Resident #50 utilized a wander guard to the left ankle. Observation of Resident #50 with NA #6 at that time identified Resident #50 did not have a wander guard in place to the left ankle or any other extremity. On 2/5/24 at 1:35 PM interview and RCP review with RN #3 (MDS Coordinator) identified the wander guard was in place until 12/16/23 when Resident #50 was admitted to the hospital status post facility fall with hip fracture. Additionally, RN #3 identified Resident #50 was immobile and the wander guard was not reordered upon return from the hospital on 12/19/23. Furthermore RN #3 identified she should have removed the use of the wander guard from the RCP and the NA care card. Subsequent to surveyor inquiry on 2/5/24 at 1:45 PM, RN #1 revised the care plan to reflect the discontinuation of the wander guard Facility policy regarding care planning directed, that the resident care plan is written, workable individualized record indicating needs and care of the resident. Identification of problems and needs including potential problems, establishing goals and limiting solutions within a time frame and implementation or approach to problems and needs. Additionally, the policy identified that care plans are reviewed every 90 days and that the resident care coordinator shall be responsible for conducting spot check reviews of written care plans to correct any deficiencies in documentation or lack of updating by any discipline. 50179

Based on review of the clinical record, facility policy, and interviews for 1 of 3 sampled residents (Resident #50) reviewed for falls, the facility failed to ensure the Resident Care Plan was comprehensive to include interventions that the facility had implemented for fall prevention. The findings include: Resident #50 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, dementia, repeated falls and ataxia. A physician's order dated 10/18/23 directed Resident #50 required assistance with transfers and ambulation of 1 and a rolling walker. An admission MDS assessment dated [DATE] identified Resident #50 was moderately cognitively impaired and required supervision touching assistance with bed to chair to bed transfers without limitation in range of motion. Additionally, the MDS identified Resident #50 was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS further identified Resident #50 had a falls prior to admission. The RCP dated 11/6/23 identified a problem with being at risk for falls, weakness from hospitalization , poor safety, and psychoactive medication use. Interventions included orthostatic blood pressure every shift for 3 days and encourage to participate in therapy if ordered. Nursing notes from 11/6/23 through 1/22/24 identified Resident #50 sustained 12 falls including a hip fracture from a fall on 12/15/23. On 2/5/24 at 10:15 AM, Resident #50 was observed in his/her room, seated in a wheelchair watching television. Fall mats were observed folded up at the bedside, auto locking brakes were observed on his/her wheelchair and a low bed was noted to be against the wall with 1 enabler on the bed. On 2/5/24 at 1:35 PM interview, RCP review and observation of Resident #50's room with RN #3 (MDS Coordinator) identified although interventions of fall mats, auto locking brakes, low bed and 1 enabler were utilized, the RCP failed to include those interventions. Additionally, RN #3 identified that nurses or herself were responsible to update the RCP when new interventions were implemented. RN #3 also identified that in January 2024, the RCP was updated and was unsure of the reason the interventions were not documented in the RCP, although implemented. Facility policy regarding care planning identified that the resident care plan is written, workable individualized record indicating needs and care of the resident. Identification of problems and needs including potential problems, establishing goals and limiting solutions within a time frame and implementation or approach to problems and needs.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident reviewed for environment, the facility failed to ensure Resident #20's call bell was within reach. The findings include: Resident #20's diagnoses included dementia, extrapyramidal movement disorder and history of falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #20 was moderately cognitively impaired and required a moderate amount of assistance for all transfers, and substantial amount of assistance for toileting and personal hygiene. The Resident Care Plan dated 12/28/23 identified Resident #20 was a fall risk due to unawareness of safety needs. Interventions included ensuring the call bell was within reach and encouraging the resident to use the call bell. Additional interventions included ensuring a working and reachable call light. A physician's order dated 1/6/24 directed to use a rolling walker and assistance of 2 for all transfers. Observation on 2/1/24 at 10:32 AM identified Resident #20 was sitting in a wheelchair next to his/her bed facing the television. The tray table was at the front of the bed. The electronic call bell was on a chair by the head of the bed behind the resident and not within his/her reach. A manual bell was on the nightstand at the head of the bed, behind the resident and not within his/her reach. Upon request, Resident #20 was unable to turn around or remove the brakes of his/her wheelchair to turn the wheelchair around to access the call bells. Interview with Licensed Practical Nurse (LPN) #3 on 2/1/24 at 10:32 AM identified Resident #20 would not be able to reach his/her call bell as he/she couldn't get up. Additionally, LPN #2 noted they usually put the tray table in front of him/her and the call bell on the tray table. Interview with Nurse Aide (NA) #7 on 2/2/24 at 10:30 AM indicated that after Resident #20 was transferred into his/her wheelchair he/she was usually transported to an activity or a meal. NA #7 was unsure of the reason the call bell wasn't placed within Resident #20's reach, other than he/she was going to be transported to an activity or a meal. Although staff indicated Resident #20 was going to be taken to an activity or a meal, he/she was observed alone in his/her room for 15 minutes after being transferred into his/her wheelchair without the call bell within reach. Facility policy regarding Call Bells dated 10/20 directed when caring for a resident, be sure to position the call bell conveniently, telling/showing resident where the call light is located.

