Every finding on record at Edgehill Health Center

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #8) reviewed for falls, the facility failed to ensure that the resident's clinical record reflected complete and accurate information related to falls and frequent monitoring. The findings include:Resident #8 was admitted to the facility in June 2025 with diagnoses that included Parkinson's disease, dementia, and repeated falls. The quarterly MDS dated [DATE] identified Resident #8 had severely impaired cognition, was frequently incontinent of bowel and bladder and was dependent on staff for bathing, toileting, and transfers. The care plan dated 9/3/25 identified Resident #8 was at risk for falls due to Parkinson's disease, cognitive deficits, and history of falls. Interventions included floor mats to both side of the bed, bed in the lowest position, monitoring out of bed activity, and visually check every 15 minutes.Review of a facility accident and incident (A&I) report identified Resident #8 had an unwitnessed fall on 10/27/25 at 8:00 AM. The report identified Resident #8 was observed kneeling on a floor mat in his/her room with his/her arm stuck in a bedrail. The report further identified that an x-ray of the right shoulder was ordered by the APRN which was negative.An immediate needs care plan for falls dated 10/27/25 included interventions of every 30 minutes checks for 3 days and that Resident #8 also had a private duty aide in place from 9:00 AM - 6:00 PM daily. Review of the 15-minute check documentation form dated 10/27/25 identified that Resident #8 was in the facility's dining room at 8:00 AM. The 15-minute check documentation form also identified Resident #8 was in the facility's dining room at 8:15 AM, 8:30 AM, and 8:45 AM.Review of a facility A&I report identified Resident #8 had a 2nd unwitnessed fall on 10/27/25 at 8:45 AM. The report identified Resident #8 was observed sitting on a floor mat leaning against the bed. The report further identified Resident #8 had no visible injuries.A subsequent immediate needs care plan for falls dated 10/27/25 directed for checks every 15 minutes for 3 days. Review of a facility A&I report identified Resident #8 had an unwitnessed fall on 11/20/25 at 10:35 PM. The report identified Resident #8 was observed on the floor lying on his/her right side, with the resident's lower body on the floor mat and upper body on the floor. An immediate care plan for falls dated 11/20/25 identified Resident #8 had a fall. Interventions included initiation of checks every 15 minutes for 3 days.Review of the 15-minute check documentation form dated 11/20/25 failed to identify any checks were done following Resident #8's fall at 10:35 PMReview of a facility accident and incident A&I report identified Resident #8 had 2nd unwitnessed fall on 11/20/25 at 11:10 PM. The report identified Resident #8 was observed with the right side of his/her face on the floor mat, and the resident's lower body on the bed. A subsequent immediate needs care plan for falls dated 11/20/25 directed for checks every 15 minutes for 3 days.Review of the 15-minute check documentation form dated 11/20/25 failed to identify any checks were done following Resident #8's fall at 11:10 PM. Further review of the form failed to identify any checks were done until 7:30 AM the following day. Interview with the DNS on 2/10/26 at 11:40 AM identified that there was an issue with documentation on the facility monitoring forms and that the forms should have been filled out completely and accurately. The DNS identified that there was some confusion among the staff about who should be documenting on the forms (nurses or nurse aides) and that in addition, Resident #8 had a private duty aide for several hours during the day and evening shifts. The DNS identified that while Resident #8 did have either 1:1 care with his/her private duty aide or from facility staff, Resident #8 did have frequent checks, but the staff was not documenting the checks accurately. The DNS identified that the facility was working on addressing the issue and the facility would likely be moving away from 15 and 30 minute checks in the future. The DNS also identified the Resident #8's falls on 10/27/25 occurred in the resident's room and not in the dining room, and that the 15-minute documentation was incorrect. Although requested, the facility failed to provide a policy on 15-minute checks, 30-minute checks, frequent monitoring and clinical documentation. The facility policy on falls directed that staff would monitor and document the resident's responses to interventions intended to reduce falling or risk of falling.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #7) reviewed for pressure ulcers, the facility failed to ensure a resident with a chronic wound was placed on enhanced barrier precautions (EBP), and for 1 resident (Resident #17) reviewed for transmission-based precautions, the facility failed to utilize Personal Protective Equipment (PPE) in accordance with policy and infection control standards of practice for a resident requiring contact precautions. The findings include: Resident #7 was admitted to the facility in May 2025 with diagnoses that included dementia, spinal stenosis, and ataxia. A physician's order dated 5/14/25 directed to admit Resident #7 to hospice level of care. The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition, was dependent for rolling left to right and chair/bed to chair transfers, was at risk of developing pressure ulcers/injuries, and had one -Stage 3 pressure ulcer. The care plan updated 2/3/26 identified Resident #7 had an alteration in skin integrity related to a right foot heel wound and left foot wound, with interventions that included administering treatments per the physician's order, monitoring and documenting wound condition, and observing wounds for signs of infection or deterioration. The care plan failed to identify Resident #7 was on EBP. The Weekly Pressure Ulcer Report dated 2/3/26 identified Resident #7 had a stage 4 facility acquired pressure ulcer (onset date 10/27/25) to the left heel measuring 1.8 x 1.0 x 0.5cm and an unstageable pressure injury to the right foot, (onset date 1/6/26) measuring 1.0 x 1.8 x 1.8cm. A physician's order dated 2/6/26 directed to cleanse the left heel wound with normal saline and pat dry, apply Medi honey gel followed by Calcium Alginate, and cover with a foam dressing, daily. Further, the physician's order directed to apply Medi honey gel, followed by Calcium Alginate to the right foot superficial heel wounds, and cover with a foam dressing daily. The physician's orders did not identify an order for EBP. Observations on 2/8/26 at 8:35 AM and 2/9/26 at 12:15 PM identified no signage or PPE outside the resident's room regarding EBP. Observation of LPN #1 and NA #1 on 1/9/26 at 12:15 PM failed to identify LPN #1 and NA #1 were wearing gowns during Resident #7's wound care, (a high-contact resident care activity) which included: the removal of a lightly soiled foam dressing to the left heel and dressing removal of the right foot wound, wound cleansing, the application of the prescribed wound treatments, and new foam dressing applications to the left heel and right foot. Interview with the facility's Nurse Consultant (to become the DNS) on 2/10/26 at 7:30 AM identified that she would expect Resident #7 to have been placed on EBP, and she would expect staff to wear the appropriate PPE, which would include a gown and gloves, while providing wound care to an open area. Observation on 2/10/26 at 8:10 AM of Resident #7's door identified signage directing staff to adhere to enhanced barrier precautions and indicating the type of personal protective equipment (PPE) required while performing high-contact resident care activities,. Interview with the current DNS/Wound Nurse on 2/10/26 at 8:37 AM identified that Resident #7 was just placed on EBP and he was not sure why enhanced barrier precautions were not in place prior to surveyor inquiry. The DNS/Wound Nurse indicated that it was realized after the fact, and that he would expect staff to wear PPE, including a gown and gloves, during a chronic wound dressing change. The DNS/Wound Nurse further indicated that he would have to check with the facility's Infection Control/Staff Development Nurse to see what type of education had been provided to the nursing staff about EBP. Interview with the Infection Control/Staff Development Nurse (RN #1) on 2/10/26 at 8:45 AM identified that he did not place Resident #7 on enhanced barrier precautions because the area started off as a blister and he did not realize that it had opened and progressed to a stage 4. RN #1 indicated that it was his responsibility to review the resident's clinical record for such updates, and he did not keep up on that. RN #1 identified that he would obtain documentation regarding EBP in-servicing for the nursing staff. Interview with RN #1 on 2/10/26 at 12:27 PM identified that after further review, the annual Infection Control: Essential Principles on-line learning module assigned to the nursing staff did not include educational content related to enhanced barrier precautions. RN #1 indicated that the last in-service related to enhanced barrier precautions was completed in July 2022. RN #1 further indicated that he initiated EBP education for nursing staff, this morning. The facility's Enhance Barrier Precautions policy directs for EBP to be utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. EBP is used as an infection prevention and control intervention to reduce the spread of MDRO's to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Glove and gowns are applied prior to performing the high contact resident care activity, PPE is changed before caring for another resident, and face protection may be used if there is also a risk of splash or spray. Examples of high contact resident care activities requiring the use of gown and gloves for EBP include wound care, dressing, bathing, providing hygiene, device care, and changing linens. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required. 2. Resident #17 was admitted to the facility in 8/2025 with a diagnosis that included enterocolitis related to clostridium difficile or C-diff (spore spreading bacterium causing severe diarrhea and colitis). The quarterly MDS dated [DATE] identified Resident #17 was severely cognitively impaired and required one person assist with bed mobility, two persons for transfers and toileting. The care plan dated 12/9/25 identified Resident #17 had active c-diff infection with sepsis. Interventions included contact precautions for an active infection and administer antibiotics as ordered. Physician's order dated 1/23/26 (original 11/7/25) directed contact isolation precautions. a. Observation on 2/8/26 at 8:25 AM identified a Contact Precautions sign was posted outside Resident #17's door (gown and gloves required before entering the room) with an isolation cart containing PPE (gowns, masks, no gloves). Housekeeper #1 was in Resident #17's room sweeping the floor wearing gloves and a mask but without the benefit of an isolation gown. Interview with Housekeeper #1 on 2/8/26 at 8:25 AM identified that she was aware an isolation gown was required for contact precautions but indicated one was not necessary prior to entering Resident #17's room because she was cleaning the environment with no direct resident contact. Interview with the Director of Operations on 2/8/26 at 8:30 AM identified he also observed Housekeeper #1 enter Resident #17's room without an isolation gown and identified she should have been wearing the required PPE before going into the room. b. Observation on 2/10/26 at 7:57 AM identified the Program Coordinator entered Resident #17's room without PPE. The Program Coordinator had a brief conversation with Resident #17, provided an activity schedule and exited the room. Person #1, a private duty nurse aide was also observed at Resident #17's bedside assisting the resident with breakfast without PPE. Interview with Person #1 on 2/10/26 at 7:57 AM identified she was aware Resident #17 was on contact precautions and should have been wearing PPE while in the room but had used the bathroom and did not replace the PPE before resuming care with Resident #17. Interview with the Program Coordinator on 2/10/26 at 8:07 AM identified he was aware Resident #17 was on contact precautions but assumed PPE was not required if not providing direct care. Interview and policy review with the DNS on 2/10/26 at 8:10 AM identified for a resident on contact precautions PPE was only required when providing direct care but indicated she wanted to consult with the infection preventionist (IP). An interview with RN #1 on 2/10/26 at 8:10 AM identified he was the IP for the facility and responsible for infection control education. RN #1 indicated a disposable isolation gown, and gloves were to be put on prior to entering the room for a resident on contact precautions. This was required for all staff including those not having direct contact. For Resident #17, this was especially important because the infecting bacteria formed spores that remained on environmental surfaces. Proper use of PPE prevents the spread of infection from the environment. A review of the Transmission-Based Precautions policy directed that contact precautions are to be implemented for residents known or suspected of being infected with microorganisms that can be transmitted by direct contact or indirect with environmental surfaces. The individual on contact precautions is placed in a private room if possible. Staff and visitors wear a disposable (isolation) gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after the gown is removed. Signage for contact precautions for staff and visitors directed that all providers and staff must put on gloves and a gown before room entry and before room exit and do not wear the same gown to care for other residents. A review of the facility policy for Precaution Room Cleaning Best Practices directed that staff entering the room wear gloves and protective clothing.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to ensure staff had current Cardiopulmonary Resuscitation (CPR) certifications. The findings include: Resident #1 had a diagnosis of right hip fracture, anemia, hypertension (high blood pressure), cerebral infarction without residual deficits and chronic kidney disease. Nursing admission note dated [DATE] at 3:21 PM identified Resident #1 was alert and oriented, and was oriented to surroundings. The Resident Care Plan dated [DATE] identified Resident #1 had difficulty chewing or swallowing related to cerebral vascular accident. Interventions directed to prepare foods to recommended consistency of speech therapist and ordered by MD. The physician order dated [DATE] directed Resident #1 was a full code (to receive CPR if necessary). Speech therapy evaluation dated [DATE] at 11:37 AM identified Resident #1's diet was changed to dysphagia level 3 chopped, adequate oral clearance was noted, no overt signs or symptoms of aspiration observed, and was self-feeding with set up. The physician order dated [DATE] directed Resident #1 to receive a dysphagia level 3 chopped diet. Accident and Incident report dated [DATE] identified at 6:05 pm Resident #1 became unresponsive during dinner after he/she had consumed soup and some swordfish. The resident's meal was reviewed, and identified the resident had received the correct diet. Family was present during the meal and indicated they thought the resident choked, 911 was activated and the Heimlich was performed with no bolus/food and no return of respirations. CPR was initiated. Emergency Medical Services (EMS) scoped Resident #1 and no food was found in the airway. EMS intubated and transported Resident #1 to the hospital, and Resident #1 expired at 7:14 PM. The facility report indicated interviews with the RN supervisor and the paramedic assessment indicated a medical event and not a choking incident. Statement from NA #1 on [DATE] at 3:20 PM identified he and LPN #1 provided CPR and respirations for Resident #1 on [DATE]. Although attempted surveyor and facility could not reach NA #1 for an interview. Statement from LPN #1 on [DATE] at 3:20 PM identified LPN #1 started CPR and respirations provided by NA #1. Although attempted, interview with LPN #1 was not obtained during survey. Review of the Medical Examiner Report dated [DATE] identified on [DATE] Resident #1 was brought to the hospital after a possible choking episode and started seizing. The Heimlich was attempted, but was unsuccessful. Pulses were lost and CPR was started. Death was pronounced on [DATE] at 7:14 PM. The cause of death was listed as hypertensive and arteriosclerotic cardiovascular disease. Facility documentation review identified LPN #1's CPR certification expired on [DATE] (6 months before the incident) and failed to identify NA #1 had any CPR certification. Interview with RN #1 on [DATE] at 1:31 PM identified she was the RN supervisor and around 6 PM the family reported Resident #1 was choking. The Heimlich maneuver was performed with no food expelled. Resident #1 was then brought to bed; a back board was placed, and CPR and respirations were performed by LPN #1 and NA #1 until EMS arrived and took over. Interview with the DNS on [DATE] at 2:01 PM identified the facility provides CPR training for staff, the Staff Development nurse was responsible for ensuring CPR certifications were current, and the DNS was unsure if the facility provided education for NAs. Further, although the DNS stated staff that provide CPR should have current CPR certifications, the DNS failed to identify LPN #1 and NA #1 had current CPR certifications/training. The DNS was unable to explain why the CPR certifications were not current for the two (2) staff. Although requested, the facility did not provide a CPR policy for surveyor review.

