Every finding on record at D'Youville Senior Care

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required daily administration of a diuretic and had been newly admitted from an acute care setting, the Facility failed to ensure he/she was free from a significant medication error, when his/her medication orders were not transcribed correctly by nursing, his/her Furosemide (diuretic) 80 milligrams was omitted and as a result, he/she was not administered his/her diuretic three days in a row.Findings include:The Facility Procedure, titled Incidents and Accidents, dated 01/30/24, indicated an incident was defined as an occurrence or situation that was not consistent with the routine care of a resident, and included medication errors. The Facility Policy, titled Medication Reconciliation, dated 01/30/24, indicated the Facility would:-During the admission process nursing would compare the Facility's orders to Hospital records, and transcribe orders.-Reconcile the resident's medications to ensure the resident was free from medication errors. -The Policy defined Medication Reconciliation as the process of verifying that the resident's current medication list matched the physician's orders for the purpose of providing the correct medications to the resident at all points throughout his/her stay. -Nursing would obtain and transcribe any new orders.-New orders required a second nurse to cosign orders, which indicated there had been a review of the orders for accuracy.-Nursing would perform a 24 hour chart check to verify all new orders had been addressed.The Facility Policy, titled Twenty Four Hour Chart Check Policy, dated as revised 02/2023, indicated medical records would be reviewed nightly for accurate and complete transcription of Physicians' Orders, and corrections would be made if a discrepancy was identified. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/29/26, indicated Resident #1 was admitted to the Facility from the Acute Care Hospital with a Physician's order for Furosemide (diuretic) 80 milligrams (mg) by mouth, daily. The Report indicated nursing failed to transcribe Resident #1's Furosemide order, which resulted in him/her missing three consecutive doses of the medication.Resident #1 was admitted to the Facility in May 2026, diagnoses included acute kidney failure, acute on chronic systolic and diastolic congestive heart failure.Review of Resident #1's Hospital Discharge Medication Summary, dated 05/18/26, indicated he/she had an order for Furosemide 80 mg, by mouth daily to begin on 05/19/26.However, review of Resident #1's Facility Physician's Order Summary Report indicated he she/ had a physician's order, dated 05/21/26 to administer Furosemide 80 mg by mouth daily beginning on 05/22/26. Further review of Resident #1's Medical Record indicated there was no documentation to support that he/she had a Physician's Order to administer Furosemide on 05/19/26, 05/20/26, and 05/21/26.During a telephone interview on 06/29/26 at 11:30 A.M., Nurse #1 said that on 05/18/26, he was the nurse assigned to Resident #1, and he reviewed and transcribed his/her admissions orders from the Hospital discharge summary into the Facility's electronic medication ordering system. Nurse #1 said he accidentally omitted Resident #1's Furosemide 80 mg order when transcribing his/her admission orders. During a telephone interview on 06/29/26 at 11:52 A.M., Nurse Supervisor #1 said that on 05/18/26, he conducted a second check review of Resident #1's admission orders after Nurse #1 had transcribed them i-to the electronic medication ordering system. Nurse Supervisor #1 said he missed that Resident #1's Hospital Discharge Summary had an order for Furosemide 80 mg which had been omitted by Nurse #1. Review of Nurse #2's written statement, dated 05/30/26, indicated he worked the 11:00 P.M., to 07:00 A.M., shift on 05/18/26, and had missed Resident #1's Medical Record that night, and therefore had not completed the necessary twenty-four-hour chart check.During a telephone interview on 06/30/26 at 10:16 A.M., Nurse Practitioner #1 said that she reviewed Resident #1's medical record on 05/21/26 and noticed that his/her Furosemide 80 mg had been omitted from his/her admission orders at the Facility. Nurse Practitioner #1 said she notified Unit Manager #1 about the medication error. During an interview on 06/29/26 at 08:09 A.M., the Director of Nurses (DON) said Nurse #1, Nurse Supervisor #1, and Nurse #2 should have carefully reviewed Resident #1's Hospital Discharge Summary and Facility admission orders to ensure there were no discrepancies or omissions but had not and therefore Resident #1's Furosemide was omitted for three consecutive doses, in error.

Based on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for four Residents (#175, #139, #93 and #143) out of a total sample of 40 Residents. Specifically,For Resident #175 the facility failed to a). ensure that they obtained physician's orders for the use of CPAP (continuous positive airway pressure, used to treat obstructive sleep apnea) and b). store the CPAP mask and tubing in a bag.For Resident #139, Resident #93, and Resident #143, the facility failed to ensure the respiratory equipment was maintained in a sanitary condition. Specifically, the oxygen concentrators used to administer continuous oxygen had filters covered with a thick layer of dust. Findings include: 1. Review of facility policy titled CPAP, dated as revised 2/26, indicated the following:Procedure: Check MD orderTubing to be labeled with date and time, cleaned daily per manufacturer's instructions and changed weekly. Mask/ tubing to be stored in a bag when not in use.Document Treatment in the ETAR (electronic treatment administration record). a. Resident #175 was admitted to the facility in March 2026 with diagnoses that included osteomyelitis of the right ankle and foot, muscle weakness and obstructive sleep apnea. Review of Resident #175's most recent Minimum Data Set (MDS) assessment, dated 3/9/26 indicated a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. The MDS failed to indicate the use of non-invasive mechanical ventilation (CPAP). On 4/13/26 at 8:12 A.M., the surveyor observed a CPAP machine on the Resident's bedside table. Review of the referring hospital's Discharge summary, dated [DATE], indicated the following: Obstructive Sleep Apnea: History of OSA (Obstructive sleep apnea). At risk for postoperative hypoventilation, especially with opioid use. Resume CPAP at night if available. Monitor oxygen saturation overnight. Review of Resident #175's active physician's orders and active care plans failed to indicate Resident #175's use of CPAP. Review of the clinical progress note dated, 4/6/26, indicated a covid test could not be completed because of CPAP use. Further review of progress notes since admission to the facility failed to indicate any CPAP use. During an interview on 4/14/26 at 7:10 A.M., Nurse #3 said that she works the night shift on Resident #175's unit. She said that Resident #175 wears his/her CPAP every night and is compliant with use. She said she gives the Resident an early morning medication and that is the only time he/she removes the mask. During an interview on 4/14/26 at 11:56 A.M., Resident #175 said he/she uses the CPAP every night since admission to the facility. During an interview and observation on 4/14/26 at 12:19 P.M., the surveyor and Unit Manager #2 observed the CPAP machine in the Resident's room. Unit Manager #2 said that the Resident should have an order for the use of the CPAP machine, including the settings of the machine, so that staff are aware of the usage and can assess the Resident appropriately and ensure compliance. During an interview on 4/14/26 at 2:31 P.M., the Director of Nurses said that there should be a physician's order in place for the use of the CPAP machine. b. On 4/13/26 at 8:12 A.M., 4/14/26 at 6:52 A.M., and 10:15 A.M., the surveyor observed a CPAP machine on the Resident's bedside table. The mask was not stored in bag and was laying out in the open on the bedside table. Review of the medical record failed to indicate physician's orders regarding cleaning and storage of the CPAP mask. During an interview and observation on 4/14/26 at 12:19 P.M., the surveyor and Unit Manager #2 observed the CPAP machine on the Resident's bedside table. The tubing and mask were on the top of the bedside table, uncovered and out in the open. Unit Manager #2 said that it should be stored in a bag. During an interview on 4/14/26 at 2:31 P.M., the Director of Nurses said that the CPAP mask should be stored in a bag and protected from potential bacteria. 2a. Resident #139 was admitted to the facility in May 2025 with diagnoses that included Alzheimer's disease, chronic diastolic heart failure, pulmonary hypertension, and severe persistent asthma. Review of the Minimum Data Set (MDS) assessment, dated 1/15/26, indicated Resident #139 scored 3 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having severe cognitive impairment. The MDS further indicated that the Resident was dependent on staff for care including hygiene, bathing, is on hospice care and is on oxygen therapy. On 4/13/26 at 9:36 A.M., the Surveyor observed Resident #139 resting in bed wearing a nasal canula receiving oxygen at 2 liters per minute (LPM). The oxygen concentrator filter was entirely covered with dust. On 4/13/26 at 12:28 P.M., the Surveyor observed Resident #139 seated in a chair with his/her lunch meal in front of him/her. Resident #139 had a nasal canula receiving oxygen from an oxygen concentrator. The side of the concentrator had a filter that was entirely covered in dust. On 4/13/26 at 2:23 P.M., the Surveyor observed Resident #139 in bed with his/her eyes closed and at this time the nasal canula was on the floor, the concentrator was running and the filter was covered with dust, obscuring the filter. On 4/14/26 at 7:23 A.M., the Surveyor observed Resident #139 in bed wearing a nasal cannula receiving oxygen at 2 liters per minute. The filter on the oxygen concentrator was covered with dust. Review of Resident #139's physician's orders indicated: -Oxygen 0.5-2 LPM via nasal cannula to maintain sats above 90-92%. Attempt to titrate down each shift, dated 5/8/25. -Change oxygen tubing every night shift Thursday, dated 5/8/25. Review of Resident #139's physician's orders, and care plans failed to indicate a plan of care to ensure the respiratory equipment was maintained in a clean and sanitary manner. During an interview and observation on 4/15/26 at 7:53 A.M., Nurse #14 said Resident #139 does require continuous oxygen and on occasion he/she will remove the nasal canula. Nurse #14 said the concentrator should be clean and have a clean filter. Nurse #14 said she was not sure how the concentrator filters are cleaned, whether nursing or maintenance does it. Nurse #14 and the surveyor went to Resident #139's room. Nurse #14 removed the filter and began pulling/removing a thick layer of dust covering the entire filter into the nearby trash bin. Nurse #14 said the filter should be clean and that if covered with dust the concentrator may not work as well as it should. During an interview on 4/15/26 at 8:19 A.M., the Director of Nursing (DON) said the oxygen concentrator filter should be kept clean and clear. The DON said the nurses do not have orders to clean the filter, but she would expect the filters to be clean for the administration of oxygen. 2b. Resident #93 was admitted to the facility in September 2025 with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and dependence on supplemental oxygen. Review of the most recent Minimum Data Set (MDS) Assessment, dated 3/12/26, indicated a Brief Interview for Mental Status (BIMS) score 00 out of 15, indicating severe cognitive impairment. On 4/13/26 at 7:36 A.M., the surveyor observed Resident #93 lying in bed with oxygen set on 2 liters via nasal cannula. The filter on the concentrator was covered with a thick layer of dust. On 4/14/2026 at 7:14 A.M., and 4/15/26 at 6:43 A.M., the surveyor observed Resident #93 sleeping in bed with oxygen set on 2 liters via nasal cannula. The filter on the concentrator was covered with a thick layer of dust. Review of Resident #93's physician orders indicated the following: -Oxygen at 2 liters via nasal cannula every shift, dated 9/12/25. -Change oxygen tubing every night shift every Thursday, dated 9/12/25. Review of Resident #93's physician orders failed to indicate maintenance orders to clean or change the oxygen filter. During an interview on 4/15/26 at 6:43 A.M., Nurse #12 said oxygen tubing and filters are changed overnight on Thursdays weekly. Nurse #12 said there would be an order to change the tubing and filter and the nurse changing the tubing usually changes the filter. During an observation and interview on 4/15/26 at 6:46 A.M., the surveyor and Nurse #12 reviewed Resident #93's physician orders. Nurse #12 said the Resident had an order to change the tubing but there was no order to change or clean the filter. During an interview on 4/15/26 at 6:49 A.M., Unit Manager #2 said there wouldn't be an order to change or clean the filter because the oxygen company manages the filters and checks on the oxygen tanks weekly. Review of the facility oxygen company contract titled 02 Safe Solutions, dated 4/19/18, failed to indicate maintenance services for the oxygen filters provided by the oxygen company. During an observation and interview on 4/15/26 at 6:52 A.M., the surveyor, Unit Manager #2 and Nurse #12 observed Resident #93's oxygen concentrator filter. The filter on the concentrator was covered with a thick layer of dust. Unit Manger #2 said the filter should've been cleaned and if the filters aren't cleaned then the Resident isn't getting clean oxygen. During an interview on 4/15/26 at 6:57 A.M., the Director of Nursing (DON) said the oxygen company maintains the oxygen tanks and she is not aware of their schedule for switching out the filters. The DON said she has not seen the oxygen filters personally but that the oxygen company was in the facility within the past week. The DON said she would expect the filters to be cleaned and the Resident would have the potential for being exposed to contaminates if the filters aren't cleaned. 2c. Resident #143 was admitted to the facility in March 2024 with diagnoses that included anemia, dementia and obstructive sleep apnea. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/15/26, indicated a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. On 4/13/26 at 8:17 A.M., the surveyor observed Resident #143 sleeping in bed with oxygen set on 1 liter via nasal cannula. The filter on the concentrator was covered with a thick layer of dust. On 4/13/26 at 4:03 P.M., the surveyor observed Resident #143 lying in bed with oxygen set on 1 liter via nasal cannula. The filter on the concentrator was covered with a thick layer of dust. On 4/14/26 at 7:17 A.M., and 4/15/26 at 6:42 A.M., the surveyor observed Resident #143 sleeping in bed with oxygen set on 1 liter via nasal cannula. The filter on the concentrator was covered with a thick layer of dust. Review of Resident #143's physician orders indicated the following: -Oxygen at 0.5-1L via nasal canula to maintain sats above 88% every shift, dated 7/30/24. -Change oxygen tubing every night shift every Thursday, dated 3/20/24. Review of Resident #143's physician orders failed to indicate maintenance orders to clean or change the oxygen filter. During an interview on 4/15/26 at 6:43 A.M., Nurse #12 said oxygen tubing and filters are changed overnight on Thursdays weekly. Nurse #12 said there would be an order to change the tubing and filter and the nurse changing the tubing usually changes the filter. During an observation and interview on 4/15/26 at 6:46 A.M., the surveyor and Nurse #12 reviewed Resident #143's physician orders. Nurse #12 said the Resident had an order to change the tubing but there was no order to change or clean the filter. During an interview on 4/15/26 at 6:49 A.M., Unit Manager #2 said there wouldn't be an order to change or clean the filter because the oxygen company manages the filters and checks on the oxygen tanks weekly. Review of the facility oxygen company contract titled 02 Safe Solutions, dated 4/19/18, failed to indicate maintenance services for the oxygen filters provided by the oxygen company. During an observation and interview on 4/15/26 at 6:54 A.M., the surveyor, Unit Manager #2 and Nurse #12 observed Resident #143's oxygen concentrator filter. The filter on the concentrator was covered with a thick layer of dust. Unit Manger #2 said the filter should've been cleaned and if the filters aren't cleaned then the Resident isn't receiving clean oxygen. During an interview on 4/15/26 at 6:57 A.M., the Director of Nursing (DON) said the oxygen company maintains the oxygen tanks and she is not aware of their schedule for switching out the filters. The DON said she has not seen the oxygen filters personally but that the oxygen company was in the facility within the past week. The DON said she would expect the filters to be cleaned, and the Resident would have the potential for being exposed to contaminates if the filters aren't cleaned.