Based on observation and staff interviews for 1 observed resident (Resident #13) using the resident television lounge, the facility failed to maintain a homelike environment in 1 of 2 resident areas. The findings include: Resident #13's diagnoses included anxiety, vascular dementia, and tremors. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #13 was cognitively intact and required set up assistance for personal hygiene, showering, and was independent with all other activities of daily living. The Resident Care Plan dated 12/29/23 identified Resident #13 was a fall risk due to deconditioning and tremors. Interventions included ensuring call bell was within reach and educating resident and family about safety reminders. A physician's order dated 1/6/24 directed to allow resident to ambulate and transfer independently with a straight cane as needed. Observation of the [NAME] Wing Television Lounge on 2/2/24 at 9:18 AM identified Resident #13 was using the television room for leisure in the presence of 2 mechanical lift devices that were stored in the lounge. Interview with Nurse Aide (NA) #7 on 2/2/24 at 10:36 AM identified the facility had been storing the mechanical lifts in the resident television lounge for some time now (unsure how long they have been storing them there.) Interview with the DNS on 2/2/24 at 10:56 AM identified that it appeared lifts were being stored in the television room and that they probably should be stored in the corral room, which was an area on the unit where wheelchairs were stored. Interview with Resident #13 on 2/6/24 at 10:10 AM identified that there were 2 lifts in the television room every day and although it didn't bother him/her, at times they were blocking the doorway and he/she had to move them out of the way. Further he/she stated that he/she never had a problem moving them, but now that they are gone there was more room. Subsequent to surveyor inquiry, the lifts have been removed. Although requested, a facility policy for medical equipment storage was not provided.

Based on review of personnel files and staff interviews for 1 of 3 Nurse Aides (NA) reviewed for annual evaluations (NA #4), the facility failed to complete annual performance evaluations. The findings include: NA #4 was hired on 11/9/97. A performance evaluation was completed on 11/11/21 with no subsequent annual reviews completed. Interview with the DNS on 1/6/24 at 1:30 PM identified that nursing supervisors were given an evaluation to complete with the NA's being evaluated. Once completed, the form is returned to the DNS. The DNS was unable to indicate a reason for the absence of performance evaluations from 11/11/21 for NA #4. Review of the facility employee handbook indicated that employees would receive a performance evaluation at least once a year.

Based on observation, facility documentation, facility policy and interviews regarding personal funds, the facility failed to ensure adequate coverage through a Surety bond for the Resident Trust Accounts. The findings include: On 2/2/24 at 2:00 PM, interview and review of the Resident Trust Account (RTA) balances with the Business Office Manager indicated that the RTA balance for the period of 9/1/23 to 9/29/23 ranged from 1,288.92 dollars ($) to $20,505.68. Additionally, the RTA balance for the period of 9/30/23 to 10/31/23 identified a balance ranging from $1,288.92 to $36,241.83 throughout that time. The RTA balance for the period of 11/2/23 to 11/30/23 identified a balance ranging from $6,089.80 to $38,789.08 during that time. Furthermore, the RTA balance for the period of 12/1/23 to 12/29/23 indicated a balance ranging from $5,629.92 to $41,901.22. Review of the facility Surety Bond identified the Resident Trust Accounts were insured for $10,000 effective February 28, 2014, with continuous coverage until canceled by either party. Additional interview with the Business Office Manager on 2/2/24 at 2:00 PM identified that the Resident Trust Account does not exceed $10,000 for more that a few days each month, once the applied income was withdrawn, and thought the Surety bond coverage was adequate. Review of the Resident Personal Funds policy dated 11/01 failed to include guidelines for a Surety bond. Subsequent to Surveyor inquiry, the Surety bond liability coverage was increased to $35,000.00 on 2/5/24.