Based on observations during the tour of the kitchen, review of facility policy and staff interview, the facility failed to ensure expired food was discarded from the dry storage area and failed to date and label food items per facility policy. The findings included: Tour of the kitchen on [DATE] at 10:40 AM during the initial walk through with the Chef #1 identified the following: 1. The dry storage room had the following food item with no expiration dates: 3 boxes of Gold Medal Chocolate Cake Mix. The Cake mix was most recently dated [DATE], however, the expiration year indicated [DATE]. Interview with Chef #1 on [DATE] at 11:00 AM identified he and the dietary team are responsible for checking food items for expiration date weekly and disposing of expired items as needed. 2. Further observation of the kitchen on [DATE] at 10;40 AM identified the salad fridge had a half bottle of blueberry sauce dated ,d+[DATE] that was not labeled or had a 'use by' date indicated. Interview with Chef 1 on [DATE] at 11:15 identified food should have a sticker indicating when the food was open and a used by date. The facility policy for food storage notes in part; dry food removed from original packaging should be labeled and have a use by date. The policy additionally stated all food stored in the refrigerator will be covered, labeled, and dated.

Based on observations, review of facility documentation and staff interviews, the facility failed to maintain the kitchen in a clean and sanitary manner. The findings include: 1. Tour of the dry food storage area on 1/4/22 at 10:00AM identified live cockroaches observed on the ground in the dry food storage rooms. Further observation identified the floor had notable food debris and a large quantity of a red sticky substance noted on the floor in the corner in the dry food storage room. Also noted was a black box on the floor which was identified by the FSD as a roach trap. Interview with the FSD on 1/4/22 at 11:25AM identified the floors are swept every day and thoroughly cleaned every Sunday evening by the dishwasher. Further interview with the FSD on 1/4/22 at 11:25AM identified that Waltham Pest services recently came and put down the black Roach box. Interview with Dishwasher #1 on 1/4/22 at 12:45PM identified that he swept and washed all the floors on Sunday, January 2nd 2022. Upon further inquiry, he stated he moved the racks to clean the floors, however was not able to explain the current condition of the floors. Review of the Dishwasher job description identified the Dishwasher is responsible to sweep floors, walk in freezer, refrigerator and under all equipment. It further identified that the dishwasher is to mop floors and clean out mop bucket. Review of the Service Inspection Report detailed Service Report # 60 dated 12/28/21 12:10PM identified storage area inspected; large spill of cranberry juice concentrate was observed. This was shown to the Chef and requested that it get cleaned as soon as possible to prevent from attracting pest activity. Further interview with the FSD on 1/4/21 at 1PM identified that the spill of red liquid had been there for at least 6 or 7 days. Subsequent visit to the kitchen on 1/6/21 at 9:00AM identified that the area in question had been cleaned appropriately. 2. Observation of the walk in freezer identifed a large area of ice buildup noted on the floor under the rack in the back of the freezer. Upon further inspection of the shelving on the back wall chunks of ice were noted on various food items. Surveyor noted a large roast on back shelf in freezer with particles of ice on it. This large roast was without the added protection of plastic wrap covering the end, leaving the end of the meat exposed to the air. Interview with Chef #1 on 1/4/22 at 11:25AM identified the fans located directly above the freezer shelves had been leaking for some time now. Upon inquiry, he identified that Commercial Kitchens is responsible for the maintenance and upkeep of the refrigerators and freezer. Chef #1 further identifed they had been called in the past for this problem and at one point he believed the problem was fixed. He stated he was aware of it dripping again over the last two weeks. He further stated that he had placed a pan underneath to catch the water but it wasn't working. Chef #1 was queried by surveyor regarding the exposed meat. He stated that if he pulled it to use, he would have immediately thrown it out. Subsequent to surveyor inquiry the roast was thrown out and food items moved off of the shelf. Consumer Kitchens were called to evaluate the fans and identified a new part was necessary.

Based on clinical record review, staff interviews, review of facility documentation, and review of facility policy for the only resident in the survey sample reviewed for an allegation of mistreatment (Resident # 1) , the facility failed to ensure that a dependent resident had the call bell within his/her reach. The findings include: Resident # 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment dated [DATE] indicated the resident had no cognitive dysfunction (BIMS = 14), no behavior or mood symptoms, required extensive assist with bed mobility, and transfer, and walking in the room only occurred once or twice in the last 7 days. A Resident Care Plan (RCP) dated 7/23/19 identified a problem with potential for risk of injury related to a recent fall. Interventions included low bed, clear pathways, bed alarm, call bell within reach, and assist with transfers. A review of a Reportable Event report dated 8/12/19 at 7:00 P.M. indicated Resident # 1 alleged that his/her phone and call bell were removed out of his/her reach because he/she was calling too much. The investigation summary indicated Resident # 1 had reported the allegation to RN # 1 on 8/12/19 at 4:00 A.M. The note further indicated RN # 1 had observed Resident # 1's call bell and phone in the room out of the reach of the resident. The investigation also noted an Alarm Average Response Time Report dated 8/11/19 through 8/12/19. The report noted Resident # 1 did not utilize his/her call bell after 8/11/19 at 7: 34 P.M. until 8/12/19 8:38 A.M. An interview on 8/29/19 at 10:15 A.M. with the ADNS (acting DNS on 8/12/19) indicated he/she went into Resident # 1's room on 8/12/19 at 7:00 P.M. to see how the resident was doing. Resident # 1 reported to him/her that a 3:00 P.M. - 11:00 P.M. nurse aide the day before (8/11/19) took away his/her call bell and phone because he/she was calling too much. The ADNS indicated although the resident initially reported the incident took place on the 3:00 P.M. - 11:00 P.M. shift, the investigation noted the incident actually took place on 8/12/19 on the 11:00 P.M. -7:00 A.M. shift and was reported by Resident #1 to RN # 1 on 8/12/19 at 4:00 A.M. The ADNS further indicated Resident # 1's call bell and phone were observed by RN # 1 to be out of the resident's reach at the time the resident made the allegation. An interview on 8/29/19 at 10:42 A.M with Nurse Aide (NA # 1) indicated he/she recalled going into Resident # 1's room at least 4 times during the 11:00 P.M.-7:00 A.M. shift on 8/11-8/12/19. He/she did not remove Resident # 1's call bell and phone from his/her reach because he/she was calling too much. NA # 1 indicated he/she did not think he/she forgot to give the resident his/her call bell and phone after providing care because he/she knew Resident #1 and knew the resident needed the call bell and phone within his/her reach. NA # 1 was unable to explain how the call bell and phone had been moved from the resident's reach. He/she was the only nurse aide on that wing and the resident was physically incapable of moving the call bell and phone him/herself. An interview on 8/29/19 at 2:00 P.M. with RN # 1 indicated Resident # 1 reported to him/her on 8/12/19 at 4:00 A.M. that NA # 1 removed his/her call bell and phone from his/her reach because he/she was calling too much. RN # 1 indicated he/she observed the call bell on the resident's wheelchair and the phone on the bed side table out of the reach of the resident. At that time Resident # 1 had no care needs. He/she had been in Resident # 1's room at 12:30 P.M. and observed the call bell was tied to the bed rail on the left side and the phone was on the over bed table on the right side. RN # 1 indicated he/she did not hear Resident # 1's call bell going off frequently and/or here the resident yelling for assistance that night. RN # 1 indicated he/she did not speak to NA # 1 about the allegation and his/her observations until around 7:00 A.M. when the nurse aide was leaving the building because NA # 1 was busy giving care and he/she was giving medications. RN # 1 indicated when he/she spoke to NA # 1, NA # 1 denied removing the call bell and phone from the resident's reach. A review of a facility policy on call bells and interview on 8/30/19 at 12:40 P.M .with the DNS indicated per facility policy call bells and other necessary items should be within reach of a resident who are able to use the call bell and answered within 5 to 8 minutes.

Based on clinical record review, staff interviews, review of facility documentation, and review of facility policy and procedures for the only resident in the survey sample reviewed for an allegation of mistreatment (Resident # 1), the facility failed to ensure the facility's abuse policy and procedures related to reporting, investigating, and/or the protection of residents were implemented when an allegation of mistreatment was reported. The findings include: Resident # 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment dated [DATE] indicated the resident had no cognitive dysfunction (BIMS = 14), no behavior or mood symptoms, required extensive assist with bed mobility, and transfer, and walking in the room only occurred once or twice in the last 7 days. A Resident Care Plan (RCP) dated 7/23/19 identified a problem with potential for risk of injury related to a recent fall. Interventions included low bed, clear pathways, bed alarm, call bell within reach, and assist with transfers. A review of a Reportable Event report dated 8/12/19 at 7:00 P.M. indicated Resident # 1 alleged that his/her phone and call bell were removed out of his/her reach because he/she was calling too much. The investigation summary indicated Resident # 1 had reported the allegation to RN # 1 on 8/12/19 at 4:00 A.M. The note further indicated that RN # 1 had observed Resident # 1's call bell and phone in the room out of the reach of the resident. A review of a Reportable Event report dated 8/12/19 at 7:00 P.M. indicated Resident # 1 alleged that his/her phone and call bell were removed out of his/her reach because he/she was calling too much. The investigation summary indicated Resident # 1 had reported the allegation to RN # 1 on 8/12/19 at 4:00 A.M. The note further indicated RN # 1 had observed Resident # 1's call bell and phone in the room out of the reach of the resident. The investigation also noted an Alarm Average Response Time Report dated 8/11/19 through 8/12/19. The report noted Resident # 1 did not utilize his/her call bell after 8/11/19 at 7: 34 P.M. until 8/12/19 8:38 A.M. An interview on 8/29/19 at 10:15 AM with the ADNS (acting DNS on 8/12/19) indicated he/she went into Resident # 1's room on 8/12/19 at 7:00 P.M. to see how the resident was doing. Resident # 1 reported to him/her that a 3:00 P.M. - 11:00 P.M. nurse aide the day before (8/11/19) took away his/her call bell and phone because he/she was calling too much. The ADNS indicated he/she initiated the investigation immediately. During his/her investigation he/she discovered the incident actually took place on 8/12/19 on the 11:00 P.M. -7:00 A.M. shift and was reported to RN # 1 on 8/12/19 at 4:00 A.M. The ADNS further indicated the call bell and phone were observed by RN # 1 at that time to be out of the resident's reach. The ADNS indicated he/she would have expected to have been notified immediately when the allegation was first reported to RN # 1. RN # 1 did not notify him/her of the allegation. The ADNS indicated his/her first notification of the allegation was when Resident # 1 reported it to him/her on 8/12/19 at 7:00 P.M. An interview on 8/29/19 at 2:00 PM with RN # 1 indicated Resident # 1 reported to him/her on 8/12/19 at 4:00 A.M. that NA # 1 removed his/her call bell and phone from his/her reach because he/she was calling too much. RN # 1 indicated he/she observed the call bell on the resident's wheelchair and the phone on the bed side table out of the reach of the resident. RN # 1 indicated he/she did not speak to NA # 1 about the allegation and his/her observations until around 7:00 A.M. when the nurse aide was leaving the building because NA # 1 was busy giving care and he/she was giving medications. Although he/she was aware the allegation should have been reported to the DNS immediately and an incident report filled out, he/she did not report the incident to the ADNS (acting DNS) and/or initiate an incident report because he/she was busy the rest of the shift, was tired and was just thinking about going home. An interview on 8/30/19 at 10:45 AM with the Administrator indicated per facility policy any allegation of abuse, including neglect should be reported immediately to the Director of Nursing and/or Administrator. The investigation process should start immediately and the employee who is the alleged abuser should be sent home pending the investigation if there is potential for harm to protect the residents. The Administrator further indicated although the abuse policy was initiated on 8/12/19 at 7:00 P.M. when it was reported to the ADNS, the policy should have been implemented when the allegation was first reported on 8/12/19 at 4:00 A.M. Review of a facility policy and procedure on reporting abuse to facility management indicated neglect is defined as failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Employees must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. If such incidents occur or discovered after hours, the Administrator and Director of Nursing must be called at home. Employees of the facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation.