Based on observation, interview and record review the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically,1. For Resident #69 the facility failed to ensure medications were not stored at the bedside. 2. For Resident #175 the facility failed to ensure medications were not stored at the bedside.3a. The facility failed to ensure the treatment cart on the Sweet Land Unit was locked.3b. The facility failed to ensure the medication carts on the Sweet Land Unit, Short Term Rehab Unit and Wannalancit Unit were secured.Findings include: Review of the facility policy titled Medication Storage in the Facility Bedside Medication Storage, dated 2024, indicated All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to given unauthorized medications to the charge nurse for return to the family or responsible party. 1. Resident #69 was admitted to the facility in June 2025 with diagnoses including vascular dementia, cognitive communication deficit, and anxiety disorder. Review of Resident #69's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #69 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15. On 4/13/26 at 8:14 A.M., and 12:59 P.M. the surveyor observed one bottle of Refresh Optive Gel Drops on Resident #69's bedside table. Resident #69 said those were his/her eye drops that he/she needs. On 4/14/26 at 7:14 A.M., the surveyor observed one bottle of Refresh Optive Gel Drops on Resident #69's bedside table. Review of Resident #69's physician orders and care plans failed to indicate the Resident had met criteria to self-administer medications at his/her bedside. Review of the Self-Administration of Medication Informed Consent and assessment dated [DATE] indicated that the Resident did not have medications he/she wants to keep at bedside or wishes to administer his/her own medication. During an observation and interview on 4/14/26 at 7:53 A.M., Nurse #2 said she was not aware of Resident #69's medications being left at the bedside. Nurse #2 and the surveyor observed one bottle of Refresh Optive Gel Drops on Resident #69's bedside table. Nurse #2 said Resident #69 should not have the bottle of eye drops left at the bedside table. Review of Resident #69's physician order dated 2/19/26 indicated the following: Refresh Tears PF Ophthalmic Solution 0.5-0.9 % (Carboxymethylcellulose Glycerin) Instill 1 drop in both eyes every hour for Dry eyes While awake. Review of Resident #69's April 2026 Medication Administration Record indicated that Resident #69's scheduled Refresh Tears PF Ophthalmic Solution was signed off as Resident receiving medication on 4/13/26 and 4/14/26. During an interview on 4/14/26 at 1:17 P.M., Unit Manager #3 said Resident #69 should not have eye drops at his/her bedside and said Resident #69 has not been assessed to self-administer medications. During an interview on 4/14/26 at 3:02 P.M., the Director of Nursing said residents who wish to self-administer medication must have a Self-Administration assessment completed prior to leaving the medications with residents and said Resident #69 should not have the eye drops stored in his/her room as he/she has not been assessed for self-administration. 2. Resident #175 was admitted to the facility in March 2026 with diagnoses that included osteomyelitis of the right ankle and foot, muscle weakness and obstructive sleep apnea. Review of Resident #175's most recent Minimum Data Set (MDS) assessment, dated 3/9/26 indicated a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. On 4/13/26 at 8:12 A.M., the surveyor observed medications stored on the Resident's overbed table. The medications included clotrimazole cream (a topical medication used to treat skin infections caused by fungi) and Hydrocortisone and acetic acid otic solution (a prescription ear drop used to treat outer ear infections and relieve associated inflammation, redness, and itching). On 4/13/26 at 12:27 P.M., the surveyor observed medications stored on the Resident's overbed table. The medications included clotrimazole cream and Hydrocortisone and acetic acid otic solution. In addition to the previously observed medications there was also a tablet of immodium (a medication used to treat diarrhea or loose stool) at the bedside. On 4/14/26 at 6:51 A.M., the surveyor observed medications stored on the Resident's overbed table. The medications included clotrimazole cream and Hydrocortisone and acetic acid otic solution. Review of Resident #175's physician's orders indicated the following: loperimide (immodium) 2 mg every 6 hours as needed for loose stools, dated 3/9/26. Further review of physician's orders failed to indicate orders for Clotrimazole cream or Hydrocortisone and acetic acid otic solution. Review of the medical record failed to indicate that the Resident was assessed to self- administer medications or store medication in his/her room. During an interview on 4/14/26 at 11:59 A.M., Resident #175 said that he/she is not utilizing the medications that are stored on his/her bedside table. During an interview on 4/14/26 at 12:15 P.M., Unit Manger #2 said that there are no residents on the unit who store medications in their rooms. She said medications are kept in the medication cart and locked up. The surveyor and the Unit Manager observed the Resident's room and noted the cream and otic drops on the overbed table. The Unit Manager said that they should not be stored unsecured in the Resident's room. She further said it was a safety concern for other residents on the unit as well as there are residents that like to walkaround the unit and visit other residents in their rooms. During a follow up interview on 4/14/26 at 12:24 P.M., Unit Manager #2 said that residents can be assessed for self-administration and storage of medications, but that Resident #175 was not. She said that if any Resident has medications in their rooms, then they need to be locked and secured in a drawer. She said she did not know that Resident #175 had these medications in his/her room. During an interview on 4/14/26 at 2:30 P.M., the Director of Nurses said that Residents should not be storing medications in their rooms. She said that facility staff should have noticed the medications in the room and removed them. 3a. On 4/13/26 at 7:39 A.M., the surveyor observed an unlocked and unsupervised treatment cart in the hallway outside of resident rooms on the Sweet Land Unit. On 4/14/26 from 7:18 A.M. to 7:35 A.M., the surveyor observed an unlocked and unsupervised treatment cart in the hallway outside of resident rooms on the Sweet Land Unit. On 4/15/26 at 7:04 A.M., the surveyor observed an unlocked and unsupervised treatment cart in the hallway outside of resident rooms on the Sweet Land Unit. The surveyor was able to access the cart and observed multiple prescription creams and treatment supplies. During an interview on 4/15/25 at 7:05 A.M., Nurse #1 said if a nurse is not present at the treatment cart, then it should be locked. During an interview on 4/15/26 at 7:07 A.M., the Director of Nurses (DON) said she expects all medication and treatment carts to be locked unless the nurse is present at the cart. The DON said if the carts are left unattended then anyone could access the medications in the carts. 3b. On 4/13/26 at 7:41 A.M., the surveyor observed an unlocked and unsupervised medication cart in the hallway outside of resident rooms on the Sweet Land Unit. On 4/13/26 at 7:47 A.M., the surveyor observed an unlocked and unsupervised medication cart in a resident's room with one resident up in his/her wheelchair on the Sweet Lane Unit. The nurse was no present in the resident's room. On 4/13/26 at 7:55 A.M., the surveyor observed an unlocked and unsupervised medication cart in the hallway outside of resident rooms on the Sweet Land Unit. On 4/14/26 at 8:26 A.M., the surveyor observed an unlocked medication cart on the Wannalancit unit. The surveyor was able to open the medication cart and gain access. The nurse was observed walking away from the medication cart. During an interview on 4/14/26 at 8:28 A.M., Nurse #2 said she should not have left the medication cart unlocked when she pushed a resident down to the dining room. On 4/15/26 at 7:02 A.M., the surveyor observed two of two medication carts were unlocked and unsupervised on the short-term unit. A resident was observed near the carts in the hallway. During an interview and observation on 4/15/26 at 7:03 A.M., Nurse #10 said his medication carts should be locked and they are not. During an interview on 4/15/26 at 7:05 A.M., Nurse #1 said if a nurse is not present at the medication cart, then it should be locked. During an interview on 4/15/26 at 7:07 A.M., the Director of Nurses (DON) said she expects all medication and treatment carts to be locked unless the nurse is present at the cart. The DON said if the carts are left unattended then anyone could access medications in the carts.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically,The facility failed to implement Enhanced Barrier Precautions (EBP) for five residents (#2, #48, #143, #33, and #183) out of a total of 69 residents who required the use of EBP.The facility failed to follow proper infection control practices for shared medical equipment, a). Nursing Staff failed to disinfect the blood pressure cuff between uses on the Sweet Land Unit and [NAME] Unit, and b). Nursing staff failed to disinfect a blood glucometer machine after use on the Wannalancit Lane Unit and c). failed to ensure staff performed hand hygiene while performing blood sugar checks. The facility failed to ensure that staff performed hand hygiene between entering and exiting resident rooms and between glove use. Findings include: 1a. Review of the facility policy titled Infection Control - Enhanced Barrier Precautions, dated as 5/28/25, indicated that it is the policy of this home to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. EBP is defined as an infection control interventions designed to reduce transmission of multidrug-resistant organisms that employees target glove use during high contact resident care activities. 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing Linens f. Changing Briefs or assisting with toileting g. Device care for use: central lines, urinary catheter, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheter, PICC lines, midline catheters. h. Wound Care: any skin opening requiring a dressing. Resident #2 was admitted to the facility in November 2024 with diagnoses including dementia, heart failure, and urinary incontinence. Resident #2's Minimum Data Set assessment, dated 2/3/26, indicated Resident #2 had a severe cognitive impairment as evidence of a BIMs score of 0. This MDS indicated Resident #2 was dependent on staff for activities of daily living, was incontinent of bowel and bladder, and Resident #2 had one unstageable pressure ulcer (severe, full thickness wound where the base is completely obscured by [NAME] or eschar) and he/she required pressure ulcer care. Review of Resident #2's physician's order, dated 1/6/26, indicated: -Maintain Enhanced Barrier Precautions due to wounds, may discontinue precautions when wounds heal, every shift. Review of Resident #2's physician's order, dated 3/4/26, indicated: - Coccyx: Cleanse wound with Vashe (wound cleaner), pat dry with gauze. Apply nickel-thick amount of Santyl (prescription medication) to wound bed. Then, cover wound bed with Calcium Alginate (wound dressing), followed by Silicone Absorbent Border form every day shift for wound healing and as needed for if soiled or not intact. On 4/13/26 at 11:07 A.M., the surveyor observed signage outside Resident #2's door a sign that indicated the following EBP, providers and staff must wear gloves and gown for the following high-contact resident care activities. Dressing, Providing Hygiene, changing briefs or assisting with toileting., The surveyor entered Resident #2's room and observed two Certified Nursing Assistants (CNA) providing direct care (incontinence care) to Resident #2 neither CNA was wearing a gown. The surveyor observed a dressing on Resident #2's coccyx that was peeling off and the wound was exposed, the CNA offered to fully remove the dressing so the surveyor could see it (the wound). During an interview on 4/14/26 at 4:22 P.M., the DON said CNA should be wearing PPE while providing direct care for Residents who require EHB, and the DON said the reason for EBP is to prevent further infection. 1b. During an observation on the Belvidere Unit on 4/13/26 at 9:17 A.M., the surveyor observed two staff members transfer a resident with a total lift. A sign on the Resident #48's door indicated the need for Enhanced Barrier Precautions during transfers. The two staff members assisting with the transfer utilized only gloves and no gowns. 1c. During an observation on the Belvidere Unit on 4/13/26 at 12:32 P.M., the surveyor observed two staff members enter a resident's room and provide care for Resident #143. There was a sign on the Resident's doorway to indicate the need for Enhanced Barrier Precautions. The two staff members utilized gloves only and did not use gowns when providing care to the Resident. During an interview on 4/15/26 at 9:44 A.M., Nurse #15 said that for any resident who requires Enhanced Barrier Precautions staff must wear a gown and gloves for high contact care which includes the use of a total lift, transfers, activities of daily living care or any care pertaining to a wound, Intravenous line or catheter. During an interview on 4/15/26 at 9:45 A.M., Unit Manager #2 said that staff should be utilizing gown and gloves for all residents on EBP who require high contact care. Unit Manager #2 said that gowns and gloves should be worn for transfers, activities of daily living, and for any care involving an intravenous line, foley catheter or wound when the resident is indicated to be on EBP. 1d. On 4/13/26 at 7:41 A.M., the surveyor observed signage outside Resident #33's door a sign that indicated the following EBP, providers and staff must wear gloves and gown for the following high-contact resident care activities. The surveyor then observed Nurse #1 providing wound care to Resident #33 without wearing a gown. 1e. On 4/14/26 at 9:08 A.M., the surveyor and Unit Manager #1 observed three staff members providing wound care to Resident #183 without PPE on. The Unit Manager said the Resident has a wound and the staff members should have PPE on while providing wound care but do not. During an interview on 4/15/26 at 7:07 A.M., the Director of Nurses (DON) said when a nurse is providing wound care it is expected they wear a gown and gloves following the EBP signage. The DON said the purpose of wearing PPE is to protect the resident from infection. 2a. Review of the facility policy titled Infection Control – Cleaning and Disinfection of Resident Care Equipment, dated 11/28/24, indicated but was not limited to the following: Resident care equipment can be a source of indirect transmission of pathogens. Reusable resident care equipment will be cleaned and disinfected in accordance with the current CDC (Centers for Disease Control) recommendations in order to break the chain of infection. 3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include: d. Multiple resident use equipment shall be cleaned and disinfected after each use. h. Use only EPA registered disinfectants that kill claims for the common organisms found in the home. If the equipment is exposed to residents and transmission based precautions verify the disinfectant are registered for use with relevant organisms. i. Verify the disinfectant is compatible with the equipment. j. Follow manufacturer recommendations for cleaning equipment. On 4/13/26 at 7:44 A.M., the surveyor observed Nurse #1 on the Sweet Land Unit obtain vitals with the vital sign machine on a Resident and then did not disinfect the vitals machine. Nurse #1 then entered another resident's room to obtain vitals with the contaminated vitals machine. On 4/14/26 at 7:43 A.M., the surveyor observed Nurse #1 on the Sweet Land Unit obtain vitals with the vital sign machine on a Resident and then did not disinfect the vitals machine. Nurse #1 then entered another resident's room to obtain vitals with the contaminated vitals machine. On 4/14/26 at 7:57 A.M., the surveyor observed Nurse #1 on the Sweet Land Unit obtain vitals with the same contaminated vital sign machine on a Resident and then did not disinfect the vitals machine. During an interview on 4/15/26 at 7:07 A.M., the Director of Nurses said she expects the vitals machine to be cleaned after each use to protect the residents from infection. 2b. The surveyor made the following observations on the [NAME] Unit on 4/14/26 at 7:47 A.M.: Nurse #7 was observed putting on a blood pressure cuff and taking vitals on a Resident who was sitting in the common room area. Nurse #7 removed the blood pressure cuff and did not sanitize the equipment. Nurse #7 then put the blood pressure cuff on a second resident in the common room area and took vitals. Nurse #7 removed the blood pressure cuff from the second Resident did not sanitize it. Nurse #7 then put the blood pressure cuff on a third resident in the common room area and took vitals. Nurse #7 removed the blood pressure cuff from the third Resident did not sanitize it. During an interview on 4/14/26 at 7:58 A.M., Nurse #7 said she should have cleaned and sanitized the blood pressure cuff in between residents and acknowledged that the blood pressure cuff could have been contaminated after each use and it should have been cleaned. 2c. The following observations were made on the Wannalancit Lane Unit: a. On 4/13/26 at 8:13 A.M., the surveyor observed Nurse #2, remove a glucometer (machine used to obtain a blood sugar level), from inside the medication cart, along with glucometer test strips, lancets, gauze and alcohol swab, and brought the items into a resident room. -Nurse #2 placed the glucometer directly on the Resident's bedside table, which had papers, cups of water, and crumbs visible on top. -Nurse #2 took out the test strip, a lancet, gauze and an alcohol swab and placed these items directly on the bedside table. -Nurse #2 obtained the Resident's blood sugar, removed the test strip from the glucometer, and with the same hand that she had just removed the bloody test strip, Nurse #2 then placed the glucometer and used tests strip back onto the Residents bedside table, and removed her contaminated gloves. Without using hand sanitizer, Nurse #2 picked up the glucometer and used test strip with her bare hand and returned to the medication cart. -Nurse #2 then placed the glucometer directly on top of the medication cart. -Nurse #2 then donned a new pair of gloves to her contaminated hands and removed a white and red container from inside the medication cart. -Nurse #2 removed a Sani-Cloth Plus wipe from the container and wiped down the glucometer machine and immediately placed it directly back on top of the medication cart. -Nurse #2 removed her contaminated gloves and with her bare contaminated hand she picked up the glucometer machine and placed it back into the medication cart. Nurse #2 did not perform hand hygiene during the observation. Review of the Sani-Cloth Plus Germicidal Disposable wipes manufactures instructions indicated the following: All blood and other bodily fluids must be thoroughly cleaned from surface objects before disinfection by the germicidal wipe. Open, unfold first germicidal cloth to remove visible soil. Contact Time: Use second germicidal cloth to thoroughly wet surface. Allow surface to remain visibly wet for two (2) minutes, let air dry. During an interview on 4/13/26 at 9:02 A.M., Nurse #2 said she should not have placed the items on the bedside table and said she uses the wipes in the cart to clean the glucometer after use but did not wait the appropriate time for cleaning and said she should have sanitized her hands between glove use. During an interview on 4/13/26, at 1:13 A.M., Unit Manager #2 said staff must use approved bleach wipes to clean the glucometer machines after each use and said they must follow the guidelines for disinfecting equipment. Unit Manager #3 said nurses must wash their hands before and after glove use and not touch contaminated equipment with their bare hands. 2d. On 4/14/26 at 8:27 A.M., the surveyor observed Nurse #2, removed a glucometer machine from inside the medication cart, along with glucometer test strips, lancets, gauze and alcohol swabs, and placed them directly on top of the medication cart. -Nurse #2 obtained the Resident's blood sugar, removed the test strip from the glucometer, with the same hand that she had just removed the bloody test strip, Nurse #2 then placed the glucometer and used tests strip back on top of the medication cart, and removed her contaminated gloves. Without using hand sanitizer, Nurse #2 picked up the glucometer and used test strip with her bare hand and moved the items to a different location on top of the medication cart. -Nurse #2 did not disinfect the glucometer machine and it remained on top of the medication cart. -Nurse #2 did not perform hand hygiene and was observed pushing the Resident in a wheelchair down to the dining room. During an interview on 4/14/26 at 8:29 A.M., Nurse #2 said she should not have placed the contaminated items on top of the medication cart and said she should have performed hand hygiene. During an interview on 4/14/26 at 3:02 P.M., the Director of Nursing (DON) said glucometers must be disinfected with approved bleach wipes and cleaning must be done after each use and stored appropriately. The DON said staff must wash their hands before and after glove use and not touch contaminated equipment. 3. Review of the facility policy titled Hand washing, dated as revised 2/26, indicated the following:-Purpose: to prevent the spread of infection.-You should always wash your hands in the following instances: after handling soiled linen, dirty utensils or soiled dressings, after removing gloves. During an observation on 4/14/26 at 7:52 A.M., on the Belvidere Unit, the surveyor observed a housekeeping staff member enter a resident room on the unit. The housekeeping staff member put on gloves, emptied the trash in the room and bathroom then cleaned the bathroom and mopped the floor. At 8:01 A.M., the housekeeping staff exited the room, removed her gloves and put up a wet floor sign. She then pushed her housekeeping cart and a trash barrel down the hall. Without performing hand hygiene, she put on a new pair of gloves and then mopped the end of the hallway. The housekeeping staff member then removed her gloves and without performing hand hygiene, pushed her cart and barrel down the hallway outside of another resident's room. At 8:05 A.M., without performing hand hygiene, the housekeeping staff member then put on another pair of gloves and entered the resident room to clean and empty trash. During an interview on 4/15/26 at 9:42 A.M., the Director of Nurses said that all staff should be performing hand hygiene between glove changes and in between entering and exiting resident rooms. During an interview on 4/15/26 at 9:59 A.M., The Infection Preventionist said that she would expect that hand hygiene is performed between glove changes and when coming in and out of a resident's room.

Based on observation, record review, and interview the facility failed to ensure for one Resident (#75), out of a total sample of 40 residents, that he/she was provided with food items that were on his/her diet slip. Specifically, staff failed to follow the diet slip, resulting in food items not being provided to Resident #75 for three observed meals. Findings include:Resident #75 was admitted to the facility in July 2025 and has diagnoses that include unspecified dementia, anemia, type 2 diabetes mellitus, osteoarthritis, and gastro-esophageal reflux. Review of the most recent Minimum Data Set assessment, dated 3/17/26, indicated Resident #75 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam signifying he/she as having moderate cognitive impairment, required setup or clean-up assistance for meals and is on a therapeutic diet. During an observation and interview on 4/13/26 at 9:55 A.M., Resident #75 was sitting up in a wheelchair with his/her breakfast tray in front of him/her. Resident #75 said he/she did not get all the food on his/her breakfast tray and said, I did not get margarine, I did not get hot cereal, I did not get my V-8. Review of the diet slip with Resident #75's name revealed, Monday Breakfast, 4/13/26 with the following food item listed on the diet slip, 6 oz (ounces) of oatmeal, 8 oz V8 Juice, both of which were underlined, and 1 Pc (piece) of Margarine. These items were not present on his/her meal tray.During an observation and interview on 4/13/26 at 2:19 P.M., Resident #75 was in his/her room, eating his/her lunch. Resident #75 said he/she just started eating his/her lunch. Resident #75 said he/she did not get his/her yogurt. Review of the diet slip on the tray, included Resident #75's name, Monday lunch dated 4/13/26, 4 oz yogurt which was underlined on the diet slip.During an observation on 4/14/26 at approximately 12:30 P.M., of the point of service meal distribution on the B unit where Resident #75 resides, the Nurse was observed reading off the diet slips to the dietary staff to make up the lunch meal to be served.During an observation and interview on 4/14/26 at 12:49 P.M., Resident #75 was eating his/her lunch in the dining room. Review of the diet slip indicated Resident #75's name, Tuesday lunch, 4/14/26. 4 oz yogurt, which was underlined. The 4 oz, yogurt was not present. Resident #75 said he/she likes to eat yogurt.Review of Resident #75's physician's orders indicated, Consistent Carbohydrate Diet, reg (regular) texture, thin liquid consistency, allow brown sugar, start date 4/28/25.Review of Resident #75's Nutritional Status, care plan with a revision date of 1/19/26 indicated I have a nutritional problem or potential nutritional problem due to: At risk for malnutrition r/t (related to) dementia, HLD (hyperlipemia), DM (diabetes mellitus) and hx (history) of weight gain, altered nutrition related to lab values r/t DM AEB (as evidenced by) A1C (a blood test that measure blood sugars over a period of time) greater than 10 percent.During an interview on 4/14/26 at 12:53 P.M., the Food Service Director (FSD) was present in the B unit dining room. The FSD said the nursing staff and the dietary staff are to make sure a diet slip is followed, so a resident gets the items on the diet slip per a resident's preference and diet order. The FSD said it is a double check system. The FSD reviewed Resident #75's diet slip and said the yogurt was not present. Resident #75 said he/she did not want the yogurt now. The FSD said the diet slip is generated from the diet or and all items should be provided.During an interview on 4/14/26 at 5:02 P.M., the Director of Nursing (DON) said typically a resident should receive the food items that are listed on the diet slip. The DON said residents can change their minds and make choices, but the diet order should be followed and that any food items underlined on the diet slip need to be on the meal tray or served.