Based on clinical record review, review of facility documentation, observations, review of facility policy and procedure, and interviews for two of four residents reviewed for accidents (Resident #42 and Resident #62) the facility failed to supervise the resident during a meal service which resulted in an accident and/or failed to maintain specific food temperatures daily when completing the food temperature logs. The findings include: a. Resident #42's [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) dated 3/26/17 identified Resident #42 with a Brief Interview for Mental Status (BIMS) score of 3 indicative of severe cognitive impairment and required supervision with one person with eating. The Resident's Care Plan (RCP) dated 4/05/17 identified that Resident #42 had a care plan for Activities of Daily Living (ADL) which indicated that Resident #42 prefered to eat in the main dining room on the first floor and was on a pureed diet. Further review of the RCP directed nursing staff to assist Resident #42 with setting up the meal and supervision with all meals. Review of the Reportable Event dated 5/21/17 at 5:30 PM identified that Resident #42 had sustained a superficial second degree burn to his/her right second, third and fourth fingers from placing his/her right hand in hot pureed food. NA #6 turned to get coffee on the beverage cart for Resident #42 and Resident #42 had placed his/her right hand in the pureed food that was just served to him/her. NA #6 immediately removed Resident #42's hand from the pureed food, called the nurse, and placed ice on the resident's right fingers and hand. RN #2 immediately assessed Resident #42 and provided immediate care. RN #2 noted Resident #42 with redness to the right hand, second third and fourth digits with pinpoint discoloration and complained of pain. Within an hour, the resident's fingers were noted to have continued redness and purple discoloration increased with onset of intact blisters forming. The APRN was notified and orders were to soak the right hand in cool water for thirty minutes X 1 then every hour as needed for pain for twenty four hours. Apply silvadene to right hand second third and fourth digit fingertip topically followed by telfa wrap every day until wound nurse evaluates the injury. Interview with NA #6 on 5/24/17 at 3:00 PM identified that Resident #42 was seated in the main dining room for dinner service and that Resident #42 required supervision with meals. NA #6 further stated that Resident #42 was in the dining room on the first floor for supper service and that NA #6 was in charge of the supervision of the supper meal service on 5/21/17. NA #6 stated that Resident #42's diet was pureed and that the resident required set up with meals and supervision during meals. NA #6 had stated that he/she had given Resident #42 his/her meal and the resident requested another cup of coffee. NA #6 turned (loosing eye contact to Resident #42) to get the coffee and heard a loud scream. NA #6 turned around and noticed Resident #42's right hand in his/her pureed vegetables. NA #6 immediately took the hand out of the pureed food and called the nurse. NA #6 further stated that when a resident requires supervision with meals such as Resident #42, that he/she usually sits directly next to them and watches the resident at all times during the meal. Interview with RN #2 on 5/24/17 at 3:15 PM identified that she was called to assess Resident #42's right hand on 5/21/17 after the incident and noticed redness on his/her third and fourth digit right hand. RN #2 further requested that the cook take a holding temperature on the steam table (which dinner was served from) of the pureed food (green beans). RN#2 stated that the cook took the temperature and stated to RN #2 that the holding temperature of the pureed green beans was 160 degrees Fahrenheit. RN #2 stated that he/she did not review the food temperature logs on that day. Interview with The Director of Nursing Services (DNS) on 5/24/17 at 4:00 PM identified that when a resident's ADL eating status is identified as supervision with meals that it is expected that all staff keep eye contact at all times on the resident during the entire meal. The DNS further stated that NA #6 did not do this because he/she turned his/her back on Resident #42 when NA #6 went to get the resident a second cup of coffee. Further interview with the DNS identified that the facility does not have a policy specifying the various levels of assistance. b. Observation of the Kitchen during tour on 5/22/17 at 9:30 AM identified the daily food temperature logs were completed with only the staff initials next to the food item and not the specific food temperature once it was taken by the cook. Further review of the food temperature logs indicated that pureed food was not being recorded on the food temperature log. Interview with the Director of Food Services on 5/24/17 at 11:00 AM identified that this was the practice of the facility to complete daily food temperatures and that the state requirements only indicate that food temperatures depending on the food item should be maintained above or under a specified amount. Review of the Facility's Dietary Food Temperatures directed dietary staff to monitor food temperatures during cooking, prior to serving residents and upon leaving the kitchen. Furthermore, hot food temperatures must be maintained at 135 degrees Fahrenheit and cold food temperatures must be maintained at 40 degrees Fahrenheit or below.