Based on clinical record review, staff interviews, review of facility documentation, and review of facility policy and procedures for the only resident in the survey sample reviewed with an allegation of mistreatment (Resident # 1) the facility failed to ensure an employee immediately reported an allegation of mistreatment to the Director of Nursing and/or Administrator in accordance to facility policy. The findings include: Resident # 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment dated [DATE] indicated the resident had no cognitive dysfunction (BIMS = 14), no behavior or mood symptoms, required extensive assist with bed mobility, and transfer, and walking in the room only occurred once or twice in the last 7 days. A RCP dated 7/23/19 identified a problem with potential for risk of injury related to a recent fall. Interventions included low bed, clear pathways, bed alarm, call bell within reach, and assist with transfers. A review of a Reportable Event report dated 8/12/19 at 7:00 PM indicated Resident # 1 alleged that his/her phone and call bell were removed out of his/her reach because he/she was calling too much. The investigation summary indicated Resident # 1 had reported the allegation to RN # 1 on 8/12/19 at 4:00 A.M. The note further indicated that RN # 1 had observed Resident # 1's call bell and phone in the room out of the reach of the resident. An interview on 8/29/19 at 10:15 AM with the ADNS (acting DNS on 8/12/19) indicated he/she went into Resident # 1's room on 8/12/19 at 7:00 P.M. to see how the resident was doing. Resident # 1 reported to him/her that a 3:00 P.M. - 11:00 P.M. nurse aide the day before (8/11/19) took away his/her call bell and phone because he/she was calling too much. The ADNS indicated he/she initiated the investigation immediately. During his/her investigation he/she discovered the incident actually took place on 8/12/19 on the 11:00 P.M. -7:00 A.M. shift and was reported to RN # 1 on 8/12/19 at 4:00 A.M. The ADNS further indicated the call bell and phone were observed by RN # 1 at that time to be out of the resident's reach. The ADNS indicated he/she would have expected to have been notified immediately when the allegation was first reported to RN # 1. RN # 1 did not notify him/her of the allegation. The ADNS indicated his/her first notification of the allegation was when Resident # 1 reported it to him/her on 8/12/19 at 7:00 P.M. An interview on 8/29/19 at 2:00 PM with RN # 1 indicated Resident # 1 reported to him/her on 8/12/19 at 4:00 A.M. that NA # 1 removed his/her call bell and phone from his/her reach because he/she was calling too much. RN # 1 indicated he/she observed the call bell on the resident's wheelchair and the phone on the bed side table out of the reach of the resident. RN # 1 indicated he/she did not speak to NA # 1 about the allegation and his/her observations until around 7:00 A.M. when the nurse aide was leaving the building because NA # 1 was busy giving care and he/she was giving medications. Although he/she was aware the allegation should have been reported to the DNS immediately and an incident report filled out, he/she did not report the incident to the ADNS (acting DNS) and/or initiate an incident report because he/she was busy the rest of the shift, was tired and was just thinking about going home. An interview on 8/30/19 at 10:45 AM with the Administrator indicated per facility policy any allegation of abuse, including neglect should be reported immediately to the Director of Nursing and/or Administrator. The investigation process should start immediately and the employee who is the alleged abuser should be sent home pending the investigation if there is potential for harm to protect the residents. The Administrator indicated although the abuse policy was initiated on 8/12/19 at 7:00 P.M. when it was reported to the ADNS, the policy should have been implemented when the allegation was first reported on 8/12/19 at 4:00 A.M. Review of a facility policy and procedure on reporting abuse to facility management indicated neglect is defined as failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Employees must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. If such incidents occur or discovered after hours, the Administrator and Director of Nursing must be called at home. Employees of the facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #285) reviewed for abuse, the facility failed to ensure the resident was free from abuse. The findings include: Resident #285 was admitted to the facility on [DATE] after a fall with evacuation of a hematoma to the mid-back, and a [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified Resident #285 had intact cognition, required limited assistance with position changes, extensive assistance with transfers, ambulation and toileting, and was continent of bowel and bladder. The care plan dated 1/11/18 identified Resident #285 had a communication delay and robotic speech. Interventions directed to allow ample time for the resident to express him/herself, and respond to any interactions with staff. Review of a reportable event form dated 1/13/18 identified Resident #285 met with the social worker and Person #1 and reported that during the 11:00 PM to 7:00 AM shift on 1/13/18, he/she rang the call bell at 1:00 AM, and a nurse aide (NA #4) came in and indicated to the resident to go back to bed, what do you want? Additionally, at approximately 2:00 AM, Resident #285 rang the call bell again because his/her legs were dangling off the bed and he/she wanted to be covered, however, assistance was not provided. Further, at 4:00 AM, NA #4 entered Resident #285's room and yelled at the resident, and told him/her to go back to bed, and what was he/she calling for? The facility associate coaching and counseling form dated 1/16/18 identified Resident #285 reported he/she rang for help at approximately 1:00 AM on 1/13/18, and NA #4 came in and told the resident to go back to sleep and asked what do you want? Resident #285 identified he/she was trying to explain to NA #4 what he/she wanted, but because his/her speech was slow he/she could not get it out in time, and NA #4 left the room without finding out what he/she wanted, and without providing assistance. At approximately 2:00 AM, Resident #285 called again because his/her legs were dangling off the bed and he/she wanted to be repositioned. NA #4 came in the room and stated what do you want, go back to sleep. Resident #285 called Person #1, who in turn, called the facility and reported the incident to a staff member. Resident #285 identified NA #4 returned to his/her room and yelled at him/her to get back to sleep and asked what was he/she calling for? Person #1 reported when he/she arrived at the facility at 8:45 AM on 1/13/18, Resident #285 cried and stated he/she is here to get better, and not be mistreated and neglected. Although NA #4 indicated that Resident #285 only rang the call light once the entire shift for assistance, review of the call light report identified Resident #285 rang 7 times that shift. Additionally, the facility investigation identified NA #4's inaction and yelling was abusive and neglectful. The investigation dated 1/19/18 identified the allegation of abuse and neglect was substantiated, and NA #4 was terminated. Interview with NA #4 on 6/12/18 at 12:20 PM identified he/she went into Resident #285's room [ROOM NUMBER] or 2 times on 1/13/18 when the resident rang his/her call light. NA #4 identified he/she asked the resident what he/she needed, and the resident did not reply, so he/she told the resident to go back to bed. He/she further identified that the only care he/she provided to the resident was to bring him/her to the bathroom once, and did not provide any other care or assistance to the resident. Interview with the Executive Director on 6/12/18 at 1:00 PM identified the facility did not tolerate NA #4's behavior, and subsequent to the facility's investigation and Resident#285's allegation of mistreatment, NA #4 was terminated. The facility abuse, prevention, reporting, and investigation policy identified that each resident has the right to be free from verbal, sexual, physical and mental abuse, mistreatment, and neglect The policy defines abuse, in part, as the deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.

Based on observation, review of the clinical record and interview for 1 of 3 residents (Resident #21) reviewed for pressure ulcers, the facility failed to utilize a heel offloading device per the physician's orders [REDACTED]. Resident #21's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #21 had no cognitive problems and required limited assistance with bed mobility and transfers. The assessment further identified that Resident #21 was at risk for developing pressure ulcers and was receiving skin and ulcer treatments that included pressure reducing devices for the chair and bed. The physician's orders [REDACTED].#21 to frequently turn and reposition, to provide the resident with a heel ramp, and to check for its placement every shift. The care plan dated 5/30/18 identified Resident #21 had a potential for impaired skin integrity due to impaired mobility. Interventions included to provide assistance with turning and positioning, and to utilize a heel ramp while Resident #21 was in bed. Observation on 6/11/18 at 6:32 AM identified Resident #21 was in bed on his/her back with a pressure reducing air mattress. The observation identified that both of Resident 321's heels were resting directly on the bed without the benefit of offloading and/or off-loading device. Observation on 6/11/18 at 8:16 AM identified Resident #21's heels remained directly on the bed. Interview with Resident #21 at that time identified his/her heels hurt every morning. Observation and interview on 6/11/18 at 9:49 AM identified Resident #21 was seated at the bedside eating breakfast. Resident #21 verbalized that his/her heels felt better now that he/she was out of bed. Observation on 6/12/18 at 6:14 AM identified Resident #21 was in bed on his/her back with both heels resting directly on the bed without the benefit of offloading and/or off-loading device. Observation on 6/12/18 at 6:36 AM with the DNS identified Resident #21 heels were on the bed without offloading. A skin evaluation form dated 6/12/18 identified non blanchable redness to both of Resident #21's heels. Additionally, the left heel red area measured 3.1cm by 3.2cm, and the right heel red area measured 3.1cm by 4.0cm. A nurse's note dated 6/12/18 during the 11:00 PM to 7:00 AM shift identified Resident #21 was alert with no complaints voiced. Interview with the 11:00 PM to 7:00 AM charge nurse (RN #2) on 6/12/18 at 6:45 AM identified the heel ramp was not available and that the nurse aide did not report that Resident #21 had refused any type of care. Interview with LPN #1 on 6/12/18 at 6:50 AM identified he/she had located the heel ramp in Resident #21's closet.

Based on observation, review of the clinical record, facility documentation and interview for 2 residents (Resident #135 and 336) reviewed for respiratory care, the facility failed to follow the physician's orders [REDACTED]. The finding include: 1. Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The care plan dated 6/7/18 identified Resident #135 was at risk for infection related to [DIAGNOSES REDACTED]. Observation on 6/11/18 at 9:00 AM identified Resident #135 nebulizer mask was laying directly on the bedside table without the benefit of a label and or storage bag. Observation and interview on 6/11/18 at 9:00 AM with LPN #2 identified the nebulizer equipment should have been dated and stored in a storage bag. Interview and review of the (MONTH) (YEAR) MAR indicated [REDACTED]. LPN #2 indicated he/she was unsure of when the equipment required replacement. Interview with the DNS on 6/12/18 at 12:34 PM identified that while an outside company oversees the changing of medical equipment, the routine cleaning, storage and replacement of the nebulizer should be completed at scheduled intervals that included weekly replacement. The DNS further indicated the procedure should be documented on the TAR, and nursing should be checking dates to ensure that it is completed. The policy for aerosolized medication administration directs the nebulizer should be dismantled, rinsed under sterile water, left to dry on a paper towel, and placed in a plastic bag for storage after it is dry. The equipment changing policy directs that all respiratory equipment must be changed in order to prevent nosocomial infections. The equipment should be changed weekly and as needed, and marked with the date that it was changed. 2. Resident #336 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Additionally, the order directed that staff measure Resident #336's oxygen level every shift and change the water bottle and nasal cannula every week on Saturday during the 3:00 PM to 11:00 PM shift, (date and initial the equipment). The admission MDS dated [DATE] identified Resident #336 had no cognitive problems, had [MEDICAL CONDITION] problems, and received respiratory treatments that included oxygen therapy. Observation on 6/11/18 at 6:27 AM identified Resident #336's nasal cannula and water container was dated 5/31/18, 11 days prior, and lacked staff initials. Additionally, the nasal cannula of Resident #336's portable oxygen tank was without the benefit of being dated. Observation on 6/11/18 at 1:40 PM with RN #1 identified Resident #336's nasal cannula and water container was dated 5/31/18, 11 days prior, and lacked staff initials. Additionally, the nasal cannula of Resident #336's portable oxygen tank was without the benefit of being dated. Interview and review of the (MONTH) (YEAR) TAR on 6/11/18 at 1:55 PM with RN #1 identified that although Resident #336's nasal cannula and water container was dated 5/31/18, staff documented that the resident's water bottle and nasal cannula tubing had been changed on 6/2/18. Additionally, the TAR failed to reflect the nasal cannula and tubing had been changed on 6/9/18 according to the physician order. Interview on 6/11/18 at 2:02 PM with RN #1 indicated that the oxygen equipment should have been changed on 6/9/18, and that the equipment should be changed due to the potential for infection. Observation on 6/12/18 at 6:14 AM identified Resident #336's nasal cannula and water container remained dated 5/31/18, 11 days prior, and lacked staff initials. Additionally, the nasal cannula of Resident #336's portable oxygen tank remained without the benefit of being dated. Review of facility respiratory equipment changing policy procedure identified all (oxygen) equipment should be changed on a weekly basis as well as when needed to prevent nosocomial infections. It further identified that equipment should be marked with the date that it was changed and/or equipment included nasal cannulas and oxygen tubing.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #135) reviewed for dining, the facility failed to deliver a meal tray in appropriate time frames. The findings include: Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/7/18 identified Resident #135 was at risk for infection related to a [DIAGNOSES REDACTED]. Observation and interview with Resident #135 on 6/11/18 at 8:48 AM identified he/she had requested a breakfast tray prior to 8:48 AM, had not yet received it, and had wondered what had occurred. Interview with Dietary Staff #1 on 6/11/18 9:21 AM identified that staff had not requested a breakfast tray for Resident #135. A subsequent interview with Resident #135 on 6/11/18 at 9:26 AM identified he/she had asked NA #1 for a breakfast tray and had been waiting over an hour. Interview with NA #1 on 6/11/18 at 9:26 AM identified that while he/she was very busy with other related tasks, he/she had not yet gone into Resident 135's room, and indicated that Resident #135 was not part of his/her assignment. Interview with NA #2 on 6/11/18 at 9:30 AM identified that he/she was not assigned to Resident #135, and he/she had not yet gone into the resident's room. Interview with NA #3 on 6/11/18 at 9:40 AM identified that while he/she initially stated Resident #135 was not on her assignment, he/she was able to confirm Resident #135 was part of his/her assignment after checking his/her assignment sheet. NA #3 further indicated that he/she had not yet gone into Resident #135's room to provide care that morning. Interview with the unit secretary on 6/11/18 at 9:48 AM identified while he/she had observed NA #1 enter Residents #135's room earlier that morning. Interview with the DNS on 6/12/18 at 8:47 AM identified that it would be him/her expectation that meal trays be delivered in a timely manner. Although a policy regarding meal delivery for residents on isolation precautions was requested, none was provided.