Based on interviews and record review, the facility failed to ensure one Resident (#28) out of a total sample of 40 residents, was seen by the Physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a Nurse Practitioner (NP) as indicated. Findings include:Resident #28 was admitted to the facility in March 2025 with diagnoses that included dementia and major depressive disorder. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 00 out of 15, indicating severe cognitive impairment.Review of the medical record indicated Physician visit notes (from Physician #3), dated 3/17/25, 10/11/25 and 2/27/26.On 4/14/26 at 12:55 P.M., the surveyor requested all of Resident #28's physician and nurse practitioner progress notes since admission to the facility from the Director of Nurses (DON). The DON said that the Physician #3 typically hand writes his progress notes and places them in the chart for the facility staff to upload into the electronic medical record (EMR). She further said that the Physician does not typically have a nurse practitioner see his residents at the facility. Review of the paper record indicated two physician visit notes (that were also uploaded and observed in the EMR) dated:-10/11/25-2/27/26 Review of the medical record failed to indicate that the Resident was seen by the Physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a Nurse Practitioner (NP) as required. During an interview on 4/14/26 at 1:46 P.M., Unit Manager #2 said that Physician #3 usually comes into the facility after his office hours. She said he hand writes notes and places them into the medical record. She also said that sometimes his notes are dictated and entered into another electronic medical record (not utilized by the facility). She said that nurses at the facility do not have access to this EMR but that she and all of the Unit Managers do have access. During a follow up interview on 4/14/26 at 1:52 P.M., Unit Manager #2 said the Physician did not have any visit notes in Resident #28's alternate EMR. During an interview on 4/14/26 at 2:38 P.M. the DON said that she too had checked the alternate EMR and did not find any other visit notes for Resident #28. She said that the physician is not in the facility as much as he should be but is generally responsive by phone or a secure texting system they have. She said she expects the Physician to see his residents as per the regulations require, but in this case, he did not. On 4/14/26 at 2:06 P.M., the surveyor placed a call to Physician #3, Resident #28's attending physician in the facility and requested a call back. As of 4/15/26 at 11:15 P.M., at the time of exit from the facility, the physician had not called back.

Based on observation, record review and interview, the facility failed to ensure dental service recommendations were provided for one Resident (#130) out of a total of 40 sampled Residents. Specifically, the facility failed to obtain a consent form to begin denture fabrication for Resident #130. Findings include: Resident #130 was admitted to the facility in January 2025 with diagnoses including atrial fibrillation, epilepsy and peripheral vascular disease. Review of the Minimum Data Set Assessment, dated 1/15/26, indicated Resident #130 was cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status Exam. The MDS also indicated that Resident had no natural teeth. During an interview on 4/13/26 at 8:12 A.M., Resident #130 said, I don't have any teeth and I need dentures. Resident #130 said that he/she had been seen by a dentist who recommended he/she get dentures, but it had been awhile and wasn't sure what the status was. Review of Resident #130's dental visit dated 2/26/26 indicated: Initial ExamPatient is edentulous. Patient reports he/she had extractions and temporary dentures made right after, but they did not fit. He/she was planned for a new set but was unable to follow up with his/her dentist. Discussed limitation of retention of lower dentures. Patient requesting new set. Upper and lower dentures recommended to improve patient's ability to eat if approved. Recommend annual exam 1X per year if approved. NV (next visit): Denture Step 1 (initial impressions) if approved. Action required by nursing home staff: Continue daily oral care. Please have responsible party sign consent for dentures form. Review of the clinical record indicated that Resident #130's health care proxy was activated on 3/11/26; approximately 13 days after Resident #120 had been seen by the dentist. Review of the clinical record failed to indicate that Resident #130 or his/her activated health care proxy signed a consent form for dentures. During an interview on 4/14/26 9:37 A.M., Resident #130 said that he/she had not been asked to sign a consent form to obtain dentures.During an interview on 4/14/26 at 9:39 A.M., Family Member #2 said that the health care proxy had activated recently, and she had not been asked to sign a consent form for Resident #130's denture fabrication.During an interview on 4/14/26 at 9:49 A.M., Unit Manager #3 said that dental recommendations are uploaded into the resident record and also emailed to the facility. Unit Manager #2 said that it did not look like a consent form for Resident #130 had been completed and that it should have been addressed.During an interview on 4/14/26 at 1:19 P.M., the Director of Nursing (DON) said that she expects dental recommendations to be reviewed timely.

Based on observation, record review and interview, the facility failed to accurately document in the medical record for one Resident (#86) out of a total sample of 40 residents. Specifically, for Resident #86 the facility documented that oxygen therapy was administered when it was not. Findings include: Resident #86 was admitted to the facility in December 2024 with diagnoses including essential primary hypertension, chronic kidney disease and dementia. Review of Resident #86's's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #86 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15. On 4/13/26 at 8:15 A.M., the surveyor observed Resident #86 in bed, and he/she was not wearing oxygen. The oxygen concentrator, respiratory tubing and equipment were next to the bed. On 4/13/26 at 12:56 P.M., the surveyor observed Resident #86 sitting in the dining room eating lunch. Resident #86 was not wearing a nasal canula and no oxygen was being administered. Resident #86 said he/she has not been using the oxygen today and said, I don't know if I need it or not. On 4/13/26 at 4:17 P.M., the surveyor observed Resident #86 sitting outside his/her room in the hall socializing with other residents. Resident #86 was not wearing a nasal canula and no oxygen was being administered. On 4/14/26 at 8:17 A.M., the surveyor observed Resident #86 sitting in the dining room eating breakfast. Resident #86 was not wearing a nasal canula and no oxygen was being administered. On 4/14/26 at 12:16 P.M., the surveyor observed Resident #86 sitting in the dining room eating lunch. Resident #86 was not wearing a nasal canula and no oxygen was being administered. Review of Resident #86's active physician orders indicated the following: O2 (oxygen) at 2l (2Liters) via nasal cannula to keep sats (saturation) above 90 every shift for hypoxia (low level of oxygen in blood). Start Date 3/30/26, every shift. Review of the Medication Administration Record dated March 2026 indicated that the nurse documented the oxygen as administered per the physician order on 4/13/26 and 4/14/26. During an interview on 4/14/26 at 7:52 A.M., Nurse #2 said Resident #86 has an order for oxygen because he/she had an upper respiratory illness. Nurse #2 said she did not administer the oxygen because his/her oxygen was 93%. Nurse # 2 said she should not document oxygen that was administered when it was not. During an interview on 4/14/26 at 1:18 P.M., Unit Manager #3 said nurses should not be documenting that oxygen was administered when it was not. During an interview on 4/14/26 at 3:03 P.M., the Director of Nursing said that the nurses are to follow physician orders and said that nurses should not document that the oxygen was administered when it was not.

Based on observation record review and interview, the facility failed to develop and implement individualized care plans related to pacemakers for two Residents (#130 and #172) out of a total of 40 sampled Residents and 13 total residents with cardiac pacemakers.Findings include: Review of the American Heart Association article titled Living with your Pacemaker, dated 10/29/24 indicated: Before you leave the hospital, your health care team will talk to you about problems to watch out for and things to avoid. You'll also receive a card with information about your pacemaker, when it was placed, its settings, your health care professional and the hospital. You should always carry this card with you. Make sure you understand your pacemaker's programmed lower and upper heart rate. Talk to your health care professional about the maximum acceptable heart rate above your pacemaker rate. Review of the facility's policy titled Use of Pacemaker policy dated 3/25/24 indicated:All residents with a pacemaker will be monitored according to standard protocol and plan of care. All documentation about the pacemaker will be placed in the residents' chart and part of their permanent record. Pacemaker checks will be performed as ordered by the physician. 1. Resident #172 was admitted to the facility in June 2025 with diagnoses including legal blindness, macular degeneration and presence of cardiac pacemaker. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #172 was cognitively intact as evidenced by a score of 15 out a possible 15 on the Brief Interview for Mental Status exam. During an interview on 4/15/26 at 7:12 A.M., Resident #130 said that he/she has a pacemaker and that the staff monitor his/her vitals. Resident #130 said that his/her family member keeps his/her pacemaker transmitter and brings it in on a set schedule made by the cardiologist to transmit the pacemaker signal to their office. Review of Resident #172's physician orders failed to include information related to Resident #172's pacemaker. Review of Resident #172's care plans indicated: Focus: The resident has a pacemaker, 6/11/25Interventions: Monitor/document/report PRN (as needed) any s/sx (signs symptoms) of infection at incision site: redness, drainage, warmth. The care plan included only one intervention and failed to include individualized information related to Resident #172's pacemaker including make, model, and pulse rate. During an interview on 4/14/26 at 9:47 A.M., Nurse #6 said that for residents with pacemakers, nurses check their heartrates and if it seems irregular or elevated, they alert the physician. Nurse #6 said that he/she wasn't sure about pacemaker settings and where that information would be documented. During an interview on 4/15/26 at 7:21 A.M., Unit Manager #3 said that residents with pacemakers have care plans identifying they have pacers including information related to the pacemaker make and model. Unit Manager #3 said that nurses monitor pulse rates, but the set rate of the pacemaker is monitored by the resident's cardiologist. During an interview on 4/15/26 at 7:28 A.M., the Director of Nursing (DON) said that the facility usually does not get information related to settings for residents with pacemakers. The DON said that staff would monitor pulse rates and if it's out of a normal range then nursing would notify the physician. The DON said that residents with pacemakers should have care plans in place that are individualized with information related to the resident's pacemaker. 2. Resident #130 was admitted to the facility in January 2025 with diagnoses including atrial fibrillation, epilepsy and presence of cardiac pacemaker. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #130 was cognitively intact as evidenced by a score of 15 out of a possible 15.Review of Resident #130's physician orders failed to indicate orders related to monitoring Resident #130's pacemaker or pulse setting.Review of Resident #130's care plans indicated: Focus, 1/20/25: The resident has a pacemaker r/t (related to) Atrial fibrillation. Interventions: Follow up with cardiology. Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of altered cardiac output or pacemaker malfunction: dizziness, syncope, difficulty breathing. Pacemaker checks as ordered per house protocol and document in chart: heart rate, rhythm, battery check.The care plan failed to include individualized information related to the make, model and pulse setting for Resident #130's pacemaker. During an interview on 4/15/26 at 7:21 A.M., Unit Manager #3 said that residents with pacemakers have care plans identifying that they have pacers including information related to the pacemaker make and model. Unit Manager #3 said that nurses monitor pulse rates, but the set rate of the pacemaker is monitored by the resident's cardiologist. During an interview on 4/15/26 at 7:28 A.M., the Director of Nursing (DON) said that the facility usually does not get information related to settings for residents with pacemakers. The DON said that staff would monitor pulse rates and if it's out of a normal range then nursing would notify the physician. The DON said that residents with pacemakers should have care plans in place that are individualized with information related to the resident's pacemaker.

Based on observation, record review and interviews, the facility failed to implement standards of care related to dialysis for the 1 Resident (#78), out of 2 residents reviewed for dialysis, out of a total sample of 40 residents. Specifically, for Resident #78 the staff failed to ensure the dialysis order was signed off in accordance with the dialysis treatment schedule. (Hemodialysis is a machine that removes blood from the body, filters it through a dialyzer (artificial kidney) and returns the clean blood to the body). Findings include: Review of the facility policy titled Dialysis, revision date 4/2021 indicated this home will provide necessary care and treatment, consistent with professional standards of practice, physician's orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of resident receiving hemodialysis.14, The home will ensure that the physician's orders for dialysis include: b. The dialysis schedule. Resident #78 was admitted to the facility in June 2026 and has diagnoses that include but are not limited to type 2 diabetes with diabetic chronic kidney disease, and dependence on renal dialysis. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #78 scored 15 out of 15 on the Brief Interview for Mental Status which indicates the Resident is cognitively intact. Further, the MDS indicated Resident #78 is on dialysis. During an observation and interview on 4/13/26 at 9:44 A.M., Resident #78 said he/she goes out to dialysis on Tuesdays, Thursdays and Saturdays, and pulled down the front of his/her shirt revealing a covered catheter with 2 lumens below the dressing, and then pointed to his/her left arm and said I just got this, referring to a left arm fistula. Review of Resident #78's physician's orders indicated the following: Patient on dialysis at (provider's name) M (Monday) W (Wednesday) F (Friday), transport by (provider's name) pick up at 6 A.M., this is a temporary schedule expected to change mid-March, date 2/22/26. Review of the March 2026, Medication Administration Record (MAR) indicated the nurses signed off and documented on the following order (Patient on dialysis at (provider) on Monday, Wednesday and Friday, transport by (provider) pick up at 6am. every shift (this is a temporary schedule expected to change mid/March, start date 2/22/26. Review of the April 2026 MAR indicated the nurses signed off and documented on the following order (Patient on dialysis at (named Provider) on Monday, Wednesday and Friday, transport by (named provider) pick up at (6am) every shift (this is a temporary schedule expected to change mid/March, start date 2/22/26. Review of the communication book that accompanies Resident #78 to dialysis and Resident #78's dialysis calendar indicated Resident #78 resumed a Tuesday, Thursday, Saturday, dialysis treatment schedule on March 17, 2026. The physician's order therefore failed to have the appropriate dialysis treatment schedule for Resident #78, which continued to be documented and signed off on by the nursing staff. During an interview on 4/13/26 at 2:29 P.M. Resident #78 said he/she goes out to dialysis Tuesdays, Thursdays and Saturdays, but went Monday, Wednesday and Saturdays for a few weeks and it has been back to Tuesday, Thursday and Saturday now for a few weeks now. Nurse #13 who was in Resident #78's room, said the dialysis schedule is in the physician's orders and should be Tuesdays, Thursdays and Saturdays. During an observation and interview on 4/13/26 2:46 P.M., Nurse #13 reviewed the physician's orders and said the order is not consistent with the Resident's dialysis schedule and it should be. Unit Manager #2 said the physician's order and the actual treatment should be the same. Unit Manager #2 said nurses are to read and verify orders and should have identified the orders were not in accordance with the dialysis schedule and should not have just been signed off.

Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Midline Catheter (A midline catheter is an IV longer than 3 inches and it is inserted into the upper arm through the basilic, brachial or cephalic vein, with the catheter tip located at the or near the level of the axilla), consistent with professional standards of practice for one Resident (#124), out of three reviewed Resident's with an IV catheter. Specifically, for Resident #124, the facility failed to ensure that the midline insertion site was able to be visualized.Findings include:Resident #124 was admitted to the facility in December 2023 with diagnoses that included adult failure to thrive, peripheral vascular disease, dementia, stage three pressure of the sacral region. Review of Resident #124's most recent Minimum Data Set (MDS) assessment, dated 3/20/26, indicated he/she was assessed to have severe cognitive impairments. Review of Resident #124's physician ordered dated, 3/12/26, indicated Midline catheter Monitor IV insertion site every shift (Signing indicates: no s/sx (signs/symptoms) of any IV complications present; dressing is c/d/i (clean/dry/intact); catheter, tubing, and needleless connectors properly present; and secured, no s/sx of infection If complication found, document in progress note. Notify provider. Review of Resident #124's April 2026 Treatment Administration Record (TAR) indicated from 4/9/26 through 4/13/26 indicated nursing signed off the Monitor IV insertion site every shift order as administered. On 4/14/26 at 11:54 A.M., the surveyor observed a midline IV in the Resident's right arm receiving IV antibiotics. The insertion site of the IV was covered with gauze unable to be visualized, blood could be seen around the gauze. The midline dressing was dated 4/9/26. During an interview and observation on 4/14/26 at 11:55 A.M., Unit Manager #2 said Resident #124 has a midline because he/she is on IV antibiotics for a wound infection. The surveyor said the nurses cannot visualize the site for signs and symptoms for infection if the site is covered in gauze. During an interview and observation on 4/14/26 at 11:57 A.M., Nurse #4 said Resident #124's midline insertion site is unable to be visualized and nursing staff would not be able to assess if there was an infection at the insertion site. During an interview on 4/15/25 at 7:07 A.M., the Director of Nurses (DON) said nurses should not cover the insertion site of a midline with gauze. The DON said the site would not be able to be assessed if it is covered in gauze and then nursing could not tell if there was an issue at the site.