Based on clinical record review, review of facility documentation, and interview for one sampled resident (Resident #19) reviewed for hydration, the facility failed to monitor the resident's intake and output per physician's orders [REDACTED]. The findings include: Resident #19's [DIAGNOSES REDACTED]. The admitting hospital laboratory results dated [DATE] identified Resident #19 with a BUN of 34 (ref range 7-20) and a creatinine level of 1.0 (ref range 0.7-1.5). The Resident Care Plan dated 3/6/14 identified Resident #19 with an alteration in ability to perform activities of daily living with interventions including to provide resident with total assistance for feeding. A physician's orders [REDACTED]. The Minimum (MDS) data set [DATE] identified Resident #19 with intact cognition and required extensive assistance with activities of daily living, including eating and drinking. A Nursing progress note dated 3/16/14 at 10:04 PM identified Resident #19 with dry mucous membranes. The Nutritional Screening and assessment dated [DATE] identified Resident #19's estimated fluid needs were 1545 cc/24 hours and although the assessment included a prompt to calculate a 3 day average of the resident's intake and output, this information was not addressed on the assessment. A review of the Nurse Aide worksheets from 3/14/14 through 3/23/14 identified the following information: 3/14/14- 3-11 shift Resident #19 consumed 360cc 11-7 shift no I&O information available 3/15/14-Resident consumed 1580 cc/24 hours 3/16/14-Resident consumed 2120 cc/24 hours 3/17/14-Resident consumed 1240 cc/24 hours 3/18/14-no I&O information available 3/19/14-no I&O information available 3/20/14-Resident consumed 1440 cc/24 hours 3/21/14-no I&O information available 3/22/14-no I&O information available 3/23/14-7-3 shift no information available 3-11 shift 290 cc consumed 11-7 shift 120 cc consumed The Nurse's progress note dated 3/23/14 identified Resident #19 was transferred to the hospital for evaluation secondary to abdominal distention. The Hospital Interfacility Transfer/Inpatient Summary (W-10) dated 3/23/14 identified Resident #19's admission [DIAGNOSES REDACTED]. The W-10 further identified Resident #19 presented as lethargic but arousable and mucous membranes were extremely dry and resident received volume resuscitation. Hospital lab results dated 3/29/14 identified the Resident's BUN was 64 and creatinine was 1.09 and on 4/18/14 BUN was 26 and creatinine was 0.75. Resident #19 returned to the facility on [DATE]. Interview and record review with the Director of Nursing Services, (DNS) on 8/7/14 at 10:20 AM failed to reflect documentation of a hydration screen in Resident #19's medical record. DNS further indicated her expectation was that Resident #19 would have been on I&O monitoring and although some information was located via the Nurse Aide flowhseets the facility was unable to produce documentation to support Resident #19's I&O was monitored consistently from 3/14/14 through 3/24/14. The DNS further indicated her expectation would be for the nurses to follow the facility hydration screen policy if Resident #19 was not meeting his/her estimated fluid needs. A review of the facility's intake and output policy and procedure identified accurate intake and output totals for residents requiring such will be documented in the resident's chart. Procedure identified the 3-11 nurses will total the intake and output for the day, noting whether or not the resident is meeting his/her intake goal and if the resident's 24 hour intake is less than fluid intake goal or if less than 1500 cc refer to the dehydration policy and procedure. The facility's dehydration policy and procedure identified all residents will be adequately hydrated and special protocol will be followed for residents identified as being at significant risk for dehydration with the following conditions included as risk factors for dehydration: abnormal lab values such as elevated BUN, uncontrolled diabetes mellitus, use of diuretics and dependence on staff for the provision of fluid intake. The facility's hydration screening policy and procedure identified residents identified with intake range below the recommended level or triggered by clinical signs and symptoms will have a hydration screen initiated. The procedure identified that upon completion of the 24 hour intake totals, the 3-11 nursing staff will identify those residents who have consumed less than the recommended level and complete an initial hydration screen and the screen will continue for the next two shifts. The facility failed to consistently monitor Resident #19's intake and output and/or failed to implement interventions addressing such.