Based on observation, review of the clinical record, facility documentation and interview for 2 residents (Resident #135 and 336) reviewed for respiratory care, the facility failed to provide care consistent with professional standards of practice, to prevent the spread of infection. The finding include: 1. Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/7/18 identified Resident #135 was at risk for infection related to [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observation on 6/11/18 at 9:00 AM identified Resident #135 nebulizer mask was laying directly on the bedside table without the benefit of a label and or storage bag. Observation and interview on 6/11/18 at 9:00 AM with LPN #2 identified the nebulizer equipment should have been dated and stored in a storage bag. Interview and review of the (MONTH) (YEAR) MAR indicated [REDACTED]. LPN #2 indicated he/she was unsure of when the equipment required replacement. Interview with the DNS on 6/12/18 at 12:34 PM identified that while an outside company oversees the changing of medical equipment, the routine cleaning, storage and replacement of the nebulizer should be completed at scheduled intervals that included weekly replacement. The DNS further indicated the procedure should be documented on the TAR, and nursing should be checking dates to ensure that it is completed. The policy for aerosolized medication administration directs the nebulizer should be dismantled, rinsed under sterile water, left to dry on a paper towel, and placed in a plastic bag for storage after it is dry. The equipment changing policy directs that all respiratory equipment must be changed in order to prevent nosocomial infections. The equipment should be changed weekly and as needed, and marked with the date that it was changed. 2. Resident #336 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Additionally, the order directed that staff measure Resident #336's oxygen level every shift and change the water bottle and nasal cannula every week on Saturday during the 3:00 PM to 11:00 PM shift, (date and initial the equipment). The admission MDS dated [DATE] identified Resident #336 had no cognitive problems, had [MEDICAL CONDITION] problems, and received respiratory treatments that included oxygen therapy. Observation on 6/11/18 at 6:27 AM identified Resident #336's nasal cannula and water container was dated 5/31/18, 11 days prior, and lacked staff initials. Additionally, the nasal cannula of Resident #336's portable oxygen tank was without the benefit of being dated. Observation on 6/11/18 at 1:40 PM with RN #1 identified Resident #336's nasal cannula and water container was dated 5/31/18, 11 days prior, and lacked staff initials. Additionally, the nasal cannula of Resident #336's portable oxygen tank was without the benefit of being dated. Interview and review of the (MONTH) (YEAR) TAR on 6/11/18 at 1:55 PM with RN #1 identified that although Resident #336's nasal cannula and water container was dated 5/31/18, staff documented that the resident's water bottle and nasal cannula tubing had been changed on 6/2/18. Additionally, the TAR failed to reflect the nasal cannula and tubing had been changed on 6/9/18 according to the physician order. Interview on 6/11/18 at 2:02 PM with RN #1 indicated that the oxygen equipment should have been changed on 6/9/18, and that the equipment should be changed due to the potential for infection. Observation on 6/12/18 at 6:14 AM identified Resident #336's nasal cannula and water container remained dated 5/31/18, 11 days prior, and lacked staff initials. Additionally, the nasal cannula of Resident #336's portable oxygen tank remained without the benefit of being dated. Review of facility respiratory equipment changing policy procedure identified all (oxygen) equipment should be changed on a weekly basis as well as when needed to prevent nosocomial infections. It further identified that equipment should be marked with the date that it was changed and/or equipment included nasal cannulas and oxygen tubing.

Based on clinical record reviews and interviews for three of four residents reviewed for pressure ulcers (R#152, 204, 149), the facility failed to initiate interventions to prevent pressure sores from developing and/or aide in healing including mattress surfaces and/or offloading, and/or repositioning, and/or failed to complete comprehensive assessments when wounds developed or were first identified. The findings include: 1. Resident #152 was admitted [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified reddened areas, bruises and open [MEDICAL CONDITION] other than stasis and/or pressure ulcers present upon admission. The skin evaluation dated 2/14/2017 identified non-blanchable redness located on coccyx / buttocks area, with area of skin peeling, and brownish discoloration. Nursing admission note dated 2/14/17 identified R#152 was admitted from hospital with ecchymosis (bruised) areas, multiple wounds to left and right lower extremities with dressings stained with brownish discharge and +3 [MEDICAL CONDITION]. The note further identified that the Registered Nurse (RN) was informed that a private care giver would stay with the resident. The resident care plan (RCP) dated 2/14/17 identified a potential for impaired skin integrity related to an abrasion noted on the buttocks. Interventions included apply Dermavase to buttocks every shift, turn and position (no time frame indicated) and provision of an air mattress (pressure relieving device). Nurse's notes dated 2/15/17 identified turn and position every two hours provided. No further nurse notes indicated provision of repositioning. Review of reverse side of the treatment administration record (TAR) dated 2/19/17 at 11:00 AM identified right heel wound noted and off load heels. No further documentation and/or assessment was noted in the clinical record. A nursing wound care note dated 02/20/2017 identified a new stage 3 pressure ulcer located on R#152's right heel and an abrasion on the buttocks. Skin evaluation dated 2/20/2017 identified a stage 3 pressure ulcer located on right heel that measured 2.5 cm x 2.2 cm x 0.1 cm. The evaluation identified the presence of slough and that the cause of the wound was pressure. An additional evaluation on the same date, identified an abrasion of the buttocks, serous drainage noted with 100 % granulation. It further identified will continue current treatment and turning repositioning program was checked off as inapplicable. physician's orders [REDACTED]. It further directed to off load heels while in bed, provide an air mattress, and to turn and reposition. Review of the treatment kardex noted entries dated 2/20/17 that directed turning and repositioning and offloading heels that noted only FYI and failed to contain any signatures to indicate that the interventions were initiated. No directions were provided from admission on 2/14/17 through 2/20/17 for offloading the heels and/or repositioning. An admission (MDS) assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance with bed mobility and transfer between surfaces. The assessment identified that the resident was at risk for developing pressure ulcers. Nurse's notes dated 02/23 and 2/25/17 identified a pillow was placed under the legs to float heels. Nurse's notes dated 2/25/17 and 2/26/17 identified private nurse aide at bed side. A skin evaluation dated 02/27/2017 identified that R#152 developed three new stage 2 pressure ulcers on his/her sacrum, right mid and upper buttocks. The sacrum pressure ulcer measured 0.1 cm x0.1 cm x 0.1 Cm. The right mid buttock measured 0.5 cm x 0.5 cm x 0.1 cm and the upper right buttock measured 1.0 cm x 1.0 cm x 0.1 cm. Interview with RN#3 on 07/27/2017 at 08:26 AM indicated that although s/he documented a wound on the back of the TAR on 2/19/17, the physician was not notified and a complete assessment was not done. RN#3 indicated that upon identifying a pressure ulcer area, it was his/her usual practice to document measurements- length, width, depth, a description which includes drainage, color, odor and notify the resident's doctor to obtain a treatment order and notify the family. During interview and review of R#152's clinical record with the Director Of Nursing (DNS) on 07/26/2017 at 11:15 AM, s/he was unable to provide documentation that an air mattress was provided until 2/20/17 and/or that offloading of heels and/or turning and positioning every 2 hours was implemented to prevent the development of pressure ulcers. Interview and review of the electronic nurse aide ADL charting record with RN#2 on 07/26/2017 at 12:16 PM identified that although the ADL care guide was signed by nurse aides indicating the provision of skin precautions which included turning side to side, limiting time up in chair, Roho cushion in wheelchair, float heels, pillow between knees, and a foot cradle, the computerized record was only a guide for staff and was not individualized to specific interventions for that particular resident. Interventions specific to the resident for prevention of pressure sores were not being documented in the electronic medical record. 2. Resident #204's [DIAGNOSES REDACTED]. Resident #204 was admitted to the facility on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE]. A nurse's note dated 7/3/2017 identified the resident was admitted on [DATE] with a stage 2 pressure ulcer on the coccyx, a stage 2 pressure ulcer on the left heel and a deep tissue injury on the right heel; will obtain air mattress. A physician's orders [REDACTED]. The admission MDS assessment dated [DATE] identified Resident #204 was without cognitive impairment, required extensive assistance for bed mobility and had two stage 2 pressure ulcers and one unstageable pressure ulcer. The care plan dated 7/11/2017 identified impaired skin integrity; presence of stage 2 pressure ulcers to the coccyx and left heel, and a deep tissue injury to the right heel. Interventions included pressure relief bed. The resident was readmitted from the hospital on [DATE]. The admission care plan dated 7/20/2017 identified a problem of pressure sores. The interventions section on the form was blank. A skin evaluation form dated 7/20/2017 identified the resident was readmitted on [DATE] with an unstageable pressure ulcer on the coccyx and an unstageable pressure ulcer on the left heel. A physician's orders [REDACTED]. An interview with the DNS on 7/27/2017 at 6:56 AM identified an air mattress should be ordered as soon as a skin issue is identified; a work order is sent to facility maintenance staff, generally they can address on the same day. An interview with LPN #1 on 7/26/2017 at 10:02 AM identified that he/she obtained the air mattress on 7/25/2017; from 7/20/2017 to 7/25/2017 the resident had the facility's regular mattress that is on all the beds, the facility changes to air mattresses for any pressure wounds. LPN #1 does not know why an air mattress was not put in place upon readmission; if he/she had been working when the resident was readmitted , he/she would have obtained an air mattress; he/she obtained an air mattress on 7/25/2017 when he/she realized the resident did not have one. An interview and record review with the DNS on 7/27/2017 at 11:59 AM identified the TARs reflect placement of air mattresses on 7/5/2017 after the 7/3/2017 admission, and on 7/25/2017 after the 7/20/2017 readmission. 3. Resident #149's [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified Resident #149 was moderately cognitively impaired and required extensive assistance with bed mobility and transfers, was at risk for pressure ulcer development and had one stage 3 and one unstageable pressure ulcer on admission. A Norton pressure ulcer scale identified a score of 10 indicating high risk. The Resident Care Plan (RCP) dated 2/7/17 identified a potential for impaired skin integrity, stage 3 pressure ulcer right heel and DTI left heel. Interventions directed to turn and position, provide pressure relief, skin prep daily and assess wound and document per facility protocol. A physician's orders [REDACTED]. The nurse's note dated 2/7/17 at 6 PM identified that the resident had a black discoloration of the left lateral heel with an area of a small intact blister and a right lateral heel with redness and discoloration, skin intact. The skin evaluation records dated 2/7/17 identified a left lateral heel, black discoloration with area of fluid filled intact skin and a right lateral heel discoloration with fluid filled intact skin, reddened. Both skin evaluation records identified the bilateral heels as a skin condition and the type of wound was identified as other. Additionally, the skin evaluation records failed to include measurements. The skin evaluation records dated 2/9/17 identified both heel areas as pressure ulcers, the left heel was identified as a blackened soft area that measured 4.5 cm x 4 cm x 0.1 cm and the right heel was identified as a blood filled blister measuring 1.2 cm x 1 cm surrounded by discolored, fragile skin with a total area that measured 5 cm x 4.5 cm x 0.1 cm. Review of the hospital discharge summary dated 2/7/17 identified bilateral lower extremity wounds likely the result of pressure. In an interview with the DNS on 7/27/17 at 8 AM failed to identify documentation that the bilateral heel pressure ulcers were measured from the day of admission (2/7/17) until 2/9/17. According to the facility policy, wounds should be measured and assessed on admission.

Based on observation, interviews and review of facility documentation, the facility failed to ensure sanitization of kitchen equipment and/or surfaces and/or failed to monitor sanitization solutions appropriately to ensure sanitization and/or failed to use the sanitizing product type identified in the facility's policy. The findings include: Observation and interview with the dining facility manager, (DFM), on 7/24/2017 at 7:20 AM identified a test strip check of the sanitizing solution in the three-bay sink done by the DFM showed test strip color did not match either test strip color indicating appropriate levels of sanitizer. The test strip was marked QT 40, and the sanitizing product was identified as a sodium hyper-chlorite (chlorine) product. The DFM was unable to identify if that was the appropriate test strip for that sanitizer, or which sanitizer type the facility had identified to use. On 7/24/2017 at 7:35 AM, the DFM identified that sanitizing solution being used to wipe and sanitize cooking areas did not indicate appropriate levels of sanitizer when tested using either quaternary ammonium compound or sodium hyper-chlorite test strips. Review of facility policy for cleaning and sanitizing in a three compartment sink identified the facility approved sanitizer was Array Ultimate Sanitizer, quaternary based sanitizer, 150 to 200 ppm.