Based on observation, record review and interview, the facility failed for one Resident (#9), out of a total sample of 40 residents, to ensure acceptable perimeters of nutritional standards of practice were implemented when Resident #9 experienced a significant weight loss. Specifically, the facility failed to ensure Resident #9, who is assessed as being at risk of malnutrition and experienced a significant weight loss of 5.1% in less than a month, had the weight verified to determine/verify the significant weight loss, and when the reweigh occurred Resident #9 had continued weight loss of a total body weight loss of 6.44 % in less than 30 days, resulting in a delay to intervene to abate further weight loss. Findings include: Review of the facility's policy, titled Weight Monitoring, with an effective date of 11/27/24 indicated the following: Based on the resident's comprehensive assessment, the home will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: 5. A weight monitoring schedule will be developed upon admission for all residents: a. weights should be recorded at the time obtained. Mathematical rounding should be utilized, b. newly admitted residents-monitor weight weekly, c. Residents with weight loss-monitor weights weekly, d. If clinically indicated-monitor weight daily, e. all others-monitor weight monthly. 6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a 5% change in weight in 1 month (30 days) b 7.5% in weight in 3 months (90 days) c 10% change in weight in 6 months (180 days) Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. e. The Registered Dietician or Dietary Manager should be consulted to assist with intervention; actions are recorded in the nutritional progress notes. Resident #9 was admitted to the facility in March 2025 and has diagnoses that include spinal stenosis, type 2 diabetes mellitus, and dysphagia. Review of the most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 scored 15 out of 15 on the Brief Interview for Mental Status indicating he/she as having intact cognition. Further, the MDS indicated Resident #9 is 72 inches (6 feet) in height and weighs 126 pounds, requires set-up and clean-up assist with eating. Review of the Care Area Assessment of the MDS indicated Resident #9 triggered for nutritional considerations and to proceed to care plan to avoid complications and minimize risks related to nutritional status. During an observation and interview on 4/13/26 at 9:17 A.M., the surveyor observed Resident #9 to be frail and slight in stature. Resident #9 said he/she just had his/her breakfast. Resident #9 said when he/she first came (to the facility) just over a year ago he/she was weighed weekly and then monthly and never varied more or less than a fraction of a pound. Resident #9 said that last week he/she was weighed on the 8th (April) and lost 7 pounds and he/she has no idea why and thinks something is wrong. Review of Resident #9's weights in the clinical record indicated the following: -3/4/26 125.6 lbs (pounds).-3/19/25 125.6 lbs. -4/9/26 119.2 lbs. No weights dated after 4/9/26 were in the clinical record. On 3/4/26, Resident #9 weighed 125.6 lbs. On 4/9/26, Resident #9 weighed 119.2 lbs. which is a -5.1% loss and meets the criteria of a significant weight loss. Review of Resident #9's physician's orders indicated the following: -No added salt (3-4 gram) House consistent carb diet, ground texture, thin consistency, allow bacon dated 7/25/25. -House supplement- diabetic 2 times a day dated 7/28/25 prefers chocolate flavor. -At risk for Malnutrition d/t (due to) BMI (body mass index) underweight dated 3/17/25. Review of Resident #9's care plan focus, Nutritional Status: I have nutritional problem or potential problem due to: -At risk for malnutrition 2/2 (due to) underweight BMI, DM (diabetes mellitus). -Underweight BMI 04/2026 5% significant weight loss revision on 4/14/26, after the surveyor brought Resident #9's weight loss to the attention of facility staff. Goal: I will maintain adequate nutritional status by showing no signs or symptoms of malnutrition: and I will consume at least 50% of at least 2 of my meals daily until my next review date initiated 3/14/25. Review of the Mini Nutrition Assessment Summary note dated 3/16/26 indicated the following: Resident (#9) has no decrease in food intake in the last 3 months. Weight loss between 1 and 3 kg (2.2 and 6.6 lbs.) in the last 3 months. Able to get out of bed/chair but does not go out. Has not suffered psychological stress or acute disease in the past 3 months. Resident has no psychological problems. Resident BMI is less than 19. Mini Nutritional Score: the score is 9.0 (at risk of malnutrition) 12-14 points: Normal nutritional status 8-11 points: At risk of malnutrition 0-7 points: Malnourished Review of the Nutrition Comprehensive Assessment, V 1.0 dated 3/16/26 indicated: most recent weight 3/4/26 125, 72 inches. Previous weights 10/9/25 127.6 (Pounds), 12/4/25 124.4, 2/5/26 127.2, 3/4/26 125.6. BMI: 17.0 Goal weight/UBW (usual body weight) was blank. Nutrition summary: Resident presents for annual review. Continues to tolerate diet a/o (as ordered). Appetite remains unchanged. Weight stable, free of sig (significant) changes. Continues on house supplement-diabetic 2x a day b/t (between meals) Nutritional Diagnosis at risk for malnutrition, explanation of risk for malnutrition underweight, DM (diabetes). During an observation and interview on 4/14/26 at 12:29 P.M., Resident #9 was in his/her bed and appeared frail and with a slight, thin stature. Resident #9 said he/she has not talked with anyone (staff) about his/her 7-pound weight loss and said he/she is concerned about it. During an interview on 4/14/26 at 3:10 P.M., Nurse #15 said if a resident has a weight change up or down a reweigh is obtained to verify the weight. Nurse #15 said the reweight is verified by the Certified Nursing Assistant (CNA) and Nurse together, and the reweigh should be done as soon as possible after the weight change. During an interview on 4/14/26 at 3:13 P.M., CNA #9 said Resident #9 is weighed monthly and the weight is put on paper then the Unit Manager enters the weight into the computer. During an interview on 4/14/26 at 3:20 P.M., Unit Manager #2 said she enters the weights that are obtained by the CNAs, usually by Wednesdays, into the medical record. Unit Manager #2 said she compares the weights and will request a reweigh if there is a weight change of about 5 lbs. or looks funny from the previous weight. Unit Manager #2 said she was not aware of Resident 9's weight loss/change and reviewed the weight record and said he/she has lost about 6-7 pounds. Unit Manager #2 said there was no warning on the weight record and reviewed the progress notes and said there was no note indicating Resident 9's significant weight loss. Unit Manager #2 said she missed the weight loss, and she would get a reweigh now and would inform the NP (nurse practitioner) of the over 5% weight loss. On 4/14/26 at 3:24 P.M., the surveyor observed Unit Manager #2 walking Resident #9 to the scale. At 3:28 P.M., Resident #9 and Unit Manager #2 were observed walking back from the scale. Resident #9 said to the surveyor apparently, I am now 117 lbs., I have lost more weight. Unit Manager #2 said Resident #9 weighed 117. 6 lbs. Review of Resident #9's weights indicated that on 4/9/26, Resident #9 weighed 119.2 lbs. On 4/14/26, Resident #9 weighed 117.6 lbs. which is a -1.34% loss. Resident #9 experienced a significant total body weight loss of 6.40 %, in 27 days. During an interview on 4/14/26 at 4:53 P.M., the Director of Nursing (DON) said typically it is the Unit Mangers that review the weights on a weekly basis and are to report any significant weight loss, so the resident can be reviewed by the team at the client at-risk meeting. The DON said they attempt to obtain monthly weights by Wednesday so if reweights are needed they can be obtained to verify a weight change. The DON said the reweight should be competed the next day. She said the floor nurses are not reviewing weights and that a reweight should have been obtained the next day, but the Unit Manager was off on Friday 4/10/26, and it was not obtained on Monday 4/13/26. The DON said any significant weight changes are to be reported to the provider and the team including the dietician could collaborate on a plan. The DON said she would need to review Resident #9's specific weight changes. Review of Resident #9's progress notes dated 4/9/26 through 4/13/26 failed to indicate any notes regarding Resident #9's significant weight loss. Review of the progress note dated 4/14/26 at 18:50 22 (6:50 P.M.) indicated weight loss reported to NP. New orders to increase diabetic supplements to TID (three times a day) and check CBCWD CMP TSH free T4 on 4/25/25 (laboratory blood tests). This note was entered after the surveyor brought Resident #9's significant weight loss to Unit Manager #2's attention. During an interview on 4/15/26 at 9:48 A.M., Registered Dietician #1 said resident weights are obtained according to the physician's order and nutritional assessment. RD #1 said if there is a weight difference of 3 pounds the nurse should do a reweigh. The RD said the reweigh should be obtained as soon as possible to ensure the weight is accurate and so the NP/MD (doctor) RD, and resident or health care proxy are notified, and the plan of care plan can be reviewed and updated. The RD reviewed Resident #9's recorded weights and said he/she had a significant weight loss and is at risk of malnutrition. The RD said it is clinical practice to verify and assess significant weight loss in a resident who is at risk of malnutrition. The RD said the reweigh was not timely and said the Resident had continued trending unplanned weigh loss.

Based on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for one Resident (#189) out of a total sample of 40 residents. Specifically, the facility failed to ensure Resident #189 was scheduled to be seen by the podiatrist since admission to the facility resulting in thickened, yellow, long-curling toenails.Findings include:Review of the facility policy titled Diabetic Foot Care, dated and revised April 2016, indicated the following: - It is the policy of the facility of the facility to provide appropriate foot care to all diabetic residents/patients.- Do not cut toenails of any Resident/patient. Notify Podiatry if immediate intervention needed. Resident #189 was admitted to the facility in October 2025 with diagnoses including unspecified dementia and type 2 diabetes mellitus with diabetic polyneuropathy.Review of Resident #189's most recent Minimum Data Set Assessment, dated 1/29/26, indicated that the Resident was unable to complete the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review of the MDS indicated that the Resident does not reject evaluation or care and has diabetes mellitus.During an interview on 4/13/26 at 10:58 A.M., Resident #189's Resident Representative (RR) told the surveyor that the facility has not taken care of Resident #189's toenails and they are very long. Resident #189's RR then said she has asked the facility multiple times for the Resident's toenails to be cut because Resident #189 has diabetes and she does not want the Resident to get an infection. Resident #189's RR then removed the Resident's socks revealing the Resident's toenails to be thickened and yellow in appearance as well as multiple toenails being roughly half an inch in length and starting to curl inwards towards the bottom of the feet.Review of Resident #189's physician's order, dated 10/28/25, indicated the following: Consultation Services: Audiology, Dental, Ophthalmology, Podiatry and Psych.Review of Resident #189's care plans failed to indicate a care plan relating to podiatry services or toenail care.During an interview on 4/14/26 at 11:45 A.M., another RR for Resident #189 said his/her family have been trying to request podiatry to come cut his/her nails for months and they have not come in.During an interview on 4/14/26 at 11:55 A.M., Unit Manager #4 said when a Resident needs an outside service such as Podiatry, the facility will fax over a consent form to the consultation service upon admission to the facility so the Resident can be scheduled to be seen. Unit Manager #4 said she faxed over a Podiatry request form yesterday because she said she heard the family member requesting Podiatry services to the surveyor. Unit Manager #4 said she believed she faxed over a request form in the past, but she heard no response and she said she should have followed up with them. Unit Manager #4 then showed the surveyor a chart of Residents needing outside Consultation service and under the podiatry section was Resident #189, Unit Manager #4 then confirmed he/she has not been seen. Unit Manager #4 said she was not aware of how long and thick Resident #189's toenails were and it could be an infection risk since the Resident has type 2 diabetes. Unit Manager #4 said the Certified Nursing Assistants (CNAs) should be telling nursing staff when they notice long toenails and then the nursing staff should be telling her so she can follow up.During an interview on 4/14/26 at 12:11 P.M., Nurse #8 said if a Resident needs podiatry services, then the facility will fax a cover sheet to the doctor's office and then they will be scheduled to be seen. Nurse #8 then said if CNAs notice long toenails while performing care they should be telling a nurse. Nurse #8 said she has never been made aware of Resident #189's long toenails.During an observation on 4/14/26 at 12:18 P.M., Resident #189's RR, Unit Manager #4, Nurse #8 and CNAs #1 and #2 observed Resident #189's toenails with the surveyor. Unit Manager #4 and Nurse #8 said Resident #189's toenails are curling and very long and they were not aware. CNA's #1 and #2 said they would have told a nurse if they realized how long the Resident's toenails were, they both said they were not aware. Resident #189's RR said when she takes off Resident #189's socks that fabric always sticks to the nails and she has to clean them.During an interview on 4/14/26 at 1:17 P.M., Nurse Practitioner #1 said Resident #189 should have been seen by Podiatry services since he/she has diabetes and is at risk of infection. Nurse Practitioner #1 said she was not made aware that Resident #189's toenails were very long and curling.During an interview on 4/14/26 at 1:45 P.M., the Director of Nursing (DON) said Resident #189 was scheduled for Podiatry services as of yesterday but was unaware that the resident had not been since admission. The DON then provided the surveyor the podiatry request form for Resident #189 dated 4/13/26.

Based on observations, record reviews and interviews, the facility failed to ensure standards of quality of care for the treatment of a pressure ulcer for one Resident (#124), who has a pressure ulcer, out of a total sample of 40 residents. Specifically, the nursing staff failed to ensure the intervention of the air mattress on Resident #124's bed was implemented in accordance with Resident #124's weight to assist with prevention and healing of the pressure ulcer. Findings include: Review of the manufacturer's operation manual titled, Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System, not dated indicated the following: Indications, the Med Aire Melody Alternating Pressure and Low Air Loss Mattress Replacement System, is indicated for the prevention and treatment of any and all stage pressure ulcers management program. Operating Instructions Step 6 Determine the patient's weight and set the control knob to that weight setting on the control unit. Resident #124 was admitted to the facility in October 2025 and has diagnoses that include atrial fibrillation, adult failure to thrive, peripheral vascular disease, moderate protein calorie malnutrition, and unspecified dementia and pressure ulcer of sacral region. Review of the most recent Minimum Data Set (MDS), dated [DATE] indicated Resident #124 scored 0 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as severely cognitive impaired. Further, the MDS indicated Resident #124 is at high risk for developing pressure ulcer/injuries and has 1 unstageable ulcer/injury. During the survey the surveyor made the following observations: -On 4/13/26 at 8:01 A.M., Resident #124 was in bed. An air mattress control unit was affixed to the footboard and was set to above 350 lbs. (pounds), firm. A piece of tape on the unit read 'keep setting here with the arrow pointing between the 120 lbs. and 150 lbs. Resident #124's eyes closed and did not participate in an interview and was observed to be frail and slight in stature. -On 4/13/26 at 11:03 A.M., and 1:08 P.M., Resident #124 had his/her eyes closed and resting on an air mattress with the control unit set above 350 lbs. -On 4/14/26 at 8:04 A.M., and 10:37 A.M., Resident #124 was in bed resting on an air mattress with the dial set at over 350 lbs. Resident #124's eyes were closed and he/she was unable to participate in an interview. During an interview on 4/14/26 at 10:38 A.M., Nurse #4 said Resident #124 is now on IV (intravenous) antibiotics for a wound infection and that she was in the Resident's room a short time ago to hang the IV medication. On 4/14/26 at 10:56 A.M., Two surveyors observed Resident #124 resting in bed with his/her eyes closed. The control unit of the air mattress was set to above 350 lbs. Review of Resident 124's clinical record indicated Resident #124 weighed 120.0 pounds dated 4/3/26. This weight is not consistent with the setting of the air mattress control unit observed multiple times. Review of Resident #124's physician's orders indicated the following: -COCCYX/SACRAL WOUND: cleanse wound with wound cleanser apply Santyl to wound bed and lightly pack undermining and wound bed with calcium alginate using a q tip and cover with border foam dressing every day shift 3/31/26-Air mattress with bolsters check placement and functions every shift dated 12/19/25. Review of the Treatment Administration Record for April 2026 indicated the nursing staff documented by signing off on the TAR the following: Air Mattress with Bolsters, Check placement and function every shift start date 12/19/25. On 4/13/26 all three shifts and 4/14/26 for 1 shift. During an interview and observation on 4/14/26 at 3:32 P.M., Nurse #4 said Resident #124 does not get up which could contribute to his/her risk for developing pressure ulcers. Nurse #4 said she did not know how long Resident #124 had a wound on his/her sacrum. Nurse #4 said interventions to prevent and treat pressure ulcers include repositioning, providing the treatment as ordered, diet including vitamin protocol and the use of the air mattress. Nurse #4 said the air mattress should be set to the Resident's weight and is used to assist with the healing of the wound. Nurse #4 and the surveyor went to Resident #124's room and observed the air mattress control unit set to over 350 lbs. Nurse #4 said the air mattress should be set at Resident #124's weight and not be set at 350 lbs., and that Resident #124 is not 350 lbs. and is small. During an interview and observation on 4/14/2026 3:40 P.M. Unit Manager #2 and the surveyor went to Resident #124's room. Unit Manager #2 said the air mattress in use is to be set to the Resident's weight and not at set 350 lbs. Unit Manager #2 said the mattress is too firm and would put more pressure on Resident #124's pressure ulcer which could impact healing. During an interview and observation on 4/14/26 at 3:50 P.M., the Director of Nursing said it is not policy to put a sticker on the air mattress and said the air mattress should be set to a resident's weight. The DON said having the air mattress too firm at 350 lbs., for Resident #124 could impact the healing of the pressure ulcer. The DON said Resident #124 is unable to say how the air mattress would feel.

Based on observation, record review and interview, the facility failed to provide care in accordance with professional standards of practice for two Residents (#96, #78) out of a total of 40 sampled residents. Specifically:1.For Resident #96 the facility failed to a. implement physician's orders for booties to bilateral lower extremities while in bed and b. implement orders for bilateral fall mats on the floor while the Resident was in bed.2. For Resident #78 the facility failed to administer medications in accordance with professional standards. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1a. Resident #96 was admitted to the facility in April 2022 with diagnoses that included senile degeneration of the brain, major depressive disorder, dysphagia and low back pain. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. The MDS failed to indicate that rejection of care was exhibited by the Resident. The MDS further indicated that the Resident was dependent on staff for assistance with activities of daily living. Review of physician's orders indicated the following: Booties while in bed at all times, dated 5/22/24. Review of the Braden Assessment for Predicting Pressure Ulcer Risk Assessment, dated 3/20/26, indicated a score of 11, indicating moderate risk for skin breakdown and pressure ulcer development. On 4/13/26 at 7:40 A.M., the surveyor observed the Resident sleeping in bed. The Resident's bilateral heels were in direct contact with the mattress. The residents' booties were observed in a chair across the room. On 4/14/26 at 6:48 A.M., 7:58 A.M., 9:01 A.M. and 10:03 A.M., the surveyor observed the Resident sleeping in bed. The Resident's bilateral heels were in direct contact with the mattress. The surveyor observed two booties across the room on the floor. Review of the April 2026 Treatment Administration Record indicated that the booties had been in place since 4/1/26 every shift as ordered. The TAR failed to indicate any refusals to wear booties while in bed. Review of Nursing progress notes since 4/1/26 failed to indicate any refusals to utilize booties while in bed. During an interview on 4/14/26 at 1:44 P.M., Unit Manager #2 said that booties should be in place and staff should be implementing physician's orders as indicated. She said she does not know if Resident #96 to refuse care, but if he/she did then it should be documented in the medical record. During an interview on 4/14/26 at 1:50 P.M., Certified Nurse Aide (CNA) #8 said that when she got the Resident up this morning he/she did not have booties on but maybe the night shift took them off to change the Resident and forgot to put them back on. She further said that the Resident should be wearing the booties if he/she is in bed. During an interview on 4/14/26 at 2:32 P.M., the Director of Nurses (DON) said that she would expect that staff are following physician's orders as written. She said that staff should not sign off something that they did not do and that if a resident refused any treatment, then it should be documented in the medical record. b. Review of physician's orders indicated the following: Floor mats to both sides of bed at all times in bed, dated 8/16/23. On 4/13/26 at 7:40 A.M., the surveyor observed the Resident sleeping in bed. There was a fall mat to the right side of the Resident's bed. No fall mat was seen on the left side of the bed or anywhere in the Resident's room. On 4/14/26 at 6:48 A.M., 8:08 A.M. and 10:03 A.M., the surveyor observed the Resident sleeping in bed. There was a fall mat to the right side of the Resident's bed. No fall mat was seen on the left side of the bed or anywhere in the Resident's room. Review of the April 2026 Treatment Administration Record (TAR) indicated every shift since 4/1/26 bilateral fall mats were in place. During an interview on 4/14/26 at 1:44 P.M., Unit Manager #2 said that bilateral fall mats should be in place and staff should be implementing physician's orders as indicated. She said staff should not be documenting it was implemented in the medical record if it was not. During an interview on 4/14/26 at 1:50 P.M., CNA #8 said that the Resident only uses one fall mat on the right side of his/her bed and that he/she does not have a second mat in the room. During an interview on 4/14/26 at 2:32 P.M., the DON said that she would expect that staff are following physician's orders as written. She said that staff should not sign off something that they did not do and if a resident refused any treatment, then it should be documented in the medical record. 2. For Resident #78 the facility failed to ensure medications were administered in accordance with standards of nursing practice. Resident #78 was admitted to the facility in June 2026 and has diagnoses that include but are not limited to type 2 diabetes with diabetic chronic kidney disease, and dependence on renal dialysis. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #78 scored 15 out of 15 on the Brief Interview for Mental Status which indicated the Resident is cognitively intact. Further, the MDS indicated the Resident is on dialysis. During an observation and interview on 4/13/26 at 9:44 A.M., Nurse #4 was standing at the medication cart outside of Resident #78's room. Resident #78 was observed in his/her room, in bed, holding a medication cup with three pills inside. Resident #78 said 'I take them (medications) one at time, until these last three small pills, I take them at once'. As Resident #78 took the medication there was no nursing staff in or near the vicinity of Resident #78. Review of Resident #78's active physician's orders failed to indicate Resident #78 has an order to administer his/her own medication. Review of Resident #78's Care Plans failed to indicate Resident #78 had a care plan to self-administer his/her own medications. During an interview on 4/14/26 at 12:34 P.M., Nurse #4 said when a nurse administers medication to a resident they are to stay and make sure the resident takes the medication as ordered. Nurse #4 said medication should not be left with a resident unless they have an order and are assessed to self-administer. Nurse #4 said she prepared and administered Resident #78's medication on 4/13/26 and should not have left the Resident until he/she finished taking all his/her medication. During an interview on 4/14/26 at 5:08 P.M., the Director of Nursing said the nurses are not to leave a resident with medications but could monitor from the doorway. The DON said it is not policy for the nurse to leave a resident before they finish taking all their medications, The DON said the nurse should stay with the Resident to ensure they take the medications entirely.