Based on clinical record review, review of facility documentation and staff interview for one sampled resident (Resident #77) who was reviewed for accidents, the facility failed to ensure the the resident was free from injury. The findings include: Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident had intact cognition (BIMS 13), required extensive assistance of two staff with transfers & toilet use, and was non ambulatory. The care plan dated 9/30/13 directed the resident be transferred via a hoyer lift. Additonally, the care plan noted that the resident was able to sit to stand transfer with assist of two staff with a third person to assist with commode or wheelchair for toileting, but was not able to stand pivot safely. Review of the physician's orders [REDACTED]. Additionally, physician's orders [REDACTED]. Accident/incident report dated 11/18/13 at an unknown time identified that the resident complained of severe right leg pain and on inspection the right leg below the knee was mishapen, and the resident had pain with any movement. A nurses note dated 11/18/13 at 11:15AM identified the resident complained of severe pain to the right leg, below the right knee was warm to touch, and the resident was unable to move the right leg on command. After physician notification an x ray was ordered. A radiology report dated 11/18/13 identified the resident was diagnosed with [REDACTED]. Review of the hospital history and physical dated 11/18/13 identified the resident presented to the emergency room complaining of right lower extremity pain with swelling. A physician specialty consult dated 11/19/13 indicated x rays showed communiated non displaced fractures of the right tibia and fibula. The facility investigation dated 11/22/13, including interviews with all staff who cared for the resident between 11/16/13 - 11/18/13, failed to determine how the injury to the resident's leg occured. Interview with NA#3 on 8/6/14 at 2:00PM identified that he/she and NA#2 lifted the resident from the commode to the recliner chair on 11/17/13 during the day shift and did not use the hoyer lift. NA#3 stated that at no time did the resident complain of pain or did his/her leg get bumped. Additionally, he/she stated that the resident's knees did not bed well due to his/her prior surgerys and would mostly remain straight. Interviews with NA#1 and NA#2, who cared for the resident on 11/18/13 when the injury was found, could not be obtained. Interview with MD#2 on 8/6/14 at 4:30PM identified that communiated fractures of the tibia and fibula would not spontanously occur. MD#2 stated that a lot of force and/or a twisting motion would have had to occur to cause the fractures.