Based on clinical record review and interview for one of four residents reviewed for pressure ulcers (R#152), the facility failed to make the physician aware of the development of a new pressure ulcer. The findings include: Resident #152 was admitted [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified reddened areas, bruises and open [MEDICAL CONDITION] other than stasis and/or pressure ulcers present upon admission. Nursing admission note dated 2/14/17 identified R#152 was admitted from hospital with ecchymosis (bruised) areas, multiple wounds to left and right lower extremities with dressings stained with brownish discharge and +3 [MEDICAL CONDITION]. Review of reverse side of the treatment administration record (TAR) dated 2/19/17 at 11:00 AM identified right heel wound noted and off load heels. No further documentation and/or assessment was noted in the clinical record. A nursing wound care note dated 02/20/2017 identified a new stage 3 pressure ulcer located on R#152's right heel and an abrasion on the buttocks. Skin evaluation dated 2/20/2017 identified a stage 3 pressure ulcer located on right heel that measured 2.5 cm x 2.2 cm x 0.1 cm. The evaluation identified the presence of slough and that the cause of the wound was pressure. An additional evaluation on the same date, identified an abrasion of the buttocks, serous drainage noted with 100 % granulation. It further identified will continue current treatment and turning repositioning program was checked off as inapplicable. physician's orders [REDACTED]. It further directed to off load heels while in bed, provide an air mattress, and to turn and reposition. Interview with RN#3 on 07/27/2017 at 08:26 AM indicated that although s/he documented a wound on the back of the TAR on 2/19/17, the physician was not notified and a complete assessment was not done. RN#3 indicated that upon identifying a pressure ulcer area, it was his/her usual practice to document measurements- length, width, depth, a description which includes drainage, color, odor and notify the resident's doctor to obtain a treatment order and notify the family. Interview with MD #1 on 07/27/2017 11:20 AM indicated that although it was the facility's usual practice, s/he expected to be notified of the development of new pressure ulcers.

Based on clinical record review and interview for one of four residents reviewed for pressure ulcers (R#152), the facility failed to accurately code the MDS assessment to reflect the development at the facility of a pressure ulcer. The findings include: Resident #152 was admitted [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified that the resident did not have any pressure sores upon admission. Review of reverse side of the treatment administration record (TAR) dated 2/19/17 at 11:00 AM identified right heel wound noted and off load heels. Nursing wound care note dated 02/20/2017 identified a stage 3 pressure ulcer located on R#152 ' s right heel that measured 2.5 cm x 2.2 cm x 0.1 cm. The evaluation identified the presence of slough and that the cause of the wound was pressure. An admission (MDS) assessment dated [DATE] identified the resident had a stage 3 pressure sore present upon admission. Interview with RN#2 on 07/27/2017 at 12:21 PM indicated that R#152 did not have identified pressure ulcers upon admission and that the MDS dated [DATE] was inaccurate identifying the presence of a stage 3 upon admission. The stage 3 pressure ulcer on his/her heel was identified on 2/20/17.

Based on observation, interviews and review of the clinical record, for one of five residents observed for medication administration, Resident #209, the facility failed to ensure the resident received thickened liquids as ordered by the physician. The findings include: Based on observation, clinical record review, and interviews for one of five residents observed for medication administration (R #209), the facility failed to ensure thickened liquids were provided as ordered. The findings include: Resident #209's [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified Resident #209 had severe cognitive impairment, required extensive assistance with eating and required a change in texture of food or liquids. The Resident Care Plan dated 7/22/2017 identified difficulty swallowing related to dysphagia and progressive dementia. Interventions directed to provide dysphagia level one diet with honey thick liquids, and directed nurse may crush appropriate medications and administer with applesauce. A physician's orders [REDACTED]. Observations on 7/24/2017 at 9:25 am identified RN #4 presented Resident #209 with whole medications and un-thickened water. Person #1 present in the room stopped RN #4 from administering the medications with water, informing RN #4 that the resident required thickened liquids and crushed medications. RN #4 informed the surveyor that this information was not on the MAR. Interview and review of Resident #209's MAR indicated [REDACTED]. RN #4 identified that he/she did not see that information before offering the medications whole with un-thickened water. Interview with the DNS on 7/24/2017 at 9:45 AM identified that the nurse is responsible for following physician's orders [REDACTED].

Based on observations, interviews, and review of facility policy and procedure for dietary services, the facility failed to ensure food items were stored properly and/or labeled and dated when opened and/or failed to maintain the ice machine in a sanitary manner. The findings include: Observation of the dietary department on 8/29/16 at 7:00 AM with cook #1 identified the following: 1. The ice machine was noted with a dusty build-up on the exterior air vent and the interior walls of the ice machine were noted with an accumulation of dark moist debris. 2. The dry food storage area was noted to have multiple unidentifiable dry food items that were not labeled and/or dated when opened. 3. The walk-in refrigerator was noted with multiple produce items that were unwrapped, not covered and stored inappropriately. 4. The walk-in freezer was noted with two frozen pies stored on top of each other with plastic wrap covering half of the pie, the plastic wrap was not dated, a bag of frozen onion rings and a bag of frozen mangos was opened, not sealed and lacking a date when opened. Interview and review of the kitchen with cook #2 on 8/30/16 at 1:00 PM identified it is the responsibilty of the cook to ensure food items are labeled and dated when opened and stored appropriately, additionally the dietary department cleans the ice machine on a weekly basis. Although facility policy and procedure identified the ice machine is cleaned on a weekly basis, the facility was unable to provide documentation when the ice machine was last cleaned. Facility policy and procedure for Food Safety: Labeling and Dating food items direct all food items including raw, prepared and packaged, must be dated. All raw and prepared food must be wrapped or covered with plastic wrap and dated. Food items not in its original package and not recognizable must be labeled with item description and dated.

Based on clinical record review and interview for one of three residents in survey sample reviewed for abuse (R#161) facility failed to provide care in a dignified manner. The findings included: Resident #161 was readmitted to facility on 09/17/2015 with [DIAGNOSES REDACTED]. The resident care plan (RCP) dated 09/17/15 identified a problem with activities of daily living (ADL) and risk for injury. Interventions included to assist with transfers as needed and to encourage the resident to participate in ADL's. physician's orders [REDACTED]. An MDS assessment dated [DATE] identified that R#161 did not have any cognitive problems and required extensive assistance with bed mobility. Psychological services progress notes dated 10/01/15 identified anxiety, depression, pain and non-compliance with treatment as concerns for therapy. Social service notes dated 10/01/15 identified repeated provision of the importance of participation in rehabilitation. Nurse's notes dated 10/06/15 at 3:00PM identified that R#161 was alert and oriented, had refused pain medication ([MEDICATION NAME]) and treatment had been provided for R#161's left AKA [DEVICE] and wound dressing. Facility reportable event documentation dated 10/06/15 identified that at 8:15 PM while the Director of Nursing was making rounds, s/he overheard an interaction between NA#1 and R#161. A written statement by the DNS identified that while providing care to R#161, NA#1 requested the resident to turn to his/her left side. The resident verbalized I can't, your hurting me, then the DNS heard NA#1 say I'm hurting you? You're hurting me. The statement identified that the resident was crying, and NA#1 stated I'm sorry your dirty and I need to clean you up, move your shoulders and again the resident stated, I can't with NA#1 response in a loud voice -yes you can. Statement further identified the resident as stating -I am sorry (NA#1) and NA#1 responding -you're not sorry. R#161 crying- Stop, stop you're hurting me and NA#1 responded- I am not hurting you. Interview with the Administrator/DNS on 08/29/16 at 10:05 AM indicated that upon entering R#161's bedroom, s/he noted that s/he was visibly shaken. NA#1 was immediately sent home and subsequently terminated. Multiple attempts to contact NA#1 was unsuccessful.

Based on observations, staff interviews, review of the clinical records, and review of facility documentation for three of six residents in the survey sample reviewed for pressure ulcers (R# 82, R # 190, R # 192), the facility failed to assess pressure ulcers when identified and/or failed to obtain appropriate treatment orders, and/or failed to thoroughly assess wounds at least weekly, and/or failed to initiate pressure relieving interventions including off loading and repositioning to treat and/or prevent pressure sores. The findings include: 1. Resident # 82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified the presence of a 0.5 cm stage 2 wound of the right heel with no drainage. No other measurements (including depth) and / or description of the area was included. The admission MDS assessment dated [DATE] identified that the resident was without cognitive impairment, had no problem behaviors, required extensive assistance from staff for all mobility, was at risk for pressure sores and had one stage three pressure sore that was present upon admission. The admission care plan dated 5/5/15 [MEDICAL CONDITION] of the right heel. An undated care plan identified impaired skin integrity related to right heel wound. Interventions included, weekly skin assessments, turning and positioning, assess wound and document per facility protocol, and evaluate effectiveness of treatment. Neither care plan addressed the resident's needs related to pressure relief to the right heel. On 5/8/15, the wound assessment noted 0.5 cm by 0.5 cm. No stage or other description was noted and most areas of the assessment form were left blank including depth, drainage, wound edges, and wound bed. On 5/11/15, the Wound physician assessed the wound and determined it was a stage 3 pressure sore with depth of 0.3 and 100% granulation tissue present. Recommendations included to float heels in bed, off load wound. On 5/13/15, the resident went to the wound care clinic where the base of the wound was curetted and returned with treatment order changes. On 5/20/15, the resident was again seen at the wound care clinic and returned with physician orders [REDACTED]. No measurements or assessments were noted on the clinic report. ON 5/23/15, the facility skin assessment noted 0.5 by 0.5 by 0.3 cm wound with serous drainage and pale pink wound bed. Interview and clinical record review with LPN#1 on 8/4/15 at 1:45 PM failed to provide documentation that the resident's wound was thoroughly assessed upon admission on 5/5/14 and/or that a complete assessment was performed at least every 7 days (no assessment from 5/11/15 through 5/23/15), and/or that the resident's heel was offloaded and/or that a waffle boot was applied to the affected foot. Further review with LPN #1 failed to provide documentation that the care plan reflected the presence of a stage 3 pressure sore and/or interventions to alleviate pressure to the area. 2. Resident # 190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing evaluation dated 7/16/15 indicated the resident required assist with bed mobility and transfer, was incontinent of bowel and bladder, and had redness on his/her groin and buttocks. A pressure ulcer scale dated 7/16/15 indicated the resident was high risk for developing a pressure ulcer. The care plan dated 7/16/15 identified a risk for skin impairment secondary to impaired mobility and fungal rash to groin. Interventions included antifungal to groin and pressure relief to bed and chair. Turning and positioning every 2 hours and prn was not checked as an intervention. A wound care specialist note dated 7/20/15 indicated the resident had a nonspecific rash to the gluteal area. Treatment included barrier cream to the gluteals every shift. A nurse's note dated 7/31/15 at 10:00 PM indicated a stage 2 pressure ulcer was noted on R # 190's coccyx. The Physician was notified and a treatment for [REDACTED]. The nurse's note did not include a description and/or assessment of the wound. A weekly pressure wound record dated 8/3/15 indicated R # 190 had a 0.5 cm x 0.7 cm x < 0.1 cm stage 2 pressure ulcer that was 100% pink. A constant observation on 8/5/15 from 6:25 AM through 9:30 AM noted R # 190 lying flat on his/her back in bed. At no time was the resident repositioned and/or provided incontinent care during this time. An interview on 8/5/15 at 9:30 AM with NA # 2 indicated he/she was aware that R # 190 needed to be repositioned off of his/her back because his/her buttock was red. NA # 2 indicated he/she was busy getting other residents into the dining room and because R # 190 did not eat, he/she waited to get R # 190 out of bed. An observation of the resident's buttock/gluteal area at time noted the area to be red with a small open area on the coccyx. The wound bed was pink. An interview on 8/5/15 at 9:40 AM with RN # 2 indicated because R # 190 had a pressure ulcer, he/she should have been positioned on his/her sides and not on his/her back and turned and repositioned every 2 hours. 3. Resident #192's [DIAGNOSES REDACTED]. An admission nursing evaluation dated 7/22/15 identified the resident was alert, oriented to person and required the assistance of one for bed mobility, toileting, and personal hygiene. The evaluation indicated there was no redness and/or open areas on the buttocks. A physician's orders [REDACTED]. The RCP dated 7/22/15 identified a potential problem with impaired skin integrity related to impaired bed mobility and incontinence. Interventions included a pressure relieving device in the bed and chair, and to provide incontinent care. A nurse's note dated 8/1/15 at 3:30 PM noted a stage II pressure ulcer was identified on the resident's buttocks. The note indicated that a treatment was already in place and would continue until the resident was seen by the wound team. A weekly pressure ulcer assessment entry dated 8/1/15 indicated the wound was a stage II with serous drainage, but lacked the the measurements of the wound. Subsequent documentation dated 8/3/15 indicated the wound measured 1.5 cm by 0.7 cm by <0.1 cm. Intermittent observations of R # 192 on 8/3/15 and 8/4/15 identified the resident seated in a wheelchair without the benefit of a pressure relieving cushion as directed in the RCP. An observation on 8/5/15 at 8:45 AM identified the resident lying in bed positioned on his/her back. NA #1 assisted the resident with turning and unfastened the incontinent brief. A superficial wound was noted on the resident's right buttocks. The wound bed was red and no drainage was noted. Additionally, the wheelchair was without a pressure relieving cushion. Interview with NA#1 at that time indicated that after providing incontinent care, the NA's apply Dermavase (a barrier cream) to the wound. An interview on 8/5/15 at 8:30 AM with the dietician indicated that she/he wasn't notified of the resident's wound until 8/4/15 (three days after it was identified). Subsequent to surveyor inquiry, the dietician assessed the resident and recommended multivitamins and healthshake two times a day. An interview and review of the clinical record and facility documentation on 8/5/15 at 8:15 with RN #1 and LPN #2 failed to provide documentation that the Physician and dietician were notified when the resident developed the wound and/or failed to obtain new treatment orders. RN # 1 indicated NA's should not be applying open wound treatments and the pressure relieving cushion should have been placed on the resident's wheelchair.