Based on observations, record reviews, and interviews, the facility failed to ensure staff treated residents in a dignified manner for two Resident (#73 and #4) out of a total sample of 40 Residents. Specifically,1. For Resident #73 the facility failed to ensure the Physician did not dictate a history and physical at the nursing station in the presence of 14 residents, a laundry aide, a housekeeper, and a nurse. 2. For Resident #4 the facility failed to ensure the Hospice Nurse did not assess the Resident in a common area. Findings include: Review of the facility policy titled, Residents Rights - Promoting and Maintaining Resident Dignity, dated as revised 4/26/23, indicated that it is the practice of this home to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 12. Maintain resident privacy. 1. Resident #73 was admitted to the facility in March 2026 with diagnoses including urinary tract infection, hypotension, and dementia. Review of the Minimum Data Set assessment, dated 3/4/26, indicated Resident #73 had a severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 2 out of a possible 15. On 4/13/26 between 10:53 A.M., through 11:02 A.M., the surveyor observed Physician #1 at the [NAME] nursing station, dictating Resident #73's history and physical loudly in the open at the nursing station in the presence of 14 residents, a laundry aide, a housekeeper, and a nurse. During an interview on 4/14/26 at 9:25 A.M., Nurse #5 said that Physician #1 always dictates his notes at the nursing station. During an interview on 4/14/26 at 11:43 A.M., Resident #73's Family Member #1 said that she and her sisters find it important to protect Resident #73's health information and she would like health concerns discussed privately and not in an open area. During an interview on 4/14/26 at 4:24 P.M., the Director of Nursing (DON) said that Physician #1 should not be dictating history and physicals at the nursing station in front of other residents and non-essential staff. The DON said that when Physician #1 is dictating notes at the nursing station the nursing staff on the unit should request Physician #1 go out back into the office to maintain Resident #73's dignity. During an interview on 4/15/26 at 8:51 A.M., the Medical Director said that Physician #1 should have dictated the Resident's history and physical in a private area. The Medical Director said that dignity and privacy should be protected for all Residents. 2. Resident #4 was admitted to the facility in July 2024 with diagnoses including dementia, anxiety, and post-traumatic stress disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/12/26, indicated that Resident #4 had a severe cognitive impairment as evidenced by a BIMS score of 3 out of a possible 15.Review of Resident #2's plan of care related to hospice, dated as revised on 2/23/26, included the following goal: I will appear at peace, be treated with dignity and comfortable daily by review date. The surveyor made continuous observations on 4/14/26 from 11:46 A.M. through 11:50 A.M. of the Hospice Nurse perform an assessment of Resident #4 in a common area on the [NAME] Unit. The Hospice Nurse obtained vital signs, listened to Resident #4's lungs and heart, and checked Resident #4's feet for edema. During this observation there were nine residents in the vicinity, two licensed nurses, and a family member who walked by during the Hospice Nurse's assessment. During an interview on 4/14/26 at 12:02 P.M., Nurse #5 said the Hospice Nurse typically does her assessment in common areas, but she shouldn't. During an interview on 4/14/26 at 12:27 P.M., the Hospice Nurse said that she assessed Resident #4 in a common area, and she said she should have brought Resident #4 back to his/her room to do the assessment, but she did not. During an interview on 4/14/26 at 4:19 P.M., the DON said that the Hospice Nurse should have assessed Resident #4 in a private location to maintain his/her dignity. The DON said that direct care staff could have asked the Hospice Nurse to assess Resident #4 in a private location.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Advanced Directives and Physician's Order indicated his/her elected code status was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest) the Facility failed to ensure nursing staff honored his/her right to self-determination, when after being found unresponsive and without a pulse, nursing staff initiated life saving measures.Findings include:The Facility Policy, titled, Resident Rights, dated [DATE], indicated all residents were afforded their right to a dignified existence, self-determination, respect, and full recognition of their individuality.The Facility Policy, titled, Advanced Directive and Care Planning Policy, dated [DATE], indicated:-Upon admission, the Facility would identify if the resident had an advanced directive and the resident's choices would be incorporated into their plan of services, care and services.-Examples of advanced directives included a Living Will, a pre-existing medical order for Do Not Resuscitate (DNR) or another document directing the resident's health care such as a Massachusetts Order for Live Sustaining Treatment (MOLST).The Facility Policy, titled Cardiopulmonary Resuscitation (CPR), dated [DATE], indicated the Facility would adhere to the resident's rights to formulate advance directives, and if the resident experienced a cardiac arrest, facility staff would provide basic life support, including CPR, in accordance with the resident's advanced directives.Resident #1 was admitted to the Facility in [DATE], diagnoses included left hip fracture, diabetes, chronic kidney disease, morbid obesity, and high cholesterol.Review of Resident #1's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], and signed by Resident #1, indicated he/she was a Do Not Resuscitate (DNR), Do Not Intubate (DNI), and to transfer to the Hospital.Review of Resident #1's Physician's Orders, dated [DATE], (related to his/her advanced directives) indicated Do Not Resuscitate (DNR) and Do Not Intubate (DNI).Review of Resident #1's Discharge Summary Due to Death in Facility, dated [DATE], indicated he/she was admitted to the Facility that evening, and was later found unresponsive by nursing. The Discharge Summary indicated nursing initiated CPR, and while CPR was being performed, Resident #1's MOLST was discovered and verified, at which time CPR was discontinued.During an interview on [DATE] at 02:27 P.M., Nurse #1 said that on [DATE] he was Resident #1's assigned nurse. Nurse #1 said at 9:15 P.M., he had prepared Resident #1's scheduled medications and upon entering his/her room, found Resident #1 unresponsive. Nurse #1 said he called out for help and said Unit Manager #1 and Nurse #2 responded. Nurse #1 said when Unit Manager #1 asked what his/her code status was, Nurse #2 (who was in the room at the time) said he/she was a full code. Nurse #1 said that he did not double check Resident #1's physician's orders or MOLST and just repeated to Unit Manager #1 what Nurse #2 said, that he/she was a full code, and then Unit Manager #1 began chest compressions.During a telephone interview on [DATE] at 4:01 P.M., Nurse #2 said that on [DATE] at 9:15 P.M., Nurse #1 called for help because Resident #1 was unresponsive. Nurse #2 said she assessed Resident #1 and he/she was unresponsive, not breathing, and did not have a pulse. Nurse #2 said she asked Nurse #1 what Resident #1's code status was and he (Nurse #1) said he/she was a full code. Nurse #2 said she did not verify what Nurse #1 said and said while Unit Manager #1 began CPR she left the room to call a Code Blue, call 911, and to begin gathering information needed to transfer Resident #1 to the Hospital. Nurse #2 said when she reviewed Resident #1's MOLST, she realized that he/she was a DNR, and immediately went and notified Unit Manager #1, Nurse #1, and other nurses who had responded to the code blue, and said CPR was then discontinued.During an interview on [DATE] at 11:56 A.M., Unit Manager #1 said that on [DATE], Nurse #1 who was assigned as Resident #1's primary nurse that evening, called for help because Resident #1 was found unresponsive. Unit Manager #1 said when she asked Nurse #1 what Resident #1's code status was, Nurse #1 said he/she was a full code (initiate CPR).Unit Manager #1 said Resident #1 was not breathing, and did not have a pulse, so she told Nurse #2 (who had also responded) to call a Code Blue and initiate 911. Unit Manager #1 said she started chest compressions, the Automated Electrical Device (AED, delivers an electric shock) was applied, and said a total of two rounds of chest compressions was performed. Unit Manager #1 said while chest compressions were underway, Nurse #2 came to Resident #1's room holding his/her MOLST, which indicated he/she was a DNR/DNI, and upon confirmation that it was Resident #1's MOLST, CPR was discontinued.Unit Manager #1 said CPR should never have been initiated for Resident #1, as his/her advanced directives were to be DNR/DNI.During an interview on [DATE] at 07:56 A.M., the Director of Nurses said staff should have verified Resident #1's code status before they initiated CPR, but had not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Advanced Directives indicated he/she was a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest), the Facility failed to ensure services provided by nursing met professional standards of quality, when nursing initiated life saving measures including performing Cardiopulmonary Resuscitation on a resident who was a DNR.Findings include:Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice.Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Titled Nursing Practice and Cardiopulmonary Resuscitation, dated as revised 12/2018, indicated that as a Standard of Nursing Practice, the nurse licensed by the Board is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board's position that these standards, in the context of practice in all settings where health care is delivered require initiating cardiopulmonary resuscitation when a patient has been found unresponsive and has not yet been declared dead by a provider authorized pursuant to M.G.L. c. 46, S 9, except when the patient has a current, valid Do Not Resuscitate order/status.It further indicated, that for the purpose of this Advisory Ruling, the licensed nurse must, at a minimum, attain and maintain the following competencies through successful completion of entry-level nursing education programs or continuing education experiences, the nurse's role in obtaining accurate information about the DNR status of all assigned patients.The Facility Policy, titled Cardiopulmonary Resuscitation (CPR), dated [DATE], indicated the Facility would adhere to the resident's rights to formulate advance directives, and if the resident experienced a cardiac arrest, facility staff would provide basic life support, including CPR, in accordance with the resident's advanced directives.Resident #1 was admitted to the Facility in [DATE], diagnoses included left hip fracture, diabetes, chronic kidney disease, morbid obesity, and high cholesterol.Review of Resident #1's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], and signed by Resident #1, indicated he/she was a Do Not Resuscitate (DNR), Do Not Intubate (DNI), and to transfer to the Hospital.Review of Resident #1's Physician's Orders, dated [DATE], (related to his/her advanced directives) indicated Do Not Resuscitate (DNR) and Do Not Intubate (DNI).Review of Resident #1's Discharge Summary Due to Death in Facility, dated [DATE], indicated he/she was admitted to the Facility that evening, and was later found unresponsive by nursing. The Discharge Summary indicated nursing initiated CPR, and while CPR was being performed, Resident #1's MOLST was discovered and verified, at which time CPR was discontinued.During an interview on [DATE] at 02:27 P.M., Nurse #1 said that on [DATE] he was Resident #1's assigned nurse. Nurse #1 said at 9:15 P.M., he had prepared Resident #1's scheduled medications and upon entering his/her room, found Resident #1 unresponsive. Nurse #1 said he called out for help, and said Unit Manager #1 and Nurse #2 responded. Nurse #1 said when Unit Manager #1 asked what his/her code status was, Nurse #2 (who was in the room at the time) said he/she was a full code. Nurse #1 said that he did not double check Resident #1's physician's orders or MOLST, just repeated to Unit Manager #1 what Nurse #2 had said, that he/she was a full code, and that Unit Manager #1 then began chest compressions.During a telephone interview on [DATE] at 4:01 P.M., Nurse #2 said that on [DATE] at 9:15 P.M., Nurse #1 called for help because Resident #1 was unresponsive. Nurse #2 said she assessed Resident #1 and he/she was unresponsive, not breathing, and did not have a pulse. Nurse #2 said she asked Nurse #1 what Resident #1's code status was and he (Nurse #1) said full code. Nurse #2 said she did not verify what Nurse #1 said and said while Unit Manager #1 began CPR she left the room to call a code blue, call 911, and to begin gathering information needed to transfer Resident #1 to the Hospital. Nurse #2 said when she reviewed Resident #1's MOLST, she realized that he/she was a DNR, and immediately went and notified Unit Manager #1, Nurse #1, and other nurses who had responded to the code blue, and said CPR was then discontinued.During an interview on [DATE] at 11:56 A.M., Unit Manager #1 said that on [DATE], Nurse #1 who was assigned as Resident #1's primary nurse that evening, called for help because Resident #1 was found unresponsive. Unit Manager #1 said when she asked Nurse #1 what Resident #1's code status was, that Nurse #1 said he/she was a full code (initiate CPR).Unit Manager #1 said Resident #1 was not breathing, and did not have a pulse, so she told Nurse #2 (who had also responded) to call a Code Blue and initiate 911. Unit Manager #1 said she started chest compressions, the Automated Electrical Device (AED, delivers an electric shock) was applied, and said a total of two rounds of 30 chest compressions was performed. Unit Manager #1 said while chest compressions were underway, Nurse #2 came to Resident #1's room holding his/her MOLST which indicated he/she was a DNR/DNI, and upon confirmation that it was Resident #1's MOLST, CPR was discontinued.Unit Manager #1 said CPR should never have been initiated for Resident #1, as his/her advanced directives were to be DNR/DNI.During an interview on [DATE] at 07:56 A.M., the Director of Nurses said staff should have verified Resident #1's code status before they initiated CPR but had not.

Based on records reviewed and interviews, for one of four sampled residents (Resident #3), who was moderately cognitively impaired and dependent on staff to meet his/her care needs, the facility failed to ensure he/she was treated in a dignified and respectful manner when Hospice Aide #1 was witnessed by staff on more than one occasion respond to Resident #1's adverse behavior by insulting and calling him/her names, and did so in a demeaning manner.Findings include:Review of Facility Policy titled Resident Rights, dated 04/23/23, indicated the facility will protect and promote the rights of the resident and afford each resident his or her basic right to be treated with dignity and respect. The Policy indicated the facility will ensure that all residents are afforded the right to a dignified existence, self determination, respect full recognition of their individuality, consideration and privacy in treatment and care for personal needs. The Policy indicated that all personnel are required to protect and promote the rights of each resident, as well as encourage and assist each resident in the fullest possible exercise of their rights.Review of Resident #3's clinical record indicated his/her diagnoses included Traumatic Brain Injury, Morbid Obesity and Major Depressive Disorder.Review of Resident #3's Significant Change in Status Minimum Data Set assessment, dated 10/21/25, indicated he/she required maximum assistance with activities of daily living, had moderately impaired cognition, and displayed physical, verbal and other behavioral symptoms towards others.During an interview on 01/13/26 at 11:45 A.M., Resident #3 said one day around 10:00 A.M. (exact date unknown), a Hospice Aide (identified as Hospice Aide #1) called him/her a pig and said she'd take him/her to the slaughterhouse to get him/her slaughtered. Resident #3 said a Certified Nurse Aide (later identified as CNA #4) was present when it happened. Resident #3 said Hospice Aide #1 told him/her that he/she was a dog and said that he/she used to live in a cage. Resident #3 said CNA #4 did not say or do anything in response. Resident #3 said he/she told Hospice Aide #1 not to call him/her names. Resident #3 said Hospice Aide #1 made him/her feel terrible.During an interview on 01/13/26 at 3:10 P.M., CNA #4 said on two or three occasions (unable to recall exact dates) she witnessed Hospice Aide #1 be verbally abuse toward Resident #3 while assisting with care. CNA #4 said the first incident occurred around three to four weeks ago. CNA #4 said Hospice Aide #1 had asked for assistance because Resident #3 had directed racial slurs at her. CNA #4 said while in the room, Resident #3 swore and directed racial slurs at Hospice Aide #1, and Hospice Aide #1 responded back and called Resident #3 a fat pig and told him/her they're going to put you in a butcher shop because you have so much meat on you, and then Hospice Aide #1 laughed at Resident #3. CNA #4 said she could not recall all the statements Hospice Aide #1 made to Resident #3 but said this is what she most vividly recalled what was stated to Resident #3 during the incidents. CNA #4 said she felt uncomfortable but did not tell Hospice Aide #1 to stop speaking to Resident #3 in that manner. During an interview on 01/13/26 at 9:30 A.M., the Assistant Director of Nurses (ADON) said on 01/02/26 she interviewed CNA #4 as a part of a facility investigation related to Hospice Aide #1. The ADON said CNA #4 told her she witnessed Hospice Aide #1 call Resident #3 a fat pig and say to Resident #3 that they will put you in a butcher shop because you have so much meat on you. The ADON said CNA #4 had not reported this altercation between Resident #3 and Hospice Aide #1 prior to their conversation on 01/02/26. During a telephone interview on 01/15/26 at 3:00 P.M., CNA #5 said sometime around 12/25/25, Hospice Aide #1 requested she assist her and CNA #4 with Resident #3. CNA #5 said when she entered the room, Resident #3 directed a racial slur at Hospice Aide #1. CNA #5 said Hospice Aide #1 immediately said to Resident #3 that if she was a (quoting the racial slur), than you (Resident #3) are fat. CNA #5 said she just continued to assist Hospice Aide #1 with care and did not tell Hospice Aide #1 that it was not acceptable to call Resident #3 names. CNA #5 said since CNA #4 was in the room at the time, she assumed CNA #4 would report the incident, because she was Resident #3's assigned aide.During an interview on 01/13/26 at 4:00 P.M., the ADON said CNA #5 told her today (01/13/26, the day of the survey) that she witnessed Hospice Aide #1 call Resident #3 fat.During a telephone interview on 01/15/26 at 11:00 A.M., the Director of Nurses (DON) said she, along with the ADON and Administrator met with CNA #5 on 01/14/26. The DON said CNA #5 stated that sometime around 12/25/25, after Resident #3 directed a racial slur at Hospice Aide #1, Hospice Aide #1 replied that if she was a (quoting the racial slur) than you (Resident #3) are fat, how do you like that.During a telephone interview on 01/27/26 at 11:40 A.M., the Administrator said no one employed in this environment should speak to a resident in the manner Hospice Aide #1 spoke to Resident #1. The Administrator said residents need to be treated with dignity and not spoken to in an offensive manner.