Based on clinical record review, review of facility documentation and staff interview for 2 of 3 sampled residents reviewed for falls, (R#18, 51), the facility failed to ensure that devices including a shower mat, and/or alarms, were in place in accordance with the plan of care to prevent falls with injuries. The findings include: 1. Resident #18's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified moderately impaired cognition, extensive assistance with bathing, and a history of falls. The resident care plan dated 5/31/11 identified frequent falls as a problem. Interventions included non skid mat while in the shower. Nurse's notes dated 5/31/11 at 2:50 PM identified that the resident fell while taking a shower. The resident complained of left pinky pain. The facility investigation dated 5/31/11 noted that a bang was heard and the resident was found on the floor in the shower. The investigation identified that no mat was on the floor while the resident was in the shower. Interview with the RN Supervisor on 7/21/11 at 2:10 PM noted that the NA was standing outside the shower room door and heard a bang. The resident was assessed and complained of left pinky pain. The RN Supervisor noted that the non skid mat that was supposed to be in place while the resident was in the shower, was not. NA # 2 was unavailable for interview. 2. Resident #51's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified moderately impaired cognition, independent with Adl's and no falls since admission. The care plan dated 1/17/11 identified a high risk for falls related to a history of falls and diagnoses. Interventions included a clutter free environment, keep items in reach and bed and chair alarms. Nurse's notes dated 1/17/11 at 6:30 PM identified R# 51 was noted lying on the floor and complained of left hip/leg pain. R#51 stated that he/she was trying to remake the bed. Facility documentation dated 1/17/11 at 6:30 PM identified that R#51 was found on the floor lying on the left side. A NA heard a "thud" and found R#51 on the floor. X-rays were obtained and noted a fractured pelvis. Review of the facility alarm documentation for December 2010 identified that R#51's bed and chair alarms were initiated on 12/30/10. The January 2011 alarm documentation failed to reflect that alarms were in use for R#51 until 1/18/11, the day after the fall and fracture. Interview with NA #1 (who heard the resident fall) on 7/20/11 at 2:10 PM noted that while she was providing care for another resident in the adjoining bathroom, she heard a thud, opened the door and saw R # 51 lying on the floor next to the bed. Additionally NA #1 stated that what alerted her was the thud noise not an alarm. Interview and review of R# 51's clinical record on 7/20/11 at 11:45 AM with the MDS coordinator identified that although the care plan identified R #51 was both independently ambulatory and had a bed and chair alarm in place, the resident should have been reassessed for the ambulation status when the bed and chair alarms were put into place.

Based on clinical record review, and interview for one of three sampled residents with pressure sores (R#16), the facility failed to initiate interventions to prevent skin breakdown on the heels/feet of a resident that required 2 staff for bed mobility and transfers. The findings include Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment indicated the lower extremities were free from skin breakdown. The pressure ulcer risk assessment dated [DATE] identified that the resident was at high risk for development of pressure sores. The admission assessment dated [DATE] identified that the resident was without cognitive impairment, required extensive assistance from 2 staff members for bed mobility and transfers and was without pressure sores. The initial care plan dated 2/4/11 identified the risk for altered skin integrity. Interventions included a pressure reduction mattress and chair cushion, assess skin every shift and report any red or open areas, and to encourage/assist to reposition every 2 hours. No interventions to prevent lower extremity pressure or breakdown were noted. Nurse's notes dated 2/21/11 identified a new stage two open area to the right outer ankle. Treatment orders were obtained at that time. The treatment kardex for February 2011 lacked any interventions to alleviate pressure to the lower extremities until 2/22/11 when protective boots were applied. Interview and review of the clinical record with the DNS and MDS coordinator on 7/22/11 at 10 AM failed to provide documentation that the plan of care included preventive measures to alleviate pressure on the resident's lower extremities/feet/heels/ankles and/or that any interventions were initiated to prevent breakdown in a resident at risk.

Based on clinical record review, and interview for one of three sampled residents with pressure sores (R#16), the facility failed to develop a comprehensive care plan and/or imitate interventions to prevent skin breakdown on the heels/feet of a resident that required 2 staff for bed mobility and transfers. The findings include Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment indicated the lower extremities were free from skin breakdown. The pressure ulcer risk assessment dated [DATE] identified that the resident was at high risk for development of pressure sores. The admission assessment dated [DATE] identified that the resident was without cognitive impairment, required extensive assistance from 2 staff members for bed mobility and transfers and was without pressure sores. The initial care plan dated 2/4/11 identified the risk for altered skin integrity. Interventions included a pressure reduction mattress and chair cushion, assess skin every shift and report any red or open areas, and to encourage/assist to reposition every 2 hours. No interventions to prevent lower extremity pressure or breakdown were noted. Nurse's notes dated 2/21/11 identified a new open area to the right outer ankle. Treatment orders were obtained. The treatment kardex for February 2011 lacked any interventions to alleviate pressure to the lower extremities until 2/22/11 when protective boots were applied. Interview and review of the clinical record with the DNS and MDS coordinator on 7/22/11 at 10 AM failed to provide documentation that the plan of care included preventive measures to alleviate pressure on the resident's lower extremities/feet/heels/ankles.