Based on clinical record reviews and staff interviews for 3 of six residents in the survey sample reviewed for accidents (R #s 55, 175), the facility failed to implement interventions to prevent skin tears and/or injury, and/or failed to ensure that van driver's were trained in securing wheelchairs and/or emergency response. The findings include: 1a. Resident # 55's [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] indicated the resident was cognitively impaired and required total care for bed mobility and transfers. The resident care plan dated 5/30/12 identified a problem with mobility. Interventions included providing assistance of 2 with use of a mechanical lift. The physician's orders [REDACTED]. Review of a nurse's note dated 7/19/12 at 10:00 PM identified the resident was noted with a swollen left ankle with 4.5 cm of faint blue discoloration. The accident and incident report and investigation dated 7/19/12 indicated the resident's left ankle was noted to be ecchymotic. The investigation indicated the nurse aide did not use a Hoyer lift for transfer as indicated in the resident care plan. Interview on 11/20/12 at 10:00 AM with NA #2 indicated she assisted the resident out of bed without the use of the Hoyer lift on 7/19/12 because she was not aware the resident required a Hoyer lift for transfer. NA #2 indicated the resident's left ankle was swollen, however, that was not unusual for this resident. At 8:00 PM when the resident was transferred back to bed with the Hoyer lift the left ankle was noted to be black and blue. NA #2 indicated she reported the change to the charge nurse at that time. b. The Minimum Data Set assessment dated [DATE] indicated the resident was cognitively impaired and required total care for bed mobility and transfers. The resident care plan dated 8/28/12 identified a potential for skin impairment. Interventions included use of geri sleeves on the legs, Hoyer lift transfers and weekly skin assessments. The nurse's note dated 11/7/12 at 5:45 PM indicated the resident bumped his/her leg during a Hoyer lift transfer sustaining a 9 cm x 4 cm skin tear on the left leg. After physician notification the resident was sent to the emergency room for an evaluation. The hospital discharge summary indicated the area was cleansed and the resident returned to the facility. The accident and incident report dated 11/7/12 indicated the resident sustained [REDACTED]. Geri-leg protectors were not in place. An interview on 11/20/12 with NA #2 indicated the resident's left leg got caught under the wheelchair leg rest during the Hoyer lift transfer on 11/7/12. NA #2 further indicated the geri-sleeve leg protectors were not on the resident at the time because they were in the wash. Interview on 11/20/12 at 10:50 AM with the Director of Nursing indicated the wheelchair leg rests should not be on the wheelchair during a Hoyer transfer. 2. Resident #175 was admitted to the facility on [DATE] for continued treatment of [REDACTED]. The MDS dated [DATE] identified that the resident was cognitively impaired with a BIMS score of 9, was dependent on two staff for transfers, and was unable to ambulate. According to facility investigation documentation, on 3/7/12, the resident was transported to a Podiatrist visit in Darien in a wheelchair van that had been rented by the facility while their own van was being serviced. The resident had an oxygen tank and boot on his/her foot, so Driver #1 decided to face the wheelchair looking out the back driver's side window. While turning a corner, the resident's chair fell backwards. Driver #1 pulled over and observed the resident lying on his/her back with his/her head against the back door. When Driver #1 opened the back door, the resident's head was partially protruding out of the door so he held the resident's head up and called the facility (Driver #2) for assistance. The statement noted that the" resident "spit up" and was experiencing some difficulty breathing which lessened when the head was held up. "Driver #2 sent Worker #3 who was in the area to assist Driver #1. The two non-nursing personnel from the facility, picked the resident up in the wheelchair and asked him/her if he/she wanted to go back to the facility, to the doctor's appointment or to the hospital. The resident chose to continue to the doctor's office. According to Driver #1's written, signed statement and interview on 11/19/12 at 10 AM, he continued to the podiatrist's office and informed the "nurse" at the office of the incident. The resident told the "nurse" he was not feeling "great" and that his/her neck was uncomfortable. Blood was noted on the resident's left shin. Driver #1 called the facility administrator who directed him to call 911 immediately. Driver #1 noted in his written statement that he was comfortable with the operation of the rental van and had not been provided with any training on the operation either verbal or written. He noted that the only difference between the facility and rental vans was the type of straps (used to secure the wheelchairs) were not self adjusting like the facility van had. Driver #1 noted that he had never received any training on the van operation or emergency procedures prior to the incident and in hindsight, should have called 911. Driver #1 demonstrated on the facility minivan how he had placed the resident and hooked the wheelchair to the straps on the floor. He noted that resident's are usually placed facing forward but that this resident was large and had an oxygen tank so he put him in the van sideways. Observations by the surveyor at that time noted that had the resident been placed facing forward, the wheelchair would have been unable to tip backward because it would have been blocked from doing so by the rear bench seat in the van. Interview with the administrator on 11/20/12 at 7:25 AM noted that there are no records of the van driver's having received any training in van operation or emergency treatment prior to the incident. Review of acute care records indicated that R#175 was hospitalized with an odontoid fracture of cervical spine #2. The resident's hospitalization was complicated by respiratory and cardiac issues. 3. Resident # 5 ' s [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified that the resident was cognitively impaired, required the assistance of 2 staff for bed mobility and transfers, and had no falls in the previous 6 months. The care plan dated 2/16/12 and physician orders [REDACTED]. Facility investigation documentation dated 4/30/12 identified that the resident rolled/fell out of bed, and was found on the floor, face down. The resident had an abrasion of the temple and bloody nose and was sent to the hospital for evaluation. Hospital records indicated that the resident sustained [REDACTED]. NA#1's statement dated 4/30/12 noted that she had removed the fall matts from the side of the resident's bed prior to obtaining the help of another NA to transfer the resident. As she was coming back to the room, she heard the alarm sound and found the resident on the floor face down. Interview and review of the facility documentation with the DNS on 11/20/12 at 11 AM noted that the fall matts were removed and resident left alone. NA#1 was terminated and unable to be reached for interview.

Based on clinical record reviews, observations, interviews and review of facility investigations for one of three sampled residents reviewed for incidents/accidents (R#50), the facility failed to identify a pattern of injuries received during care, and/or failed to initate changes in the plan of care to prevent further injuries. The findings include: Resident #50's [DIAGNOSES REDACTED]. The care plans dated 5/11/11 and 8/9/11 identified that the resident had behaviors that included yelling and verbally/physically abusive to staff during care. The care plan also identified that the resident was at risk for injury due to the same behaviors. Interventions included geri sleeves (does not keep them in place), call bell in reach, Hoyer transfer with assistance of 2 staff, ensure the Hoyer pad is properly placed, and to leave the resident and re-approach as needed. Nurse's notes and/or facility documentation noted that the resident had episodes of combative/agitated behaviors and/or was verbally abusive towards the caregivers while providing hands on care and documented the following injuries: 5/17/11: Combative during care; sustained a skin tear on right hand between the fingers. 6/15/11: Very resistive to care. 3x5 cm area of bruising noted to left lower extremity. Will use geri legs as protection. 6/19/11: At 6 AM, the NA found a 4 x 9 cm yellow/purplish area on the right breast. 6/26/11: NA reported discoloration on left arm measuring 4 x 5 cm. Cooperative with care. Bruise was noted by 3-11 NA but nurse was not notified. 7/5/11: During care the resident struck out at the nurse and missed, but hit siderail sustaining a skin tear on the left arm. 9/22/11: During ADL care, found .1 x .2 cm open area on the right forearm. 9/30/11: Attempting to grab and scratch during care. Noted with swollen pinky. X-rays identified the pinky finger was fractured. Observations of the resident on 10/3/11 at 7:30 AM noted the resident in bed with 2 quarter rails up. A large bruise/discolored area was noted on the left forearm. A gerisleeve was observed on the left arm only, none on right. Interview and reviewed all injury reports and nurse's notes with ADNS on 10/4/11 at 6:51 AM noted that although nurse's notes indicated that the resident was combative with staff and sustained skin injuries, she was unable to provide documentation that any interventions were initiated to prevent further injuries. The ADNS was unable to provide documentation and/or care planning and/or different approaches to take for a resident with dementia to prevent injuries.

Based on clinical record review and staff interview for the only resident in the survey sample reviewed with injuries of unknown origin (Resident #50), the facility failed to review and revise the care plan after multiple injuries of unknown origin and/or sustained during care by staff to prevent further injuries. The findings include: Resident #50's [DIAGNOSES REDACTED]. The care plans dated 5/11/11 and 8/9/11 identified that the resident had behaviors that included yelling and verbally/physically abusive to staff during care. The care plan also identified that the resident was at risk for injury due to the same behaviors. Interventions included geri sleeves (does not keep them in place), call bell in reach, Hoyer transfer with assistance of 2 staff, ensure the Hoyer pad is properly placed, and to leave the resident and re-approach as needed. Nurse's notes and/or facility documentation noted that the resident had episodes of combative/agitated behaviors and/or was verbally abusive towards the caregivers while providing hands on care and documented the following injuries: 5/17/11: Combative during care; sustained a skin tear on right hand between the fingers. 6/15/11: Very resistive to care. 3x5 cm area of bruising noted to left lower extremity. Will use geri legs as protection. 6/19/11: At 6 AM, the NA found a 4 x 9 cm yellow/purplish area on the right breast. 6/26/11: NA reported discoloration on left arm measuring 4 x 5 cm. Cooperative with care. Bruise was noted by 3-11 NA but nurse was not notified. 7/5/11: During care the resident struck out at the nurse and missed, but hit siderail sustaining a skin tear on the left arm. 9/22/11: During ADL care, found .1 x .2 cm open area on the right forearm. 9/30/11: Attempting to grab and scratch during care. Noted with swollen pinky. X-rays identified the pinky finger was fractured. Observations of the resident on 10/3/11 at 7:30 AM noted the resident in bed with 2 quarter rails up. A large bruise/discolored area was noted on the left forearm. A gerisleeve was observed on the left arm only, none on right. Interview and reviewed all injury reports and nurse's notes with ADNS on 10/4/11 at 6:51 AM noted that although nurse's notes indicated that the resident was combative with staff and sustained skin injuries, she was unable to provide documentation that any interventions were initiated to prevent further injuries. The ADNS was unable to provide documentation and/or care planning, and/or inservices that staff were educated about resident's rights and different approaches to take for a resident with dementia to prevent injuries.