Based on records reviewed and interviews, for two of four sampled residents (Resident #1, Resident #3), the facility failed to ensure staff consistently implemented and followed their abuse policy related to protecting residents and reporting abuse allegations, when 1) on 12/19/25 Resident #1 reported to Nurse #1 that he/she had been slapped in the face, and 2) despite multiple staff member witness Hospice Aide #1 allegedly verbally abuse Resident #3, neither of these incidents were immediately reported to a Supervisor or Administrative staff, as required. Findings included: Review of Facility Policy titled Abuse, Neglect and Exploitation, dated 05/28/25, indicated the home will report all alleged violations to the Administrator, Medical Director, state agency, adult protective services and to all other required agencies immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse. The Policy indicated it would achieve in providing staff information on how and to whom they may report concerns and incidents without fear of retribution, and assigning responsibility for the supervision of staff on all shifts for identifying inappropriate behaviors. The Policy indicated the home will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The Policy indicated efforts are not limited to responding immediately to protect the alleged victim and integrity of the investigation, removal of the alleged perpetrator(s) from the facility, and staffing changes if necessary to protect the resident from the alleged perpetrator.1) Review of Resident #1's clinical record indicated his/her diagnoses included Dementia, Osteoarthritis, and Mood DisorderDuring a telephone interview on 01/15/25 at 2:20 P.M., Certified Nurse Aide (CNA) #2 said on 12/19/25 around 7:00 P.M., while she and CNA #1 were transferring Resident #1 to bed, she heard a slap sound and immediately thereafter a cry from Resident #1. CNA #2 said Resident #1 yelled out she slapped me, swore at CNA #1 and held his/her face. CNA #2 said the door to the room opened, and Nurse #1 asked them if Resident #1 was slapped. CNA #2 said she did not recall what was said, and that Nurse #1 left the room. CNA #2 said after she and CNA #1 finished caring for Resident #1, they left the room and Nurse #1 told her to report the incident. CNA #2 said she immediately reported the incident to the Nursing Supervisor, which was around 30 minutes after Resident #1 alleged to have been slapped. During an interview on 01/13/26 at 4:15 P.M., Nurse #1 said in the evening on 12/19/25 (exact time unknown) she heard a slap sound, followed by a scream from Resident #1's room. Nurse #1 said she immediately left her medication cart located outside Resident #1's room and entered. Nurse #1 said CNA #1 and CNA #2 were in the room with Resident #1. Nurse #1 said she asked (to neither in particular) did you slap Resident #1? Nurse #1 said one of the two CNAs replied no. Nurse #1 said Resident #1 covered his/her face and said she hit my face, I can't see. Nurse #1 said she stepped out of the room and returned to her work at the medication cart since one of the CNAs replied no and assumed no one had hit Resident #1. Nurse #1 said she waited about 15 minutes until CNA #1 and CNA #2 finished caring for Resident #1, had exited his/her room, and then asked CNA #2 what happened in Resident #1 room. Nurse #1 said that CNA #2 (who seemed visibly shaken) replied that she did not know why people can't control their temper. Nurse #1 said without asking for further clarification from her, she told CNA #2 to go report whatever she saw to the Nursing Supervisor. Nurse #1 said the Nursing Supervisor ensured CNA #1 and CNA #2 were removed from resident care areas for further investigation. Nurse #1 said she should have intervened immediately by asking CNA #1 and CNA #2 to leave Resident #1's room, and she should have reported the allegation of physical abuse immediately to the Nursing Supervisor. During an interview on 01/13/26 at 2:45 P.M., the Nursing Supervisor said on 12/19/25 at around 8:00 P.M. CNA #2 reported to her that CNA #1 allegedly slapped Resident #1. The Nursing Supervisor said she immediately contacted the Director of Nurses and removed CNA #1 from the unit.During an interview on 01/13/26 at 10:00 A.M., the Director of Nurses (DON) said the Nursing Supervisor notified her in the evening on 12/19/25 that it was alleged CNA #1 slapped Resident #1. The DON said based on facility investigation, Nurse #1 should have immediately removed CNA #1 and CNA #2 from Resident #1's room when she heard and suspected that he/she was slapped by one of the CNAs, instead of allowing for the completion of his/her care. 2. Review of Resident #3's clinical record indicated his/her diagnoses included Traumatic Brain Injury, Morbid Obesity, and Major Depressive Disorder.During an interview on 01/13/26 at 11:45 A.M., Resident #3 said one day around 10:00 A.M. (exact date unknown), a Hospice Aide (identified as Hospice Aide #1) called him/her a pig and said she'd take him/her to the slaughterhouse to get him/her slaughtered. Resident #3 said a Certified Nurse Aide (later identified as CNA #4) was present when it happened. Resident #3 said Hospice Aide #1 told him/her that he/she was a dog and that he/she used to live in a cage. Resident #3 said CNA #4 did not say or do anything in response, to Hospice Aide #1's comments.During an interview on 01/13/26 at 3:10 P.M., CNA #4 said on two or three occasions (unable to recall exact dates) she witnessed Hospice Aide #1 allegedly verbally abuse Resident #3. CNA #4 said the first incident occurred around three to four weeks ago. CNA #4 said Hospice Aide #1 asked for assistance because Resident #3 had directed racial slurs at her. CNA #4 said while in the room, Resident #3 swore and directed racial slurs at Hospice Aide #1, and Hospice Aide #1 responded back and called Resident #3 a fat pig and told him/her they're going to put you in a butcher shop because you have so much meat on you, and then Hospice Aide #1 laughed at Resident #3. CNA #4 said she did not report any of these incidents of alleged verbal abuse until she was interviewed as a part of a Facility investigation related to Hospice Aide #1.During an interview on 01/13/26 at 9:30 A.M., the Assistant Director of Nurses (ADON) said on 01/02/26 she interviewed CNA #4 as a part of a facility investigation related to Hospice Aide #1. The ADON said CNA #4 told her she witnessed Hospice Aide #1 call Resident #3 a fat pig and say to Resident #3 that they will put you in a butcher shop because you have so much meat on you. The ADON said CNA #4 had not reported that Resident #3 was allegedly verbally abused by Hospice Aide #1 prior to their conversation on 01/02/26. During a telephone interview on 01/15/26 at 3:00 P.M., CNA #5 said sometime around 12/25/25, when she entered Resident #3's room, Resident #3 directed a racial slur at Hospice Aide #1. CNA #5 said Hospice Aide #1 immediately said if she was a (quoting the racial slur), then you (Resident #3) are fat in a matter-of-fact tone. CNA #5 said since CNA #4 was in the room at the time, she assumed CNA #4 would report it as Resident #3's assigned aide. CNA #5 said although she initially denied any knowledge of Resident #3 being verbally abused during a facility investigation, she later decided to report the incident on 01/13/26 (during the Department of Public Health investigation).During an interview on 01/13/26 at 4:00 P.M., the Assistant Director of Nurses (ADON) said CNA #5 told her today (01/13/26, the day of the survey) that she lied a few weeks ago when questioned if she witnessed Resident #3 being verbally abused by Hospice Aide #1. The ADON said CNA #5 told her she had witnessed Hospice Aide #1 call Resident #3 fat and had not previously reported it to anyone.During a telephone interview on 01/15/26 at 11:00 A.M., the Director of Nurses (DON) said CNA #5 denied any knowledge when asked by the ADON on 01/02/26 if Resident #3 had been allegedly verbally abused by the Hospice Aide. The DON said she, along with the ADON and Administrator met with CNA #5 on 01/14/26, and CNA #5 stated to them that sometime around 12/25/25, after Resident #3 directed a racial slur at Hospice Aide #1, Hospice Aide #1 replied that if she was a (quoting the racial slur) than you (Resident #3) are fat, how do you like that. The DON said CNA #5 told them that when she was initially interviewed (on 01/02/26), she lied because it was her day off from work and did not want to be asked to come into the Facility to provide information. The ADON said CNA #5 told her because she did not report it immediately, she lied to avoid getting in trouble. The DON said staff were expected to report allegations of abuse immediately per Facility's Abuse Policy.During an interview on 01/13/26 at 2:25 P.M., the Administrator said it was the facility's expectation that staff immediately report allegations of suspected abuse per facility policy, and through training provided.

Based on observations, record review and interviews, the facility failed to 1. prevent a fall that resulted in facial fractures for Resident (#137) and 2. implement chair sensors for safety for Resident (#64) out of a total sample of 37 Residents. 1. For Resident #137, the facility failed to provide the required two person assist with a transfer, resulting in a fall with facial fractures. Findings include: Review of the facility policy titled Fall Prevention/Reduction Program dated and revised on 2/2023 indicated the following: *The falls prevention/reduction program is designed to ensure a safe environment for all residents based on identified risk factors with continuous assessment and evaluation to maintain their safety, comfort, mental and physical wellbeing, with the respect to ethical issues bearing the management of falls and the balance between promoting independence and freedom of movement and the desire to eliminate falling and prevent related injuries. *The facility recognizes the definition of a fall to be unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). *Nursing staff to ensure appropriate information is included in the care plan/care card and then communicated to appropriate staff with documented education instructions as needed. Resident #137 was admitted to the facility in February 2023 with diagnoses including Parkinson's disease, and a history of repeated falls. Review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) exam score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that the Resident needs extensive assistance for self-performance and needs two person physical assistance for support. During an observation on 4/11/23 at 8:24 A.M., Resident #137 was observed with facial bruises on the right side of his/her face. He/she told the surveyor approximately two weeks ago, a Certified Nurse's Assistant (CNA) dropped him/her on the floor during a transfer. The Resident said he/she requires two person assist with transfers. Resident #137 added that as a result of the fall, he/she had several fractures on his/her face. A Review of the fall care plan initiated 2/27/23 indicated the following: *Transfers-2 staff assist for all transfers *Toileting-I need 2 staff assist *Bed mobility-I need 2 assist with repositioning A Review of Resident #137's Kardex care card indicated 2 assist for transfers. A review of an incident report dated 4/4/23 included the following witness statement from (CNA) #2. I brought the resident his/her linen as he/she was about to be put in the chair by someone from therapy. I asked if I could get his/her weight before she/he got into a recliner chair and then I would move him/her to the chair. I got his/her weight and then brought him/her back to her room, positioned his/her chair facing the recliner and locked the wheels. I put my arms under him/her and got him/her by the pants to stand while he/she had his/her arms around me. I counted to three and we stood together. I began to pivot him/her to the right when I think he/she tripped or slipped and his/her weight started to shift to the left. I couldn't support his/her sudden change and fell to the left with him/her. We fell to the ground together and he/she hit his/her head on the table and started bleeding from his/her nose. The person from therapy left to get the nurses who came, and we moved him/her to the bed. A review of an X-ray report completed by the Medical Doctor (MD) #1 on 4/4/23 at 7:24 P.M., indicated the following final result: *Acute, displaced fracture of the floor and lateral wall of the right orbit without evidence of extraocular muscle entrapment. *Acute, displaced fractures of multiple walls of the right maxillary sinus, with hemorrhage filling the sinus. *Acute, mildly displaced fractures of the bilateral nasal bones *Right periorbital/facial subcutaneous hematoma During an interview on 4/13/23 at 2:50 P.M., with CNA #2, she said she was working on 4/4/23 on the 3 P.M.-11 P.M. shift. She said she made an error in judgement while transferring Resident #137 alone to his/her chair. She lost her balance and they both fell to the ground. CNA#2 said she should have followed the plan of care and transferred the Resident with another CNA or Nurse. During an interview on 4/13/23 at 9:53 A.M., with Nurse #4, she said CNA #2 should not have transferred Resident #137 alone because Resident #137 requires 2 staff assist for all transfers. During an interview on 4/13/23 at 10:12 A. M., with the Director of Nurses and the Assistant Director of Nurses, they said the CNAs on the unit are expected to follow the plan of care, and the Kardex care card. They said Resident #137 is a 2 person for all transfers and CNA #2 should not have transferred him/her on her own. 43882 2. For Resident #64 the facility failed to implement an intervention of chair sensors to prevent recurring falls. Resident #64 was admitted to the facility in May 2022 with diagnoses including fracture of the right femur, history of falling, and dementia. Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status score of 3 out of possible 15 indicating severe cognitive impairment. Review of Resident #64's medical record indicated the following: -A Care Plan for falls revision date of 11/28/22, indicated an intervention initiated 7/8/22 for bed and chair sensor for safety. Review of the facility fall incident report dated 8/5/22, indicated Resident #64 had an unwitnessed fall and safety alarms that were ordered but not in place at the time of the fall. Review of the facility fall incident report dated 8/23/22, indicated Resident #64 had an unwitnessed fall and safety alarms were attached but not sounding at the time of the fall. Review of the facility fall incident report dated 12/17/22, indicated Resident #64 had a fall that resulted in a laceration to the eyebrow and documentation indicated that Resident #64 did not have a chair alarm at the time of the fall. During an interview on 4/13/23 at 12:10 P.M., Unit Manager #3 said Resident #64 required both chair and bed alarms for safety.