Based on resident interview, staff interview, clinical record review, and review of facility documentation for the only resident in the survey sample reviewed for resident rights (R #1), the facility failed to honor the resident's right to access an area on the facility grounds without restrictions. The findings include: Resident #1 (R #1) was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An admission minimum data assessment dated [DATE] identified R #1 with no short or long-term memory problems, independent with decision-making, requiring limited assistance with transfers and locomotion off the unit, and limited assistance with dressing. A resident care plan dated 9/18/10 identified impaired physical mobility related to above the knee amputations with bilateral prostheses. Interventions included physical therapy 6 times a week for 4 weeks and to encourage the patient to self mobilize to the highest level of function. On 9/27/10, the care plan identified an altered mood related to an incident that occurred on 9/24/10. Interventions included non-judgmental interaction, establish a trust relationship, obtain psychiatric consult order per physician if needed, and give the patient a way to channel anger and frustrations. A nurse's note dated as a late entry for 9/25/10 at 5:30 PM noted R #1 expressed sadness saying that he/she was told by the Nursing Director to wear a lap rope while going downstairs. Emotional support was provided and the Assistant Director of Nursing was notified. A social service note dated 9/27/10 indicated, in part, that R#1 was upset due to an incident that occurred several days ago. The resident started crying stating his/her family took him out front for a few minutes and when he/she returned a nurse came into his room and stated he/she could not be out front unless his/her legs were covered. The note further indicated R #1 believed he/she was told this not only because of the amputations, but because he was black. The note indicated the matter would be looked into and emotional support was provided. A subsequent social service noted dated 9/28/10 indicated R #1 appeared in good spirits. The note indicated the resident was informed a psychiatrist came in weekly if he/she needed to discuss his/her feelings about the incident that took place on 9/24/10. The note indicated the resident stated he/she was not crazy and was not interested in this. A social service note dated 10/2/10 indicted R #1 had been upset a week ago secondary to being asked to cover his/her stumps when off the unit. The resident verbalized being hurt and was weepy for several days. Now resident appears in better spirits and has not voiced any concerns. Review of a grievance report and investigation dated 9/27/10 indicated that on 9/24/10, a complaint was received from the receptionist who indicated several independent living residents were upset that R #1 had nothing to cover his/her bilateral knee stumps. At that time, the Director of Nursing went to R #1's room where the resident was found neatly dressed in a shirt and shorts. The report indicated it was 80 degrees outside. The Director of Nursing explained a request was received that the resident cover his/her legs while sitting in the front of the building. The note indicated the Director of Nursing informed the resident that he/she could use the back patio and another area without covering up. The report indicated, in conclusion, the independent residents would be upset at seeing any person, of any race sitting outside the building with their stumps showing. An interview on 10/27/10 at 12:30 PM with Person #1 indicated that on 9/24/10 he wheeled R #1 in the wheelchair outside to the front of the building. Person #1 stated that when they returned to R #1's room, a nurse came into the room and requested the resident not go out in the front of the building because the residents living there got upset looking at the amputations. Person #1 indicated the nurse took him/her to a patio in the back of the building where the resident could go outside. Person #1 indicated that when he returned to the room, R#1 wanted to leave the facility and felt he/she had done something wrong. An interview on 10/28/10 at 11:30 AM with R#1 indicated that when he/she was at the facility, a nurse told him/her to go outside in other areas. R#1 indicated that he/she could not understand why other people could go out in the front of the building and he/she could not. R #1 further indicated he/she was so upset he/she wanted to go home. An interview on 10/28/10 at 11:50 AM with Nurse Aide #1 indicated R #1 routinely wore shorts while a resident, and did not recall seeing R #1 with a towel and/or blanket on his/her lap while a resident at the facility. An interview on 10/27/10 at 1:40 PM with the Director of Nursing indicated that on 9/24/10, she received a call that R #1 was in front of the building and the independent living residents were upset because the resident had no legs with bandages on. She indicated that she went into R #1's room and asked the resident to put something on his/her lap if going on in the front of the building. The DNS also indicated that she informed the resident that there were other places he/she could go if he/she didn't want to cover the legs. She indicated there was a visitor in the room and she showed the visitor the patio in the back of the building. At that time, the DNS indicated the facility is different from most nursing homes because there are independent, elderly residents living on the grounds and they sometimes become upset and/or complain about residents who have physical changes or who are declining. An interview on 10/28/10 at 12 noon with the administrator indicated the facility had a meeting with R #1 and family members on 9/27/10. She indicated at that meeting the resident and family were informed they could go anywhere in the building, but if going out front the resident should be covered. She further indicated her intention was to protect the resident from the other residents living on the grounds. Review of the facility Resident Rights Handbook indicated, in part, the resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. A resident has the right to reside and receive services in the facility within reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.

Based on resident interview, staff interview, clinical record review, and review of facility documentation for the only resident in the survey sample reviewed for resident rights (R #1), the facility failed to allow the resident access to the facility grounds, dressed as he/she desired resulting in mental abuse. The findings include: Resident #1 (R #1) was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An admission minimum data assessment dated [DATE] identified R #1 with no short or long-term memory problems, independent with decision-making, requiring limited assistance with transfers and locomotion off the unit, and limited assistance with dressing. A resident care plan dated 9/18/10 identified impaired physical mobility related to above the knee amputations with bilateral prostheses. Interventions included physical therapy 6 times a week for 4 weeks and to encourage the patient to self mobilize to the highest level of function. On 9/27/10, the care plan identified an altered mood related to an incident that occurred on 9/24/10. Interventions included non-judgmental interaction, establish a trust relationship, obtain psychiatric consult order per physician if needed, and give the patient a way to channel anger and frustrations. A nurse's note dated as a late entry for 9/25/10 at 5:30 PM noted R #1 expressed sadness saying that he/she was told by the Nursing Director to wear a lap rope while going downstairs. Emotional support was provided and the Assistant Director of Nursing was notified. A social service note dated 9/27/10 indicated, in part, that R#1 was upset due to an incident that occurred several days ago. The resident started crying stating his/her family took him out front for a few minutes and when he/she returned a nurse came into his room and stated he/she could not be out front unless his/her legs were covered. The note further indicated R #1 believed he/she was told this not only because of the amputations, but because he was black. The note indicated the matter would be looked into and emotional support was provided. A subsequent social service noted dated 9/28/10 indicated R #1 appeared in good spirits. The note indicated the resident was informed a psychiatrist came in weekly if he/she needed to discuss his/her feelings about the incident that took place on 9/24/10. The note indicated the resident stated he/she was not crazy and was not interested in this. A social service note dated 10/2/10 indicted R #1 had been upset a week ago secondary to being asked to cover his/her stumps when off the unit. The resident verbalized being hurt and was weepy for several days. Now resident appears in better spirits and has not voiced any concerns. Review of a grievance report and investigation dated 9/27/10 indicated that on 9/24/10, a complaint was received from the receptionist who indicated several independent living residents were upset that R #1 had nothing to cover his/her bilateral knee stumps. At that time, the Director of Nursing went to R #1's room where the resident was found neatly dressed in a shirt and shorts. The report indicated it was 80 degrees outside. The Director of Nursing explained a request was received that the resident cover his/her legs while sitting in the front of the building. The note indicated the Director of Nursing informed the resident that he/she could use the back patio and another area without covering up. The report indicated, in conclusion, the independent residents would be upset at seeing any person, of any race sitting outside the building with their stumps showing. An interview on 10/27/10 at 12:30 PM with Person #1 indicated that on 9/24/10 he wheeled R #1 in the wheelchair outside to the front of the building. Person #1 stated that when they returned to R #1's room, a nurse came into the room and requested the resident not go out in the front of the building because the residents living there got upset looking at the amputations. Person #1 indicated the nurse took him/her to a patio in the back of the building where the resident could go outside. Person #1 indicated that when he returned to the room, R#1 wanted to leave the facility and felt he/she had done something wrong. An interview on 10/28/10 at 11:30 AM with R#1 indicated that when he/she was at the facility, a nurse told him/her to go outside in other areas. R#1 indicated that he/she could not understand why other people could go out in the front of the building and he/she could not. R #1 further indicated he/she was so upset he/she wanted to go home. An interview on 10/28/10 at 11:50 AM with Nurse Aide #1 indicated R #1 routinely wore shorts while a resident, and did not recall seeing R #1 with a towel and/or blanket on his/her lap while a resident at the facility. An interview on 10/27/10 at 1:40 PM with the Director of Nursing indicated that on 9/24/10, she received a call that R #1 was in front of the building and the independent living residents were upset because the resident had no legs with bandages on. She indicated that she went into R #1's room and asked the resident to put something on his/her lap if going on in the front of the building. The DNS also indicated that she informed the resident that there were other places he/she could go if he/she didn't want to cover the legs. She indicated there was a visitor in the room and she showed the visitor the patio in the back of the building. At that time, the DNS indicated the facility is different from most nursing homes because there are independent, elderly residents living on the grounds and they sometimes become upset and/or complain about residents who have physical changes or who are declining. An interview on 10/28/10 at 12 noon with the administrator indicated the facility had a meeting with R #1 and family members on 9/27/10. She indicated at that meeting the resident and family were informed they could go anywhere in the building, but if going out front the resident should be covered. She further indicated her intention was to protect the resident from the other residents living on the grounds. Review of the facility Resident Rights Handbook indicated, in part, the resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. A resident has the right to reside and receive services in the facility within reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.

Based on resident interview, staff interview, clinical record review, and review of facility documentation for the only resident in the survey sample reviewed for resident rights (R #1), the facility failed to allow the resident choices regarding outdoor visits where he/she chose and/or dressed as he/she desired. The findings include: Resident #1 (R #1) was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An admission minimum data assessment dated [DATE] identified R #1 with no short or long-term memory problems, independent with decision-making, requiring limited assistance with transfers and locomotion off the unit, and limited assistance with dressing. A resident care plan dated 9/18/10 identified impaired physical mobility related to above the knee amputations with bilateral prostheses. Interventions included physical therapy 6 times a week for 4 weeks and to encourage the patient to self mobilize to the highest level of function. On 9/27/10, the care plan identified an altered mood related to an incident that occurred on 9/24/10. Interventions included non-judgmental interaction, establish a trust relationship, obtain psychiatric consult order per physician if needed, and give the patient a way to channel anger and frustrations. A nurse's note dated as a late entry for 9/25/10 at 5:30 PM noted R #1 expressed sadness saying that he/she was told by the Nursing Director to wear a lap rope while going downstairs. Emotional support was provided and the Assistant Director of Nursing was notified. A social service note dated 9/27/10 indicated, in part, that R#1 was upset due to an incident that occurred several days ago. The resident started crying stating his/her family took him out front for a few minutes and when he/she returned a nurse came into his room and stated he/she could not be out front unless his/her legs were covered. The note further indicated R #1 believed he/she was told this not only because of the amputations, but because he was black. The note indicated the matter would be looked into and emotional support was provided. A subsequent social service noted dated 9/28/10 indicated R #1 appeared in good spirits. The note indicated the resident was informed a psychiatrist came in weekly if he/she needed to discuss his/her feelings about the incident that took place on 9/24/10. The note indicated the resident stated he/she was not crazy and was not interested in this. A social service note dated 10/2/10 indicted R #1 had been upset a week ago secondary to being asked to cover his/her stumps when off the unit. The resident verbalized being hurt and was weepy for several days. Now resident appears in better spirits and has not voiced any concerns. Review of a grievance report and investigation dated 9/27/10 indicated that on 9/24/10, a complaint was received from the receptionist who indicated several independent living residents were upset that R #1 had nothing to cover his/her bilateral knee stumps. At that time, the Director of Nursing went to R #1's room where the resident was found neatly dressed in a shirt and shorts. The report indicated it was 80 degrees outside. The Director of Nursing explained a request was received that the resident cover his/her legs while sitting in the front of the building. The note indicated the Director of Nursing informed the resident that he/she could use the back patio and another area without covering up. The report indicated, in conclusion, the independent residents would be upset at seeing any person, of any race sitting outside the building with their stumps showing. An interview on 10/27/10 at 12:30 PM with Person #1 indicated that on 9/24/10 he wheeled R #1 in the wheelchair outside to the front of the building. Person #1 stated that when they returned to R #1's room, a nurse came into the room and requested the resident not go out in the front of the building because the residents living there got upset looking at the amputations. Person #1 indicated the nurse took him/her to a patio in the back of the building where the resident could go outside. Person #1 indicated that when he returned to the room, R#1 wanted to leave the facility and felt he/she had done something wrong. An interview on 10/28/10 at 11:30 AM with R#1 indicated that when he/she was at the facility, a nurse told him/her to go outside in other areas. R#1 indicated that he/she could not understand why other people could go out in the front of the building and he/she could not. R #1 further indicated he/she was so upset he/she wanted to go home. An interview on 10/28/10 at 11:50 AM with Nurse Aide #1 indicated R #1 routinely wore shorts while a resident, and did not recall seeing R #1 with a towel and/or blanket on his/her lap while a resident at the facility. An interview on 10/27/10 at 1:40 PM with the Director of Nursing indicated that on 9/24/10, she received a call that R #1 was in front of the building and the independent living residents were upset because the resident had no legs with bandages on. She indicated that she went into R #1's room and asked the resident to put something on his/her lap if going on in the front of the building. The DNS also indicated that she informed the resident that there were other places he/she could go if he/she didn't want to cover the legs. She indicated there was a visitor in the room and she showed the visitor the patio in the back of the building. At that time, the DNS indicated the facility is different from most nursing homes because there are independent, elderly residents living on the grounds and they sometimes become upset and/or complain about residents who have physical changes or who are declining. An interview on 10/28/10 at 12 noon with the administrator indicated the facility had a meeting with R #1 and family members on 9/27/10. She indicated at that meeting the resident and family were informed they could go anywhere in the building, but if going out front the resident should be covered. She further indicated her intention was to protect the resident from the other residents living on the grounds. Review of the facility Resident Rights Handbook indicated, in part, the resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. A resident has the right to reside and receive services in the facility within reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.

Based on resident interview, staff interview, clinical record review, and review of facility documentation for the only resident in the survey sample reviewed for resident rights (R #1), the facility failed to allow the resident access to the facility grounds, dressed as he/she desired. The findings include: Resident #1 (R #1) was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An admission minimum data assessment dated [DATE] identified R #1 with no short or long-term memory problems, independent with decision-making, requiring limited assistance with transfers and locomotion off the unit, and limited assistance with dressing. A resident care plan dated 9/18/10 identified impaired physical mobility related to above the knee amputations with bilateral prostheses. Interventions included physical therapy 6 times a week for 4 weeks and to encourage the patient to self mobilize to the highest level of function. On 9/27/10, the care plan identified an altered mood related to an incident that occurred on 9/24/10. Interventions included non-judgmental interaction, establish a trust relationship, obtain psychiatric consult order per physician if needed, and give the patient a way to channel anger and frustrations. A nurse's note dated as a late entry for 9/25/10 at 5:30 PM noted R #1 expressed sadness saying that he/she was told by the Nursing Director to wear a lap rope while going downstairs. Emotional support was provided and the Assistant Director of Nursing was notified. A social service note dated 9/27/10 indicated, in part, that R#1 was upset due to an incident that occurred several days ago. The resident started crying stating his/her family took him out front for a few minutes and when he/she returned a nurse came into his room and stated he/she could not be out front unless his/her legs were covered. The note further indicated R #1 believed he/she was told this not only because of the amputations, but because he was black. The note indicated the matter would be looked into and emotional support was provided. A subsequent social service noted dated 9/28/10 indicated R #1 appeared in good spirits. The note indicated the resident was informed a psychiatrist came in weekly if he/she needed to discuss his/her feelings about the incident that took place on 9/24/10. The note indicated the resident stated he/she was not crazy and was not interested in this. A social service note dated 10/2/10 indicted R #1 had been upset a week ago secondary to being asked to cover his/her stumps when off the unit. The resident verbalized being hurt and was weepy for several days. Now resident appears in better spirits and has not voiced any concerns. Review of a grievance report and investigation dated 9/27/10 indicated that on 9/24/10, a complaint was received from the receptionist who indicated several independent living residents were upset that R #1 had nothing to cover his/her bilateral knee stumps. At that time, the Director of Nursing went to R #1's room where the resident was found neatly dressed in a shirt and shorts. The report indicated it was 80 degrees outside. The Director of Nursing explained a request was received that the resident cover his/her legs while sitting in the front of the building. The note indicated the Director of Nursing informed the resident that he/she could use the back patio and another area without covering up. The report indicated, in conclusion, the independent residents would be upset at seeing any person, of any race sitting outside the building with their stumps showing. An interview on 10/27/10 at 12:30 PM with Person #1 indicated that on 9/24/10 he wheeled R #1 in the wheelchair outside to the front of the building. Person #1 stated that when they returned to R #1's room, a nurse came into the room and requested the resident not go out in the front of the building because the residents living there got upset looking at the amputations. Person #1 indicated the nurse took him/her to a patio in the back of the building where the resident could go outside. Person #1 indicated that when he returned to the room, R#1 wanted to leave the facility and felt he/she had done something wrong. An interview on 10/28/10 at 11:30 AM with R#1 indicated that when he/she was at the facility, a nurse told him/her to go outside in other areas. R#1 indicated that he/she could not understand why other people could go out in the front of the building and he/she could not. R #1 further indicated he/she was so upset he/she wanted to go home. An interview on 10/28/10 at 11:50 AM with Nurse Aide #1 indicated R #1 routinely wore shorts while a resident, and did not recall seeing R #1 with a towel and/or blanket on his/her lap while a resident at the facility. An interview on 10/27/10 at 1:40 PM with the Director of Nursing indicated that on 9/24/10, she received a call that R #1 was in front of the building and the independent living residents were upset because the resident had no legs with bandages on. She indicated that she went into R #1's room and asked the resident to put something on his/her lap if going on in the front of the building. The DNS also indicated that she informed the resident that there were other places he/she could go if he/she didn't want to cover the legs. She indicated there was a visitor in the room and she showed the visitor the patio in the back of the building. At that time, the DNS indicated the facility is different from most nursing homes because there are independent, elderly residents living on the grounds and they sometimes become upset and/or complain about residents who have physical changes or who are declining. An interview on 10/28/10 at 12 noon with the administrator indicated the facility had a meeting with R #1 and family members on 9/27/10. She indicated at that meeting the resident and family were informed they could go anywhere in the building, but if going out front the resident should be covered. She further indicated her intention was to protect the resident from the other residents living on the grounds. Review of the facility Resident Rights Handbook indicated, in part, the resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. A resident has the right to reside and receive services in the facility within reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.

Based on resident interview, staff interview, clinical record review, and review of facility documentation for the only resident in the survey sample reviewed for resident rights (R #1), the facility failed to ensure that the social worker protected the rights of the resident and/or support the resident appropriately. The findings include: Resident #1 (R #1) was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An admission minimum data assessment dated [DATE] identified R #1 with no short or long-term memory problems, independent with decision-making, requiring limited assistance with transfers and locomotion off the unit, and limited assistance with dressing. A resident care plan dated 9/18/10 identified impaired physical mobility related to above the knee amputations with bilateral prostheses. Interventions included physical therapy 6 times a week for 4 weeks and to encourage the patient to self mobilize to the highest level of function. On 9/27/10, the care plan identified an altered mood related to an incident that occurred on 9/24/10. Interventions included non-judgmental interaction, establish a trust relationship, obtain psychiatric consult order per physician if needed, and give the patient a way to channel anger and frustrations. A nurse's note dated as a late entry for 9/25/10 at 5:30 PM noted R #1 expressed sadness saying that he/she was told by the Nursing Director to wear a lap rope while going downstairs. Emotional support was provided and the Assistant Director of Nursing was notified. A social service note dated 9/27/10 indicated, in part, that R#1 was upset due to an incident that occurred several days ago. The resident started crying stating his/her family took him out front for a few minutes and when he/she returned a nurse came into his room and stated he/she could not be out front unless his/her legs were covered. The note further indicated R #1 believed he/she was told this not only because of the amputations, but because he was black. The note indicated the matter would be looked into and emotional support was provided. A subsequent social service noted dated 9/28/10 indicated R #1 appeared in good spirits. The note indicated the resident was informed a psychiatrist came in weekly if he/she needed to discuss his/her feelings about the incident that took place on 9/24/10. The note indicated the resident stated he/she was not crazy and was not interested in this. A social service note dated 10/2/10 indicted R #1 had been upset a week ago secondary to being asked to cover his/her stumps when off the unit. The resident verbalized being hurt and was weepy for several days. Now resident appears in better spirits and has not voiced any concerns. Review of a grievance report and investigation dated 9/27/10 indicated that on 9/24/10, a complaint was received from the receptionist who indicated several independent living residents were upset that R #1 had nothing to cover his/her bilateral knee stumps. At that time, the Director of Nursing went to R #1's room where the resident was found neatly dressed in a shirt and shorts. The report indicated it was 80 degrees outside. The Director of Nursing explained a request was received that the resident cover his/her legs while sitting in the front of the building. The note indicated the Director of Nursing informed the resident that he/she could use the back patio and another area without covering up. The report indicated, in conclusion, the independent residents would be upset at seeing any person, of any race sitting outside the building with their stumps showing. An interview on 10/27/10 at 12:30 PM with Person #1 indicated that on 9/24/10 he wheeled R #1 in the wheelchair outside to the front of the building. Person #1 stated that when they returned to R #1's room, a nurse came into the room and requested the resident not go out in the front of the building because the residents living there got upset looking at the amputations. Person #1 indicated the nurse took him/her to a patio in the back of the building where the resident could go outside. Person #1 indicated that when he returned to the room, R#1 wanted to leave the facility and felt he/she had done something wrong. An interview on 10/28/10 at 11:30 AM with R#1 indicated that when he/she was at the facility, a nurse told him/her to go outside in other areas. R#1 indicated that he/she could not understand why other people could go out in the front of the building and he/she could not. R #1 further indicated he/she was so upset he/she wanted to go home. An interview on 10/28/10 at 11:50 AM with Nurse Aide #1 indicated R #1 routinely wore shorts while a resident, and did not recall seeing R #1 with a towel and/or blanket on his/her lap while a resident at the facility. An interview on 10/27/10 at 1:40 PM with the Director of Nursing indicated that on 9/24/10, she received a call that R #1 was in front of the building and the independent living residents were upset because the resident had no legs with bandages on. She indicated that she went into R #1's room and asked the resident to put something on his/her lap if going on in the front of the building. The DNS also indicated that she informed the resident that there were other places he/she could go if he/she didn't want to cover the legs. She indicated there was a visitor in the room and she showed the visitor the patio in the back of the building. At that time, the DNS indicated the facility is different from most nursing homes because there are independent, elderly residents living on the grounds and they sometimes become upset and/or complain about residents who have physical changes or who are declining. An interview on 10/28/10 at 12 noon with the administrator indicated the facility had a meeting with R #1 and family members on 9/27/10. She indicated at that meeting the resident and family were informed they could go anywhere in the building, but if going out front the resident should be covered. She further indicated her intention was to protect the resident from the other residents living on the grounds. Review of the facility Resident Rights Handbook indicated, in part, the resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. A resident has the right to reside and receive services in the facility within reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.

Based on resident interview, staff interview, clinical record review, and review of facility documentation for the only resident in the survey sample reviewed for resident rights (R #1), the facility failed to allow the resident access to the facility grounds, dressed as he/she desired resulting in emotional harm to the resident. The findings include: Resident #1 (R #1) was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An admission minimum data assessment dated [DATE] identified R #1 with no short or long-term memory problems, independent with decision-making, requiring limited assistance with transfers and locomotion off the unit, and limited assistance with dressing. A resident care plan dated 9/18/10 identified impaired physical mobility related to above the knee amputations with bilateral prostheses. Interventions included physical therapy 6 times a week for 4 weeks and to encourage the patient to self mobilize to the highest level of function. On 9/27/10, the care plan identified an altered mood related to an incident that occurred on 9/24/10. Interventions included non-judgmental interaction, establish a trust relationship, obtain psychiatric consult order per physician if needed, and give the patient a way to channel anger and frustrations. A nurse's note dated as a late entry for 9/25/10 at 5:30 PM noted R #1 expressed sadness saying that he/she was told by the Nursing Director to wear a lap rope while going downstairs. Emotional support was provided and the Assistant Director of Nursing was notified. A social service note dated 9/27/10 indicated, in part, that R#1 was upset due to an incident that occurred several days ago. The resident started crying stating his/her family took him out front for a few minutes and when he/she returned a nurse came into his room and stated he/she could not be out front unless his/her legs were covered. The note further indicated R #1 believed he/she was told this not only because of the amputations, but because he was black. The note indicated the matter would be looked into and emotional support was provided. A subsequent social service noted dated 9/28/10 indicated R #1 appeared in good spirits. The note indicated the resident was informed a psychiatrist came in weekly if he/she needed to discuss his/her feelings about the incident that took place on 9/24/10. The note indicated the resident stated he/she was not crazy and was not interested in this. A social service note dated 10/2/10 indicted R #1 had been upset a week ago secondary to being asked to cover his/her stumps when off the unit. The resident verbalized being hurt and was weepy for several days. Now resident appears in better spirits and has not voiced any concerns. Review of a grievance report and investigation dated 9/27/10 indicated that on 9/24/10, a complaint was received from the receptionist who indicated several independent living residents were upset that R #1 had nothing to cover his/her bilateral knee stumps. At that time, the Director of Nursing went to R #1's room where the resident was found neatly dressed in a shirt and shorts. The report indicated it was 80 degrees outside. The Director of Nursing explained a request was received that the resident cover his/her legs while sitting in the front of the building. The note indicated the Director of Nursing informed the resident that he/she could use the back patio and another area without covering up. The report indicated, in conclusion, the independent residents would be upset at seeing any person, of any race sitting outside the building with their stumps showing. An interview on 10/27/10 at 12:30 PM with Person #1 indicated that on 9/24/10 he wheeled R #1 in the wheelchair outside to the front of the building. Person #1 stated that when they returned to R #1's room, a nurse came into the room and requested the resident not go out in the front of the building because the residents living there got upset looking at the amputations. Person #1 indicated the nurse took him/her to a patio in the back of the building where the resident could go outside. Person #1 indicated that when he returned to the room, R#1 wanted to leave the facility and felt he/she had done something wrong. An interview on 10/28/10 at 11:30 AM with R#1 indicated that when he/she was at the facility, a nurse told him/her to go outside in other areas. R#1 indicated that he/she could not understand why other people could go out in the front of the building and he/she could not. R #1 further indicated he/she was so upset he/she wanted to go home. An interview on 10/28/10 at 11:50 AM with Nurse Aide #1 indicated R #1 routinely wore shorts while a resident, and did not recall seeing R #1 with a towel and/or blanket on his/her lap while a resident at the facility. An interview on 10/27/10 at 1:40 PM with the Director of Nursing indicated that on 9/24/10, she received a call that R #1 was in front of the building and the independent living residents were upset because the resident had no legs with bandages on. She indicated that she went into R #1's room and asked the resident to put something on his/her lap if going on in the front of the building. The DNS also indicated that she informed the resident that there were other places he/she could go if he/she didn't want to cover the legs. She indicated there was a visitor in the room and she showed the visitor the patio in the back of the building. At that time, the DNS indicated the facility is different from most nursing homes because there are independent, elderly residents living on the grounds and they sometimes become upset and/or complain about residents who have physical changes or who are declining. An interview on 10/28/10 at 12 noon with the administrator indicated the facility had a meeting with R #1 and family members on 9/27/10. She indicated at that meeting the resident and family were informed they could go anywhere in the building, but if going out front the resident should be covered. She further indicated her intention was to protect the resident from the other residents living on the grounds. Review of the facility Resident Rights Handbook indicated, in part, the resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. A resident has the right to reside and receive services in the facility within reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.