Based on record review and staff interview, the facility failed to maintain acceptable parameters of nutritional status by providing adequate interventions to maintain usual body weight and prevent significant weight loss or gain, for 6 Residents (#1, #40, #127, #178, #121 and #27) out of a total sample of 36 residents. Findings include: Review of the facility policy titled, Weight Monitoring, last revised 6/2021, indicated the following: *All residents/patients will be weighed within 24 hours of admission or re-admission, then daily times 3 days. *Weekly weights thereafter performed on Sunday through Tuesday unless otherwise specified by the physician. *The charge nurse on the shift when the weight is obtained will compare the current weight with the previous weight, any change up or down 3 pounds requires a re-weigh within 24 hours. Immediate interventions will be put in place as clinically appropriate. Confirmed weight changes will be discussed at the next Client at Risk Meeting. *Determine whether or not the weight change is significant. A loss or gain of 5% or more within one month, 7.5% in three months, and 10% in six months is considered significant. *Dietitian will review any resident/patient with significant weight change. Recommendations will be made to the physician who should be notified within 72 hours of determination. 1. For Resident #1, the facility failed to implement interventions after a significant weight loss. Resident #1 was admitted to the facility in March 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's most recent Minimum Data Set (MDS) dated [DATE], revealed Resident #1 has a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 which indicated he/she is cognitively intact. The MDS also indicted that Resident #1 requires extensive assistance from staff for feeding tasks. Review of Resident #1's weights indicated the following: *On 07/15/21 144.8 lbs. (pounds) *On 10/28/21 134 lbs. (a 7.46% loss in 3 months) *On 12/21/21 128.2 lbs. (a 11.46% loss in 5 months) *On 01/26/22 124 lbs. (a 14.36% loss in 6 months) *On 03/8/22 122 lbs. *The weight logs also indicated Resident #1 was not weighed for the entire months of August or November 2021. During an interview on 3/09/22 at 8:54 A.M. Resident #1 said he/she was aware that he/she had lost weight. Resident #1 said he/she would like to avoid further weight loss at the facility and would like the Dietitian to put an intervention in place to help with his/her goal. Review of Resident #1's physician orders failed to indicate any nutritional supplements except for vitamins initiated in March 2020. Review of Resident #1's nutritional care plan last revised 12/20/21 indicated the following interventions: *1:1 feeding by staff - assist of 1, feed as needed to ensure optimal meal % intake, offer finger foods, hand Resident his/her cup, initiated 3/7/2020 *Educate the Resident and his/her family on appropriate foods and food/drink textures to bring in for enjoyment, as well as food/textures to avoid, initiated 3/4/2020. *Notify Dietitian/MD/NP of any changes in my ability to swallow or take in sufficient calories, initiated 3/6/2020. Review of Resident #1's physician notes failed to indicate he was aware that Resident #1 had any weight loss. Further review of Resident #1's medical record indicated the following: *A Quarterly Nutrition assessment dated [DATE] (after the 7.46% loss) failed to indicate a change in weight. The assessment did note missing weights for the month of November. The intervention implemented on 12/1/21 was to continue to be available for consult. *A weight change note dated 2/17/22 indicated the Dietitian was aware of Resident #1's 10% weight loss and had indicated the loss was due to his/her disease process and the Resident was choosing to stay on regular diet. The Dietitian did not indicate a new nutritional intervention to be added and noted the Resident will continue to consume Boost (a nutritional drink) that his/her family brings in from home due to the Resident not liking the nutritional drink the facility offers. *A Comprehensive assessment dated [DATE] indicated Resident #1 had a 10% weight loss in the previous few months. The Assessment failed to indicate a new intervention added by the Dietitian after this loss noting the Resident would continue to consume Boost (a nutritional drink) brought in by family. During an interview on 3/9/22 at 12:06 P.M., Unit Manager (UM) #1 said all residents have their weights taken weekly in the facility. UM #1 said if a resident were to have a weight change of 3 pounds or more a reweigh should be taken and the Dietitian should be notified. UM #1 said she did not discuss Resident #1's weight loss with the Dietitian. During an interview on 3/09/22 at 2:29 P.M., Dietitian #2 said that Resident #1 recently refused a downgraded diet that was recommended by the Speech Therapist in September 2021. Dietitian #2 said this may have contributed to Resident #1's weight loss because intake of food may be less. Dietitian #2 said that Resident #1 has been drinking Boost (that the family brings in) as an intervention for years and that no new intervention was put into place with this significant weight loss. 2. For Resident #40, the facility failed to implement interventions after a significant weight loss. Resident #40 was admitted to the facility in November 2014 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #40's most recent Minimum Data Set (MDS) dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #40 requires supervision with self-feeding tasks. Review of the document titled, Quarterly Nutritional Assessment, dated 12/17/21, indicated a recent 10% weight loss that that Dietitian contributed to a recent hospitalization . The recommendation on the assessment was for Resident #40 to consume 50-75% of meals to help meet nutritional needs, nursing to monitor labs and obtain a weight quarterly. There were no new interventions to address prevention of further weight loss. Review of Resident #40's weights indicated the following: *Upon readmission from hospital, on 12/13/21 Resident #40 weighed 143 lbs. (pounds) *On 3/2/22, 132.2 lbs. (a 7.55% loss in 3 months) *On 3/6/22, 131.2 lbs. (a 8.25% loss in 3 months) During an interview on 3/9/22 at 12:06 P.M., Unit Manager (UM) #1 said if a resident were to have a weight change of 3 pounds or more a reweigh should be taken and the Dietitian should be notified. UM #1 said she was unaware of Resident #40's weight loss, therefore, the Dietitian was never notified. A review of Resident #40's medical record indicated the following: *Physician orders failed to indicate any nutritional supplements. *A Speech Therapy Evaluation was completed on 3/2/22 due to a decline in chewing ability and an increased difficulty swallowing. The referral for speech therapy was made by nursing due to increased difficulty with swallowing and there was no indication on the evaluation that this was a dietary intervention due to weight loss. *A nutritional care plan last revised 6/22/21 with an intervention to notify the Dietitian/MD of any changes in my ability to swallow or take in sufficient calories. *The Medical record failed to indicate that either the physician or dietitian were notified of Resident #40's significant weight loss. *The medical chart failed to indicate any further dietary assessments or notes since 12/2021. During an interview on 3/09/22 at 10:56 A.M., Dietitian #1 said that a 7.5% weight loss in 3 months is significant and should be addressed by the interdisciplinary team to prevent further weight loss. Dietitian #1 confirmed Resident #40's significant weight loss and no interventions were put in place to address it. 3. For Resident #127, the facility failed to implement interventions after a significant weight loss. Resident #127 was admitted to the facility in February 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #127's most recent Minimum Data Set (MDS) dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 which indicated he/she is cognitively intact. The MDS also indicated Resident #127 is independent with self-feeding tasks. During an interview on 3/09/22 at 8:56 A.M., Resident #127 said he/she has a typical weight of 145 pounds. Resident #127 said that this is his/her preferred weight and would not want to weigh any less. Review of Resident #127's weights indicated the following: *On 2/1/22 146.5 lbs. (pounds) *On 2/18/22 134.4 lbs. (a 8.26% loss in 2 weeks). A re-weight did not occur. *On 3/8/22 135 lbs. A review of Resident #127's medical record indicated the following: *Physician orders failed to indicate any nutritional supplements. *A nutritional care plan initiated 2/1/22 failed to include interventions to address weight loss. The interventions on the care plan included educating the resident on the appropriate food textures to consume and letting the dietary staff know about his/her food preferences. *The Medical record failed to indicate that either the physician or dietitian were notified of Resident #127's significant weight loss. During an interview on 3/9/22 at 12:06 P.M., Unit Manager (UM) #1 said if a resident were to have a weight change of 3 pounds or more a reweigh should be taken and the Dietitian should be notified. UM #1 said she did not discuss Resident #127's weight loss with the Dietitian. During an interview on 3/09/22 at 10:56 A.M., Dietitian #1 said that a 5% weight loss in 1 month is significant and should be addressed by the interdisciplinary team to prevent further weight loss. Dietitian #1 confirmed Resident #127's significant weight loss and said she had been unaware of it until the surveyor brought it to her attention, therefore, no interventions were put in place to address it. 4. For Resident #178, the facility failed to implement interventions for a significant weight gain. Resident #178 was admitted to the facility in August 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #178's most recent Minimum Data Set (MDS) dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 which indicated he/she has moderate cognitive impairment. The MDS also indicated Resident #178 is independent with self-feeding tasks. During an interview on 3/9/22 at approximately 10:00 A.M., Resident #178 said he/she did not know his/her current weight. When the surveyor told Resident #178 when he/she was last weighed at the facility, his/her weight was 169 pounds, Resident #178 was surprised and said he/she had never weighed that much prior to coming to the facility. During the interview, Resident #178's legs and feet were not swollen. Review of Resident #178's weights indicated the following: On 08/27/21 143.4 lbs. (pounds) On 11/11/21 160 lbs. (a 11.58% weight gain in 3 months) On 01/19/22 159 lbs. On 02/22/22 168.8 lbs. (an additional 6.16% weight gain in 1 month) During an interview on 3/09/22 at 8:20 A.M., Unit Manager (UM) #1 said all residents have their weight taken weekly regardless of orders. UM #1 said that a physician and dietitian would need to be involved if a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . UM #1 said Resident #178 takes a daily diuretic [MEDICATION(S)] and has had to have a single extra dose on 3 occasions due to the Resident's medical condition of [CONDITION(S)]. Review of Resident #40's medical record indicated the following: *Review of the physician notes from November 2021 to present failed to indicate the physician was aware of Resident #178's weight gain. *A nutritional care plan last revised 9/29/21 with interventions that included a low sodium diet and education to the Resident for appropriate food and drink textures to consume. Review of the document titled, DSYC Quarterly Nutritional Assessment, dated 2/24/22, indicated the Dietitian was aware of the weight gain. The assessment indicated Resident #178's diuretics were increased but that there was no [CONDITION(S)] reported. The Dietitian questioned the Resident's compliance with his/her diet and made to following recommendations: *Consistently consume 50-75% meals to help meet nutritional needs while adhering to a low NA (sodium) diet, monitor labs, weight quarterly. During an interview on 3/09/22 at 10:37 A.M., Dietitian #1 said any resident with [CONDITION(S)] and a significant weight gain would benefit from being assessed by a dietitian and having appropriate interventions put in place. Dietitian #1 said Resident #40 had not been discussed at the weekly interdisciplinary team risk meetings and no dietary interventions had been put into place. During an interview on 3/09/22 at 12:04 P.M., UM #1, Nurse Practitioner (NP) #1 and NP #2 discussed Resident #40's weight gain. NP #1 said Resident #40 had multiple medical issues within the past 4 months with changes made to his/her diuretics. NP #1 said that although these changes were made, she felt that the weight gain had been so gradual that it was a true nutritional only weight gain and not due to [CONDITION(S)] or a medical concern. 5. For Resident #121 the facility failed to develop and implement interventions to prevent further weight loss. Resident #121 was admitted to the facility in June 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #121 is severely cognitively impaired, is an extensive assist for eating and weighed 156 pounds (lbs). Review of Resident #121's weights are as follows: On 11/04/21- 167 lbs On 12/22/21-156 lbs which equals a significant weight loss of 6.59% in 6 weeks. Resident #121 was hospitalized ,d+[DATE]-[DATE] On 02/09/22 - 156.6 lbs On 02/17/22 - 150.6 lbs On 03/01/22 - 150.2 lbs which equals a significant weight loss of 10.06% in 4 months. Review of the facility document titled Dietary Assessment and dated 3/4/22, indicated Resident #121 had a significant weight loss with no recommendations for further intervention. During an interview on 3/09/22, at 11:07 A.M., the dietician said she did know about the significant weight loss but did not put an intervention in place to prevent further weight loss. 6. Resident #27 was admitted to the facility in December 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #27 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognition. The MDS also indicated that Resident #27 required extensive assistance for all personal hygiene tasks and was independent for eating. Review of Resident #27's weight record indicated the following: 12/08/21: 180.6 pounds (lbs.) 12/26/21: 177.6 lbs. 12/29/21: 175.0 lbs. 01/12/22: 171.2 lbs. 01/18/22: 170.8 lbs. 01/21/22: 170.8 lbs. 02/02/22: 168.9 lbs 03/01/22:161 lbs. - 10.85 % weight loss from the 12/8/21 weight. Review of Resident #27's medical record indicated: -A Dietitian consult request dated 2/11/22 -A physician's order dated 2/11/22: May have nutritionist evaluate patient. Further review of Resident #27's medical record failed to indicate a dietitian consult was completed as ordered by the physician. During an interview on 03/09/22 at 10:28 A.M., Dietician #1 said she pulls up a weekly weight loss reports on Residents and communicates with the unit managers via email and if weight loss is unplanned, she makes recommendations. During an interview on 03/09/22 at 12:52 P.M., Dietician #1 said interventions put in place for Resident #27 included ensure plus which began in January 2022. The dietitian was unable to find any further documentation on Resident #27. During an interview on 03/10/22 at 10:45 A.M., Unit Manager (UM) #4 was unable to find documentation from the requested dietitian consult on 2/11/22 and was unable to say what happened.

Based on interviews and records reviewed, the Facility failed to prevent a significant medication error for 1 out of 3 sampled residents (Resident #1), when Resident #1 was administered Resident #3's medications including [MEDICATION NAME] (an opioid pain medication), and [MEDICATION NAME] (a sedative). Resident #1 became unresponsive and was transferred to the emergency room where he/she was administered [MEDICATION NAME] for the reversal of opioid overdose. Findings include: The Facility policy titled Medication Administration, dated September 2005, indicated the nurse would identify the resident by his/her name and by the facility identification system in place, for example, an identification bracelet, photo, etc. The Facility policy titled Identification of Residents/Patients dated 4/2016, indicated that staff who were not familiar with the resident would identify the resident using 2 forms of identification which included: the identification bracelet, a photo recorded in the Medication Administration Record [REDACTED]. Resident #1 was admitted to the Facility 11/6/16, and his/her [DIAGNOSES REDACTED]. physician's orders [REDACTED].#1 was not prescribed [MEDICATION NAME] or [MEDICATION NAME]. Resident #3 was admitted to the Facility 11/1/16, and his/her [DIAGNOSES REDACTED]. physician's orders [REDACTED].#3 was prescribed [MEDICATION NAME] 5mg every 6 hours as needed for pain and [MEDICATION NAME] 1mg three times a day as needed for anxiety. A Nurse Progress Note, dated 11/11/16, timed 11:30 P.M. indicated Resident #1 was transferred to the emergency room at 6:00 P.M. after he/she was found unresponsive. A Medication/Treatment Incident Report dated 11/11/16 indicated Resident #1 was administered Resident #3's medications in error, was found unresponsive, and was transferred to the emergency room . A Patient Care Referral Form, undated, indicated Resident #1 was found, unresponsive, with a low blood pressure, low respiratory (breathing) rate, and low oxygen level. The Referral form indicated that at 5:30 P.M. Resident #1 had received [MEDICATION NAME] 1 milligram (mg) and [MEDICATION NAME] 5mg. Nurse #1 was interviewed at 1:23 P.M. on 1/18/17. Nurse #1 said that on 11/11/16 at approximately 5:30P.M. a Certified Nurse Aide (CNA) told him Resident #3, who was Resident #1's roommate, had requested [MEDICATION NAME] and [MEDICATION NAME]. Nurse #1 said he did not identify the Resident or assess the Resident's pain level before administering him/her the medications. Nurse #1 said Resident #1 was found unresponsive, approximately 30 minutes later, and at that time he realized he had administered Resident #3's [MEDICATION NAME] and [MEDICATION NAME] to Resident #1 in error. A Hospital History and Physical Record, dated 11/11/16, indicated Resident #1 was admitted through the emergency room , was unresponsive, was arousable only with painful stimuli, had a low blood pressure, and required intravenous (IV) [MEDICATION NAME] (a medication used to reverse the effects of opioid medications) after having been administered [MEDICATION NAME] and [MEDICATION NAME] in error at the Facility. On 1/18/17 at the time of this Complaint Investigation, the Facility was found to be in past non-compliance, effective 12/11/16. The Director of Nurses was interviewed at 9:10 A.M. and throughout the day of this survey. The Director of Nurses said the Facility provided an education packet, which included the Facility's Medication Administration policy, to the staffing agency who employed Nurse #1, which was reviewed with Nurse #1. An inservice educational attendance sign in sheet, dated 12/11/16, indicated nursing staff had been re-educated to the Facility's policy and procedure for proper Resident identification prior to administration of medications. The Facility's Medication Error Report, dated December 2016, indicated Medication errors were documented and reviewed on an ongoing basis through the Facility's Quality Assurance Program. A written statement provided by the Director of Nurses on 2/27/17, indicated that on 11/11/16, the Director of Nurses had performed an audit of all medications administered by Nurse #1 on 11/11/16, and no other medication errors or discrepancies were identified.

Based on record review, observation and interview, the facility failed for 1 resident (#5) of 6 residents with pressure ulcers, in a total sample of 30 residents and 2 non-sampled residents to ensure a resident with a pressure ulcer received appropriate treatment and services to heal a pressure ulcer. The facility also failed to accurately measure Resident #5 's left ischial pressure ulcer. Findings include: Review of the Resident #5's clinical record on 1/29/14 indicated that the resident was admitted to the facility in 6/2011 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated that the resident had severe cognitive limitations (scoring a 3 out of 15 on the Brief Interview of Mental Status), required extensive assist with transfers and bathing, was totally dependent on staff for bed mobility and dressing, and had no pressure ulcers. Review of the facility's "Skin Management Program", dated November 2011, indicated the following: The "Weekly Pressure Ulcer Report" will be completed weekly by the licensed staff and should include description, size, and stage. Size: Measurements in centimeters (cm) as follows: *First - Length: longest measurement in a "head-to-toe" direction. *Second - Width: widest part in a "side-to-side" direction. *Third - Depth: deepest part of a wound, perpendicular to wound base. Percentage of eschar (dead matter that was cast off the surface of the skin), slough (necrotic tissue separated from living tissue), [MEDICATION NAME] (layer of cells), granulation (healing) should also be noted. Review of the clinical record indicated a physician's orders [REDACTED]. *Santyl ([MEDICATION NAME] agent) to left ischial pressure ulcer daily and cover with [MEDICATION NAME] and [MEDICATION NAME]. *Wash wounds with soap and water. *Continue to turn side to side. Review of Weekly Pressure Ulcer Report indicated the following: * 01/07/14 - appears as Stage 3; size: (length) 1.5 cm by 1.5 cm (width), depth was left blank; appearance of base - necrotic; quantity of necrotic tissue was to be measured by percentage and, nursing only documented an "N" for necrotic. Drainage - serosanguinous (thin bloody drainage). Odor was present. *01/14/14 - appears as Stage 3; size: 2.5 cm by 1.8 cm, depth was left blank; appearance of base - necrotic, quantity of necrotic tissue was to be measured by percentage, nursing only documented an "N" for necrotic. Drainage - serosanguinous. Odor was present. *01/21/14 - appears as Stage 3; size: 3 cm by 2 cm, depth was left blank; appearance of base - necrotic, quantity of necrotic tissue was to be measured by percentage, nursing only documented an "N" for necrotic. Drainage - serosanguinous. Odor was present. *01/28/14 - appears as Stage 3; size: 3 cm by 4 cm, depth was left blank; appearance of base - necrotic, quantity of necrotic tissue was to be measured by percentage, nursing only documented an "N" for necrotic. Drainage - was left blank. Odor was present. Review of the National Pressure Ulcer Advisory Panel guidelines indicated the following definitions: *Stage III pressure ulcer was defined as a full thickness of tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. *An unstageable pressure ulcer was defined as full thickness tissue loss in which actual depth of the ulcer was completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar were removed to expose the base of the wound, the true depth cannot be determined. *Stage IV pressure sore was defined as a full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The facility termed the resident's pressure ulcer as Stage III when it actually was unstageable. Review of the Consultant Wound Doctor's progress notes indicated the following: *01/07/14 - Left ischial pressure ulcer (Stage 3) has some dried necrotic tissue at base. Remains fairly shallow at 0.3 cm deep. Recommend Santyl to left ischial pressure ulcer every day. *01/21/14 - No improvement in left ischial pressure ulcer. Still a deep stage 3 with necrotic tissue over 30 percent of base. Recommend continue same dressings as above, off load as much as possible. A treatment observation on 1/29/14 at 1:45 P.M. revealed a pressure ulcer with approximate dimensions of 3 cm by 4 cm, and depth of approximately 2.5 cm. From the 7 o'clock to the 12 o'clock section of the wound, this tissue was beefy red in color. The tissue from 12 o'clock to the 7 o'clock was black with surrounding slough (nonviable tissue). The skin surrounding the wound was deep purple in color. The odor from the wound was foul. During this observation, the surveyor asked Nurse #3 about measuring the depth (because there was no documentation of the depth on the facility "Weekly Pressure Ulcer Report"). Nurse #3 said that it would get worse before it got better, therefore he didn't measure the depth. Nurse #3 continued to say that the resident was being followed by the wound doctor. The surveyor asked when the wound doctor would see this resident again. He said not until next Tuesday (02/04/14). The resident was last seen by the wound doctor on 1/21/14. During an interview on 1/29/14 at 3:00 P.M., Nurse Manager (NM) #3 said that she was not aware that staff were not measuring the depth of the pressure ulcer and that measuring the depth of a pressure ulcer was part of the facility pressure ulcer protocol. She said she would have the nurse measure the depth when he did the dressing change tomorrow. On 01/30/14 at 2:00 P.M., Nurse # 3 and NM #3 said they would obtain accurate measurements of the resident's left ischial pressure ulcer. During this observation of the wound, the surveyor observed Nurse #3 measure the wound. The measurements were 3.7 cm (length) by 2.8 cm (width) by 2.7 cm (depth). NM #3 was present. NM #3 agreed that the wound area from 7 o'clock to 12 o'clock was deeper with healthier tissue, and because the wound doctor would not be in the facility until next week, she would call him to see if they should make changes in the treatment plan. Further interview on 1/30/14 at 4:00 P.M., NM #3 said that the wound doctor was notified and a new treatment order has been put into place. The wound will now be packed with [MEDICATION NAME] AG rope (a silver impregnated microbial dressing for the absorption of fluids from the wound) and covered with a foam dressing daily. The physician also ordered a culture and sensitivity of the wound.

Based on record review, interview and observation for 1 of 3 sampled residents (Resident #1) the Facility failed to ensure that the plan of care was followed to prevent injury and the personal alarm was plugged in and functioning. On 8/10/12 Resident #1 fell from his/her chair and, on inspection, staff determined that the alarm box was not connected to the sensor pad and as a result the alarm did not sound. Resident #1 required a personal alarm, per the plan of care. Resident #1 sustained a concussion, hematomas and a laceration to the lower part of the left ear requiring sutures. Findings include: Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 6/05/12, indicated the following conditions: impairments in short and long term memory; moderately impaired cognitive skills for daily decision-making (decisions poor; cues/supervision required); a [DIAGNOSES REDACTED]. Resident #1's plan of care, last reviewed on 6/19/12, indicated that he/she was at a risk for falls. Interventions included a chair sensor alarm to alert staff. Resident #1's physician orders, dated September 2011, indicated that Resident #1 required a bed and chair alarm at all times. Resident #1's treatment record, dated 8/10/12, indicated that the 3:00 P.M. to 11:00 P.M. nurse (Nurse #1) initialed that Resident #1's personal sensor alarm functioned. Resident #1's nurse's note, dated 8/10/12, indicated that staff found Resident #1 on the bedroom floor. The note indicated that Resident #1 told staff that he/she "just got up, for no reason", or words to that effect. The note indicated that nursing staff assessed Resident #1, informed the Physician, and transferred Resident #1 to the Hospital for treatment. Resident #1's incident report, dated 8/10/12, indicated that at approximately 7:15 P.M. nursing staff discovered Resident #1 on the bedroom floor. The report indicated that nursing staff assessed Resident #1 and determined that he/she sustained a laceration behind the left ear and back of the head and bruising to to the left side and back of the head. The report indicated that Resident #1's personal alarm was not plugged in (to the sensor pad). The Facility's policy and procedure for the fall prevention and reduction program, dated September 2011, indicated that nursing staff were required to check device/equipment for proper functioning and placement every shift and as appropriate. The Surveyor interviewed Resident #1 on 9/07/12 at 2:40 P.M. Resident #1 said that he/she recalled falling in the bedroom and that no one was in the room at the time of the fall. Resident #1 said that, when he/she fell , the alarm on his/her chair did not sound. Resident #1 said that he/she did not detach the sensor pad cord from the alarm box. The Surveyor interviewed Certified Nurse Aide (CNA) #1 on 9/07/12 at 2:10 P.M. CNA #1 said that she was assigned to care for Resident #1 on 8/10/12 during the 7:00 A.M. to 3:00 P.M. shift. CNA #1 said that at approximately 1:15 P.M. she transferred Resident #1 from his/her bedroom chair to the toilet and then returned Resident #1 to the chair. CNA #1 said that she knew that the alarm system was in place and functioning on the chair because she heard the alarm box "beep", indicating that the system was functioning. CNA #1 said that no one transferred Resident #1 from the chair for the remainder of the shift. The Surveyor interviewed CNA #2 on 9/07/12 at 3:15 P.M. CNA #2 said that she worked on Resident #1's unit on 8/10/12 during the 3:00 P.M. to 11:00 P.M. shift. CNA #2 said that she entered Resident #1's bedroom at approximately 4:00 P.M. and observed Resident #1 sitting in his/her chair. CNA #2 said that she asked Resident #1 if he/she wanted to be toileted. CNA #2 said that Resident #1 declined and that CNA #2 then left the bedroom to provide care to other residents. CNA #2 said that, per Facility policy, she was supposed to check Resident #1's alarm system to ensure that it was in place and functioning, but that because Resident #1 declined to be toileted and no transfer took place, CNA #2 forgot to complete this task. CNA #2 said that she did not communicate to Nurse #1 whether Resident #1's personal alarm was in place or not. CNA #2 said that at approximately 6:15 P.M. she checked in on Resident #1 and he/she was still seated in the bedroom chair. CNA #2 said that at approximately 7:00 P.M. she heard Resident #1 yelling from his/her bedroom. CNA #2 said that she entered the bedroom and observed Resident #1 on the floor. CNA #1 said that she alerted licensed nursing staff at this time. The Surveyor interviewed Nurse #1 on 9/07/12 at 1:45 P.M. Nurse #1 said that she worked on Resident #1's unit on 8/10/12, from 7:00 A.M. until 11:00 P.M. Nurse #1 said that, prior to the fall, Nurse #1 did not personally examine Resident #1's personal alarm system to determine if it was in place or functioning. Nurse #1 said that it was the responsibility of the CNAs to check the alarms for placement and functioning. Nurse #1 said that she did initial on the treatment sheet that Resident #1's personal alarm was on and functioning during both shifts. Nurse #1 said that, after Resident #1's fall, she entered the bedroom and assessed Resident #1. Nurse #1 said that Resident #1's personal alarm was not sounding. Nurse #1 said that she examined the alarm and observed that the sensor pad with its attached cord was in place on the chair seat but that the other end of the cord was not attached to the alarm box, which hung from the bed siderail. The Surveyor interviewed the Unit Manager on 9/07/12 at 2:55 P.M. The Unit Manager said that she worked on the Resident's unit on 8/10/12, at the time of Resident #1's fall. The Unit Manager said that, after assessing Resident #1, she examined the personal alarm system and determined that the electrical cord from the sensor pad, located on Resident #1's chair seat, was not plugged into the alarm box, which was placed on Resident #1's bed siderail. The Unit Manager said that she plugged the sensor pad into the alarm box and tested the system and the alarm box sounded. The Unit Manager said that the battery and all other parts of the personal alarm system functioned properly. The Hospital Short Stay Summary, dated 8/11/12, indicated that Resident #1 was evaluated following a fall at the Facility which resulted in a large hematoma to the back of the head, a concussion and a laceration to the lower left earlobe which required sutures (number of sutures not documented).

Based on observation, staff interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 sampled resident (#18) of 7 sampled residents who had sustained bruises and/or abrasions as identified by the facility roster and/or resident assessments, out of a total sample of 30 residents. Findings included: The facility failed to provide adequate supervision and failed to implement an effective care plan to prevent injury to Resident #18, who was confused, dependent on staff for transfers and mobility, with poor safety awareness and gait instability. For Resident #18, the facility failed to develop and implement effective interventions as evidenced by the facility's failure to ensure safe staff transfers of the Resident, failure to place protective padding on the Resident's wheelchair when it was known that the resident sustained [REDACTED]. Record review and review of facility incident reports revealed that over 10 months, between 11/9/09 and 9/15/10 (the exit date of survey) there were 11 documented incidents (10 reportedly unwitnessed) in which the resident sustained [REDACTED]. The 9/2/10 injury resulted in a large blood filled hematoma in the Resident's right lower leg and a subsequent deep vein thrombosis in the right lower leg diagnosed on [DATE] requiring the insertion of a filter. Resident #18 was admitted to the facility in 7/09 with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment of 8/6/09 indicated that the resident was moderately impaired in cognitive skills for decision making, with a short term and long term memory problem, required extensive assistance of two staff for bed mobility, transfers, walking, toilet use, and bathing, was total dependence of one staff for wheelchair locomotion on the unit and off the unit, had limitations in range of motion and partial loss of voluntary movement of both arms, had fallen in the past 31 to 180 days, had edema and an unsteady gait. The 9/27/09 care plan addressed use of Aspirin daily with increase risk for bruising/bleeding. The related interventions included: - Conduct a systematic skin inspection weekly, daily. - Tubi pads bilateral arms on in am (morning) off at night. a. ) Review of the following facility incident reports for Resident #18 revealed the facility's failure to implement effective interventions to reduce the risk factors associated with injury (related to the use of a wheelchair that was not padded, and unsupervised attempts to ambulate): - On 11/9/09 at 9:00 pm 2 purple bruises to left knee care (6.5 cm by 2.5 cm and the other was 4 cm by 1.5 cm). Probably bumped knee while propelling self in wheelchair. - On 2/22/10 at 6:30 am CNA noted 2.5 by 2 deep purple top of left hand. 11 to 7 notes increasing agitation with continual attempts to get out of bed and later out of the chair, will pad 1/2 side rails. - On 3/6/10 at 4:15 pm the Resident's leg was caught on a piece of the wheelchair when CNA #1 was transporting the Resident and the resident sustained [REDACTED].The supervisor's follow up on 4/6/10 documented "Physical therapy consult ? wheelchair padding." On 9/15/10 at approximately 2:00 pm, surveyor interview with the Director of Nurses (DNS) confirmed that at the time of the incident on 3/6/10 the Resident's care plan called for a two person assist to transfer. The DNS reported that the CNA involved in this incident, who had performed the transfer with 1 assist, was disciplined and counseled regarding the need to follow the Resident's care plan. The DNS further confirmed that the PT consult was not obtained and the Resident's wheelchair was not padded although the Resident had sustained injury on 3/6/10 due to banging against the wheelchair. b.) The Resident continued to sustain injuries (while using an unpadded wheelchair) as detailed in the following excerpts from the facility's incident reports and incident follow up documentation. - On 3/25/10 at 7:00 pm a 5 by 2.5 cm "purple, ecchymotic area on left mid thigh noted while toileting Resident." - On 4/12/10 at 9:30 am CNA noted a 12 cm by 5 cm ecchymotic area to left flank area. Immediate activity prior to incident resident self propelling in wheelchair. Resident uses handrail to proper self when up in wheelchair. She also uses the public restroom on C unit, and pulls herself up using the hand rail. - On 5/22/10 at 10:00 am CNA reported a 7 cm by 2 cm purplish/blue bruise left wrist, 2 cm circular bruise below left chin - purplish blue. Witnessed resident yesterday propelling herself in wheelchair using hand rail and standing at nurses station trying to reach plant. - On 7/20/10 at 12:00 am CNA's were toileting Resident before putting her to bed and noticed a total of 7 bruises on the front and back of the resident's arms extending under the resident's arm pits and one bruise on the left wrist. - On 8/24/10 at 2:20 pm staff toileting resident in afternoon noted 3 cm bruise pubic area. Resident was reported to be up all night (11 pm -7 am) banging into wheelchair - standing at siderails. Writer also witnessed resident standing up and leaning against lunch table. - On 8/30/10 at 6:00 am when a CNA went into the day room to redirect the Resident, she noted a bruise to left side of neck that was described as 6.5 by 6.5 cm bruise - irregular shaped and light purple and left at left side of neck and a 2 by 1 cm circular purple bruise to left occipital - slightly swollen. Resident #18 had been up propelling self in the dayroom since 2:00 am on the morning the bruise was found, with periods of motor restlessness. May have bumped her neck on the wing of the recliner. - On 9/2/10 at 10:45 am, prior to am care, CNA found a bruise on the Resident's calf. Prior to the incident, the Resident was in a wheelchair (that was not padded) in the hallway. The bruise was described as "a 10 cm by 15 cm purple bruise to right inner calf 8.3 by 9.0 swelling, distal to the bruise was a 0.5 by 1.0 skin tear with scant amount of serosanguineous drainage. Faded bruise to right knee." On 9/2/10 "from 9:30 am to 10:00 am prior to the injury being discovered the resident was sitting in wheelchair and had taken off her sweatshirt and unsnapped her Johnny, had increased agitation was not able to be verbally redirected and was given a prn (as needed) Ativan (antianxiety medication)." The Resident's annual MDS conducted on 9/2/10 indicated that the Resident now had a stage II pressure ulcer, however, no overall change in the Resident's care needs. On 9/2/10, the Resident's care plan for bruises was updated to include the problem of self inflicted bruises as the Resident self propels in the wheelchair and 9/2/10 large hematoma right lower extremity with small skin tear. A goal was added: "area will resolve with use of proper treatment/interventions." The only new interventions added to this problem area at this time were skin prep to left heel and no shoes until area healed. These interventions were to address the pressure ulcer which had developed on the Resident's heel. There were no specific interventions documented to prevent this Resident from further injury. c.) The facility's incident investigative document below reflected that on 9/3/10 the Resident's calf hematoma was noted to burst open and the facility could not explain how the injury occurred. However, as noted below, immediately after the incident CNA #2 was observed transferring the Resident with one assist instead of two. - On 9/3/10 at 10:00 am it was reported that the hematoma on the Resident's calf burst open. Shortly after this report on the morning of 9/3/10, when the Nurse Practitioner (NP) entered the Resident's room to evaluate the right lower extremity, the NP observed CNA #2 transferring the resident from the toilet to the wheelchair with one assist, and no gait belt. It was determined by the facility at this time, that "the possibility that CNA #2 may have caused the initial injury to the resident's right calf on 9/2/10 by not following the care plan could not be ruled out as CNA #2 was assigned to Resident #18's unit on 9/2/10 and may have provided care to Resident #18 at this time." Interview with the DNS on 9/15/10 revealed that CNA #2 was terminated after this incident as the CNA had been instructed only a couple of hours before of the need to follow the CNA care card for transfer of two assist and the use of a gait belt for Resident #18. In addition, the DNS said this CNA had received a disciplinary warning/counseling previous to this one on 8/10/10, due to failure to follow another resident's care plan for geri sleeves which resulted in a skin tear to this non sampled resident. On 9/9/10 at 2:33 pm the surveyor observed the wound on Resident#18's right leg during a dressing change. The Resident was sitting in a sofa recliner during the dressing change with her legs elevated. The area was on the Resident's right lower leg just below the knee on the mid front section and extended to the inner part of the calf. The area appeared almost circular and was approximately 4.5 inches long by 5 inches wide. The main wound bed was red and raw and was oozing serosanguineous fluid. The top perimeter of the wound was purple, and it appeared that the outer layer of skin from a blister had rolled back and was resting at the top half of this wound. The bottom edge of the wound had a section that was blackened. The DNS described the wound as a hematoma (sustained on 9/2/10) that had blistered and then burst open on 9/3/10. On 9/10/11, the Resident was sent out to the hospital for a question of a Deep Vein Thrombosis (DVT) which was confirmed by the hospital. The Resident returned to the facility on [DATE], status [REDACTED]. Upon return from the hospital, the Resident's care plan included the intervention to elevate the Resident's legs. Although the care plan called for leg elevation, the following observations (as noted below) were made of this Resident seated in a wheelchair that had not protective padding on it, and had footrests with no calf supports. Instead of the Resident's legs being elevated, the Resident was observed attempting to move the wheelchair, which had the brakes locked, using her legs and feet to self propel and in doing so was observed to bang her legs and feet into the wheelchair footrests. In addition, the Resident was observed to attempt to unlock the wheelchair brakes and was observed hitting her hands against the wheel of the chair and brakes as she tried to move the chair and unlock the brakes. Although CNAs and nurses on the unit observed this behavior they did not intervene. Note: The Resident's wheelchair did not have a mechanism to elevate the footrests. On 9/14/10 at 10:55 am, Resident #18 was observed in the dining room seated at a table in a wheelchair that was not padding. The wheelchair had footrests attached. The footrests included a bottom rest for the resident's feet, but did not include a back support for the calves. On each metal footrest about 1/3 of the way up the leg piece, there was a ring of a hard material (question plastic or metal) around the bar that was about 1/2 inch wide with a hard piece of metal or plastic protruding from it. Although this piece was not razor sharp, the edges could cause injury if bumped into as they were not smooth. The Resident had slipper socks on her feet and was observed moving her left leg on and off the footrest trying to get her foot on the floor. As the Resident did this, her foot was banging into the footrests. In addition, the Resident did not have Tubi pads on her arms as ordered. On 9/14/10 at 11:32 am, this Resident was observed still sitting at the table in the wheelchair (that was not padded) in the dining room. At this time, the Resident was observed to have her left foot off the footrest, and behind the back of the left footrest. The top of the Resident's left foot was hitting the back of the footrest. The Resident was still wearing slipper socks and had no Tubi pads on her arms. On 9/14/10 at 11:45 am this Resident was observed in the dining room, and was pushing against the table with her hands in attempt to move her wheelchair away from the table. The Resident was observed reaching down trying to grasp the wheelchair lock to unlock it but was unsuccessful in unlocking the chair. The Resident was able to push her wheelchair away from the table about 1 foot and a CNA came over and intervened and put her feet back up on the footrests and pushed her back to the table. On 9/14/10 at 12:35 pm this Resident was observed still sitting in the dining room awaiting lunch. The Resident at this time was observed with both her feet behind the footrest and was propelling by thrusting her body forward in the chair and pushing with her feet. The chair was inching forward only a couple of inches with each thrust as the brakes were locked. The Resident propelled herself about 6 ft away from the table and was making her way to the door when a CNA intervened and wheeled her out into the hallway. When the CNA wheeled the resident she did not put the Resident's feet up on the footrests and they were dragging behind for a few seconds before the CNA realized it and then put the Resident's feet on the footrests. The CNA wheeled the Resident in the corridor for a few minutes then brought the Resident back to the table in the dining room. On 9/14/10, at 2:30 pm the Resident was observed in the wheelchair (that was not padded) in the dining room still with no Tubi pads on her arms and her feet were on the footrests. On 9/14/10, at 2:50 pm, Charge Nurse #6 was interviewed as to whether the Resident was suppose to have Tubi pads on her arms. The charge nurse did not know and then looked in the record and confirmed that these should have been on. The surveyor then informed the nurse that the Resident did not have the Tubi pads on and asked where they were. The nurse then went to the Resident's room and found the Tubi pads on the Resident's bedside stand. The nurse said sometimes she refuses to wear them. The nurse left the Tubi pads on the bedside stand and made no attempt to put them on the Resident. On 9/14/10 at 3:15 pm, the Resident was observed in the wheelchair in the Dining Room while an activity was going on. The Resident, at this time, was observed with both her feet behind the footrests propelling by pushing on the heels of her feet. The Resident pushed herself backwards in the wheelchair all the way to the door about 6 feet before an activity staff person stopped her, put her feet back on the footrests and wheeled her back to the table. The Resident was still wearing slipper socks and had no Tubi pads on. On 9/14/10 at 4:00 pm staff wheeled the Resident from the dining room to the small activity across from the nurses station. On 9/14/10 from 4:10 pm to 4:14 pm the Resident was observed in the wheelchair (that was not padded), in the small activity room across from the nurses station. During this time, the Resident once again was observed with her feet off the footrests and slowly (as the brakes were locked) inching the wheelchair towards the doorway. During this time the resident was observed reaching down the sides of the wheelchair numerous times as she tried to no avail to unlock the wheelchair brakes. At one point, the Resident was leaning forward and holding onto the top of the leg rest as she tried to propel herself forward. When the Resident got to the doorway, she reached up and was holding onto the door frame and a chair outside the door to pull herself through the doorway. Although there were several staff at the nurses' station, they did not intervene to assist the Resident as she was pulling herself out of the room. Then at 4:15 pm the MDS Coordinator, who walked by, noticed the Resident pulling herself out of the activity room and intervened by unlocking the wheelchair brakes and moving the legrests to the sides of the wheelchair so that the Resident could self propel without banging her feet and legs into them. On 9/15/10 from 8:05 to 8:45 am, Resident #18 was observed in the dining room seated at a table in a wheelchair that was not padded. The Resident was wearing Tubi pads on her arms and had a heel protector on her right foot and slipper sock on the left foot. The wheelchair had footrests attached. The Resident's left foot was off the left footrest and resting behind it. On 9/15/10 from 9:50 am to 10:35 am, Resident #18 was observed sitting in this wheelchair in the hall, sound asleep, outside her room. At 9:50 am, the back of her right foot was observed resting against the top edge of the footrest. At 10:25 am, the right foot was still off the foot rest as well as the left foot, which was off the footrest to the left side of the footrest. On 9/15/10 at approximately 10:40 am, the surveyor observed two CNAs providing morning care to this Resident and observed the following bruises which were not documented in the resident's record: - right forearm 0.5 cm small abrasion - right hand deep red and purple area about 2 cm long and 0.5 cm on top of wrist - inner left wrist/hand two nickel size bruise red and purple in color - left leg just below the inner ankle two rectangular shaped small reddish purple bruises approximately 1.5 cm by 2.0 each In addition at this time, the following faded bruises, which were documented in the Resident's record, were observed on the Resident: - a bruise on the pubic area about 3 inches wide and 3 inches long that was faded in the center and outlined on the sides with a deep purple line with some red colors splattered throughout - left upper arm outer small light purple circular bruise approximately 1.5 cm - left hip faded circular bruise about 2.0 cm and two small faded bruises on upper outer thigh - right upper arm small about 0.5 cm bruise - left knee faded bruise - top of right hand darkened skin.